Case Presentation

A 66-yr-old female, initially admitted to hospital with anorexia, malaise, weakness, shortness of breath, developed urosepsis and acute renal failure. Appropriate treatment, including transient dialysis, was started and her renal function improved. One week later, she complained of bilateral leg weakness and lower extremity swelling that was followed 2 d later by acute dyspnea. She reported no chest pains or hemoptysis. On examination she was tachypneic (respiratory rate > 28 min),...

Barnard Echocardiography

Rupture Ecg

Apical 2-C hamber Parasternal Apical Long Axis Fig. 5. Coronary artery territories and segments. Anatomical left ventricular segments used in reporting regional wall motion (American Heart Association classification) and their corresponding blood supply. Significant overlap and congenital variations in coronary blood supply can occur. individual myocytes, and thereby causes a wall motion abnormality in the respective segment. At least a 70 reduction in cross-sectional diameter is required...

Justina C Wu MD PhD

Case Vignette 1, Elderly Patient Case Vignette 2, Younger Patient Suggested Work-Up for Source of Embolus Suggested Reading A 75-yr-old female with a history of hyperlipi-demia, smoking, and hypertension awoke with acute right arm and leg numbness and right facial weakness that lasted for 30 h before she presented to the emergency room. She had no history of chest pain, shortness of breath, or other symptoms. She was evaluated by the neurology service, who felt she had suffered an embolic...

A4c

Echo Lvef Mode

Ruptured papillary muscle. (A) Transthoracic images a patient 5 d post-MI showed a mobile linear echodensity that ping-ponged between left atrium and left ventricle with each cardiac cycle (left panel). Attached at its end was the avulsed tip (head) of the posterior-medial papillary muscle. Right panel showed large postero-laterally directed MR jet as seen in from the apical four-chamber view. (B) Mid-esophageal views from patient showed the mobile tip of the dehisced papillary muscle...

Ra

Echo Image Sydo Anyursim

When present, the Eustachian valve (arrow) can be well visualized in the right ventricular inflow view (see Chapter 3, Fig. 20). This patient's tricuspid valves were thickened and immobile owing to the carcinoid syndrome. echobright and irregular, whereas fat usually appears as a less echodense, homogenous mass with smoother edges. Myxomatous mitral valves, when severely thickened, have been mistaken for tumors. Within the left atrial appendage, pectinate muscles appear as small...

J Apical 3Chamber

Mural Thrombus Echo

Fig. 10. (A) Pseudo-aneurysm (postmyocardial infarction post-MI ). This 64-yr-old woman suffered an inferior MI and required implantable cardioverter defibrillator placement. Her apical two-chamber images show a narrow-necked cavity (left panel) that communicated with the left ventricular cavity. No intracavitary thrombus was seen. Surgical removal confirmed it was a pseudo-aneurysm. (B) Pseudo-aneurysm anatomy. A post-MI pseudoaneurysm of the left ventricular wall is essentially a contained...

Conventional Approach To Cardioversion Of Atrial Fibrillation

Left Atrial Appendage Anatomy

Although no prospective, randomized studies have been performed to determine the optimal INR or duration of precardioversion warfarin, historical data suggested 3-4 wk of warfarin (INR 2.0-3.0) before elective cardioversion is sufficient. The use of this conservative strategy comes at the cost of a delay in cardioversion for the vast majority of patients who could otherwise undergo early and safe cardioversion. This 1-mo delay exposes the patient to prolonged precardioversion warfarin therapy...

Inter Atrial Septum Shunt

Interatrial Septum Echo Anomalies

4SdB 3-A1 1 2 CW Focus -160mm CVi Gon 6dB 4SdB 3-A1 1 2 CW Focus -160mm CVi Gon 6dB Fig. 5. Quantification of shunt flow (Qp Qs) requires measurement (see Anatomic and Echocardiography Overview section). Systemic flow calculation requires measurement of left ventricular outflow tract diameter (A) and the velocity time integral (VTI) by PW Doppler (B). along with bicuspid aortic valves. The lesion results from the incomplete development of the septum secundum, leaving a central patency between...

Anatomic And Echocardiographic Overview

Fetal Atrial Septum Thickened

During embryological development, the right and left cardiac atria are formed with the growth of the atrial septum. This dividing wall between the atria originates with the growth of two separate septa septum primum and septum secundum. The first to be formed is the septum primum, which grows from the superior aspect of the atria wall inferiorly, toward the enodcar-dial cushions between the atria and ventricles (Fig. 1A). In its normal development, the septum primum attaches to the endocardial...

La

Right Ventricular Pressure Wave

Fig. 42. Transgastric long axis (J). Fig. 44. Transgastric right ventricular inflow (N). Fig. 44. Transgastric right ventricular inflow (N). Fig. 46. Deep transgastric long axis (K). (Please see companion DVD for corresponding video.) Fig. 46. Deep transgastric long axis (K). (Please see companion DVD for corresponding video.) ME level multiplane from 0 to approx 120 . ME mitral commissural 60 (G). ME four-chamber (A) Figs. 8-10 (please see companion DVD for...

