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Apex Echocardiography
A Two-dimensional Technique
for Evaluating Congenital Heart Disease
NORMAN H. SILVERMAN, M.D.,
AND
NELSON B. SCHILLER, M.D.
With the technical assistance of Patricia A.
Hart,
M.A., R.D.M.S.
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SUMMARY We have evaluated apex echocardiography, using an
800 phased array sector scanner, in 368 patients with congenital
heart disease. With the patient lying with the left side dependent, the
transducer is placed over the apex of the heart and cross sectional images are obtained in the plane perpendicular to the cardiac septa and
through the orifices of the mitral and tricuspid valves. In this view, the
chambers are side by side and both atria and ventricles are separated
by their respective septa and atrioventricular valves. Defects in the
region of the septa can be detected. Congenital defects involving the
atrioventricular valves, such as endocardial cushion defects, tricuspid
atresia, and Ebstein's anomaly, can be defined. The location of the
baffle after Mustard's operation for aortopulmonary transposition
and intra-atrial structures, such as the membrane in cor triatriatum,
can be seen. The position of the apex of the heart can be located in
dextro, levo, or mesocardia by definition of the apex image. The
relative size of the cardiac chambers can be compared. The localized
thickness of the ventricular septum can be identified with the apex image. We have found this technique to be valuable in patients with congenital heart disease who are undergoing cross sectional echocardiography.
TWO-DIMENSIONAL phased array sector scanners allow
high resolution imaging of large cross sections of the heart
from small echocardiographic windows. Conventionally,
precordial window transducer placement has been used to
produce the images."'' Alternative transducer application in
the suprasternal notch,20 over the cardiac apex21 and subxyphoid areas allows alternative approaches for obtaining
tomographic images of cardiac chambers. Using an 800
phased array sector scanner, we have used the apex as a
locus from which to display simultaneously the four cardiac
chambers, the atrioventricular valves, and the cardiac septa.
Because of this unique presentation, this view has been
useful in defining a wide variety of congenital heart defects.
Patients
We examined 368 patients, with ages ranging from newborn to adult, who had congenital heart disease. Apical cardiac images were performed as part of the two-dimensional
echocardiographic examination. The diagnosis was established at cardiac catheterization in 218 of these patients.
In the remainder, the diagnosis was made by clinical means,
electrocardiography, roentgenography, and M-mode
echocardiography.
Examination Techniques
The recording of the apical image requires precise positioning of the patient and application of the transducer to
produce an optimal image (fig. la and b). The subject is
positioned as for performance of an apexcardiogram, lying
supine with the left side of the thorax dependent. When the
cardiac apex is difficult to palpate, the transducer is applied
to the apex region and moved around in this region until the
precise image is obtained with the apex of the heart in the
apex of the image. When the subject is lying on the left side,
the apex may be very close to the bed; to compensate for
this, we have constructed a 6-inch foam rubber mattress with
a piece carved out that enables the transducer to be placed
directly on the apex impulse. In patients with cardiac
malposition, examination of the chest roentgenogram is
helpful in defining the location of the cardiac apex. Once the
apex is located, the tomographic plane is directed toward the
base with the beam plane perpendicular to the ventricular
and atrial septa and through the plane of the mitral and
tricuspid valve orifices. Fine adjustment of gain settings and
transducer position is required to produce an optimal image.
Simultaneous display of both atria and ventricles, with the
atrioventricular valves and cardiac septa, is sought (fig. 2).
Angulation of the transducer slightly toward the base of the
heart allows visualization of the pulmonary veins posteriorly and the aorta and right ventricular outflow tract
anteriorly (fig. 3). In some patients in whom the studies were
performed during cardiac catheterization, contrast echocar-
Methods
Equipment
We performed the studies using a Varian Associates
phased array sector scanner with an 800 scanning angle. The
transducer has 32 elements with a frequency of 2.25 MHz
and an active area of 1.2 by 1.3 cm. The line density of the
image was either 64, 128 or 256 lines per arc and displayed
at a tissue depth of 7, 15 or 21 cm. The images were displayed on an XY oscilloscope screen at 30 frames per second
and recorded on video tape at a rate of 60 half-frames per
second. This mismatch resulted in only a half density image
per single frame recorded on the video tape. Single images
could be recorded with a Polaroid camera mounted on a
slave X-Y screen (full density frame), or from the video
television screen. A centimeter grid for depth and breadth
was displayed at the top and left side of the recorded image
and an electrocardiogram was displayed below the image for
reference to events within the cardiac cycle.
