This document provides guidance on standardized cardiac chamber quantification by echocardiography. It summarizes recommendations from the 2015 ASE Guidelines for assessing left ventricular size and function, right ventricular size and function, and size of other cardiac chambers. Accurate quantification requires using standardized imaging windows and measurements. Left ventricular ejection fraction calculated from volumes is the primary parameter of global systolic function, while new techniques like global longitudinal strain provide additional data. Right ventricular size and function assessment requires a comprehensive exam using multiple standardized views and parameters.
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
This document discusses various methods for quantifying intracardiac shunts in patients with congenital heart lesions. It describes invasive oximetry and indicator dilution techniques as well as noninvasive Doppler echocardiography methods. For echocardiography, it outlines techniques for quantifying left-to-right shunts using pulmonary and aortic flow measurements, as well as a simplified method using diameter ratios. It also discusses limitations and sources of error for these quantification methods.
Echocardiography is a key tool for diagnosing and evaluating mitral stenosis (MS). It is essential to use an integrative approach when grading MS severity by combining Doppler, 2D imaging, and measurements, rather than relying on one alone. Echocardiography plays a major role in MS by confirming diagnosis, quantifying severity, analyzing consequences, and examining valve anatomy. Mitral valve planimetry directly measures valve area and is considered the reference standard, but additional measurements like pressure gradient and half-time are also useful. Echocardiography aids clinical decision making for patients with MS.
A 30-minute talk, presented as part of the weekly teaching activities in Alder Hey Children's Hospital (Liverpool, UK). It addresses PDA evaluation in children - starting with embryology & anatomy with the basis behind physiological closure versus patency after birth. What is the role of echo study in diagnosing/evaluating PDA? Modes used with some clear movies? Its limitations?
This document provides guidelines for assessing right heart structure and function using echocardiography. It describes the basic views needed to evaluate the right ventricle and atria. Key measurements are outlined such as ventricular dimensions, tricuspid annular plane systolic excursion (TAPSE), and inferior vena cava (IVC) size and collapse. Methods for estimating pulmonary artery pressures from tricuspid regurgitation are presented. The document recommends routinely reporting right ventricular size and function on echocardiograms.
1. Significant unprotected left main coronary artery (ULMCA) disease occurs in 5–7% of patients undergoing CAG and is treated medically has a 3-year mortality rate of 50%.
2. Studies have shown PCI with drug-eluting stents for ULMCA disease can achieve low rates of death, MI, and TLR at 12 months compared to bare-metal stents which had high rates of restenosis and mortality.
3. While CABG remains the standard of care for many patients, randomized trials found PCI with DES to have non-inferior outcomes to CABG at 1-2 years for death, MI, and stroke in selected patients with low complexity lesions. Rates
This document discusses the echocardiographic assessment of atrial septal defects (ASDs). It describes the main types of ASDs and notes that 80% are secundum defects. Echocardiography is used to identify and characterize ASDs, detect associated anomalies, diagnose complications, and guide treatment. Transthoracic echocardiography is the initial study, while transesophageal echocardiography provides better views of the atrial septum. Key measurements include ASD size, location, rim dimensions, and quantifying shunt severity with Qp/Qs. Echocardiography guides decisions about ASD device closure or surgery.
The document discusses fractional flow reserve (FFR), a technique used in coronary catheterization to measure pressure differences across a coronary artery stenosis to determine if it impedes blood flow. FFR is measured using intracoronary pressure wires during maximal hyperemia induced by intravenous adenosine. While FFR allows real-time assessment of lesion severity, it does not provide information on plaque morphology and requires an invasive procedure.
Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
This document discusses various methods for quantifying intracardiac shunts in patients with congenital heart lesions. It describes invasive oximetry and indicator dilution techniques as well as noninvasive Doppler echocardiography methods. For echocardiography, it outlines techniques for quantifying left-to-right shunts using pulmonary and aortic flow measurements, as well as a simplified method using diameter ratios. It also discusses limitations and sources of error for these quantification methods.
Echocardiography is a key tool for diagnosing and evaluating mitral stenosis (MS). It is essential to use an integrative approach when grading MS severity by combining Doppler, 2D imaging, and measurements, rather than relying on one alone. Echocardiography plays a major role in MS by confirming diagnosis, quantifying severity, analyzing consequences, and examining valve anatomy. Mitral valve planimetry directly measures valve area and is considered the reference standard, but additional measurements like pressure gradient and half-time are also useful. Echocardiography aids clinical decision making for patients with MS.
A 30-minute talk, presented as part of the weekly teaching activities in Alder Hey Children's Hospital (Liverpool, UK). It addresses PDA evaluation in children - starting with embryology & anatomy with the basis behind physiological closure versus patency after birth. What is the role of echo study in diagnosing/evaluating PDA? Modes used with some clear movies? Its limitations?
This document provides guidelines for assessing right heart structure and function using echocardiography. It describes the basic views needed to evaluate the right ventricle and atria. Key measurements are outlined such as ventricular dimensions, tricuspid annular plane systolic excursion (TAPSE), and inferior vena cava (IVC) size and collapse. Methods for estimating pulmonary artery pressures from tricuspid regurgitation are presented. The document recommends routinely reporting right ventricular size and function on echocardiograms.
1. Significant unprotected left main coronary artery (ULMCA) disease occurs in 5–7% of patients undergoing CAG and is treated medically has a 3-year mortality rate of 50%.
2. Studies have shown PCI with drug-eluting stents for ULMCA disease can achieve low rates of death, MI, and TLR at 12 months compared to bare-metal stents which had high rates of restenosis and mortality.
3. While CABG remains the standard of care for many patients, randomized trials found PCI with DES to have non-inferior outcomes to CABG at 1-2 years for death, MI, and stroke in selected patients with low complexity lesions. Rates
This document discusses the echocardiographic assessment of atrial septal defects (ASDs). It describes the main types of ASDs and notes that 80% are secundum defects. Echocardiography is used to identify and characterize ASDs, detect associated anomalies, diagnose complications, and guide treatment. Transthoracic echocardiography is the initial study, while transesophageal echocardiography provides better views of the atrial septum. Key measurements include ASD size, location, rim dimensions, and quantifying shunt severity with Qp/Qs. Echocardiography guides decisions about ASD device closure or surgery.
The document discusses fractional flow reserve (FFR), a technique used in coronary catheterization to measure pressure differences across a coronary artery stenosis to determine if it impedes blood flow. FFR is measured using intracoronary pressure wires during maximal hyperemia induced by intravenous adenosine. While FFR allows real-time assessment of lesion severity, it does not provide information on plaque morphology and requires an invasive procedure.
The document summarizes the 3-year outcomes of the SYNTAX clinical trial for patients with left main coronary artery disease. The SYNTAX trial randomized patients with complex coronary artery disease to either coronary artery bypass grafting (CABG) or percutaneous coronary intervention with paclitaxel-eluting stents (PCI). For the 705 patients in the left main subgroup, the rates of all-cause death at 3 years were similar between CABG (8.4%) and PCI (7.3%). However, the rate of stroke was significantly higher in the CABG group (4.0%) compared to the PCI group (1.2%).
