Download Echocardiography Imaging Protocols and Measurements

Echocardiography Imaging Protocols and Measurements
Standard E1
Standard E3
Standard E4
Preamble:
1. Quantitation of chamber and vessel size should be done on all studies.
2. Images of the four valves and color flow Doppler assessment of each valve is
required.
3. Left ventricular diastolic and systolic function assessed on all studies.
4. Right ventricular assessment separate from the left ventricular study.
Abbreviation List
AI
AO
ASD
AV
CW
EDP
EF
ERO
IAS
IVS
LA
LAD
LM
LV
LVES
LVOT
MPA
MR
MV
NCC
PA
PDA
PFO
PHT
PISA
PR
PV
PW
RA
aortic insufficiency
aorta
atrial septal defect
aortic valve
continuous wave
end diastolic pulmonary
ejection fraction
effective regurgitant orifice
intra atrial septum
intra ventricular septum
left atrium
left anterior descending
left main
left ventricular
left ventricular end systolic
left ventricular outflow tract
main pulmonary artery
mitral regurgitation
mitral valve
non-coronary cusp
pulmonary artery
patent ductus arteriosus
patent foramen ovalis
pressure half time
proximal isovelocity surface area
pulmonary regurgitation
pulmonary valve
pulsed wave
right atrial
RAP
RCA
RCC
RV
RVSP
RVOT
SAM
S of V
STJ
TR
TV
TVI
VSD
VTI
2D
3D
right atrial pressure
right coronary artery
right coronary cusp
right ventricular
right ventricular systolic pressure
right ventricular outflow tract
systolic anterior motion
sinus of valsalva
sinotubular junction
tricuspid regurgitation
tricuspid valve
tissue velocity index
ventricular septal defect
velocity time interval
two dimensional
three dimensional
Parasternal Long Axis
1. 2D of RV, AO, LA, and LV
 Assessment of the RV wall and RV size
 Measurement of the LVOT, AV, S of V, STJ and ascending aorta diameter
 Measure the LA diameter from the AO (not the MV leaflets) to the LA posterior wall
 Assessment of LV function: anteroseptal and inferolateral walls from base to distal
segments
2. 2D still at end-diastole to show LV wall and cavity measurements
 Measure IVS wall thickness below the level of the sigmoid septum
 Measure the LVED diameter at the level of the MV chords
 Measure the posterior wall thickness
3. 2D still at end-systole to show LV wall and cavity measurements
 Scroll through to end-systole and measure the LVES diameter at the same level as
the LVED
4. M-mode of the LV, AO, and LA
 M-mode is still a very useful tool and as part of a complete exam; m-mode spectrals
of the LV, AO and LA are required. Measurements do not need to be made.
5. 2D of AV and MV
 Zoom on the AV cusps and assess the movement of the right coronary and noncoronary cusps; assess for thickening, prolapse and masses
 Zoom on the MV and assess both leaflets for movement, coaptation and thickness
 Enlarge the zoom so the MV chords are visualized and assess for SAM, thickening
and masses on the chords
6. Color flow images of AV and MV
 Assess color flow in the LVOT, through the valve and in the ascending aorta
 Look for regurgitation and turbulence
 If there is AI do a vena contracta measurement – measure the narrowest neck of the
AI jet coming through the AV and then measure the diameter of the AV root
7. 2D still image of AV at end-systole to measure AV diameter
 Zoom on the AV and freeze frame the aortic valve at end systole to view the
insertion of both cusps into the annulus. Measure at the point of insertion of the
RCC, at the annulus, to the insertion of the NCC for a diameter—using markers will
ensure continuity with serial exams and multiple scanners
8. 2D RV inflow showing RVF and TV function
 Assess right ventricular wall function and size
 Assess TV movement, coaptation and thickness
9. Color flow image of TV
 Sector down the color over the TV and the RA and assess for TR. Scan through the
valve to pick up any eccentric jets
10. CW Doppler of TR for RVSP
 Using the color as a guide place the CW cursor into the most turbulent section of the
TR jet and measure the spectral wave that shows best with a complete round
segment.