From the Departments of Pediatrics and Medicine and the Cardiovascular
Research Institute, University of California, San Francisco, California.
Address for reprints: Norman H. Silverman, M.D., 1403-HSE, University
of California, San Francisco, California 94143.
Received September 16, 1977; revision accepted October 18, 1977.
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a
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FIGURE 1. a) Demonstration ofplacement of the transducer over the apex and the plane of the tomogram. The im age is
displayed as if one were lookingfrom below in the position of the left hip showing the right a nd left a tria (RA and LA ) and
the right and left ventricles (R V and L V). b) Section of the normal heart in the plane shown in (a) mounted as it appears
on the television screen with the cardiac apex at top. L V left ventricle; RV - right ventricle; SEPT = interventricular
septum; MV mitral valve; TV= tricuspid valve; LA left atrium; RA = right atrium; IAS= interatrial septurm.
diography with a bolus of 2-5 ml of normal saline was performed to verify certain anatomic features.
the tomographic plane from below. The apex of the ultrasonic fan contains the ventricular images, whereas the atria
lie inferiorly.
Display
The images are displayed with the apex of the heart in the
apex of the fan at the top of the screen and the atria at the
bottom (fig. 2). Left-sided structures are to the right and
right-sided structures are to the left of the observer. The image is displayed, therefore, as if one were observing the
tomographic plane from the patient's left hip and looking at
Results
The Normal Image
We examined 20 patients without heart disease. Figure 2
shows a stop frame image in a normal individual. The four
chambers are displayed with the ventricles and atria lying
FIGURE 2. Diagrammatic representation (left) of apical image (right). The stop frame is taken in early diastole. The
right ventricle (R V) shows coarse trabeculation whereas the left ventricle (L V) is smooth. The tricuspid and mitral valves
(TV, MV) are seen to be opening. The ventricular septum is seen between the two ventricles. The interatrial septum between the left and right atria (LA, RA ) is seen but echo dropout in the region of the fossa ovalis is present. The left pulmonary vein (PV) is identified. The electrocardiogram is seen below the image indicating the time and the cardiac cycle.
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side-by-side; the ventricles lie at the apex and the atria lie at
the base of the fan. The ventricular and atrial septa and the
atrioventricular valves form a cruciate confluence that
divides the image into four sections. The ventricles are displayed in their long axes from the apex to the base and occupy approximately the upper two-thirds of the image, and
the atria occupy the lower third.
The left ventricle, noted on the right, is roughly ellipsoid
in shape, with the mitral valve forming the flattened base. In
this projection, the apex is formed mainly by the left ventricle with a much smaller contribution by the right, except in
younger children where the right and left ventricles occupy
similar portions of the apical image. The lateral wall of the
left ventricular image is formed by the posterior portion of
the left ventricular free wall, whereas the medial border is
the ventricular septum. Papillary muscles sometimes can be
defined by slight clockwise rotation of the transducer along
its axis. In real time, the left ventricle is seen to contract concentrically. With the onset of diastole, the mitral valve
leaflets are seen to separate abruptly and move into the left
ventricle. The larger anterior leaflet is medial whereas the
smaller posterior leaflet is lateral. The motion of the mitral
leaflet in diastole is biphasic related to the phasic diastolic
blood flow.
The left side of the anterior portion of the image is formed
by the sinus portion of the right ventricle (fig. 2). The right
ventricle is seen in its long axis and is triangular in shape.