Admixture lesions in congenital cyanotic heart diseaseRamachandra Barik
Admixture lesions in congenital cyanotic heart disease
Jaganmohan A Tharakan
Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
Three sentences:
The document provides details on the anatomy and evaluation of aortic stenosis using echocardiography. It describes the normal aortic valve anatomy and how various types of aortic stenosis like calcific, rheumatic, bicuspid and subvalvular present on echo. Quantitative assessment of aortic stenosis severity is done using Doppler ultrasound to measure the maximum jet velocity and calculate the pressure gradient across the stenotic valve.
Cardiac catheterization is useful for assessing left-to-right shunts through three main techniques: oximetry runs to detect oxygen saturation step-ups, indicator dye dilution to detect early recirculation of dye injected into the proximal chamber, and angiocardiography to directly visualize the anatomic site of the shunt. While oximetry is best to localize the shunt, dye dilution can detect smaller shunts and angiography confirms anatomy. Together these techniques allow diagnosis and quantification of left-to-right intracardiac shunts.
This document discusses speckle tracking and strain analysis in echocardiography for diagnosing restrictive cardiomyopathy (RCM). It defines key terms like strain, strain rate, displacement and velocity. It describes the different types of strain - longitudinal, circumferential, and radial. Normal strain values are provided. RCM is characterized by restrictive filling and reduced diastolic volume. Echocardiography can detect features like left ventricular hypertrophy, dilated atria, and diastolic dysfunction by Doppler. Strain imaging further aids in the diagnosis by detecting reduced longitudinal and circumferential strain.
Low flow Low gradient severe aortic stenosisAnuj Mehta
1) Low flow, low gradient severe aortic stenosis can occur with both low and preserved ejection fraction. Dobutamine stress echocardiography is important to differentiate true from pseudo-severe stenosis.
2) For low ejection fraction, aortic valve replacement is recommended irrespective of symptoms or flow reserve.
3) For preserved ejection fraction, alternatives to ejection fraction like valvulo-arterial impedance and global longitudinal strain can help identify intrinsic myocardial dysfunction and predict outcomes. Aortic valve replacement may be better than medical management in these patients.
This document discusses the echocardiographic assessment of mitral stenosis (MS). It describes the causes and anatomical features of different types of MS and the use of 2D, M-mode, Doppler, and 3D echocardiography to evaluate the severity of MS. Key findings that can be assessed include mitral valve area, pressure gradients, flow velocities, and the effects of MS on cardiac chambers and function. Severity is graded based on parameters such as mitral valve area, mean gradient, and pulmonary artery pressure. Stress echocardiography may help unmask symptoms in questionable cases.
This document summarizes techniques for echocardiographic assessment of right ventricular function. It describes RV anatomy, physiology, and normal measurements. Parameters for assessing RV systolic function include tricuspid annular plane systolic excursion, tricuspid annular velocity, fractional area change, myocardial performance index, RV ejection fraction, and strain imaging. RV diastolic function is also evaluated. The document outlines limitations of echocardiography for RV assessment and discusses evaluation of RV wall motion, septal shape, eccentricity index, and hemodynamics including pulmonary artery pressure.
1. A ventricular septal defect (VSD) is an opening in the wall separating the ventricles that allows blood to shunt between them.
2. VSDs are the most common congenital heart defect in children and can be classified based on their location as membranous, perimembranous, muscular, inlet, or outlet.
3. A complete echocardiogram is needed to evaluate the location, size, direction of shunting, and effects of the defect. Three-dimensional echocardiography can help further define the anatomy and guide potential transcatheter closure of the VSD.
hemodynamic in cath lab: aortic stenosis and hocmrahul arora
1) Cardiac catheterization can provide key information about aortic stenosis including transvalvular pressure gradients, the level of stenosis, and estimation of valve area.
2) Low-flow, low-gradient aortic stenosis can be further classified as either having a decreased ejection fraction or a paradoxically normal ejection fraction.
3) In hypertrophic cardiomyopathy, cardiac catheterization can identify dynamic intraventricular pressure gradients that may only be provoked with maneuvers like the Valsalva maneuver.
A lecture on the echocardiographic evaluation of hypertrophic cardiomyopathy. Starts with an overview of the topic then a systematic approach to diagnosis and then a differential diagnosis followed by take-home messages and conclusion.
The document discusses electrocardiogram (ECG) patterns associated with cardiac chamber enlargement, specifically right atrial enlargement (RAE) and left atrial enlargement (LAE). RAE is suggested by a tall, peaked P wave in leads II, III, AVF and a positive P wave in V1. LAE results in prolongation of the left atrial component of the P wave, increased posterior deviation of the left atrial vector, and left axis deviation of the P wave. The diagnostic accuracy of ECG findings for chamber enlargement is limited but can provide clues when correlated with imaging studies.
1. A case of Ebstein's anomaly is presented with ECG findings including tall P waves and right bundle branch block.
2. A 50-year-old male with palpitations shows wide complex tachycardia that is irregularly irregular, concerning for atrial fibrillation with aberrancy or SVT due to preexcitation.
3. Two devices for occluding the left atrial appendage to reduce risk of emboli, the Watchman device and Amplatzer cardiac plug, are identified based on their designs and implantation procedures.
A cardiac shunt is a pattern of blood flow in the heart that deviates from the normal circuit of the circulatory system. It may be described as right-left, left-right or bidirectional, or as systemic-to-pulmonary or pulmonary-to-systemic.
This document provides an overview of AV nodal reentrant tachycardia (AVNRT) including its mechanisms, diagnosis using electrophysiology study techniques, and treatment with catheter ablation. It discusses the criteria for diagnosing dual AV nodal physiology, how AVNRT is initiated via programmed stimulation, its characteristic surface ECG patterns, and how the arrhythmia responds to different tests such as atrial and ventricular stimulation. The document emphasizes that AVNRT is the most common type of supraventricular tachycardia and is due to reentry involving slow and fast pathways in the AV node.
1. Echocardiography is the standard method for evaluating the severity of aortic stenosis. The primary parameters used are peak transvalvular velocity, mean transvalvular gradient, and valve area calculated by the continuity equation.
2. Echocardiography plays a major role in evaluating mitral stenosis by allowing confirmation of diagnosis, quantification of stenosis severity, and analysis of valve anatomy. Key indices of severity include pressure gradient, mitral valve area measured by planimetry, and pressure half-time.
3. Guidelines are provided for standardized data collection and measurement techniques for assessing aortic and mitral valve stenosis severity, including recommendations for primary and secondary parameters to measure based on clinical use.
The document discusses assessment of mechanical dyssynchrony for cardiac resynchronization therapy. It defines electrical and mechanical dyssynchrony, and describes the deleterious hemodynamic effects of left ventricular dyssynchrony. It then summarizes various echocardiographic tools for assessing atrioventricular dyssynchrony, interventricular dyssynchrony, and intraventricular dyssynchrony, including M-mode, tissue Doppler imaging, and three-dimensional echocardiography. Measurement techniques for different dyssynchrony parameters such as septal-posterior wall motion delay, lateral wall postsystolic displacement, and time to peak systolic velocity are outlined.