Info

Principles of Echocardiography. In Braunwald E, Goldman L, eds. Primary Cardiology, 2nd ed. Philadelphia, Saunders-Elsevier, 2003. Modified from Solomon SD. Principles of Echocardiography. In Braunwald E, Goldman L, eds. Primary Cardiology, 2nd ed. Philadelphia, Saunders-Elsevier, 2003. Echocardiography in Chest Pain and Coronary Artery Disease Class I indications (ACC AHA ASE, 2003) Echocardiography useful in myocardial ischemia infarction, aortic dissection, valvular...

Echocardiography Assessment of Ventricular Systolic Function

Solomon, MD, Rajesh Janardhanan, MD, MRCP Echocardiographic Assessment of LV Size LV Parameters by 2D Echocardiography Limitations of 2D Assessment of LV Systolic Function Qualitative and Semi-Quantitative Measures of LV Systolic Function Qualitative Grades of LV Systolic Function Limitations of Regional Wall Motion Assessment Quantitative Measures of LV Systolic Function Limitations of Volumetric Measures (EF) of LV Systolic Function Assessment of...

JtLJLuPLAX

Left Atrial Appendage Thrombus

A 75-yr-old female with cardiovascular risk factors and acute neurological deficits. High parasternal long-axis view showing calcified atherosclerotic plaque. Fig. 1. A 75-yr-old female with cardiovascular risk factors and acute neurological deficits. High parasternal long-axis view showing calcified atherosclerotic plaque. Fig. 2. Midesophageal zoomed image of the left atrial appendage (LAA) at omni 90 showing well-defined thrombus in a patient with atrial fibrillation. Fig. 2....

Left Ventricular Remodeling

Gross Lvef

Three-dimensional (3D) images showing gross distortion of left ventricular geometry post-myocardial infarction. 3D representation of progressive remodeling of the left ventricle in a patient with a large anterior-apical myocardial infarction. Note the progressive distortion of the ventricular geometry with time (A-C). Fig. 6. Three-dimensional (3D) images showing gross distortion of left ventricular geometry post-myocardial infarction. 3D representation of progressive remodeling of the...

Proximal Isovelocity Surface Area Method

Mitral Regurgitation Jet Area

Moderate 0.3-0 - 69 cm Severe > 0.7 cm Fig. 21. Vena contracta width measurement. Table 9 Vena Contracta Width Measurements in MR 1. Relatively quick and easy to assesses using standard windows 2. Good for extremes of MR (mild and severe MR) 3. Assesses basic size of defect 4. Relatively independent of flow rate, driving pressure, or entrainment (Coanda effect) 5. Not influenced by the presence of another regurgitant leak, for example, aortic regurgitation 6. No need for correction for...

Tumors Involving The Heart And Pericardium

Cardiac Tumors

Primary tumors arising in the heart are rare, and only 25 of these are malignant. Ninety percent or more are Fig. 11. These images show a floppy myxomatous anterior mitral valve leaflet that prolapsed into the left atrium during systole, which can create a tumor-like appearance. Marked mitral regurgitation was present. Fig. 11. These images show a floppy myxomatous anterior mitral valve leaflet that prolapsed into the left atrium during systole, which can create a tumor-like appearance. Marked...

Bernard E Bulwer MD MSc and Scott D Solomon MD

Dilated Cardiomyopathy Case Presentation Restrictive and Infiltrative Cardiomyopathy Case Presentation Hypertrophic Cardiomyopathy Case Presentation Hypertensive Cardiomyopathy Case Presentation Cardiomyopathies are a varied group of heart diseases that are characterized by abnormalities of the heart muscle. Although these generally exclude those secondary to coronary artery disease, hypertension, congenital, valvular, or pericardial pathology, this definition has loosened, and terms such as...

Suggested Reading

Fedullo PF, Auger WR, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. N Engl J Med 2001 345 1465-1472. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999 353 1386-1389. Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med 2002 136 691-700. Goldhaber SZ. Pulmonary embolism. In Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald's...

Case Vignette 2 Continued

Interatrial Shunt Device

A neck MRI magnetic angiogram study (MRA) and hypercoagulability work-up in the patient was negative. A TEE showed a normal interatrial septum with a PFO, but no atrial septal aneurysm was detected. He was treated with aspirin, and is considering either Coumadin or percutaneous PFO closure in the future is further neurological events occur. Suggested Work-Up for Source of Embolus The utility and yield of echocardiography in searching for a presumed cardiac source of embolus will vary with...

Us Mcconnell Sign Picture

Echocardiography

A higher magnification of the parasternal short axis view at the aortic valve level of the patient with the pulmonary saddle embolus (arrow) described in Fig. 1. (Please see companion DVD for corresponding video.) and indirect evidence of the diagnosis in patients with pulmonary embolus (Table 1). Thrombi can be visualized within the venous system from the inferior vena cava, through the right atrium, the RV, the right ventricular outflow tract, and the pulmonary arteries until just...

Chronic Thromboembolic Pulmonary Hypertension And Other Pulmonary Hypertension

Ecocardiografia Immagini

Chronic pulmonary hypertension occurs in about 5 of patients within 2 yr following the first PE. The pulmonary vascular tree is a unique high flow, low pressure system (normal systolic diastolic pressures 25 10 mmHg mean 15 mmHg), but a number of pathological states, including PE, can trigger a vicious cycle of structural changes within the pulmonary vasculature, resulting in chronic pulmonary hypertension. Chronic or recurrent PE can progressively obstruct the pulmonary vasculature, leading to...