The medial border of the right ventricular image is the ventricular septum, whereas the lateral part is the anterior right
ventricular wall. The coarse trabeculations of the right ventricle and moderator band are identified as bright linear
echoes in the apical area. The echo pattern within this area
of the right ventricle is different from that of the left so that
morphological identification of the right ventricle often can
be made on the basis of this echo pattern. The tricuspid
valve, like the mitral valve, forms the base of the triangular
right ventricular image. Two leaflets of the tricuspid valve
are seen; the anterior tricuspid leaflet is lateral whereas the
septal leaflet is medial. In real time, the tricuspid valve,
which lies at the same level as the mitral valve in diastole,
moves in a manner similar to the mitral valve; in systole, the
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size of the right ventricle diminishes, but the septum moves
toward the left ventricle.
The left atrium forms the inferior right quadrant of the
image. The atrial outline is roughly circular and the upper
arc of the image is formed by the mitral valve apparatus and
anulus. The lateral portion of the left atrial wall forms the
lateral border of the image. The inferior portion of the image is formed by the posterior left atrial wall and its junction
with the pulmonary veins. The medial margin of the left
atrium is formed by the interatrial septum. In real time, the
left atrium is seen to expand and contract reciprocally with
the left ventricle.
The right atrium forms the lower left quadrant of the image (fig. 2). It, too, is circular in shape and is formed
superiorly by the corresponding atrial walls. The medial wall
is formed by the interatrial septum. In real time, the
chamber is seen to contract and expand reciprocally with the
right ventricle.
The two atrioventricular valves lie on the same horizontal
level and move with almost identical phasic motion. The image is divided into left and right halves by the ventricular and
atrial septa. The ventricular septum is situated in the apex of
the image and runs vertically; the septum joins the confluence between the mitral and tricuspid valves. The apical
portion of the septum is the muscular septum, and the portion near the confluence between the atrioventricular valves
is the membranous septum. Slight cranial and caudal
angulation of the transducer also allows imaging of larger
areas of both the interatrial and interventricular septa. With
cranial transducer angulation, a left ventricular outflow
tract is brought into view and, with further angulation, the
aortic valve and its leaflets can be identified clearly (fig. 3).
Atrial Septal Defects
We examined 19 patients with secundum atrial septal
defects, including four who had had closure by means of a
patch. It is not possible, from the apical approach, to
differentiate between normal echo dropout caused by
thinness of the atrial septum in the region of the fossa ovalis
(Rosenquist, personal communication) and secundum atrial
FIGURE 3. Diagrammatic representation (left) of tomogram on the right. Cranial angulation of the transducerfrom the
apex showing the aortic valve and leaflets. The tricuspid valve (TV) is seen to the left of the aortic valve. The right atrium
(RA) and left atrium (LA) are separated by the interatrial septum. The ventricular septum is not imaged anteriorly
because it moves out of thefield with this sweep and is replaced by the right ventricular outflow tract (R VO). Pulmonary
veins are not seen in this still frame recording.
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VOL 57, No 3, MARCH 1978
A
FIGURE 4. Apical image of an ostium primum atrial septal defect. The apex is made up of the right ventricle (R V) which
is larger than the left ventricle (L V). The septum is rotated to the left by the enlarged ventricle in the absence of echoes
from the interatrial septum. The dropout of echo from the atrial septum in the region of confluence with the mitral and
tricuspid valves and ventricular septum is pathognomonic of primum type defects.
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septal defects. Detection of this defect has been verified by
demonstrating the atrial patch postoperatively.
We examined 12 patients with ostium primum atrial septal defects. In this lesion the echo dropout is different from
that in secundum defects; it is situated lower in the atrial
septum, adjacent to and involving the atrioventricular valve
junction (fig. 4). Frequently, a bright echo is seen in the
atrial septum which, we believe, arises from the free edge of
the interatrial septum. The entire echo from the interatrial
septum may be missing in this condition either because of
associated secundum atrial septal defect or the normal septal echo dropout from the fossa ovalis region. We have not
been able to detect mitral valve clefts from this view.
