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 aortic insufficiency AO aorta ASD atrial septal defect AV aortic valve CW continuous wave EDP end diastolic pulmonary EF ejection fraction ERO effective regurgitant orifice IAS intra atrial septum IVS intra ventricular septum LA left atrium LAD left anterior descending LM left main LV left ventricular LVES left ventricular end systolic LVOT left ventricular outflow tract MPA main pulmonary artery MR mitral regurgitation MV mitral valve NCC non-coronary cusp PA pulmonary artery PDA patent ductus arteriosus PFO patent foramen ovalis PHT pressure half time PISA proximal isovelocity surface area PR pulmonary regurgitation PV pulmonary valve PW pulsed wave RA right atrial RAP right atrial pressure RCA right coronary artery RCC right coronary cusp RV right ventricular RVSP right ventricular systolic pressure RVOT right ventricular outflow tract SAM systolic anterior motion S of V sinus of valsalva STJ sinotubular junction TR tricuspid regurgitation TV tricuspid valve TVI tissue velocity index VSD ventricular septal defect VTI velocity time interval 2D two dimensional 3D 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  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

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.