Adult Congenital Heart Disease In General Echocardiography Practice

Tga Echocardiography View

The spectrum of adult congenital heart defects seen in echocardiography practice varies according to institutional practice and expertise. Half a century ago, survival with severe congenital heart disease was less common. Today, nearly 80 of such patients in industrialized societies now survive into adulthood. Most are followed up in centers that specialize in adult congenital heart diseases (CHDs), but it is not uncommon for such adults to be seen in general echocardiography practice. Most...

Echocardiography Transesofageal Atrial

Transesophageal Echocardiography

A Images showing pectinate muscle morphology on transesphageal echocardiography TEE . Note their identical echo-reflectivity pattern compared the left atrial appendage LAA wall. B Views of LAA containing thrombi in patients with atrial fibrillation AF . Note the presence of spontaneous echocontrast. C Views of LAA containing thrombi arrows in a patient with AF, visualized in both subcostal view top panels and on TEE bottom panels . Spontaneous echo contrast was also seen in bottom...

Lv

Short Ribs Definition

Even with suboptimal imaging left panel, parasternal short axis view of the left ventricle tissue harmonic imaging markedly improves endocardial definition. Note reverberation artefacts arrows arising from ribs. B Left ventricular opacification endocardial border definition. Contrasts methods assist in delineating the endocardial border. Left ventricular opacification using microspheres e.g., Optison or Definity are popular compare left and middle panels ....

Dilated Coronary Sinus Echocardiogram

Dilated Right Ventricle Septal Bowing

Midesophageal four-chamber views A,B obtained from a 51-yr-old male with TOF with previous palliative surgery show a significant residual VSD arrows with left-to-right shunt. Note the moderate dilation of right cardiac chambers. Midesophageal long-axis views of the same VSD arrows, C,D . Please see companion DVD for corresponding video. Fig. 28. Tetralogy of fallot. Midesophageal views showing residual stenosis restenosis arrow, A of right ventricular outflow...

Upper Esophageal Aortic Lax Echocardiography

Rvot View From Plax

Midesophageal aortic valve long axis I . Please see companion DVD for corresponding video. Fig. 26. Midesophageal ascending aortic short axis view O . Please see companion DVD for corresponding video. Fig. 26. Midesophageal ascending aortic short axis view O . Please see companion DVD for corresponding video. Mid esophageal aortic valve short axis Fig. 28. Midesophageal aortic valve short axis H . Please see companion DVD for corresponding video. Fig. 28. Midesophageal aortic valve...

Ivc

Double Chamber

Inferior vena cava respirophasic movments inspiratory collapse Corresponding right atrial pressures mmHg 1.5-2.5 gt 1.5 gt 2.5 gt 2.5 with dilated intrahepatic veins Complete collapse lt 50 collapse lt 50 collapse No collapse aBased on inferior vena cava measurements using subcostal window. These adverse echocardiographic markers may identify a subset of individuals who may benefit from the use of more aggressive therapy in the management of PE, including thrombolytic therapy or pulmonary...

J wL V m

Aortic Regurgitation Pressure Half Time

A From the apical windows, the aortic regurgitation jet appears as a diastolic color flow disturbance in the left ventricular outflow tract. Jet length and jet area are influenced by the aortic driving pressure aorta-to-left ventricular pressure and are therefore less reliable indicators of disease severity. Measuring jet width from the apical projections is possible, but generally less reliable than parasternal measurements. B Continuous-wave CW Doppler assessment of flow across the...

Echocardiography Assessment of Aortic Stenosis

Pulmonary Cusps Orientation

Two-Dimensional Assessment Doppler Assessment Calculation of Aortic Valve Area Assessment of Stenosis Severity Low-Gradient Aortic Stenosis Pitfalls Conclusion Suggested Reading Transthoracic echocardiography has largely replaced cardiac catheterization as the primary modality for the hemodynamic assessment of valvular heart disease. A comprehensive evaluation of valve structure, function, and hemodynamics is possible through a carefully performed transthoracic study. In the case of aortic...

Enddiastole

Normal Tissue Doppler Wave Forms

Septal leaflets-TRICUSPID VALVE Anterior leaflets Anterior leaflet MITRAL VALVE Posterior leaflet lateral annulus MITRAL VALVE medial annulus Fig. 33. Annotated apical four-chamber view A4C . Coarse trabecu-lations with -Septo-marginal Moderator bj nd showing leaflet . insertion levels - ' Papillary Fig. 34. Defining morphological left and right ventricles on two-dimensional 2D echocardiography A4C . The confluence of the interventricular and interatrial septa and the septal insertions of the...

Isovolumic Relaxation Time Echo

Echocardiogram Pictures Explained

Pulmonary venous flow normal vs dysfunction. Doppler patterns of pulmonary venous flow. Abnormal pulmonary venous flow is characterized by blunting of the systolic wave and increased atrial reversal velocity and or duration. S, systolic flow D, diastolic flow A, atrial reversal. Fig. 10. Measuring pulmonary venous flow see Technical Issues in Measuring PV Flow section for explanation . Fig. 10. Measuring pulmonary venous flow see Technical Issues in Measuring PV Flow section for...