In both types of atrial septal defects there are secondary
changes in the size of the ventricles and ventricular septal
motion. The enlarged right ventricle forms a proportionately
larger portion of the apex image and the ventricular septum
is displaced toward the subject's left. In real time the septal
motion can be seen to contract in a paradoxical fashion. The
right atrium occupies a considerably larger area than does
the left atrium. In ostium primum defects with associated
mitral incompetence, left atrial size also may increase.
Atrioventricular Canal Defects
We examined 24 patients with partial or complete
atrioventricular canal defects. The apex view offers a unique
image of these deformities. In complete atrioventricular
canal defects there is absence of echoes from the upper portion of the ventricular septum. The extent of echo dropout
gives an estimate of the size of the ventricular septal defect.
The estimate of the size of the atrial component of the defect
may be erroneously large because of dropout from the area
of the fossa ovalis unless a bright echo from the free edge of
the atrial septum can be identified. When there is a single
anterior atrioventricular valve leaflet (Rastelli type C),22 a
single linear echo is seen across the two ventricles (fig. 5).
When the common leaflet is divided and attached to the crest
of the ventricular septum (Rastelli type A),22 the echo from
the common anterior leaflet is seen to be broken. In real
time the motion of the echo from the two forms of defect is
entirely different. With diastole in type C the undivided echo
moves toward the ventricle in a single line whereas in the
type where the common anterior leaflet is divided, the
separate portions move toward their respective ventricles.
We have not encountered any complete atrioventricular
valve disorders of the Rastelli type B group. In partial endocardial cushion defects, the separate valve leaflets appear
attached to the crest of the ventricular septum. Secondary
anomalies in the size of the ventricles and the atria are displayed and help to define the hemodynamic consequences of
the lesion. When there is a predominant left-to-right shunt at
the atrial level, right atrial and right ventricular enlargement
can be detected; when a large ventricular shunt is present, or
FIGURE 5. Apical image of a patient with a complete atrioventricular canal, Type C of Rastelli. Note the area of echo
dropout in the region of the ventricular septal defect. Rather than separate mitral and tricuspid valves, there is a linear
echo from the an terior common atrioventricular valve leaflet. There is dropout of atrial septal echoes from the entire atrial
septum. A pulmonary vein is identified posteriorly (PV).
APEX ECHOCARDIOGRAPHY/Silverman, Schiller
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FIG U RE 6. A pical view of a ventricular septal aneurysm. The diagram on the left is a diagrammatic representation of the
echo tomogram on the right. In systole, the aneurysm is seen to prolapse into the right ventricle (R V) below the tricuspid
valve (TV), arrowed in the diagram on the left.
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there is significant mitral regurgitation, the left-sided
chambers also are enlarged. We have noted that, postoperatively, the position of the patch across the atrial and ventricular septal defects can be clearly defined as bright echoes
from the synthetic material,
Ventricular Septal Defects
Idiopathic Hypertrophic Subaortic Stenosis
There were 15 patients who had idiopathic hypertruphic
subaortic stenosis. In this lesion the area of septal hypertrophy and its relationship to the left ventricular outflow
tract can be identified by angling the transducer cranially
toward the aortic valve (fig. 7). During the scan the septum is
noted to thicken with the cranial angulation. The area of
We examined 27 patients with membranous ventricular
septal defects. The demonstration of the ventricular septum
from the apex to its confluence with the interatrial septum
allows identification and localization of defects. Exploration
of a large part of the septum is possible by cranial and
caudal angulation of the transducer. Larger membranous
ventricular septal defects and those associated with tetralogy
of Fallot (26 patients), truncus arteriosus (7 patients), and
double outlet right ventricle (8 patients) can be identified.
Smaller septal defects often cannot be seen. Postoperatively
the ventricular septal patches used to close these defects can
be identified because of their brighter echo characteristics.