Single ventricle presentation for pediatricianLaxmi Ghimire
As the number of children who survive single ventricle physiology, it is very important for the pediatrician to understand about them to give them the best care.
This document discusses the importance of assessing left atrial function using echocardiography. Left atrial volume and strain are superior to other echocardiographic markers for diagnosing left ventricular diastolic dysfunction. Left atrial reservoir strain in particular shows high specificity but relative low sensitivity for diagnosing heart failure with preserved ejection fraction compared to invasive exercise assessment. More research is still needed to establish robust clinical data on using left atrial function metrics for diagnosis.
This document discusses the importance of quality control for echocardiography interpretation and summarizes several studies on improving inter-observer reliability and accuracy. The first study found low agreement between experts in assessing diastolic function from the same patient data due to a lack of hierarchy for integrating parameters. A later study developed a consensus strategy to improve grading of aortic regurgitation severity from 70% to over 90% agreement. Another study reduced inter-observer variability in left ventricular ejection fraction measurements from echocardiograms by having readers review their measurements alongside cardiac MRI images. A final study showed quantitative measurements of right ventricular function improved accuracy and agreement compared to qualitative assessments alone. The studies demonstrate the value of quality improvement efforts like developing consensus guidelines
Echocardiography is commonly used to evaluate patients receiving continuous-flow left ventricular assist devices (LVADs), but evidence for its applications is limited and guidelines do not exist. The document reviews the evidence for using echocardiography in pre-operative planning, predicting post-operative right ventricular failure, assessing hemodynamics noninvasively, and optimizing device settings. However, most evidence is from axial-flow LVADs and applications to newer centrifugal devices require validation. Standardization of echocardiography for LVAD patients is needed.
The document summarizes the 3-year outcomes of the SYNTAX clinical trial for patients with left main coronary artery disease. The SYNTAX trial randomized patients with complex coronary artery disease to either coronary artery bypass grafting (CABG) or percutaneous coronary intervention with paclitaxel-eluting stents (PCI). For the 705 patients in the left main subgroup, the rates of all-cause death at 3 years were similar between CABG (8.4%) and PCI (7.3%). However, the rate of stroke was significantly higher in the CABG group (4.0%) compared to the PCI group (1.2%).
Admixture lesions in congenital cyanotic heart diseaseRamachandra Barik
Admixture lesions in congenital cyanotic heart disease
Jaganmohan A Tharakan
Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
Three sentences:
The document provides details on the anatomy and evaluation of aortic stenosis using echocardiography. It describes the normal aortic valve anatomy and how various types of aortic stenosis like calcific, rheumatic, bicuspid and subvalvular present on echo. Quantitative assessment of aortic stenosis severity is done using Doppler ultrasound to measure the maximum jet velocity and calculate the pressure gradient across the stenotic valve.
Cardiac catheterization is useful for assessing left-to-right shunts through three main techniques: oximetry runs to detect oxygen saturation step-ups, indicator dye dilution to detect early recirculation of dye injected into the proximal chamber, and angiocardiography to directly visualize the anatomic site of the shunt. While oximetry is best to localize the shunt, dye dilution can detect smaller shunts and angiography confirms anatomy. Together these techniques allow diagnosis and quantification of left-to-right intracardiac shunts.
This document discusses speckle tracking and strain analysis in echocardiography for diagnosing restrictive cardiomyopathy (RCM). It defines key terms like strain, strain rate, displacement and velocity. It describes the different types of strain - longitudinal, circumferential, and radial. Normal strain values are provided. RCM is characterized by restrictive filling and reduced diastolic volume. Echocardiography can detect features like left ventricular hypertrophy, dilated atria, and diastolic dysfunction by Doppler. Strain imaging further aids in the diagnosis by detecting reduced longitudinal and circumferential strain.
Low flow Low gradient severe aortic stenosisAnuj Mehta
1) Low flow, low gradient severe aortic stenosis can occur with both low and preserved ejection fraction. Dobutamine stress echocardiography is important to differentiate true from pseudo-severe stenosis.
2) For low ejection fraction, aortic valve replacement is recommended irrespective of symptoms or flow reserve.
3) For preserved ejection fraction, alternatives to ejection fraction like valvulo-arterial impedance and global longitudinal strain can help identify intrinsic myocardial dysfunction and predict outcomes. Aortic valve replacement may be better than medical management in these patients.
This document discusses the echocardiographic assessment of mitral stenosis (MS). It describes the causes and anatomical features of different types of MS and the use of 2D, M-mode, Doppler, and 3D echocardiography to evaluate the severity of MS. Key findings that can be assessed include mitral valve area, pressure gradients, flow velocities, and the effects of MS on cardiac chambers and function. Severity is graded based on parameters such as mitral valve area, mean gradient, and pulmonary artery pressure. Stress echocardiography may help unmask symptoms in questionable cases.
This document summarizes techniques for echocardiographic assessment of right ventricular function. It describes RV anatomy, physiology, and normal measurements. Parameters for assessing RV systolic function include tricuspid annular plane systolic excursion, tricuspid annular velocity, fractional area change, myocardial performance index, RV ejection fraction, and strain imaging. RV diastolic function is also evaluated. The document outlines limitations of echocardiography for RV assessment and discusses evaluation of RV wall motion, septal shape, eccentricity index, and hemodynamics including pulmonary artery pressure.
1. A ventricular septal defect (VSD) is an opening in the wall separating the ventricles that allows blood to shunt between them.
2. VSDs are the most common congenital heart defect in children and can be classified based on their location as membranous, perimembranous, muscular, inlet, or outlet.
3. A complete echocardiogram is needed to evaluate the location, size, direction of shunting, and effects of the defect. Three-dimensional echocardiography can help further define the anatomy and guide potential transcatheter closure of the VSD.
hemodynamic in cath lab: aortic stenosis and hocmrahul arora
1) Cardiac catheterization can provide key information about aortic stenosis including transvalvular pressure gradients, the level of stenosis, and estimation of valve area.
2) Low-flow, low-gradient aortic stenosis can be further classified as either having a decreased ejection fraction or a paradoxically normal ejection fraction.
3) In hypertrophic cardiomyopathy, cardiac catheterization can identify dynamic intraventricular pressure gradients that may only be provoked with maneuvers like the Valsalva maneuver.
A lecture on the echocardiographic evaluation of hypertrophic cardiomyopathy. Starts with an overview of the topic then a systematic approach to diagnosis and then a differential diagnosis followed by take-home messages and conclusion.
The document discusses electrocardiogram (ECG) patterns associated with cardiac chamber enlargement, specifically right atrial enlargement (RAE) and left atrial enlargement (LAE). RAE is suggested by a tall, peaked P wave in leads II, III, AVF and a positive P wave in V1. LAE results in prolongation of the left atrial component of the P wave, increased posterior deviation of the left atrial vector, and left axis deviation of the P wave. The diagnostic accuracy of ECG findings for chamber enlargement is limited but can provide clues when correlated with imaging studies.