Aortic Insufficiency In Plax Color Flow

Plax Aortic Dissection Ultrasound

Parasternal long-axis PLAX view showing aortic root dissection flap that prolapses into the left ventricular outflow tract during diastole. It was accompanied by new onset aortic regurgitation. Please see companion DVD for corresponding video. Fig. 1. Parasternal long-axis PLAX view showing aortic root dissection flap that prolapses into the left ventricular outflow tract during diastole. It was accompanied by new onset aortic regurgitation. Please see companion DVD for corresponding...

Aortico Pulmonary Window

Fallot Tetralogy Echocardiogram

Pulmonary artery banding was also performed to reduce volume and pressure effects of a previous unrestricted VSD. Note the increased echodensity A . Flow acceleration indicating band stenosis was noted on color flow Doppler evaluation B , and stenosis gradient was quantified by CW Doppler C revealing a peak velocity of 2.8 m s peak gradient of mmHg . Fig. 17. Pulmonary artery banding was also performed to reduce volume and pressure effects of a previous unrestricted VSD. Note the...

Qp Qs Ratio In Echo

Ventricular Septal Defect

A4C, apical four-chamber A5C, apical five-chamber AV, atrioventricular PLAX, parasternal long-axis PSAX, parasternal short-axis RVOT, right ventricular outflow tract TEE, transesophageal echocardiography. A4C, apical four-chamber A5C, apical five-chamber AV, atrioventricular PLAX, parasternal long-axis PSAX, parasternal short-axis RVOT, right ventricular outflow tract TEE, transesophageal echocardiography. Define anatomical site type and size Figs. 11-17 please see companion DVD for...

Pictures Of The Coronary Sinus In 2d Echo

Coronary Sinus Asd

This rare type of ASD presents an interatrial communication via an unroofed coronary sinus. Therefore, the defect is seen at the site of origin of the coronary sinus. A persistent left SVC is associated with this defect and can often be seen to drain into the coronary sinus or left atrium. This defect may not be visualized on routine trans-thoracic echocardiography. However, the defect may be suggested by the constellation of right heart overload, a dilated coronary sinus, and the presence of a...

Subcostal view

Lipomatous Interatrial Septum

Lipomatous hypertrophy arrow of the interatrial septum. Please see companion DVD for corresponding video. Fig. 6. A false tendon straight arrow appears as a mobile string a few millimeters in width that bowstrings the ventricular cavity. Note the attachments to the interventricular septum ivs and the base of the papillary muscle pm . Note the appearance of the true tendon chorda tendinae curved arrow . Fig. 6. A false tendon straight arrow appears as a mobile string a few millimeters in...

Picture Of A Leaky Valve On Peds Echo

Panus Mitral

A 72-yr-old man 2 wk after coronary artery bypass graft mitral valve repair, left ventricle aneurysm resection. Fig. 39. Prosthetic mitral valve paravalvular leak. Prosthetic mitral valve dysfunction leading to prosthetic mitral regurgitation can occur secondary to thrombus formation or pannus ingrowth that can interfere with normal valve closure. This is most often seen with mechanical valves compared to bioprosthetic valves. The most common type of regurgitation following mitral...

Restrictive Diastolic Dysfunction3

Unclassified Connective Tissue Disease

Arrhythmogenic Right Ventricular Cardiomyopathy Autosomal dominant Autosomal recessive Naxos disease mal de Meleda Primary idiopathic Loeffler's Endomyocardial fibrosis Secondary Infiltrative Amyloidosis Sarcoidosis Storage Diseases Hemochromatosis Glycogen storage Lysosomal storage Fig. 1. Cardiomyopathies classification. fibroelastosis Mitochondrial diseases Ischemic Hypertensive Valvular Metaboliic Connective tissue Stress-related Takotsubo Myocardial Stunning Fig. 2. Cardiomyopathies three...

Pisa

Pisa Mitral Valve

3 D Isovelocity 2nd Isovelocity 1ST Isovelocity PISA Fig. 24. Proximal isovelocity surface area PISA . severity itself, but should be further integrated with global cardiac function and the patient's clinical status. Newer methods of assessing MR severity show promise, e.g., 3D echocardiography and power Doppler imaging, but are not yet routinely used in clinical practice Fig. 34 please see companion DVD for corresponding video . Precise determination of the mechanism of MR results is necessary...

Eroa Mitral Valve

PLAX, PSAX PLAX, PSAX PLAX and A3C, A5C Ascah 1985 AV MV , Kitabatake 1985 AV PV , Rokey 1986 AV MV MV, mitral valve PLAX, parasternal long-axis PSAX, parasternal short-axis AV, aortic valve A5C, apical five-chamber view A3C, apical three-chamber view A4C, apical four-chamber view LVOT, left ventricular outflow tract TTE, transthoracic echocardiography CSA, cross-sectional area EROA, effective regurgitant orifice area. assessment of mitral valve area in a patient with mitral stenosis can be...

Companion DVD

Frequency Dvd

The companion DVD-ROM contains a video playback application with more than 200 individual video clips corresponding to the chapters in this book. The application is compatible with most Mac and PC computers. You will need a computer with a DVD-ROM drive, as the DVD will not operate in a CD-ROM drive. The individual video clips are cited in the text along with the figure to which they correspond by number. In addition, descriptive captions are provided in the DVD, and these will appear when you...