We have detected ventricular septal aneurysms in 10
patients (fig. 6). The aneurysm is located in the upper portion of the ventricular septum adjacent to the atrioventricular valve. These aneurysms cannot be differentiated from
pouches associated with tricuspid valve in partial endocardial cushion defects" on the basis of the aneurysmal
protuberance, but associated features of an endocardial
cushion defect favor the diagnosis of a pouch of the tricuspid
valve. In real time motion, the aneurysm is seen to prolapse
into the right ventricle below the tricuspid valve with each
ventricular systole and move toward a central position with
ventricular diastole.
Single Ventricle Complexes
This view is helpful for differentiating large ventricular
septal defects from single ventricle complexes. We have en-_
countered 12 patients with single ventricle complexes. Even
in very large ventricular septal defects a rim of ventricular
septum in the apex of the image can be identified, whereas in
single ventricle complexes, even in the presence of a small
outflow chamber, this endocardial protuberance dividing the
11 and not
outflow chamber> from the ventricle is displaced
readily identifiable from the apex view. Papillary muscles
may be erroneously interpreted as being a rim of the ventricular septum. In addition, the definition of one or two
atrioventricular valves in single ventricle complexes can be
identified readily from the apex approach.
7. Cross-sectional
~~~~~~~~~~~~FIGURE
patient with
idiopathic
The second and
echocardiogram from the apex in a
hypertruphic ubtructive cardiomyopathy.
third frames
show progressive
angulation in a
cranial direction through the left ventricular outflow tract. Note the
ventricular septum appears to increase in thickness in successive
cranial frames. The brightness of the septal echo appears stronger
than the rest of the myocardium.
CIRCULATION
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maximal thickening of the septum and narrowing of the left
ventricular outflow tract were identified by angling the
transducer toward the aortic valve (fig. 7). In real time motion, the systolic anterior motion of the mitral valve is appreciated in this area, and can be identified by passing an M
mode from the phased array system through this region.
Portions of the mitral valve can be identified. The systolic
narrowing of the left ventricular outflow tract also is identified in real time. The echo reflectance characteristics of the
hypertrophic portion of the septum also appear to be
different from the rest of the ventricular septum.24
Ebstein's Anomaly
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The apex view demonstrates the two atrioventricular
valves lying side-by-side in the normal individual. We have
examined 11 patients with Ebstein's anomaly of the
tricuspid valve. The apex projection shows the displacement
of the tricuspid valve into the right ventricle (fig. 8). The
tricuspid portion of the atrioventricular crux is distorted
because the valve is displaced anteriorly when compared to
the mitral valve. The atrioventricular valve groove
sometimes can be imaged simultaneously, displaying the
area of atrialized right ventricle. Several features of this disorder can be appreciated from the image. Displacement of
the tricuspid valve from the mitral valve indicates the area of
the atrialized right ventricle and the size of the functioning
VOL 57, No 3, MARCH 1978
right ventricle; the degree of right atrial dilatation also can
be seen. The septal leaflet of the tricuspid valve is small and
is the more displaced leaflet. The anterior leaflet is seen and
is large (fig. 8a), but the posterior leaflet is not recorded.
We have observed different degrees of tricuspid displacement in patients with this disorder. In one patient, after
postoperative plication of the anterior leaflet of the tricuspid
valve, we noted a reduction in the size of the atrialized right
ventricle and an increase in the size of the functioning right
ventricle (fig. 8b).
Tricuspid Atresia
In four patients with tricuspid atresia, the whole apical
image was formed by the left ventricle. The size of the ventricular septal defect could be identified in some patients (fig.
9). Only a left-sided atrioventricular valve was detectable.
The two atria are observed posteriorly with the right atrium
appearing larger than the left. The relative degree of hypoplasia of the right ventricle in this disorder can be identified.
The area of the tricuspid valve shows dense echoes but no
tricuspid valve can be seen.
