Check for previous studies per and review key elements
Optimize instrument settings prior to starting study
Verify indication for exam
Review order and understand physician’s reques
Review the order for type of study to be performed. A verbal order may be used for stat echocardiography and written order will be obtained as soon as possible.
Enter patient information into ultrasound system (from pick list or manually)
Enter demographics, heights, weight, BP, sonographers’ name, all other information as needed.
Explain procedure to patients
Verify patient ID
Instruct patient to lie on left side
Apply electrodes and attach lead
Make sure that you have adequate ECG signal
Patients in sinus rhythm 2 beat captures are used
Patient in A Fib or any irregular rhythm 3-5 beat captures should be used as needed
When capturing a bubble contrast study use 5-10 second loops.
If images are suboptimal (greater than or equal to two adjacent segments in an apical view) and primary question is LV function and wall motion, consider use of a transpulmonic agent (echo contrast) after discussion with Cardiology Fellow or Attending.
Basic Exam (note: in general obtain a 2 D image of the view first, followed by color / spectral Doppler in order to provide anatomic orientation). In general, spectral Doppler and M-mode should be captured at a sweep speed of 50 mm/s speed. Use 25-50 mm/s speed to demonstrate respirophasic changes that require documentation of changes across several cardiac cycles and 100 mm/s speed when making timing measurements.
Optimization of Doppler signals. Doppler display occupies about 2/3 of scale for each velocity.
Pay particular attention to:
Narrow aiming sector to optimize color and frame rate
If 2D imaging is poor (esp. in apical views) or two or more LV segments are unable to be assessed, contrast may be considered to enhance the image.
Rule out the effusions and examine extracardiac structure by increasing depth, then reduce depth to assess cardiac structures. Digitally capture 2D view without color Doppler for routine dimensional measurements. Zoom of aortic and mitral valve. The measurements include wall thickness and chamber dimension.
Measurement of dimensions of the Ventricular Septal Thickness, Left Ventricular End-Diastolic Dimension and Posterior Wall Thickness in end-diastole at the level of the mitral valve chordae.
Measurement of Left Ventricular end-systolic dimension in the end systole at the level of the mitral valve chordate.
Measure Ascending Aorta (routinely measured by 2D at level of the sinus). The additional measurements of the diameters of aortic annulus, sino-tubular junction and mid ascending aorta are needed when abnormal aorta is suspected. A separate ascending aorta image may be required.
Measure the Left Atrial Dimension in the end-systole.
Perform Color flow Doppler of AV/MV/Ventricular septum (require separate captures). Aortic and mitral valves with zoom and color Doppler as needed.
A Right Ventricular Outflow view may be obtained as clinically needed (congenital heart disease)
RV inflow view
Capture 2D image first
Perform Color flow Doppler of Tricuspid Valve for Tricuspid Regurgitation.
Measure Peak Tricuspid Regurgitant Velocity for calculation of RA/RV pressure gradient
Parasternal Short-Axis View
Capture at level of Aortic Valve (imaging AV, TV, PV and Left Atrium), examine Aortic, Pulmonic and Tricuspid Valve Leaflet Structures with 2D, PW, CW and color Doppler
Aortic valve level:
2D image first
Aortic valve with zoom and color Doppler
Pulmonic valve and pulmonary artery with color Doppler
Pulsed and CW Doppler across the pulmonic valve
Perform CW Doppler to obtain tricuspid regurgitant velocity to calculate Pulmonary Artery Systolic Pressure if Tricuspid Regurgitation is present
Left ventricle (2D):
Capture 2D LV at basal, middle (papillary muscle) and apex levels
LV at the MV leaflet level with zoom and color Doppler in the presence of mitral valve disease as needed
Apical 4-Chamber View
Capture 2 D image (without color Doppler) to examine the structure and wall motion; avoid foreshortening of the left ventricle. Using a narrow 2D sector and /or zoom to improve image quality to assess LV wall motion and thrombus. Adjust depth, focal point, probe setting (frequency) and gains to optimize images
Color Flow Doppler of Mitral Valve, Tricuspid Valve and Aortic Valve
Perform Pulsed Doppler of the Mitral Valve with the sample Volume at the leaflet tips, measure E/A waves velocities
Perform tissue Doppler of lateral and septal mitral annulus to measure E’, for E/E’ ratio as needed
Perform Color M-mode Doppler as needed
Perform CW of Mitral Valve, Tricuspid Valve
Left Ventricular volumes are measured in diastole and systole to obtain an ejection fraction. During tracing, pay particular attention to: apical foreshortening; including (not excluding) papillary muscle in tracing; apical alignment; mitral annulus. If calculated EF is significantly discordant with visual estimate, review, acquire and measure additional cardiac cycles.
Each of the above measurements will be frozen and then acquired.
Measurement of Left and Right atrium area as needed
PW Doppler of pulmonary veins (sample volume 3-4 mm) as needed.