1. A case of Ebstein's anomaly is presented with ECG findings including tall P waves and right bundle branch block.
2. A 50-year-old male with palpitations shows wide complex tachycardia that is irregularly irregular, concerning for atrial fibrillation with aberrancy or SVT due to preexcitation.
3. Two devices for occluding the left atrial appendage to reduce risk of emboli, the Watchman device and Amplatzer cardiac plug, are identified based on their designs and implantation procedures.
A cardiac shunt is a pattern of blood flow in the heart that deviates from the normal circuit of the circulatory system. It may be described as right-left, left-right or bidirectional, or as systemic-to-pulmonary or pulmonary-to-systemic.
This document provides an overview of AV nodal reentrant tachycardia (AVNRT) including its mechanisms, diagnosis using electrophysiology study techniques, and treatment with catheter ablation. It discusses the criteria for diagnosing dual AV nodal physiology, how AVNRT is initiated via programmed stimulation, its characteristic surface ECG patterns, and how the arrhythmia responds to different tests such as atrial and ventricular stimulation. The document emphasizes that AVNRT is the most common type of supraventricular tachycardia and is due to reentry involving slow and fast pathways in the AV node.
1. Echocardiography is the standard method for evaluating the severity of aortic stenosis. The primary parameters used are peak transvalvular velocity, mean transvalvular gradient, and valve area calculated by the continuity equation.
2. Echocardiography plays a major role in evaluating mitral stenosis by allowing confirmation of diagnosis, quantification of stenosis severity, and analysis of valve anatomy. Key indices of severity include pressure gradient, mitral valve area measured by planimetry, and pressure half-time.
3. Guidelines are provided for standardized data collection and measurement techniques for assessing aortic and mitral valve stenosis severity, including recommendations for primary and secondary parameters to measure based on clinical use.
The document discusses assessment of mechanical dyssynchrony for cardiac resynchronization therapy. It defines electrical and mechanical dyssynchrony, and describes the deleterious hemodynamic effects of left ventricular dyssynchrony. It then summarizes various echocardiographic tools for assessing atrioventricular dyssynchrony, interventricular dyssynchrony, and intraventricular dyssynchrony, including M-mode, tissue Doppler imaging, and three-dimensional echocardiography. Measurement techniques for different dyssynchrony parameters such as septal-posterior wall motion delay, lateral wall postsystolic displacement, and time to peak systolic velocity are outlined.
Single ventricle presentation for pediatricianLaxmi Ghimire
As the number of children who survive single ventricle physiology, it is very important for the pediatrician to understand about them to give them the best care.
This document discusses the importance of assessing left atrial function using echocardiography. Left atrial volume and strain are superior to other echocardiographic markers for diagnosing left ventricular diastolic dysfunction. Left atrial reservoir strain in particular shows high specificity but relative low sensitivity for diagnosing heart failure with preserved ejection fraction compared to invasive exercise assessment. More research is still needed to establish robust clinical data on using left atrial function metrics for diagnosis.
This document discusses the importance of quality control for echocardiography interpretation and summarizes several studies on improving inter-observer reliability and accuracy. The first study found low agreement between experts in assessing diastolic function from the same patient data due to a lack of hierarchy for integrating parameters. A later study developed a consensus strategy to improve grading of aortic regurgitation severity from 70% to over 90% agreement. Another study reduced inter-observer variability in left ventricular ejection fraction measurements from echocardiograms by having readers review their measurements alongside cardiac MRI images. A final study showed quantitative measurements of right ventricular function improved accuracy and agreement compared to qualitative assessments alone. The studies demonstrate the value of quality improvement efforts like developing consensus guidelines
Echocardiography is commonly used to evaluate patients receiving continuous-flow left ventricular assist devices (LVADs), but evidence for its applications is limited and guidelines do not exist. The document reviews the evidence for using echocardiography in pre-operative planning, predicting post-operative right ventricular failure, assessing hemodynamics noninvasively, and optimizing device settings. However, most evidence is from axial-flow LVADs and applications to newer centrifugal devices require validation. Standardization of echocardiography for LVAD patients is needed.
TRICUSPID VALVE ANATOMY PATHOPHYSIOLOGY INDICATIONS AND INTERVENTIONS.pptxJaydeep Malakar
The document discusses tricuspid valve intervention techniques. It describes Tricuspid Annular Plane Systolic Excursion (TAPSE) which measures tricuspid annular motion and is used to estimate right ventricular function. It discusses approaches to tricuspid valve repair including annuloplasty techniques using rings. It also discusses transcatheter therapies being developed for tricuspid regurgitation including annuloplasty devices and coaptation devices.
This document provides guidelines for using multimodality imaging to evaluate patients with repaired tetralogy of Fallot (TOF). It describes the role of echocardiography, cardiovascular magnetic resonance (CMR), computed tomography (CT), nuclear scintigraphy, and angiography. Echocardiography and CMR are well-suited for longitudinal follow-up due to lack of radiation. CMR is considered the reference standard for assessing right ventricular size and function and pulmonary regurgitation. A multimodality approach is recommended to comprehensively evaluate the complex anatomy and physiology while considering each patient's needs and institutional resources.
This research article evaluated the diagnostic power of cardiac MRI to detect pulmonary hypertension in patients pre-selected by echocardiography. Fifty-six patients suspected of pulmonary hypertension based on echocardiography underwent right heart catheterization and cardiac MRI. The study extracted various MRI parameters proposed in previous studies as surrogates for pulmonary arterial pressure. Multivariate regression analysis identified right ventricle ejection fraction and pulmonary trunk minimum area as predictors of mean pulmonary arterial pressure, with an r-squared value of 0.5. However, the limits of agreement between MRI-predicted and catheterization-measured pressures were too wide. MRI was able to distinguish patients with normal and elevated pressures, achieving a specificity of 80% for detecting pulmonary hypertension at
This document provides updated guidelines and reference values for cardiac chamber quantification by echocardiography. It summarizes recommendations for measuring and evaluating left ventricular size, function, mass and regional wall motion. Reference values are given for linear dimensions, volumes and ejection fraction of the left ventricle based on a large number of normal subjects. The document also summarizes guidelines for assessing right ventricular size and function, as well as the size and function of the left and right atria, aortic root dimensions, and inferior vena cava size. Partition values are only provided for left ventricular ejection fraction and left atrial volume due to limitations of existing data.
This document discusses the echocardiographic evaluation of left ventricular systolic function. It indicates that assessment of LV systolic function is important for diagnosing and managing heart disease and conditions that can affect the heart. The document outlines the indications for evaluating LV systolic function and describes techniques like M-mode, measurements of LV dimensions and volumes, wall motion scoring, and newer techniques using tissue Doppler imaging and speckle tracking echocardiography to assess systolic function parameters. Echocardiography is recommended as the initial imaging modality to evaluate LV systolic function.