Hypoplastic Left Heart Complexes
In hypoplastic left heart complexes the presence or
absence of a mitral valve and left ventricular cavity was
detected in three patients.
a
b
ATRIAUZ
FIGURE 8. a) Apical cross-sectional echocardiogram of a patient with Ebstein's anomaly of the tricuspid valve. The
tricuspid valve (TV) is displaced into the body of the right ventricle (R V). The anuli of the atrioventricular valves are on
the same level and the mitral valve can be identified in the appropriate region in the right hand panel which is a stop frame
recording. The area between the atrioventricular valve groove and the tricuspid valve is the atrialized right ventricle. b)
Cross-sectional echogram from the patient shown in (a) after surgical plication of the an terior tricuspid valve leaflet. The
area of atrialized right ventricle is diminished in size from the preoperative example. Note that the septal leaflet of the
tricuspid valve is as displaced as in the preoperative pictures.
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FioU RE 9. Cross-sectional echocardiogram from the apex in a case of tricuspid atresia. The left ventricle (L V) is large.
Only one atrioventricular valve - the mitral valve (M V) - could be iden tified. A small ventricular septal defect ( VSD)
comnmunicates with the small right ventricle (R V). The left atrium (LA) and pulmonary vein (PV) are seen posteriorly.
The right atrium (RA ) is enlarged. The absence of echoes in the region of the atrial septum is technical and was present in
other frames.
Mustard's Operation
into view the lower limb of the systemic venous atrium from
the inferior vena cava to the mitral valve (fig. lOb). Areas of
narrowing within these conduits can be detected.
We examined 36 patients after Mustard's operation. The
standard apical position identifies the pulmonary venous
atrium from the area of the pulmonary veins through the
tricuspid valve (fig. lOa). Slight caudal angulation brings
Cor Triatriatum
The fine membrane of cor triatriatum also has been
detected in this view. The membrane lies within the atrium
Aortopulmonary Transposition -The Intra-atrial Baffle after
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a
V
b
FIGURE 10. Apical cross-sectional echocardiograms in a patient who had undergone Mustard's prooedure. a) The right
ventricle (R V) is larger than the left ventricle (L V) and the interventricular septum is displaced. This frame is angled
through the systemic venous atrium defining the pulmonary venous atrium (PVA) between the pulmonary veins (PV) and
the tricuspid valve ( TV). The systemic venous atrium (SVA ) in this view is enclosed posteriorly by the baffle and anteriorly
by the mitral valve. b) With slight caudal angulation the inferior limb of the systemic venous atrium (SVA) can be seen
from the area of the inferior vena cava to the mitral valve. It is surrounded on both sides by the baffle (arrows). The
pulmonary venous atrium (PVA) is located on both sides of the baffle. Posteriorly it joins with the confluence of the
pulmonary veins and anteriorly lies between the baffle and the tricuspid valve.
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VOL 57, No 3, MARCH 1978
FIGURE 1 1. Apical cross-sectional echocardiogram in a patient with cor triatriatum. The diagram is on the right to
define the unretouched echogram on the left. The membrane is identifled behind the mitral valve (MV). The left atrium
(LA) is enlarged.
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behind the mitral valve. In real time the membrane is seen to
toward the ventricle with the onset of ventricular
diastole, and the area between it and the mitral valve leaflet
enlarges (fig. I 1). After surgical removal of the membrane,
this echo was no longer present behind the mitral valve.
move
Anomalous Pulmonary Venous Drainage
Because the pulmonary veins can be seen readily to drain
into the left atrium, this view appears useful in defining the
presence of total anomalous pulmonary venous drainage.
We examined three patients with total, and three with partial anomalous pulmonary venous connection. In one patient
with total anomalous pulmonary venous drainage in whom a
catheter was passed into the left vertical vein at catheterization, the echocardiographic image failed to show the confluence of the pulmonary veins with the left atrial wall. On
injecting saline contrast material into the vertical vein, the
right atrium was seen to fill before any left atrial filling. In a
patient with partial anomalous pulmonary venous connection associated with the polysplenia syndrome, only left
pulmonary veins were seen to enter the left atrium. These
findings were confirmed at cardiac catheterization. It does
not appear to be possible to image the upper pulmonary
veins from the apex and abnormalities discovered have been
of the lower veins only.