Mitral Regurgitation

Tee Views Mitral Valve Scallops

Pulmonary vein systolic flow reversal. Pulsed Doppler examination right upper pulmonary vein flow in severe mitral regurgitation shows reversal of pulmonary vein systolic flow, as depicted by the negative S-wave. Fig. 30. Mitral E-point velocity. A Pulsed Doppler of normal mitral inflow characteristically shows an early diastolic E-wave followed by the atrial A wave. B In severe mitral regurgitation MR , marked E-wave dominance is seen gt 1.2 m s , reflecting a marked increased in...

Jet Area To Left Atrial Area In Mitral Regurgitation

Task Force 118

Values from cardiac ultrasound laboratory, Massachusetts General Hospiiall Fig. 14. Left ventricle dimensions in mitral regurgitation. Values from cardiac ultrasound laboratory, Massachusetts General Hospital. Values from cardiac ultrasound laboratory, Massachusetts General Hospiiall Fig. 14. Left ventricle dimensions in mitral regurgitation. Values from cardiac ultrasound laboratory, Massachusetts General Hospital. mitral valve surgery Tables 6 and 7 . In chronic compensated MR, cardiac output...

N N

Normal Acute

Small, central jet usually lt 4 cm2 or lt 20 of left atrium area Mitral E- point velocity - PW A-wave dominant lt 0.3 cm lt 30 lt 30 lt 0.2 cm2 N or Dilated N or Dilated N or abnormal Abnormal Flail leaflet Ruptured papillary muscle Large central jet usually gt 10 cm2 or gt 40 left atrium area or variable size wall-impinging jet swirling in left atrium E-wave dominant E usually gt 1.2 m Modified from ASE, American Society of Echocardiography Report 2003 ASE ACC AHA ESC Guidelines. See ref. 3....

Myxomatous Mv With Trace Mr Image

Mitral Valve Leaflet Bowing

One benefit of this method is that, in theory, the measurement of MVA is not affected by coexistent mitral regurgitation as flow across the MV orifice and flow across the aliasing point in the LA will not be significantly different in the presence of mitral regurgitation. However, the proximal isovelocity surface area method is technically challenging and it is not commonly used in many laboratories when evaluating mitral stenosis. In summary, the echocardiography assessment of mitral stenosis...

Psax

Poor c w angiography Perry 1987, Cape 1991 Comparable with angiography Perry 1987, Tribouilloy 1992 Better than jet width and area in parasternal projections Tribouilloy 2000 , parasternal short-axis doesn't underestimate multiple irregular jets Taylor 1990 Accurate quantitation Recusani 1991, Utsunomiya 1991, Vandervoort 1993, Giesler 1993, Chen 1993, Tribouilloy 1998 Echocardiographic Findings of Aortic Regurgitation and Relationship to Disease Severity Literature evidence for grading with...

Ml I

Echocardiography Images

Intracavitary isovolumetric relaxation time IVRT flow. A Asynchronous relaxation of the hypertrophied ventricle is common in hypertrophic cardiomyopathy. Early relaxation of the apical anterior segments can create low suction pressure regions within the left ventricular cavity during the IVRT. This resulted in a complex pattern of flow that appeared triphasic top panels B . Systolic midcavity obstruction can result in bidirectional flow as shown on color flow Doppler bottom left panel...

Lvef

Evaluation and management of chronic asymptomatic mitral regurgitation. N Engl. J Med 2001 345 740-746. Adapted from Otto CM. Evaluation and management of chronic asymptomatic mitral regurgitation. N Engl. J Med 2001 345 740-746. and small errors in measurement easily lead to large errors in calculation. Therefore, they should be applied in the context of the patient, without reliance on a single measure. two-dimensional echocardiographic parameters for grading mr severity...

Trabecula In Lv Echocardiogram

Parasternal Long Axis View And Segments

Relaxation abnormality diastolic Fig. 32. Apical hypertrophic cardiomyopathy vs left ventricular LV noncompaction. The apical variant of hypertrophic cardiomyopathy should not be confused with LV noncompaction. The latter exhibits a spongiform appearance-reflecting deep tra-beculations within the endocardium. Fig. 32. Apical hypertrophic cardiomyopathy vs left ventricular LV noncompaction. The apical variant of hypertrophic cardiomyopathy should not be confused with LV noncompaction. The...

Bacterial Pericarditis On Echocardiogram

Early Echo Signs Endocarditis

Contributes to resting diastolic pressures within the heart and it may also limit acute cavity dilation. Although these effects may be modest in normal individuals, in states of pericardial pathology they can have a profound impact on the heart's hemodynamic performance. Of particular import is that the relative stiffness of the parietal pericardium causes the intrapericardial pressure to rise rapidly with an acute increase in volume. Conversely, a chronic, slow accumulation of pericardial...

Echo Mv Area By Pressure Half Time

Left Ventricular Outflow Track

Apical four-chamber views of severe longstanding mitral stenosis in a 44-yr-old Vietnamese female. A Note marked thickening and calcification of mitral valve leaflets arrows and subvalvular apparatus accompanied by marked distortion in left heart chamber architecture. B This patient had severe pulmonary hypertension with grossly dilated right heart chambers and severe tricuspid regurgitation arrow . Fig. 5. Measurement of pressure gradients in mitral stenosis. Tracing the...