This document discusses the echocardiographic evaluation of left ventricular systolic function. It indicates that assessment of LV systolic function is important for diagnosing and managing heart disease and conditions that can affect the heart. The document outlines the indications for evaluating LV systolic function and describes techniques like M-mode, measurements of LV dimensions and volumes, wall motion scoring, and newer techniques using tissue Doppler imaging and speckle tracking echocardiography to assess systolic function parameters. Echocardiography is recommended as the initial imaging modality to evaluate LV systolic function.
1. The document outlines a step-by-step approach for evaluating left ventricular systolic function using echocardiography.
2. Step 1 involves measuring left ventricular size, including dimensions, volumes, wall thickness and mass using 2D and 3D echocardiography.
3. Step 2 evaluates left ventricular systolic performance using measures like ejection fraction, stroke volume, cardiac output, and global longitudinal strain.
4. Additional measures discussed include assessing regional ventricular function, ejection acceleration times, and left ventricular dP/dt.
Measurement of Aortic area in Echocardiography and DopplerNizam Uddin
This study compared aortic valve area (AVA) measurements from Doppler echocardiography (AVAEcho) and multidetector computed tomography (MDCT) (AVACT) in 269 patients with aortic stenosis. The study aimed to determine if AVACT was superior to AVAEcho in assessing hemodynamic correlations, predicting survival outcomes, and resolving discordant assessments of aortic stenosis severity. The study found that while AVACT measurements of the left ventricular outflow tract were larger than AVAEcho, leading to slightly higher calculated AVA values, AVACT did not improve correlations with transvalvular gradients, concordance between gradient and AVA, or prediction of mortality compared to AVAEcho. Both AVAEcho and AV
Speckle tracking echocardiography is a new, unique and evolving tool to assess the myocardial deformation which can detect LV systolic dysfunction much earlier than can be reflected in LVEF. The importance of defining predictors is to predict whom patient will be at risk for the deleterious effect of RV pacing on LV function, and who will need observation with possible upgrading to biventricular pacing.
Guidelines for the use of echocardiography as a monitor for therapeutic inter...Alexandra Victoria
This document provides guidelines for using echocardiography as a monitoring tool to guide therapy in critically ill patients. It outlines specific echocardiographic parameters that can be used for hemodynamic monitoring, including left ventricular dimensions, inferior vena cava size and collapsibility, mitral inflow, tissue Doppler imaging, and calculated parameters like stroke volume, cardiac output, and pulmonary artery pressure. The guidelines discuss advantages and recommendations for echocardiography as a monitoring tool and provide examples of its use in clinical scenarios such as acute congestive heart failure, critical care, pericardial tamponade, and various perioperative settings.
echocardiography evaluation of LV Function using an automated analysis algorithmAndiTiaraSAdam
1. The study compared left ventricular functional parameters obtained from 3D transthoracic echocardiography using an automated software algorithm to quantitative assessment using cardiac magnetic resonance imaging and qualitative visual grading using left ventricular angiography.
2. The study found a strong correlation between the measurements obtained from the automated algorithm and the other methods considered gold standards. The correlation was stronger when compared to cardiac MRI measurements than visual grading.
3. Clinical experience of the echocardiographer did not impact the correlation, supporting the use of the automated algorithm for less experienced clinicians. The algorithm could correctly stratify patients into heart failure classes in around 90% of cases.
This study used 4D flow cardiac magnetic resonance imaging (CMR) to measure three-dimensional left atrial blood flow velocities in 40 patients with atrial fibrillation, 20 age-matched controls, and 10 young healthy volunteers. Left atrial velocities were significantly reduced in patients with atrial fibrillation compared to controls. Mean, median, and peak left atrial velocities decreased by 10-44% in patients with atrial fibrillation. Higher CHA2DS2-VASc scores, indicating greater risk of stroke, were associated with lower mean, median, and peak left atrial velocities. Left atrial 4D flow CMR may help improve risk stratification for stroke in atrial fibrillation
This document discusses using echocardiography to assess cardiac function and hemodynamics in a non-invasive manner. It covers:
1. Assessment of left ventricular systolic function using ejection fraction measured by M-mode, Simpson's method, and mitral regurgitation dP/dT.
2. Assessment of left ventricular diastolic function and filling pressures using mitral inflow patterns, mitral annular velocities, and pulmonary venous inflow patterns.
3. Estimation of right heart pressures and pulmonary artery systolic pressure using measurements of the inferior vena cava and its collapsibility.
This study evaluated how well 2D echocardiography (2DE) indices of right ventricular systolic function correlate with and predict cardiac magnetic resonance imaging (CMR) measurements of right ventricular ejection fraction (RVEF) in patients with congenitally corrected transposition of the great arteries (ccTGA). The study found that 2DE indices, including fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and tricuspid annular systolic velocity (Ts'), correlated poorly with CMR-measured RVEF. Additionally, 2DE indices were weak predictors of RVEF as determined by CMR. This suggests that 2DE may not be an
This document provides guidance on how to reliably measure right ventricular (RV) strain using speckle-tracking echocardiography. It recommends using an RV-focused 4-chamber view and outlines how to determine the region of interest, analyze the data, and interpret the results clinically. Measuring RV free wall longitudinal strain (RVFWLS) provides a superior metric of RV function compared to conventional parameters. Reference values for RV strain vary depending on software and views used, but RVFWLS averages around -28.5% in healthy individuals. Proper technique and understanding of limitations is important for accurate and reproducible RV strain assessment.
Assessment of Intermediate Coronary Artery Lesion with Fractional Flow Reserv...Premier Publishers
Fraction flow reserve (FFR) is considered the gold standard for assessing intermediate coronary lesions. Retrospective data analyses showed variable relationship between intravascular ultrasound (IVUS) parameters and FFR results. This study aimed to determine the optimal minimum lumen area (MLA) by IVUS that correlates with FFR and to assess the correlation between two modalities in assessing intermediate coronary lesions. Methods: Fifty eight intermediate coronary lesions mainly located in proximal and mid segments of large main coronary vessels with RVD (3-4mm) were analyzed using both IVUS and FFR to assess the significance of coronary stenting and to determine the optimal IVUS-MLA that correlates with FFR value < 0.8. Results: IVUS-MLA ranged from 2.5 to 4.2 mm2 had a highly significant positive correlation with FFR value < 0.8 (p < 0.0001). Using the ROC curve analysis, IVUS-MLA < 3.9 mm2 (84.2% sensitivity, 80% specificity, area under curve (AUC) = 0.68) was the best threshold value for identifying FFR <0.8>< 0.8 in coronary vessels with RVD (3-4mm). Different MLA cutoffs should be used for different vessel diameters.
