Download TTE Protocol

11/26/07 v8
BIDMC Complete Echo Scan protocol
Turn machine power on- hook cable to vault port if scanning in labhit cap lock on keyboard- all name demographic info should be in ALL CAPS
Press NEW EXAM button, ; log on to machine from pull down list of initials
- if fellow, choose USR and enter the
Patient LAST name
Patient ID = Hosp Med Record Number 7dig,no spaces
FIRST name
Birthdate- verify with patient if possible
Check box for Male or Female sex
Under ECHO LAB put W, E or S for site
If new patient, select CREATE PATIENT
If patient know to machine from previous recent study, hit SELECT PATIENT
On second screen of patient info, fill in
Height, Weight , Blood Pressure;
Under TAPE specify Tape number- for vidid I’s , fill in 000-000Log name , med rec no info on tape cover
HIT BEGIN EXAM – record back-up tape thru entire exam if option available
Apply three EKG electrodes (white right shoulder, black left shoulder, red lower chest)
or use auxiliary EKG cable from machine pocket to defib/sync port of room monitor
Hit Physio button to adjust gain, lead change and sweep speed as needed.
Patient ideally should be in left lateral decubitus position for optimal initial views:
I. PARASTERNAL VIEWS:
The left parasternal window is located in the 3rd, 4th or 5th intercostal
space. Transducer groove/ridge oriented at approximately 10:00 o’clock.
A. Parasternal Long Axis view
Optimize and image store at least two 2 beat clips of 2D image. First image
should be at max depth to show presence/absence of pericardial and pleural
effusions
Move m mode cursor over Ao/LA – m mode at sweep speed 50- 66.
Freeze m mode of Ao/LA and measure .
M mode through LV at mid chordal level, below MV, above pap,
Freeze m mode and make septal, p wall and LV dias, and sys measures.
If LV is too vertical or 2D more clear, make 2D rather than m mode measures.,
or use anatomic m mode.
Measure Ascending AO on 2D- sometimes this is easier from a higher interspace.
In all patients, zoom on LVOT and measure LVOT diameter in systole.
Optional- Zoom on aortic and mitral valve.
Turn on Color flow over the aortic and mitral valves- optimize sector for gain and
frame rate. Acquire a long axis with color .
11/26/07 v8
Aim the transducer inferiorly and medially, Transducer groove still at 10:00 o’clockno rotation, just pitch change, angled toward the patient’s right hip to see:.
B. Right ventricular INFLOW view- long axis of the right- RV/ TV / RA
Optimize and image store 2D view.
Color flow over the TV for TR jet.
CW Doppler to find maximum TR jet for estimate of PA pressure.
Groove still at 10:00 – aim superiorly toward patient’s left shoulder to see:
C. Right ventricular OUTFLOW view-Pulmonic valve, main PA, bifurcation
2D- image store
Color flow over the PV and PA –
Doppler across PV leaflets, use CW to document peak pulmonic flow velocities.
From the long axis view, rotate the transducer clockwise to see the Aorta and LV
in short axis. The indicator groove will be about 1:00 or 2:00. Aim superiorly to see
the aortic valve in cross section, then pan down towards the apex of the heart to
see through MV level and short axis of the LV with the pap muscles and then to
apex of the heart.
D. Parasternal Short Axis views
Record 2D over aortic valve- optimizing to show leaftlet number and morphology.
Scan slightly superiorly above valve plane for aortic root info.
Color Doppler over the aortic valve to look for AI and over the LA to see MR..
While over the aortic valve level in 2D, aim medially to see the TV and RVOT
Color over the TV/RA to look for TR, then CW to find TR jet and PASP estimate
Try to have color sector include IAS to watch for any trans septal flows..
Also while at the Aortic valve level, aim laterally and slightly superiorly to image
the PV, the main PA and the bifurcation.
Color over the PV and RVOT to look for PS, PI and PDA.
Pulse down the main PA, then CW.
Note- - IF PREFER- the PV/PA data may be acquired first, and then the TV data
.
After recordings at the great vessel level, scan down through the MV level.
Put color over the MV if needed to help evaluate MV leaks.
Scan the LV from base to apex to evaluate for wall motion abnormalities.
Record multiple clips of short axis.
11/26/07 v8
II. The Apical window- Apical Views
Start with the transducer over the apical impulse with the indicator ridge approx
2:00 to find:
A. Apical four chamber view
Record initial clips at full depth- to show entire atrial length.
Freeze image in systole with MV leaflets closed- measure LA and RA length , from
annulus level to back of atrial wall, excluding venous entry.
Color over the MV/LA. Record PW of MV inflow profile at MV tips. Determine
Peak E, Peak A, decel time of E . If any MS, trace MV V2 flow profile to get mean
gradient in diastole. Use CW across MV for MR jets , optional PISA data.
Record pw of right upper pulm vein for systolic and diastolic wave profiles.
Measure pulmonary vein s, d and a waves if clear.