Echocardiography Images

Mode Image Pulmonary Stenosis

Echocardiographic features of rheumatic mitral stenosis. A Diastolic doming of the thickened anterior mitral valve leaflet hockey stick appearance, curved arrow is indicative of restricted anterior leaflet motion. Note the thickened subvalvular structures, including the chordae arrow . Note also the posterior pericardial effusion PE . B A systolic frame showing thickened mitral valve leaflets. C Commissural fusion arrowheads and bilateral leaflet thickening curved arrows resulting in...

Mitral Valve Prolapse Overdiagnosis

Echocardiographic Valvular Thickening

During diastole, the myxomatous leaflets can be measured. Thickened leaflets more than 5 mm support the diagnosis of classic MVP. Please see companion DVD for corresponding video. Fig. 6. Bileaflet prolapse is easily visualized in the apical four-chamber A4C view. However, the mitral valve profile is normally exaggerated in this view and may lead to overdiagnosis of mitral valve prolapse left panel . Severe mitral regurgitation was present right panel . Please see companion DVD for...

Septal Knuckle Hypertrophy Causing Lvot Obstruction

Valsalva Lvot

No clear etiological relationship to hypertrophic cardiomyopathy. Nevertheless, the prominent septal knuckle found in DUST may cause dynamic outflow tract obstruction Fig. 24 . Mitral Regurgitation in Hypertrophic Cardiomyopathy A posteriorly directed jet of mitral regurgitation typically accompanies SAM of the mitral valve for reasons explained previously Figs. 18 and 19 . It temporally follows the onset of LVOT obstruction and care should be taken not to confuse its Doppler velocity profile...

Pfd On Echogram

Echocardiography Images

Impaired diastolic indices with reduced EF, ejection fraction ECG, electrocardiogram LV, left ventricular LVH, left ventricular hypertrophy. EF, ejection fraction ECG, electrocardiogram LV, left ventricular LVH, left ventricular hypertrophy. Fig. 29. Case presentation hypertensive cardiomyopathy. These images are from a 33-yr-old Haitian immigrant who was perfectly well until he vomited and fell to the floor unresponsive. Admission blood pressure was 300 150 mmHg show severe concentric left...

Tee

Doppler Envelope

Planimetry by TEE, when transthoracic study suboptimal A3C, apical three-chamber view A5C, apical five-chamber view AF, atrial fibrillation CW, continuous wave 2D, two-dimensional LVOT, left ventricular outflow tract PLAX, parasternal long axis SSN-suprasternal notch TEE, transesophageal echocardiography VTI, velocity time integral PVC, premature ventricular contraction. A3C, apical three-chamber view A5C, apical five-chamber view AF, atrial fibrillation CW, continuous wave 2D, two-dimensional...

Echo M-mode With Pathologic Findings

Mode Echo Images

Dilated cardiomyopathy Mitral regurgitation. Mitral annular dilatation, lateral papillary muscle displacement, and apical tethering prevent normal leaflet coaptation. The result is typically mitral regurgitation MR with a centrally directed jet. Worsening MR heralds a worse prognosis. Color M-mode Doppler across the mitral valve apical four-chamber view during diastole provides a spatio-temporal display of blood velocities across the vertical interrogation line. This parameter may be...

Pericardial Disease

Prominent Epicardial Fat Pad

Lilly, MD Case Presentation Introduction Anatomy Physiology Acquired Pericardial Disease Acute Pericarditis Chronic Constrictive Pericarditis Pericardial Effusions and Compressive Syndromes Conclusion of Case Presentation Suggested Reading A 59-yr-old woman presents with a history of diabetes mellitus, hypertension, and end-stage renal disease. She presented with several weeks of fevers, sweats, fatigue, and progressive exertional dyspnea. On initial...

Section Area Measurement Aortic Valve Echocardiogram

Ava Echocardiography

Calculation of trans-aortic gradients by continuous-wave Doppler. Fig. 9. Calculation of trans-aortic gradients by continuous-wave Doppler. In some situations, patients present with severe aortic stenosis calculated AVA lt 1.0 cm2 and low trans-valvular gradients lt 30 mmHg . These patients have low ejection fractions and low cardiac output Fig. 6 . In this situation, the calculated AVA may be small secondary to the low flow state, and should be interpreted with caution. These patients...

Coronary Artery Regions

Coronary Arter Bulls Eye

Pseudo-dyskinesis in 54-yr-old male with end-stage liver disease. Left ventricular walls in this 54-yr-old male with end-stage cirrhosis owing to chronic alcohol use and hepatitis C virus infection was normal during diastole A-C . Apparent hypokinesis dyskinesis in the postero-inferior walls B,D, arrows was a result of external pressure from tense ascites secondary to his end-stage liver disease. Please see companion DVD for corresponding video. echocardiographic findings in acute mi...