Strain cardíaco na avaliação da função cardíaca fetalgisa_legal
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1. 1
THE AMERICAN SOCIETY OF ECHOCARDIOGRAPHY RECOMMENDATIONS FOR
CARDIAC CHAMBER QUANTIFICATION IN ADULTS: A QUICK REFERENCE GUIDE FROM
THE ASE WORKFLOW AND LAB MANAGEMENT TASK FORCE
Accurate and reproducible assessment of cardiac chamber size and function is essential for clinical care. A standardized
methodology creates a common approach to the assessment of cardiac structure and function both within and between
echocardiography labs. This facilitates better communication and improves the ability to compare results between studies as well as
differentiate normal from abnormal findings in an individual patient. This document summarizes key points from the 2015 ASE
Chamber Quantification Guideline and is meant to serve as quick reference for sonographers and interpreting physicians. It is
designed to provide guidance on chamber quantification for adult patients; a separate ASE Guidelines document that details
recommended quantification methods in the pediatric age group has also been published and should be used for patients <18 years
of age (3). (1) For details of the methodology and the rationale for current recommendations, the interested reader is referred to the
complete Guideline statement. Figures and tables are reproduced from ASE Guidelines. (1,2)
Table of Contents:
1. Left Ventricle (LV) Size and Function p. 2
a. LV Size p. 2
i. Linear Measurements p. 2
ii. Volume Measurements p. 2
iii. LV Mass Calculations p. 3
b. Left Ventricular Function Assessment p. 4
i. Global Systolic Function Parameters p. 4
ii. Regional Function p. 5
2. Right Ventricle (RV) Size and Function p. 6
a. RV Size p. 6
b. RV Function p. 8
3. Atria p. 10
a. Left Atrium (LA) Area and Volume Measurements p. 10
b. Right Atrium (RA) Area and Volume Measurements p. 12
4. Aorta p. 13
5. Inferior Vena Cava p. 15
6. Appendix – Normative Values p. 16
References:
1. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the
American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1-39.e14.
2. Rudski LG, Lai WW, Afilato J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American
Society of Echocardiography. J Am Soc Echocardiogr 2010;23:685-713.
3. Lopez L, Colan SD, Frommelt PC, Ensing GJ, Kendall K, Younoszai AK, Lai WW, Geva T. Recommendations for quantification methods during the
performance of a pediatric echocardiogram: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography
Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 2010 May;23(5):465-95.
Notice and Disclaimer: This report is made available by ASE as a courtesy reference source for members. This report contains recommendations
only and should not be used as the sole basis to make medical practice decisions or for disciplinary action against any employee. The statements
and recommendations contained in this report are primarily based on the opinions of experts, rather than on scientifically verified data. ASE makes
no express or implied warranties regarding the completeness or accuracy of the information in this report, including the warranty of
merchantability or fitness for a particular purpose. In no event shall ASE be liable to you, your patients, or any other third parties for any decision
made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of
medical advice by ASE or create any physician-patient relationship between ASE and your patients or anyone else.
ASE Workflow & Lab Management Taskforce: David A. Orsinelli, MD, FASE (Chair), Alicia Armour, BS, MA, RDCS, FASE, Jeanne De Cara, MD, FASE,
Brian Fey, RDCS, ACS, FASE, Peter Frommelt, MD, FASE, Juan Lopez-Mattei, MD, FASE, Jane Marshall, BS, RDCS, FASE, Athena Poppas, MD, FASE,
Vandana Sachdev, MD, FASE, Liza Sanchez, RCS, FASE, and Timothy Woods, MD, FASE, Columbus, Ohio; Durham, North Carolina; Chicago, Illinois;
Milwaukee, Wisconsin; Houston, Texas; Boston, Massachusetts; Providence, Rhode Island; Bethesda, Maryland; Memphis, Tennessee.
July 2018
2. 2
LEFT VENTRICLE (LV) SIZE AND FUNCTION
(For full recommendation refer to the Chamber Quantification Guideline p. 3-16)
LV Size
Linear Measurements
LV Volume Measurement
2D Methods
LVID Diastole (LVIDD)
Inner edge to inner edge, perpendicular to the long axis of the LV,
at or immediately below the level of the mitral valve leaflet tips.
Perform at end-diastole (defined as the first frame after mitral valve
closure or the frame with the largest LV dimensions/volume.) Each
laboratory should choose one method for consistency.
LVID Systole (LVIDS)
Inner edge to inner edge, perpendicular to the long axis of the LV,
at or immediately below the level of the mitral valve leaflet tips.
Perform at end-systole (defined as either as the frame after aortic
valve closure or the smallest LV dimension/volume.) Each
laboratory should choose one method for consistency.
Preferred technique is Biplane Method of Discs (modified Simpson’s
rule). See ASE 2015 chamber quantification document for the
alternative area-length technique.
Measured from the apical 4- and 2-chamber views (preferably an LV
focused view) tracing the endocardial – blood pool interface (between
the compacted myocardium and the cavity) at end-diastole and end-
systole on images with clear endocardial border definition.
Papillary muscles should be excluded from the cavity tracing.
Maximize LV area and avoid foreshortening.
When approaching the MV plane, the contour is closed by connecting
the two opposite sections of the MV ring with a straight line.
The LV length is the bisector between this line and the apical point of
the LV contour distant from it.
Endocardial Border Enhancement
When ≥ 2 contiguous endocardial segments cannot be visualized in
the apical views, contrast should be used. If employed, the
contrast-enhanced images should be used for Biplane tracing
o Avoid acoustic shadowing in the basal segments of the LV
when contrast concentration is high.
o Note: Normal reference values for contrast enhanced LV
volumes are not well established, however contrast enhanced
images have been demonstrated to provide more reproducible
volumetric and therefore ejection fraction data that correlate
better with CMR.
3. 3
3D Methods (Specific methodology varies by vendor / software versions)
LV Mass Calculations
Linear Method
LVID, IVS, PW Diastole
Electronic calipers should be positioned on the interface between myocardial wall and cavity, and the
interface between wall and pericardium.
Perform at end-diastole (previously defined) perpendicular to the long axis of the LV, at or immediately
below the level of the mitral valve leaflet tips.
LV mass = 0.8x (1.04x [(IVS+LVID+PWT)3
-LVID3
] + 0.6 grams
2D-based formulas
Infrequently used in most clinical labs, see full Guideline statement for details.
Relative Wall Thickness (RWT)
Familiarize staff with platforms in lab.
LV volumes are calculated from a “full volume” data set (raw data).
Perform on an LV focused volume (atria are not important).
o Focus on including the entire LV in the pyramidal dataset and
obtaining good endocardial border definition.
On most systems, the volume/frame rate should be 15Hz or higher.
Semi-automated software algorithm is then employed to detect
endocardial borders in three orthogonal imaging planes. Once
borders are reviewed and approved by the operator, volume is
computed.
Self-checks:
o Volumes should be feasible in ED and ES.
o Borders should track the endocardium, similar to a bi-plane.
Contours / tracking may need to be manually adjusted.
Record and store the “report page”. This will contain the full analysis
data vs. the biplane volumes and EF.
RWT= (2x posterior wall thickness)/(LVIDD).
Useful to categorize LV mass and pattern of
remodeling.