Parasternal Short Axis
1. 2D of RVOT, AV, LA, RA and IAS
 Acquire a 2D image of the SAX view of the AV
 Swing slightly to the left and concentrate on TV, RA and RV looking for masses and
valve pathology
 Zoom on the AV – look at all 3 cusps for thickening, motion, masses and raphii
(partial or full)
 By making small movements with the transducer, look for the RCA and then swing
again looking for the LM and LAD and circumflex
 Look at the RVOT and look for muscle bundles or other possible obstruction
 2D image of the IAS looking for movement, aneurysm, thickening or defects
2. Color flow image of AV and IAS for ASD
 Zoom in on the AV and turn color on for AI – comment on the location of the jet(s)
 Move down and concentrate on the IAS and look for color going from one side to the
other through the wall; take the color off and measure the diameter of the defect
 Describe the flow – left to right, right to left or bidirectional

PW on the color jet to demonstrate the difference between PFO and ASD flow
3. 2D of PV and PA
 Zoom in on the PV and look for motion of the cusps – if possible do a sax view to
show all 3 cusps in one view. If the PW movement looks restricted, put the m-mode
through to look for the “flying W”
 Demonstrate the PA from RVOT to the pulmonary branches
 Freeze and measure the diameter of the MPA
4. Color flow image to assess RVOT, PV, PA and to look for PDA flow
 Turn on color feature and concentrate on each section of the pulmonary starting
with the RVOT looking for turbulent flow then moving to the PV looking for PR and
any unusual jets--you may pick up a fistula or aortopulmonary window. Look
carefully with the color on in the MPA at the junction of the branches for a
continuous PDA jet; if jet seen demonstrate flow velocities with Doppler.
 If PR seen, place the CW over the PR jet and obtain an EDP measurement
5. Pulsed wave (PW) Doppler of RVOT velocity
 PW just below the PV in the RVOT to get a PV VTI
6. CW of PV flow
 Turn on the color and place the CW cursor through the most turbulent section of the
jet to obtain a PPG and MPG
7. 2D and color flow of TV
 Zoom in on the TV and look at coaptation of the leaflets, then turn on the color and
look for TR; complete an RVSP by CW placing the cursor through the most turbulent
section of the jet to get a complete spectral (very important)
 Zoom out and look at the TR jet showing the full RA chamber
8. 2D of RV and LV at base level
 PSAX of the LV at the base level – just below the MV annulus – the annulus should
not be seen – both MV leaflets should be seen
 RV wall function can be assessed here also
9. 2D of RV and LV at mid ventricular level
 PSAX of the LV at mid ventricular level which commonly includes the papillary
muscles
 RV wall function can also be assessed here
10. 2D of RV and LV at apical level
 PSAX of the LV at the apex – this may require movement of an interspace to get a
true apical sax image
 RV apex may be seen at this level
Apical 4 and 5 Chamber
1. 2D showing all of each of the 4 chambers
 First apical view should incorporate all of the chambers – the edges of all the walls
should be seen: appropriate depth setting required
 From this view can assess the size of the atria compared to the ventricles
 The size of the RV compared to the LV
 Presence of pericardial fluid
 Presence of masses
 Compression of any of the chambers
2. 2D of end-diastolic LV volume trace
 Change the depth setting – you do not need the atrial chambers in this view
 Obtain a true 4 chamber view of the LV – true apex with LVOT not showing
 Freeze frame at end-diastole and trace from the anterior MV annulus around the
entire chamber to the posterior MV annulus (using markers to start and finish
ensures continuity between studies and between techs)
 Save the image
3. 2D of end-systolic LV volume trace (estimates EF)
 Scroll the same image to end-systole and retrace the LV from anterior MV annulus
around to the posterior MV annulus; ultrasound machine will calculate a 4 chamber
EF
 Save the image
4. 2D still of LA and RA end-systolic volume traces
 Change the depth setting to ensure the RA and LA are completely visible in the 4
chamber view
 Begin with the RA and measure from the anterior TV annulus, trace around the RA
to the septal TV annulus during end-systole to obtain a volume – stop at the
annulus—do not trace into the TV valve
 Repeat for the LA and obtain a 4ch LA volume
 Store images
5. 2D focusing on RV function
 RV study does not require a clear LV image
 Adjust your imaging plane slightly anterior to obtain a nice view of the RV from base
to apex
6. 2D still image with RV diameter just above the TV annulus - widest point
 Once you have obtained a nice RV image, freeze frame and scroll until you have the
widest point of the RV and measure the diameter just above the TV annulus from
internal ventricular septum to internal lateral RV free wall
7. M-mode TAPSE measurement of RV motion
 Place the m-mode cursor through the anterior wall so it goes through the lateral TV
annulus, hit m-mode—when you have a clear tracing, measure the lowest point of
the spectral to the highest point. This is not a slope measurement but a motion
measurement.
8. PW Doppler TDI to assess lateral tricuspid annulus motion
 Using the same image as before, turn the TDI on and placed the PW cursor over the
lateral TV annulus, adjusting the gain for better placement. Turn the PW on, adjust
the scale and gain to get a clear spectral wave showing the systolic and diastolic
wave forms. Freeze and place the caliper at the systolic peak, the diastolic E and
diastolic A points. Store the measurements.