Psax Echocardiography

Mode Bicuspid Aortic Valve Eccentric

Acquired in the apical five-chamber, right parasternal long axis, or suprasternal views to obtain the highest velocities across the valve. The maximum velocity obtained is highly dependent on accurate transducer positioning, and will be underestimated when Doppler beam angle deviates from that of blood flowing through the stenotic valve Fig. 8 . A nonimaging probe can be used if inadequate envelopes are found with the duplex imaging transducer. The calculation of transvalvular pressure...

Diastolic Flow Reversal Aortic Regurgitation

Deceleration Time Regurgitation

SVAV 0.785 x LVOT x VTIlvdt im pw, SVmv 0.785 x Dmv 2 x YWntbypin Regurgitation Severity by RV mL beat Moderate 30 -59 mL beat Severe gt 60 mL beat Moderate 30-49 Severe gt 50 Fig. 15. Aortic regurgitant volume and fraction. diastole and is proportional to regurgitant severity. Grading of aortic regurgitation severity using the regurgitant orifice area is as follows mild, less than 0.10 cm2 moderate, between 0.10 and 0.30 cm2 and severe, more than 0.30 cm2. Calculation of the regurgitant...

Regurgitation Color Doppler

Aortic Valve Cusp Names Plax

I I I LV Minor chord, i - IA Afp Dkim. I I Fig. 16. Left ventricular M-mode dimensions. M-mode delivers superior image resolution compared to 2D, but variations in cardiac topography and morphology frequently leads to off-axis measurements. Some newer instrument models are equipped with software for postprocessing measuring M-mode from selected 2D images to overcome this frequent pitfall. However, it is logistically simpler to obtain 2D measurements leading...

Echocardiography Foreshortening

Foreshorten Apex

Two-dimensional-guided M-mode measurements and derived indices. M-mode is simple, reproducible, and accurate when ventricular geometry is normal. It provides good endocardial resolution. The ejection fraction EF, Teich is an automated calculation based on the Teichholz method see Table 4 . Fig. 3. Two-dimensional-guided M-mode measurements and derived indices. M-mode is simple, reproducible, and accurate when ventricular geometry is normal. It provides good endocardial resolution. The...

Echocardiography Evaluation of Aortic Regurgitation

Aortic Valve Leaflets Echocardiography

Reimold, MD Echocardiography Assessment in Patients With Aortic Regurgitation Assessment of Aortic Valve Morphology Anatomy of Aortic Valve Echocardiographic Evaluation of Aortic Valve Morphology Impact of Aortic Regurgitation on the Left Ventricle Doppler Echocardiographic Evaluation of the Patient With Aortic Regurgitation Quantitative Measures of Aortic Regurgitation Suggested Reading Aortic regurgitation occurs when a fraction of the blood ejected from the...

Carolyn Y Ho MD

Cardiac Cycle Mitral Inflow

Case Presentation Physiology of Diastole Diastolic Dysfunction Standard Echocardiographic Assessment of Diastolic Function Advancements in the Assessment of Diastolic Function Comprehensive Echocardiographic Assessment of Diastolic Function Suggested Reading A 63-yr-old female presents to her primary care physician complaining of increased exertional dyspnea. Her exercise tolerance has been slowly declining for the past several months and she occasionally notes orthopnea and paroxysmal...

Parasternal shortaxis view

Psax Aortic Level

Annotated parasternal short-axis view aortic valve level PSAX . M W 1 1 cwr w gt Mm O San t Fig. 25. Parasternal short-axis PSAX aortic valve level. A,B, see companion DVD. M W 1 1 cwr w gt Mm O San t Peak tricuspids-regurgitant velocity 2.5 m s Fig. 25. Parasternal short-axis PSAX aortic valve level. A,B, see companion DVD.

Ww Subcostal

Loculated Pericardial Effusion

Localized pericardial effusion with cardiac compression. This patient who underwent a previous pericardial window creation for malignant effusions presented with hypotension. An apical four-chamber view A reveals multiple, loculated fluid collection at the ventricular apex, lateral to the left ventricle LV , posterior to the left atrium, and adjacent to the right atrium see arrows . B M-mode echocardiography through the LV apex shows a region of loculated effusion see arrow . C A...

Tissue Doppler Imaging High Output Heart Failure

BSA, body suface area PLAX, parasternal long-axis LVIDd, left ventricular internal diameter at end diastole LVIDs, left ventricular internal diameter at end systole PSAX, parasternal short-axis A4C, apical four chamber. M-mode or 2D, essentially subtract ventricular cavity volume from the total ventricular volume to obtain the shell or myocardial volume Fig. 15 . This value Fig. 13. Geometric models to estimate left ventricle LV volumes by two-dimensional echocardiography use short-axis area...

Susan M Sallach

Companion 1 Echocardiography Instrumentation and Principles of Doppler 2 Introduction to Imaging The Normal 19 3 Protocol and Nomenclature in Transthoracic 4 Clinical Utility of Bernard E. Bulwer, Faisal Shamshad, and Scott D. Solomon Part II Diseases of the Myocardium and Pericardium 5 Echocardiography Assessment of Ventricular Systolic Bernard E. Bulwer, Scott D. Solomon, and Rajesh Janardhanan 6 Echocardiographic Assessment of Diastolic 7 Echocardiography in Myocardial 133 8 Stress...