4. 4
Left Ventricular Function Assessment
(For full recommendation refer to the Chamber Quantification Guideline p. 6-13)
LV Global Systolic Function Parameters
Fractional Shortening (use is discouraged)
o FS = LVIDD – LVIDS / LVIDD (normal > 25%)
o Derived from M-mode or linear 2D measurements
Ejection Fraction (EF) (see below) is the predominant method for assessing global systolic function
(see below) and is derived from the LV end-diastolic volume (LVEDV) and LV end-systolic volume
(LVESV).
Global Longitudinal Strain is a new parameter to assess LV systolic function.
LV Volumes used to calculate EF
Volumes can be derived from 2DE or 3DE (see section on LV size for methodology).
o The biplane method of disks is the preferred 2DE method.
o In laboratories with 3D experience, three-dimensional volumes should be utilized.
Volumes derived from linear measurements should NOT be used.
Use of contrast is encouraged as detailed in LV Volumetric Measurement (Cannot use contrast with3D
data acquisitions).
LVEF by Biplane Method of Disks (modified Simpson’s rule) or 3DE
See prior section for methodology of volume measurements.
LVEF = LVEDV – LVESV / LVEDV
Normal Ranges for LV Size and Function
Normal values for LV chamber dimensions (linear), volumes and ejection fraction vary by gender.
A normal ejection fraction is 53-73% (52-72% for men, 54-74% for women).
Refer to Table 2 (normal values for non-contrast images) and Table 4 (recommendations for the normal
range, mildly, moderately and severely abnormal ejection fraction).
Global Longitudinal Strain (GLS)
Defined as the change in length of an object within a certain direction relative to its baseline length.
A measurement of deformation that is used to assess LV systolic function.
Strain (%) = (Lt – Lo) / Lo
o Lt is the length at time t, Lo is the length at time 0.
GLS is assessed by speckle tracking, the specific methodology varies by vendor.
Peak GLS describes the relative length change between end-diastole and end-systole.
GLS (%) = (MLs-MLd)/MLd
(MLs= myocardial length end-systole, MLd= myocardial length end-diastole)
Since MLs is smaller than MLd peak GLS is a negative number.
CW of the aortic valve or PW of the LVOT should be obtained for timing of aortic valve opening and
closure.
The three standard apical views should be acquired in succession as LV focused views optimizing
endocardial borders at a frame rate of 60Hz-90Hz. Heart rate should not vary more than 5bpm.
Follow the system software prompts for analysis (specific method varies by vendor).
GLS should be measured in the 3 standard apical views (apical 4 chamber, 2 chamber and long axis) and
the average GLS should be reported.
5. 5
Normal values depend on several factors including the vendor and version of software. As a general guide,
a peak GLS of -20% can be considered normal. The smaller the absolute number, the more abnormal is the
strain.
LV Regional Function
Segmentation of the LV
Segmentation schemes should reflect coronary perfusion territories and allow standardized
communication within echocardiography and with other imaging modalities.
When using this 17-segement model to assess wall motion or regional strain, the 17th segment (the apical
cap) should not be included.
Although certain variability exists in the coronary artery blood supply to myocardial segments, segments
are usually attributed to the three major coronary arteries.
Visual Assessment
Semi quantitative wall motion score (1-4) can be assigned to each segment to calculate the LV wall motion
score index (sum score of all segments assessed / # segments assessed).
Regional Wall Motion during Infarction and Ischemia
Coronary artery distribution varies among patients. Some segments have variable coronary perfusion.
Echocardiography may over or underestimate the amount of ischemic or infarcted myocardium,
depending on the function of adjacent regions, regional loading conditions, and stunning.
6. 6
Regional Abnormalities in the Absence of Coronary Artery Disease
Regional wall motion abnormalities may also occur in the absence of coronary artery disease (examples:
myocarditis, sarcoidosis and takotsubo cardiomyopathy).
Interventricular septal wall motion abnormalities may be found in:
o Left bundle branch block
o RV pacing
o RV pressure/volume overload
o Post op septal motion
Wall motion patterns due to conduction delays (abnormal sequence of myocardial activation):
o Septal bounce (“beaking”, “flash”)
o Lateral apical motion during systole (“apical rocking”).
RIGHT VENTRICLE (RV) SIZE AND FUNCTION
(For full recommendation refer to the Chamber Quantification Guideline p. 16-20)
In order to assess RV size and function it is important to use all available views. Each view adds complementary
information, permitting a more complete assessment of the different segments of the RV.
The essential views for imaging and assessment of the RV are:
Left parasternal long-axis view (PLAX)
Left parasternal short-axis view (PSAX)
Left parasternal RV inflow view
Apical 4-chamber view
Focused apical 4-chamber RV view
Modified apical 4-chamber view
Subcostal views
RV Size
RV size should be routinely assessed by conventional 2DE using multiple acoustic windows. All chamber
measurements should be made inner-edge to inner-edge. The report should include both qualitative and
quantitative parameters. Most of the values are not indexed to gender, BSA, or height.
7. 7
To measure the RV diameter, the RV focused apical 4-chamber view (a dedicated view which keeps the LV apex in
the center and displays the largest basal RV diameter as shown below) should be used. Since RV linear dimensions
are dependent on probe rotation and different RV views, the echocardiographic report should state the window
from which the measurement was obtained. A single measurement may not reflect global RV size. An RV diameter
of >41mm at the base and >35mm at the mid-level is abnormal.
8. 8
RV wall thickness should be measured by 2DE or M-mode at end-diastole, zoomed on the RV mid- wall
(preferably from the subcostal view). A thickness of >5mm is abnormal.
RV Function
RV systolic function should be assessed by at least one or a combination of the following recommended
parameters:
1. TAPSE (Tricuspid Annular Plane Systolic Excursion)
2. DTI-Derived Tricuspid Lateral Annular Systolic Velocity S’
3. FAC (fractional area change)
4. RV longitudinal strain
5. 3D EF
6. Right Index of Myocardial Performance (RIMP or MPI)
1) TAPSE predominantly reflects RV longitudinal function, but it has shown good correlation with parameters
estimating RV global systolic function. TAPSE may over- or underestimate RV function because of cardiac
translation.
2) DTI -derived tricuspid lateral annular systolic velocity S’ represents basal systolic function, not global RV
function. The velocity may not be accurate in patients who are post thoracotomy, pulmonary
thromboendarterectomy or heart transplantation. It is also angle dependent.
9. 9
3) FAC reflects both longitudinal and radial components of RV contraction. It does not include the contribution
of RV outflow tract to overall systolic function.
4) RV longitudinal strain is less confounded by overall heart motion, but depends on RV loading conditions as
well as RV size and shape. RV longitudinal strain should be measured in the RV-focused view. A normal value
is approximately -20%, the smaller the absolute number the more abnormal is the strain.
10. 10
5) RV 3D EF does not directly reflect RV contractile function, but provides an integrated view of the interaction
between RV contractility and load. The limitations of 3D assessment of RV EF are load dependency,
interventricular changes affecting septal motion, poor acoustic windows, and irregular rhythms.
