Regurgitation Color Doppler

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 edge to leading edge"—during image acquisition as shown.

apical four-chamber view

The examination proceeds to the apical position, with the index mark at approx 3 o'clock position (Fig. 31). The apical four-chamber view is then visualized and optimized, initially at a depth 20-24 cm, and then 15-16 cm for better visualization of cardiac structures (Figs. 32-34).

Depth is then further decreased to visualize the left ventricular apex (Fig. 35A). This is important when looking for apical thrombus.

Next come color flow Doppler (Fig. 35B) assessment of the MV for regurgitation followed by PW Doppler to the pulmonary vein , usually the right upper pulmonary vein (Fig. 35C,D).

Mitral inflow (left ventricular inflow) is assessed by PW at the level of the tips of the mitral leaflets (Fig. 36A) to assess velocities and the E/A ratio. This is followed by CW Doppler across the MV.

Tissue Doppler imaging (or Doppler tissue imaging) at the mitral annulus (lateral and septal Fig. 36B) with the velocity scale set at 20:20 (Fig. 36C,D) is then performed.

RV function is evaluated by systolic function assessment (see Chapter 4) color Doppler and CW across the tricuspid valve to assess tricuspid regurgitation (Fig. 37).

apical five-chamber view

Superior angulation of the tranducer toward to aortic valve level brings the aortic root into view (Figs. 38-40).

The aortic valve is visualized and color Doppler applied to assess aortic insufficiency.

Color flow Doppler application reveals flow along the interventricular septum, the left ventricular outflow tract and the aortic outflow (Fig. 40B).

PW Doppler interrogation along the interventricu-lar septum from the apex to the valve can detect intracavitary gradients including dynamic left ventricular outflow tract obstruction (Fig. 40C). CW Doppler across the aortic valve detects peak transaortic gradients (Fig. 40D).

In suspected or existing aortic stenosis (see Chapter 11) the following measurements should be performed: PW measurement is acquired at 1 cm below the aortic valve. The "freeze" function is applied and the spectral Doppler envelope is traced to quantify the velocity time integral (TVI or VTI). CW Doppler across the aortic valve is then performed and its TVI measured. From these, the aortic valve area can be calculated using continuity equation.

apical two-chamber view

Counter-clockwise rotation of the transducer as shown in Figs. 41-43 permits visualization of the apical two-chamber view.

This view permits the best visualization of the infer-oposterior ventricular wall.

Color flow Doppler is applied to assess for mitral regurgitation and additional measurements, e.g., tissue Doppler can be performed (Fig. 43).

apical three-chamber view

Further anti-clockwise rotation of the transducer (with the index mark pointing toward the right shoulder (Fig. 44) permits visualization of the apical three-chamber view (Figs. 45-47).

Color Doppler application (Fig. 48) can reveal aortic and mitral regurgitation.

subcostal views

Proper patient positioning for subcostal imaging are shown in Fig. 49A,B.

The knee-flexed position relaxes the upper abdominal muscles and breath holding at end-inspiration moves the heart closer to the transducer thereby improving visualization (Figs. 50 and 51).

Several views are obtainable from the subcostal position, but the subcostal four-chamber view is recommended in the standard examination.

Tricuspid and mitral regurgitation are well visualized on color flow Doppler, and the interatrial septum is then evaluated for a patent foramen ovale or an atrial septal defect (Fig. 52).

Anti-clockwise rotation of the transducer permits visualization and pulsed Doppler examination of the IVC, the intrahepatic veins, and the upper abdominal aorta (Fig. 53).

suprasternal views

With the patient supine and the neck extended the standard transthoracic examination concludes with the suprasternal examination (Figs. 54 and 55).

This includes the application of color Doppler and pulsed Doppler to the descending thoracic aorta (Fig. 56). Coarctation of the aorta can be visualized in this view.

Tricuspid valve

Anterior leaflet -Septal leaflet -Posterior leaflet

Fig. 18. Anatomical sketch: right ventricle inflow scan plane.

Subcostal Ivc Inflow View
Fig. 19. Right ventricular inflow scan plane and two-dimensional image. (See companion DVD.)

Tricuspid valve

Anterior leaflet -Septal leaflet -Posterior leaflet

Anterior Septum Abnormality

Fig. 18. Anatomical sketch: right ventricle inflow scan plane.

examination report

The examination report follows recommendations outlined by the America Society of Echocardiography.

The standard report format includes patient demographic data, echocardiography evaluation— comprising semi-quantitative and quantitative measures, Doppler assessment, and wall scoring (Figs. 57-59).


Optimal image acquisition in 2D echocardiography is the foundation for accurate assessment and interpretation.

Familiarity with the normal transthoracic examination serves as the basis for interpreting abnormality.

Additional components and applications of 2D transthoracic echocardiography are addressed in the chapters that follow.


Posterior papillary muscle

Inferior wall

Septal leaflets?* (tricuspid valvef *

Coronary sinus -orifice

Eustachian valve -

Posterior right atrial wail

Inferior vena cava (IVC)

- Right ventricular free wall

, Anterior leaflet (tricuspid)

Superior vena cava (SVC)

Posterior right atrial wail

Inferior vena cava (IVC)

Right ventricular inflow

Fig. 20. Annotated right ventricular inflow view.

Fig. 20. Annotated right ventricular inflow view.

Eustachian Valve Echo

Color flow Doppler 0

i ßrightm 1 WccnttM rtoipllí*

2:20.57 pm Trec-5 5wc h4,0f1Hz 1 ZOiiifii iijlfrf» ■T^rtril

Hfi3 59bpm Sw»«p-100nniA

Color-guided CW Doppler

2.5 m/s%—Peak tricuspid regurgitant velocity cw

Doppler N LA

Pulmonary 7| regurgitation velocities (peak 1.0 m/s) I

Pulmonary ^ Systolic jet Artery (PA)

Pulmonary Valve Regurgitant Jet

Fig. 21. Right ventricular (RV) inflow and outflow. Color Doppler still frame of the RV ventricular inflow (A) at end systole. Color Doppler should guide Doppler examination across the tricuspid valve. Mild tricuspid regurgitation—a finding in normal individuals— was detected on color Doppler. The resulting spectral Doppler profile shows peak tricuspid regurgitant velocity measuring 2.5 m/s (B). Color Doppler applied across the right ventricular outflow tract/pulmonary artery (C) shows peak ejection velocities of 1.4 m/s on continuous-wave (CW) spectral Doppler (D) with mild pulmonary regurgitant velocities of 1.0 m/s. (A,C, see companion DVD.)

Fig. 22. Patient and transducer positioning: parasternal short-axis view (PSAX).

Aortic Valve Cusp Names Plax

Right coronary cusp x


Anterior tricuspid, leaflet

Interatrial RA septum

Non-coronary' cusp or

-Free wall (RVOT)

Pulmonary valve

Pulmonary artery (PA)

Left coronary cusp

.Left atrial appendage

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