Ventricular Size and Contraction
The apical view enhances the ability to observe ventricular contraction, especially when combined with other
techniques of transducer placement. One of the chief advantages is the ability to define large areas of the ventricular
walls, especially in the right ventricle. The relative and absolute sizes of the ventricles can be detected (figs. 4, 5, 8-10).
The identification of the coarse trabeculation and moderator
band identifies the morphological right ventricle which aids
delineation of situs problems where the ventricular inversion
is suspected. The detection of the apex by echocardiography
defines not only levocardia, but mesocardia (two patients)
and dextrocardia (eight patients).
Discussion
The technique of apex echocardiography has augmented
our perception of two-dimensional echocardiographic imaging. We have found that the technique for applying the
transducer to the apex impulse locus is no more difficult than
obtaining precordial images and less difficult than suprasternal and subxyphoid imaging. For that matter, it is also
less difficult than properly applying a pressure transducer for
performing an apexcardiogram. Whereas the wide, electronically-generated scanning arc provides a sufficiently
large sector to apically image the entire heart, we have been
able to use smaller mechanically-generated sectors to image
portions of the apex views. Our attempts with the linear
array transducers have suggested that they are not suitable
for generating this projection because of the small size of the
apical echocardiographic window and the relatively large
size of the transducers.
The apical ultrasonic tomogram that we describe is
similar to the clavicular hepatic angiographic projection
used by Bargeron and his colleagues. These clavicular
hepatic views are similar to the hemiaxial views used for coronary angiography.
Among the unique features of the apex approach is the
ability to define each ventricle in its long axis. Preliminary
assessment of the use of the apical approach in biplane left
ventricular volume determination has suggested that this approach is feasible.25 This view also affords demonstration of
a much larger area of the right ventricle than other precordial echocardiographic views. This feature of the projection
has considerable value in that it is possible to analyze the left
and right ventricles for size and position by a side-by-side
comparison. Not only is it useful for assessing ventricular
size but also relationships of position of the two ventricles.
We have found that degrees of anterior angulation and
long axis rotation have produced additional useful information. For example, with superior-to-inferior angulation in
the apical position it is possible to explore most of the interventricular septum, to image the confluence of the
pulmonary veins, to explore the venous and systemic limbs
of the intra-atrial baffle of Mustard, to image the aortic root
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and valve leaflets and to explore the interatrial septum and
right ventricular outflow tract. This approach to evaluating
aortic valve leaflet morphology previously has been reported
with the M-mode technique.26 Rotation of the transducer
along its long axis a full 900 produces another unique view of
the heart, the right anterior oblique equivalent.27 This view is
more useful in the adult and has the unique echocardiographic feature of imaging the anterolateral and inferior
walls of the left ventricle. This view has been used with the
precordial short axis for noninvasive biplane volume determination.25
Because this view affords another approach to define
atrial structures, we surmise that it will be useful to study
forms of left ventricular inflow obstruction such as supravalvar mitral rings and atrial myxomas causing mitral
obstruction. Mitral stenosis and prolapse also are readily
detected in this view, but we have relied on more conventional views to evaluate these deformities. The presence of
vegetations on the atrioventricular valves can be detected
readily from this plane augmenting their localization to a
specific valve leaflet.
Our preliminary experience with higher frequency
transducers and instruments that allow the image size to be
increased suggest that these innovations will be valuable for
studying small children and infants. Appropriate magnification of the image in small children is required to produce an
adequate image.
The technique of apex echocardiography has greatly
augmented our two-dimensional perception of echocardiographic images in congenital heart disease. With a number
of lesions, it appears to be the most valuable view for
delineation and often is easier to record than conventional
precordial images.
Acknowledgment
We wish to thank Drs. Abraham Rudolph and Paul Stanger for their advice, criticism, and support.
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Circulation. 1978;57:503-511
doi: 10.1161/01.CIR.57.3.503
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