As you sweep the color sector from LA toward the right heart, evaluate the
interatrial septum for ASD.; Color flow over the TV for TR evaluation.
CW over TV to find peak TR jet and use PW at TV tips if TS if present.
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From the 4 chamber view, aim the transducer more superiorly to add the aortic
valve and the aortic root to the image ( no rotation)
B. Apical 5 chamber view
2D- at least 1 clip showing clear valve motion and lv outflow tract info
Color over the aortic valve to assess AI
PW in LVOT to document AI, and LVOT flow by pulsing from apex to aortic valve.
Image store at various levels. to watch for a step up in flow velocity, suggesting
AS or inter cavity or sub valve gradient. Trace LVOT.
CW Doppler across the Aortic valve to obtain peak velocities and the peak/mean
pressure gradients for AS calculations, and AI P1/2 analysis if AR.
If AS present- use Pedoff probe for AS jet at apical window, high parasternal
window ( usually right para) and SSN windows for maximal jet velocities.
Rotate the transducer counterclockwise about 20 degrees to get the
C. Apical two chamber view- anterior and inferior walls
2D- with image optimized for maximal endocardial view.
Color flow over the mitral valve for MR
Rotate the transducer counterclockwise another 20 degrees- you should be back to
about 10 o clock- to add the aortic valve and root to the image. This is called:
D. Apical three chamber or Apical Long Axis view
2DColor over the MV and the Aortic/ LVOT –
PW and CW Doppler to evaluate valves and outflow tract as needed.
11/26/07 v8
OPTIONAL TVI Acquisition:This can be done as a set after all apical
imaging, or integrated into each view .
Return to apical 4 chamber view. Reduce image depth to maximize LV view,
Narrow sector size to increase frame rate. Turn on TVI. Further increase frame
rate- FPS >/= 140
Store one red/blue TVI image of apical 4 chamber
Hit PW- place same volume about 1 cm distal to lateral MV annulus. Hit Update
menu so that 2 D image frozen to maximize spectral clarity.
Freeze, measure e prime of lateral wallPlace PW sample volume on septum and measure E prime again..
Now , get apical 2 Chamber with LV optimized for depth- get TVI- no spectra
needed
Get apical 3 Chamber view maximized LV image get TVI- - no spectra needed.
III Subcostal Views- often easiest with patient supine, but not always.
Place the transucer inferior and slightly to the RIGHT of the xyphoid process,
aiming cranial, with the groove at about 3:00 to find the:
A. Subcostal 4 chamber view
2D- Goal is to show as much as possible of RV , anterior pericardium.
Color over the interatrial septum to look for ASD, color over IVS to look for VSD,
Increase number of heart cycles stored to capture atrial septal motion and any
trans septal color flow.
When possible get a 5 chamber and see aortic valve- color for AI.
Aim more medially to see the IVC, hepatic veins- sometimes it’s helpful to rotate
counterclockwise about 20 degrees . Color of IVC – optional m mode of IVC to
look for respiratory change in diameter.
Aim more posteriorly to see the abdominal aorta- 2D and color flow to eval for
aneurysm, clot , dissection and reversal of flow in severe AI.
B. Subcostal Short Axis View- Optional
This view can be very helpful for patients with limited parasternal views.
2D scan of heart from base to apex.
Color ,PW and CW Doppler as needed
Angling superiorly, good view for PA, RVOT and Pulmonic Valve flows
IV Suprasternal Notch- Option to obtain this view before subcostal
11/26/07 v8
Place the transducer in the suprasternal notch directly below the chin with the
indicator groove pointing towards 12 or 1 o ‘clock to see:
A. The aortic arch - if possible
2D- image store
Color flow in descending aorta to look for dissection, PDA or turbulence from
Reversal of flow in severe AI and coarctation
CW in ascending aorta as needed for AS gradients
CW in descending aorta to exclude coarc and PW asess for AI flow reversal if
needed..
Rotate the transducer clockwise about 90 degrees to get a
B Long axis of the right PA and a short axis of the aorta-optional view
2D
Color flow to look for PDA and dissection
If needed for evaluation of AS, ASD, dilated ascending aorta, place patient on their
right side for the following additional view:
V. Right Parasternal Window- Optional Supplemental Views
Place the transducer in the 3rd or the intercostal space, close to right sternal edge,
With the indicator at about 2 or 3 oclock to obtain:
Right parasternal view of the left and right atria ( right will be on top) and ascending
aorta,
2D- valuable view for ascending aorta dilatation cases.
Color flow to look for ASD , dissections, and medially directed MR jets.
This window can be especially helpful to look for MR from mechanical valves ,
as well as a supplemental view for AS and AI jets.
CW across aortic valve as needed, especially with Pedoff probe.
At the end of the study, hit END EXAM to archive data
Edit study and Export study to Image vault.
Record the end footage of study on tape jacket on the next line- this will become the
start footage of the next case.