Echo InterpretationJason R. Morrissette, MSHS, MBA-HCM, PA-C
Echo Machine
Transthoracic Echocardiography Windows
• Left parasternal• Long axis view
• Short axis view
• Apical window• 4 chamber view
• 5 chamber view
• 3 chamber view
• 2 chamber view
• Subcostal/Subxiphoid window• Interatrial septum
• IVC
• Suprasternal window
Parasternal Window, Long Axis
Parasternal Window, Short Axis
Parasternal window, short axis
Apical window, 4 Chamber
Apical window, 5 Chamber
Apical window, 2 Chamber Apical window, 3 Chamber
Subxiphoid View
Suprasternal View
Chamber Evaluation
• Left ventricle size and function
• Left ventricle wall thickness
• Left atrium dimensions
• Right ventricular size and shape
Left Ventricle Size
• Measure in parasternal long axis, at the tip of the mitral leaflets
• Diastolic diameter: End diastole, frame after mitral closure; largest cardiac dimension
• Systolic diameter: End systole, frame preceding mitral valve opening; smallest cardiac dimension
• Exclude chordae and papillary muscle from measurement
• Measure perpendicularly to long axis of LV
• LV apex should not be visualized
Left Ventricle Size
Diastolic Diameter of LV
Systolic Diameter of LV
M-Mode of LV
Left Ventricular Thickness
• Measure in parasternal long axis at end-diastole
• Exclude chordae and papillary muscle
• Exclude moderate bands from right ventricle
NormalMildly
abnormalModerately abnormal
Severely abnormal
LV Thickness (cm) 0.6 - 0.9 1.0 - 1.2 1.3 - 1.5 ≥1.6
Left Ventricular Thickness
Left Atrial Size
• Measured at end systole where LA chamber is at its greatest dimension
• Parasternal long axis, perpendicularly to the LA walls, leading edge to leading edge
Women MenAP Dimension (cm) 2.7 - 3.8 3.0 - 4.0
Left Atrial Size
Left Atrial Size - Volume
4 Chamber 2 Chamber
Right Ventricle Size
Right Ventricle Size
Normal Mildly abnormalModerately abnormal
Severely abnormal
RV ED Diameter (cm) 2.7 - 3.3 3.4 - 3.7 3.8 - 4.1 ≥4.2
Normal: RV < LV
Mildly enlarged: RV < LV
Moderately enlarged: RV = LV
Severely enlarged: RV > LV
Right Ventricle Shape• Normal: Crescent
• Pressure/Volume overload: End-diastolic pressure of RV exceeds LV causing flatness of septum and inward bowing of LV during end-diastole and then in systole
RV
LV
IVC assessment
• Subcostal 4 chamber view
• Visualize IVC merging with right atrium
• Measure 2-3 cm before merging with RA, parallel walls
• M mode across IVC
IVC Abdominal Aorta
Direction Goes through liver Goes through liver
Relationship to heart Merges with RA Continues down the heart
Flow Continuous Pulsatile
Walls Not visible Hyperechoic
Respiratory variation Yes No
Collateral vessels Hepatic veins merge with IVC Not visible at this level
IVC and Aorta
IVC and Aorta
IVC Aorta
Left Ventricular Segmentation
Ejection Fraction
•Normal 52 – 72%
•Mildly reduced 41 - 51%
•Moderately reduced 30 – 40%
• Severely reduced < 30%
EF – Normal (52-72%)
EF-Mildly Reduced (41-51%)
EF-Moderately Reduced (30-40%)
EF-Severely Reduced (<30%)
Regional Wall Motion Abnormalities
• Septal hypokinesis
• Inferior and inferolateral hypokinesis
• Left and Right Ventricle dysfunction
Septal hypokinesis
Inferior and inferolateral hypokinesis
Left and Right Ventricle Dysfunction
Pericardial Effusion
Pericardial Effusion
Tamponade
• Early signs• IVC dilated, not collapsing • Increased respiratory variation in
mitral (> 25%) and tricuspid (> 40%) inflows
• Late signs• RA/RV collapse
• Very late signs• LA/LV collapse
Valve pathology
• Mitral regurgitation
• Mitral stenosis
• Aortic insufficiency
• Aortic stenosis
• Tricuspid regurgitation
• Tricuspid stenosis
Mitral Regurgitation
Jet area–Color Flow• Simple, quick screen for mild or severe central MR;
evaluates spatial orientation of jet
• Subject to technical, hemodynamic variation; significantly underestimates severity in wall-impinging (eccentric) jets
Mitral Regurgitation
Mitral Regurgitation: Torn MV Chord
Mitral Stenosis
Mild Moderate Severe
Valve Area (cm2) > 1.5 1.0 - 1.5 < 1.0
Mean gradient (mmHg) < 5 5.0 - 10 > 10
Aortic Insufficiency
Jet width in LVOT–Color Flow• Mild• Moderate • Severe
Jet deceleration rate – Pressure ½ time (msec)• Mild severity: > 500 • Moderate severity: 500-200 • Severe severity < 200
Aortic Insufficiency
Aortic Insufficiency – Pressure ½ time
Aortic Stenosis
• (LVOT) velocity: measured from the apical approach either in an apical long-axis view or an anteriorly angulated four-chamber view
• Left ventricular outflow tract (LVOT) diameter- measured in the parasternal long-axis view in mid-systole
• Aortic valve jet velocity
Aortic Stenosis: Grading Severity
Aortic Stenosis
Aortic Stenosis: Pre surg
Aortic Stenosis: Post surg
Systolic anterior motion (SAM) of MV
•Apposition of the tip of the mitral leaflet and septum in mid to late systole
• Subaortic obstruction in hypertrophic cardiomyopathy
SAM
SAM
Tricuspid Regurgitation
Jet area–Color flow
• Simple, quick screen for TR
• Underestimates severity in eccentric jets
Pulmonary Artery Pressure
• MPAP systole = 4 * (TR jet velocity)2 + Right Atrial Pressure (RAP)
RAP IVC diameter IVC collapsibility
3 mmHg < 21 mm >50%
8 mmHg < 21 mm <50%
10 mmHg > 21 mm >50%
15 mmHg > 21 mm <50%
Tricuspid Stenosis
Mean pressure gradient (mm Hg) ≥ 5
Mitral Inflow patterns
• Flow from Left Atrium to Left Ventricle occurs in 3 phases:
• E wave: Initial rush of blood into LV as MV opens in early diastole
• Diastasis: Period of low or no flow
• A wave: Atrial contraction results in final rush of blood into LV in end-diastole
Mitral inflow, diastolic dysfunction
Diastolic dysfunction
Normal Severe dysfunction
Myxoma
Right Atrial Mass
Bubble Study
Bubble Study - PFO
Left Ventricle Apical Thrombus
American Society of Echocardiography
• http://asecho.org