6) RIMP (Right Index of Myocardial performance) assesses global RV function. The measurement requires beats
with similar RR intervals and is unreliable when RA pressure is elevated. The IVCT, IVRT and ET intervals used
in the calculation can be obtained from PW Doppler of the TV inflow and RVOT outflow or from tissue Doppler
of the lateral TV annulus (see figure). Normal values differ depending on the method used.
a. RIMP = (TCO – ET)/ET where TCO is the TV closure to opening time (and equals the IVRT + IVCT).
ATRIA
(For full recommendation refer to the Chamber Quantification Guideline p. 20-29)
Left Atrium (LA) Area and Volume Measurements
Should be measured at end-systole when the LA chamber is at its greatest dimension (prior to MV
opening).
11. 11
Avoid foreshortening.
Dedicated acquisition of LA from the apical approach should be obtained to maximize LA length and
alignment of the true long axis of the LA for area and volume measures.
For LA tracings (area or volume) the confluences of the pulmonary veins and LA appendage should be
excluded.
The atrioventricular interface should be represented by the mitral annulus plane.
LA Anterior-Posterior (AP) dimension
Should not be used as sole LA measurement (does not represent accurate LA size).
2D measure is preferred over M-mode.
Perpendicular to the long axis of the LA posterior wall, leading edge to leading edge (M-mode) or inner
edge to inner edge (2DE).
Measured at the level of the aortic sinuses.
LA Area and Volumes (Apical 4 and 2 chambers)
LA Area
The base of the LA should be at its largest size.
Trace the LA inner border, excluding the area under the MV annulus, pulmonary veins, and LA appendage.
12. 12
LA Volume (Preferred over linear or area measurements)
Volume can be calculated by the Area-length method or disk summation technique (modified biplane)
which is preferred.
Trace the LA inner border, excluding the area under the MV annulus, pulmonary veins, and LA appendage
from the apical 4 and 2 chamber views.
Area-length technique: the length (L) should be measured from the shorter of the two long axes in the 4C
and 2C views
Right Atrium (RA) Area & Volume Measurements
RA area
The RA should be measured at end-ventricular systole when the
RA chamber is at its greatest dimension, prior to TV opening.
A dedicated right heart view (from an Apical 4 chamber view
that includes the entire RA and is not foreshortened) should be
used for acquisition to ensure the RA is not foreshortened.
The RA length should also be maximized ensuring alignment
along the true long axis of the RA.
The base of the RA should be at its largest size indicating that
the imaging plane passes through the maximal short-axis area.
When performing planimetry of the RA, trace the RA inner
border excluding the area under the TV annulus and the
confluences of the RA appendage.
13. 13
RA Volume (single plane)
AORTA
(For full recommendation refer to the Chamber Quantification Guideline p. 28-32)
Aortic Annulus and Aortic Root
Aortic annulus
Not a true or distinct anatomic structure but is a virtual ring that may be defined by joining the basal
attachments, or nadirs, of the three aortic leaflets.
The distal (uppermost) attachments of the leaflets, in the shape of a crown, form a true anatomic ring.
Measurements of the aortic annulus should be made in the zoom mode using standard electronic calipers
in mid-systole, when the annulus is slightly larger and rounder than in diastole.
Measurement should be performed between the hinge points of the aortic valve leaflets (usually between
the hinge point of the right coronary cusp and the edge of the sinus at the side of the commissures
between the left coronary cusp and the non-coronary cusp) from inner edge to inner edge.
As a general rule, calcium protuberances should be considered as part of the lumen, not of the aortic wall,
and therefore excluded from the diameter measurement.
More robust and accurate when compared with linear
measurements.
Should be performed from an Apical 4 chamber view that
includes the entire RA and is not foreshortened (dedicated
right heart view), tracing the RA inner border excluding
the area under the TV annulus.
No standard orthogonal RA view to use for biplane so a
single-view area-length and/or disk summation technique
should be used.
Area-length method: the length should be performed at
the center of the area under the TV annulus to the
superior RA wall.
14. 14
Aortic Root
The diameter of the aortic root (at the maximal diameter of the sinuses of Valsalva) should be obtained
from the parasternal long-axis view, which depicts the aortic root and the proximal ascending aorta.
The tubular ascending aorta is often not adequately visualized from a standard parasternal window. In
these instances, moving the transducer closer to the sternum and/ or to a higher intercostal space may
allow visualization of a longer portion of the ascending aorta.
Measurements should be made in the view that depicts the maximum aortic diameter perpendicular to
the long axis of the aorta and at end-diastole.
An asymmetric closure line, in which the tips of the closed leaflets are closer to one of the hinge points, is
an indication that the cross-section is not encompassing the largest root diameter.
The leading edge to leading edge convention for measurements of the aortic root and aorta is
recommended.
Two-dimensional echocardiographic aortic diameter measurements are preferable to M-mode
measurements, because cardiac motion may result in changes in the position of the M-mode cursor
relative to the maximum diameter of the sinuses of Valsalva.
15. 15
INFERIOR VENA CAVA
(For full recommendation refer to the Chamber Quantification Guideline p. 32-33)
The diameter of the IVC should be measured in the subcostal view with the patient in the supine, using
the long-axis view. For accuracy, this measurement should be made perpendicular to the IVC long axis.
For simplicity and uniformity of reporting, specific values of RA pressure, rather than ranges, should be
used in the determination of systolic pulmonary artery pressure.
IVC diameter < 2.1 cm that collapses >50% with a sniff suggests normal RA pressure of 3 mm Hg.
IVC diameter > 2.1 cm that collapses < 50% with a sniff suggests high RA pressure of 15 mm Hg.
In indeterminate cases in which the IVC diameter and collapse do not fit this paradigm, an intermediate
value of 8 mm Hg (range, 5-10 mm Hg) may be used, or, preferably, secondary indices of elevated RA
pressure should be integrated.
16. 16
APPENDIX – Normative Values
Left Ventricle (LV) Size and Function p. 2
Standard LV Measurement Parameters
Normal Ranges and Severity Cutoff Values for 2D-derived LV Volumes
Normal Reference Values for Indexed LV Volumes by 3DE
Normal Ranges and Severity Cutoff Values for LV Wall Thickness and Mass Using Linear Method
18. 18
Atria p. 10
Standard LA Anterior-Posterior Dimensions
Parameter Male Female
LAd (cm) 3.0-4.0 2.7-3.8
LAd indexed by BSA (cm/m2
) 1.5-2.3 1.5-2.3
LAd, left atrium diameter; BSA,body surface area
Normal ranges and severity cutoff values for LA Area and LA Volume
Parameter Normal Mildly
enlarged
Moderately enlarged Severely
enlarged
LA Area (cm2
) ≤ 20 21-30 31-40 ≥41
LA Volume indexed by BSA (mL/m2
) 16-34 35-41 42-48 >48
LA, left atrium; BSA, body surface area
RA Measurement Standards from JASE 2010 Right Heart Guidelines (2)
Normal ranges and severity cutoff values for RA Area
Parameter Normal Enlarged
RA (cm2
) ≤18 >18
RA, right atrium
Aorta p. 13