Download Protocol for Echocardiographic Imaging and Measurements

Protocol for Echocardiographic Imaging and Measurements
Standard E1
Standard E3
Standard E4
Preamble
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Quantification of chamber and vessel size should be done on all studies.
Images of the four valves and colour flow Doppler assessment of each valve is required.
Left ventricular diastolic and systolic function assessed on all studies.
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
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
RA
RAP
RCA
RCC
RV
RVSP
RVOT
SAM
S of V
STJ
TR
TV
TVI
VSD
VTI
2D
3D
Right Atrial
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 non-coronary
cusps; assess for thickening, prolapse and masses.
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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. Colour flow images of AV and MV
 Assess colour 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. Colour flow image of TV
 Sector down the colour 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 colour 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 raphe (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. Colour flow image of AV and IAS for ASD
 Zoom in on the AV and turn colour on for AI – comment on the location of the jet(s).
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Move down and concentrate on the IAS and look for colour going from one side to the
other through the wall; take the colour off and measure the diameter of the defect.
Describe the flow – left to right, right to left or bidirectional.
PW on the colour 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. Colour flow image to assess RVOT, PV, PA and to look for PDA flow
 Turn on colour 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 colour 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 colour and place the CW cursor through the most turbulent section of the
jet to obtain a PPG and MPG.
7. 2D and colour flow of TV
 Zoom in on the TV and look at coaptation of the leaflets, then turn on the colour 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 (ch)
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 place 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 colour flow
 Switching to a 5 chamber view, image the LVOT.
 Turn the colour on and look at the LVOT colour 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 colour 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 colour 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 colour on to look for defects, aneurysms or
diverticulum.
 Place colour sector over the IVS looking at the perimembranous right out to the
muscular apex.
 If defect viewed, turn the colour off and measure the diameter of the defect if possible.
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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. Colour flow and CW images of MV
 Focus on the MV and image separately before turning the colour 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 –zoom in on the valve where the
colour jet is coming through; change the colour scale to approximately 38, 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. Colour M-mode for colour flow propagation
 Acquire a 2D LV 4ch view showing the MV and the entire LV. Turn the colour 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 colour flow; the colour 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 colour 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 colour 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 the spectral—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
place the marker at the orifice, but in the LA, will receive artifact.
 Measure the systolic, diastolic and A wave points, then measure the A wave duration in
diastolic function presets.
21. Colour flow image of TV
 Focus on the right heart and the TV, turn the colour 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
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. Colour flow of MV
 Image the MV leaflets and turn the colour 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.
 Review LVOT, MV and LA for pathology.
2. Colour flow imaging of MV and AV
 Turn on the colour 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 small adjustments
to show all 4 chambers, the TV and MV
 Look for pericardial effusion, extracardiac mass compressing the heart, pleural effusion
and ascites
2. Colour flow on IAS to look for PFO or ASD
 Zoom in on the IAS showing it in its entirety, turn the colour on, decrease the colour
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 colour 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. Colour on the IVC and Hepatic vein
 Turn on the colour 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 measurement of the diameter occurs.
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. Colour on aortic arch
 Place the colour 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. Colour image of SVC flow
 From the suprasternal notch, move slightly left and with the colour 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.