Edmund A Bermudez Md Mph and Ming Hui Chen MD MMSc

Stress Echo Protocol

Introduction Indications Stress Protocols Interpretation Pitfalls Stress echocardiography is a common diagnostic procedure used in the evaluation of coronary artery disease. In fact, stress echocardiography is now a widely accepted test utilized for the diagnosis, prognostication, and risk stratification of ischemic heart disease Fig. 1 . Imaging is most often coupled with treadmill stress, however, it can be easily coupled with pharmacological stress, bicycle exercise, or pacing. In skilled...

Segment Left Ventricle Model ASE

Tomography Heart Model Echocardiography

Parasternal Long-Axis I Apical Long-Axis Parasternal Long-Axis I Apical Long-Axis Fig. 10. The American Society of Echocardiography ASE issued a 16-segment left ventricle model for wall motion assessment. The American Heart Association's AHA 17-segment model has an additional apical segment cap added to harmonize left ventricular segment nomenclature with nuclear cardiology and cardiac magnetic resonance imaging. A A 16-segment model of left ventricular segments ASE . B A 17-segment model of...

Plax Echocardiography

Parasternal long-axis view at end systole demonstrating the following cardiac structures RV, right ventricle LV, left ventricle AV, aortic valve MV, mitral valve. M-mode images M stands for motion can be thought of as a one dimensional, or ice-pick image, recorded over time. Most M-mode images are recorded in the parasternal long-axis view previously described still frame of M-mode in parasternal long-axis . The ultrasound beam is maneuvered to slice through the structure of interest,...

A

Echocardiography

A 72-yr-old female patient underwent dobutamine infusion with atropine to achieve targeted heart rate. Baseline echocardiography images showed borderline left ventricular hypertrophy with preserved systolic function. Minimal septal hypokinesis was noted. With increasing doses of dobutamine, augmentation of all segments accompanied by decrease in left ventricular cavity size up to a heart rate of 110 bpm. However, at heart rates more than 115 bpm, left ventricular dilatation accompanied...

Echo Pulmonary Vein Doppler

Pulmonary Venous Doppler Young

Table modified from Garcia MJ, Thomas JD, Klein AL. New Doppler echocardiography applications for the study of diastolic function. J Am Coll Cardio 1998 32 865-875. Unless atrial mechanical failure present. AR, pulmonary venous peak atrial contraction reversal velocity EDT, early left ventricular filling deceleration time IVRT, isovolumic relaxation time S D, systolic-to-diastolic pulmonary venous flow ratio. Table modified from Garcia MJ, Thomas JD, Klein AL. New Doppler echocardiography...

Hr

Muscle Health

Annotated parasternal short-axis view mitral valve level PSAX . Fig. 28. Annotated parasternal short-axis view mitral valve level PSAX . Fig. 29. Parasternal short axis PSAX view midventricle papillary muscle level. See companion DVD. Mid-ventricular or papillary muscle level

Plax 2d Measurements

Echocardiography Probe

Protocol and Nomenclature in Transthoracic Echocardiography Bernard E. Bulwer, MD, MSc and Jose Rivero, MD Transducer Scan Plane and Index Mark Two-Dimensional Echocardiographic Imaging Planes Apical Four-Chamber View Apical Five-Chamber View Apical Two-Chamber View Apical Three-Chamber View Subcostal Views Suprasternal Views Examination Report Summary The transducer probe is the component that houses the piezoelectric crystals see Chapter 1 and emits and receives the sound waves Fig. 1 . The...

Suprasternal longaxis view

Long Axis Echocardiography

Suprasternal long-axis view. Fig. 58. Coronary artery territories. Fig. 58. Coronary artery territories. Diastolic Function f set normal Pi art Tunc RV Thickness Sys fx RV se g fx Left Atrium AR Pl 2 time Peak Velocity Peak Gradient Mean Gradient Aortic root size 2D Pulmonary Artery Ig-No Evidence of Endocarditis Bl5c Evidence of Intracardiac Tt romt

Plax

Subcostal Short Axis View

M-mode through the mitral valve. From this measurement, the morphology of the mitral valve can be visualized. Note the typical M configuration of the mitral valve during early diastolic filling E , and atrial filling A . The anterior mitral leaflet AML and the posterior mitral leaflet PML are noted, as is the pericardium. Fig. 4. M-mode through the mitral valve. From this measurement, the morphology of the mitral valve can be visualized. Note the typical M configuration of the mitral...

Prominent Rv1 And Right Axis

Parasternal Short Axis

Parasternal short-axis view, mitral position. This view represents a breadloaf slice through the heart at the level of the mitral valve. From this view, you can see the mitral valve in cross-section fishmouth view with anterior and posterior leaflets arrows indicating the wide open early diastolic position. Please see companion DVD for corresponding video. right of the screen moving leftward, the aortic valve AV right coronary AV leaflet superiorly and noncoronary leaflet inferiorly and...

Reverberation Artifact

Mirror Image Artifact Ultrasound

Resolution of tissue interfaces, in particular, the endocardial border. Harmonic imaging is an option on many modern ultrasound machines Fig. 5 please see companion DVD for corresponding video . However, image quality is not always improved by harmonic imaging, and in some patients, fundamental imaging provides better overall image quality. Echocardiography is dependent on the operator applying the transducer to the chest of the patient and obtaining images in real-time. The quality of the...

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