9. 2D of LVOT in 5 chamber view with and without color flow
 Switching to a 5 chamber view, image the LVOT
 Turn the color on and look at the LVOT color flow for turbulence
 Assess for AI
10. PW Doppler of LVOT velocity in 5ch view
 Open the LVOT so both AV cusps are visible; place the PW cursor just off the AV
(not on the valve) and adjust the scale and gain to receive a nice tracing; freeze the
frame and trace the spectral to get peak velocity, VTI, SV and CO
11. CW Doppler of AV flow in 5ch view
 Using the same view, turn the color on and place the CW cursor through the most
turbulent part of the AV flow to obtain the highest gradient across the valve; adjust
the scale and gain to receive a nice spectral image and trace the spectral to obtain a
PPG, MPG, VTI and AVA
 If AI viewed, place the CW cursor over the jet and obtain a PHT
12. 2D with color flow on entire IVS wall looking for VSD
 Using the 5ch view and concentrating on the IVS from the AV to the apex
 Visualize the IVS before putting the color on to look for defects, aneurysms or
diverticulum
 Place color sector over the IVS looking at the perimembranous right out to the
muscular apex
 If defect viewed, turn the color off and measure the diameter of the defect if possible
 Doppler the shunt flow from the best possible angle to receive a peak velocity and
gradient
 A shunt ratio calculation should be obtained
13. 2D imaging of MV and TV simultaneously
 2D image of the MV and TV with the focus at the level of the valves, looking at
movement, thickness and coaptation
14. Color flow and CW images of MV




Focus on the MV and image separately before turning the color on; scan through the
valve, anterior to posterior and look for the best jet(s)
If the MR jet is moderate or more, perform a PISA – you will need to zoom in on the
valve where the color jet is coming through, change the color scale to
approximately38, freeze frame the best cap and using the PISA preset measure the
radius of the cap
Next unfreeze, place the CW cursor over the jet and obtain a MR spectral that can
be outlined with the PISA package
The MR CW spectral is also important for looking at timing of the jet and density of
the flow—this helps to decide the severity of the MR jet.
15 PW Doppler at the tips of the MV leaflets for diastolic function measurement
 Place the PW cursor at the tips of the MV leaflets in the 4ch view, obtain a nice PW
spectral of the MV flow wave. Pick the E/A wave marker from the diastology preset
list. Place the marker at the top of the E wave and move the marker down the slope
of the E wave to the bottom to obtain the deceleration slope measurement—move
the marker to the top of the A wave.
16. TDI of medial and lateral MV annulus for diastolic function measurement
 Acquire a 2D 4ch image showing the MV septal annulus and lateral annulus. Turn
the TDI feature on, adjust the gain, place the PW marker on the septal annulus and
obtain a clean spectral waveform showing the systolic and diastolic waves. Measure
each wave using the TDI preset.
 Repeat the process for the lateral wall
17. PW Doppler through the MV leaflets at the level of the annulus
 Obtain a 4ch LV image focusing on the MV and place the PW cursor through the MV
at the level of the annulus. Turn on the spectral; there should be an image of a
blunted E wave and an A wave. Using the diastology preset for MV A wave duration,
measure the onset of the A wave to the end.
18. PW Doppler at the level of the LVOT while catching the MV inflow
 To measure the IVRT for diastolic function, place the PW cursor in the LVOT along
the anterior MV leaflet so that the spectral wave will show the V1 AV spectral and
the onset of the MV inflow waveform. Using the IVRT preset for diastolic function,
measure from the end of the AV wave to the start of the MV wave—this will give you
the IVRT.
19. Color M-mode for color flow propagation
 Acquire a 2D LV 4ch view showing the MV and the entire LV. Turn the color on
showing the MV inflow from valve to apex. Adjust the scale (opposite way from
PISA) to 38. Put the m-mode cursor through the color flow; the color m-mode should
show a line for the MV leaflet closed in systole and a flow jet in diastole. Freeze
frame on a nice image and using the slope calipers, measure from the base of the
color jet to the top. Ensure that the jet is not cut off.
20. PW Doppler for pulmonary vein flow
 Using the 4ch view (centering the image on the LA, not the ventricles) and with 2D
imaging, locate the orifice of the superior pulmonary veins
 Turn the color on and adjust the scale to enhance the flow jet, and then place the
PW cursor in the vein. Hit the PW and look at your spectral—you may need to adjust
the scale to get a nice waveform. Always place the PW marker in the vein to get a
cleaner spectral; if you place the marker at the orifice, but in the LA, you will receive
artifact.
 Measure the systolic, diastolic and A wave points, then measure the A wave
duration in your diastolic function presets.
