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Basic Echocardiography Wendy Blount, DVM Nacogdoches TX Echo Technique - Anatomy Tricuspid valve • Septal leaflet • Parietal leaflet Mitral valve • Leaflets are less distinct Pulmonic Valve • Right cusp • Left cusp • Intermediate cusp Aortic Valve • Right cusp • Left cusp • Septal cusp Echo Technique - Anatomy RV • Conus arteriosus • 3 papillary muscles LV • 2 papillary muscles Echo Technique - Physiology Ventricular filling - volume • 70% passive • 30% atrial contraction Diastole – time period • First 1/3 - rapid passive filling from atria • Second 1/3 – filling slows (diastases) • Final 1/3 – atria contract Echo Technique - Physiology Heart Sounds • HS1 – AV Valves close – Beginning of systole • HS2 – Semilunar valves close – Beginning of diastole Echo Technique - Physiology Heart Sounds • HS3 – protodiastolic gallop – – – – Rapid ventricular filling First 1/3 of diastole stiff LV large diastolic volume • HS4 – Atrial contraction – Last 1/3 of diastole – Stiff LV or 3rd degree heart block Echo Technique - Physiology Heart Sounds Gallop Rhythms – HS3? – HS4? – Can’t tell the difference if heart rate is above 160-180 – Just call it a summation gallop Echocardiography Equipment • Transducer – small footprint • Fan-shaped beam or sector • High frequency for small animals • Low frequency for large animals • Machines range from 2.5-10 Mhz • 5-7 mHz will work fine for most dogs and cats for echo Echocardiography Equipment • Double window with simultaneous B and M modes • Can do measurements on B-mode or M-mode • Need a cursor which can measure mm, or cm marks on the images • Ability to capture images is important Echocardiography Preparation • Thin coated animals – alcohol, part the hairs, gel • Thick coated animals – shave the window – at the sternum, just behind the elbow • Sedation only if needed – Acepromazine – 0.025 mg/lb (max 1 mg) – Buprenex – 0.01-0.02 mg/kg – Mix together and give IV Echocardiography Positioning for 8 standard views • Right lateral recumbency • Cardiac table is nice but not necessary • Sonographer needs a stool or chair • Placement of probe: – 3rd-6th ICS – Usually 4th-5th ICS – Feel the apical beat, and put your probe there – Adjust one space forward or back as needed – Rarely move the probe head – just fan and twist 1. Short Axis – Left Ventricle • • • • Feel the right apical beat Point the probe marker cranially Place the probe at the apical beat Rotate and fan until papillary muscles are seen, and the same in size • If you are getting a shadow, try one intercostal space forward or back 1. Short Axis – Left Ventricle Abbreviations - Structures • P – pericardium • RV – right ventricle • LV – left ventricle • PPM – posterior papillary muscle • APM – anterior papillary muscle 1. Short Axis – Left Ventricle Measurements • IVSTD - IntraVentricular Septum Diastole • LVIDD - LV Inner Diameter Diastole • LVPWD – LV Posterior Wall Diastole • IVSTS - IntraVentricular Septum Systole • LVIDS - LV Inner Diameter Systole • LVPWS – LV Posterior Wall Systole 1. Short Axis – Left Ventricle Measurements - Calculated • FS – fractional shortening (LVIDD – LVIDS) LVIDD – Assumes perpendicular to myocardium – Assumes contractility is uniform in the LV – Extremes in prelood and afterload can affect FS, as well as myocardial function 1. Short Axis – Left Ventricle Measurements - Calculated • FS – fractional shortening • >30% in the dog • >40% in the cat • >45% if MR is compensated 1. Short Axis – Left Ventricle Measurements - Tips • Make sure you don’t include PM in the LFPW measurement – If you do, your LVPW will be artifactually thicker – Clue – check for this if LVPW is much thicker than IVS • Make sure you are not too far apical – If you are, your LVID will be artifactually small – And LVPW will be artifactually thick 1. Short Axis – Left Ventricle Measurements - Tips • Measure three times – Take the average – Throw out any outliers • Several sets of normals published – 1-2mm outside normal may not always be significant 2. Short Axis – Apex Structures • Pericardium • May or may not see RV • LV apical lumen No measurements here 3. Short Axis – Chordae Tendinae Structures • Pericardium • RV • LV • CH - Chordae Tendinae (posterior & anterior) No measurements here 4. Short Axis – Mitral Valve Structures • Pericardium • RV • RV Papillary Muscles • LV • MV - Mitral Valve (Posterior & Anterior) 4. Short Axis – Mitral Valve Measurement • EPSS – E-Point to Septal Separation – Can denote decreased LV systolic function – Less than 6 mm in large dogs – Less than 3-5 mm in small dogs and cats 5. Short Axis – Aortic Valve Structures • RVOT – Right Ventricular Outflow Tract • TV – Tricuspid Valve • PV – Pulmonic Valve • Ao – Aortic Valve • LA – Left Atrium 5. Short Axis – Aortic Valve Measurements • Ao – at largest dimension (systole) • LA – at largest dimension (diastole) • LA:Ao – – 0.8 to 1.3 in dogs – 0.8 to 1.4 in cats 6. Short Axis – Pulmonary Artery Structures • RA – Right Atrium • Ao – Aorta (ascending) • PA– Pulmonary Artery – LPA – left pulmonary artery – RPA – right pulmonary artery • CaVC – Caudal Vena Cava Ferret Echo Normal Values (Mean) • • • • • LVIDD – 11.0 mm LVIDS - 6.4 mm LVPW - 3.3 mm FS - 42% EPSS - 0 7. Long Axis – 4 Chamber Technique • Get short axis LV-PM view • Rotate 90 degrees counterclockwise 7. Long Axis – 4 Chamber Structures • • • • • • • RV – Right Ventricle RA – Right Atrium – difficult to view completely TV – Tricuspid Valve LV – Left Ventricle LA – Left Atrium MV – Mitral Valve, PM – papillary muscle PVe – Pulmonary Vein 7. Long Axis – 4 Chamber Video 8. Long Axis – LVOT Technique • Find 4 Chamber view • Angle the “dot” toward the shoulders • Elevate the cord end of the probe 8. Long Axis – LVOT Structures • RV, TV, RA • LV, PM, MV • Very edge of the LA • LVOT – AV (LC, SC), ascending Ao • RPA – Right Pulmonary Artery 8. Long Axis – LVOT Video Normal Dog Video