21. Color flow image of TV
 Focus on the right heart and the TV, turn the color on and scan through the TV
looking for the largest TR jet
 If the jet is more than mild, a PISA measurement can be performed for an ERO
22. CW TV to get RVSP estimation
Place the CW cursor over the best TR jet and look for the cleanest spectral showing a
complete TR waveform to measure. If the full jet is not demonstrated, it may be due to a
measurement of the valve opening or closing.
Apical 2ch
1. 2D showing LA and LV optimized for segmental function
 Demonstrate a 2D image of the LV showing the inferior and anterior walls ; in this
view you may also see the coronary sinus. The MV anterior leaflet must be attached
to the anterior wall, rather than inferior. Also use a depth setting that gives a full 2D
view of the LA.
2. 2D of end-diastolic LV volume traced
 Assess LV wall motion, then freeze and scroll to an image at end-diastole and using
the annulus as markers trace the LV from the inferior annulus around the apex and
down to the anterior annulus. Do not trace the pap muscles as part of the
myocardium.
3. 2D of end-systolic LV volume traced
 After completing the end-diastolic measurement, scroll through image to end-systole
and repeat the process. This will provide an estimated biplane EF measurement.
4. 2D of end-systolic LA volume traced
 Trace the LA at end-systole for an LA volume; with the completed 4ch volume the
computer should give an LA indexed measurement.
5. Color flow of MV
 Image the MV leaflets and turn the color on scanning through the leaflets to get the
maximum jet

PISA and CW of the MR jet can be completed
ALAX
1. 2D of LV, RV, AO, LA, AV and MV
 From the 2ch view, turn slightly until the LVOT comes into view on the right side of
the screen
 Assess LV anteroseptal, inferolateral, and RV for regional wall motion abnormalities
 Look at the LVOT, MV and LA for any pathology.
2. Color flow imaging of MV and AV
 Turn on the color and assess for abnormal flow or regurgitant jets not seen in other
views
Subcostal
1. 2D of 4 chamber view
 2D image of the heart from just below the rib cage looking up; make tiny adjustments
to show all 4 chambers, the TV and MV
 Look for pericardial effusion, extracardiac mass compressing the heart, pleural
effusion and ascites
2. Color flow on IAS to look for PFO or ASD
 Zoom in on the IAS showing it in its entirety, turn the color on, decrease the color
scale if needed and look for flow crossing the IAS
 Scan through to show SVC flow and the segment of the IAS where a sinus of
venosus shunt would be located.
 If shunt flow is seen, turn off the color and measure the defect diameter. A shunt
ratio calculation is required.
3. 2D of 5 chamber view
 With slight movement demonstrate the LVOT and ascending aorta. This view is a
good alternative if unable to get an AS gradient from the apical views.
4. 2D of IVC
 While the IAS is in view, turn the transducer and demonstrate the IVC. Attempt to
show a fairly long segment of the IVC so the ostium is visible, where the hepatic vein
attaches and the distal segment of the IVC. Measure the diameter at the proximal
segment about 5mm from the ostium.
 The size and movement of the IVC will help determine the RAP
5. Color on the IVC and Hepatic vein
 Turn on the color and watch for flow reversal in the hepatic vein. PW Doppler in the
vein and show the spectral.
6. M-mode to measure change in IVC diameter with sniff
 Place the m-mode cursor through the IVC where you would measure the diameter.
When a clean signal is achieved, ask the patient to sniff. Freeze the waveform and
measure the maximum IVC diameter and the sniff diameter. The ultrasound
machine should have presets for this.
7. SAX 2D view of AV, PA, pulmonary branches, TV, RA
 This SAX view is useful when the 3 AV cusps are not visible from any other view/or
the PA, PV and branches are not visible; this is a good view to do an RVOT PW
Doppler.
8. 2D abdominal view of the abdominal aorta
 From the subcostal view move slightly to the left and angle into the abdomen
following the descending aorta as far as possible; observe for dilatation of the aorta
(if seen), freeze and measure widest diameter and document the presence of
thrombus.
Suprasternal
1. 2D of aortic arch
 Have the patient lie on their back and tilt their head back as if they are trying to see
behind them. Set the transducer in the suprasternal notch and image all segments of
the aortic arch. With fine movements the ascending, transverse, branches and
descending aorta will be visible.
2. Color on aortic arch
 Place the color over the ascending aorta, move through the arch and into the
branches – then along the descending aorta
 Observe for turbulence, narrowing, shunting and flow reversal
3. CW of descending aorta to assess for coarctation
 Place the CW cursor into the flow of the descending aorta and Doppler looking for
narrowing, increased turbulence and Doppler spectral run off.
4. Color image of SVC flow
 From the suprasternal notch, move slightly left and with the color on look for a
continuous blue flow
Note: If pathology is found during the course of the study, additional images and off
angle views may be required for a complete study.