Apical 5-Chamber View
Aortic valve with color, LVOT, PW and CW Doppler, pay attention to the position of PW sample volume.
Apical 2-Chamber View
Perform 2 D image, take care not to foreshorten the image
LV wall assessment, optimization using appreciate depth, 2D sector and zoom function
Mitral valve with color Doppler
Left atrial area and volumes as needed
Apical 3-chamber view (apical long-axis view)
Perform 2 D image, take care not to foreshorten the image
Color flow Doppler of the Mitral Valve and the Aortic Valve
Perform PW/CW of LVOT /Aortic Valve (in presence or suspicious of aortic stenosis or calcification or LVOT obstruction. Pay attention to the position of PW sample volume.
Perform 2 D image
Perform Color flow Doppler of the Mitral and Tricuspid Valve and Interatrial and Interventricular Septa to look for shunt
Perform CW for the Tricuspid Regurgitant velocity to calculate pressure gradient as needed
Rotate transducer to bring in The Inferior Vena Cava and observe for collapse (For capture set for 3–5 second to appropriately capture. Be sure to include inspiration / expiration and “sniff” if needed)
Color flow of Hepatic Vein/Inferior Vena Cava
Perform Pulsed Doppler of the Hepatic Vein / the Inferior Vena Cava flow
Perform 2D subcostal short-axis view as needed (if parasternal view is not optimal)
Perform 2D image of Aortic arch upper descending aorta as needed
Perform 2D image of the Ascending aorta as needed, especially if aortic dissection & aneurysm are suspected
Perform CW Doppler as needed for aortic stenosis
Additional off-axis 2D image/color Doppler imaging may be performed as needed to supplement standard views (eccentric mitral regurgitation, congenital heart disease, etc.)
Aortic Stenosis or Suspected Aortic Stenosis
Measure LVOT at the parasternal long-axis view
“Zoom” on LVOT; adjust focal point and gain, to optimize measurement of LVOT diameter.
In the apical 5-chamber view, obtain PW aortic outflow with appropriate position of PW sample volume, trace the best wave form.
In the apical 5-chamber view, obtain CW of aortic outflow
In the apical long-axis view, perform PW and CW of aortic flow.
Dedicated non-imaging CW Doppler in multiple locations, at the Apex, Suprasternal Notch and Right Parasternal Border (reposition patient onto right side position may be required) to obtain maximal velocity.
Trace the best Doppler wave form for calculation of aortic valve area using Continuity Equation
Pay attention to the size of LVOT, PW LVOT flow, ascending aorta and arch.
Pay attention to the morphology and mechanism of the aortic regurgitation (e.g. bicuspid, flail, prolapse) including jet direction and origins
Pay attention to the size of the annulus, ascending aorta, arch and co-existing AS assessment
Measure deceleration slope on continuous wave (CW) Doppler of AI from apical 4 or 3 chamber views as needed.
Imaging Suprasternal Notch (SSN) and perform pulsed Doppler of Descending Aorta Flow distal to the Subclavian Artery to check for Diastolic Flow Reversal as needed
Prosthetic Aortic Valve
Type and size of prosthesis (from consult, note or patient card) should be entered into report if information available.
Peak and mean gradients and CW velocities (from apical 5 chamber or apical long axis views right sternal or suprasternal notch flow.) Average 3 the best beats for patient in A Fib as needed.
Assessment of Degree of aortic regurgitation
Review prior report and / or images; if gradients / regurgitation are significantly different, review to reconcile if there has been a true change.
Perform Pulse Doppler of the Pulmonic Flow in Parasternal Short Axis and RVOT
Use CW Doppler (Pedoff) at Left Parasternal Border
Calculate pressure gradient by tracing CW.
If trivial, demonstrate with color Flow Doppler. If there is significant PI, use CW to obtain gradient/deceleration slope.
Pay attention to the morphology including subvalvular apparatus.
Trace CW of Mitral Valve Inflow for mean and peak pressure gradients (average of three beats with A Fib).
Obtain deceleration slope of mitral CW at 100 mm/sec for measurement of pressure Half-time).
In short axis, obtain optimized view at leaflet tips and trace mitral orifice for valve area (native valve only) if possible
Mitral Regurgitation (more that mild)
Pay attention to the mechanisms of MR (chordal rupture; flail leaflet; myxomatous degeneration; papillary muscle infarct; chordal thickening/rheumatic changes) including the origin & jet direction
Demonstrate presence of Mitral Regurgitation with color Doppler, search for maximal color mapping of regurgitation if eccentric mitral regurgitation is present in multiple views including off-axis view. If mitral regurgitation is more than moderate, consider calculation of ERO by PISA method as needed.
“Zoom” of the Mitral Valve
Baseline shift of color Doppler to reduce aliasing velocity to approximately 30-40 cm / sec)
Measure aliasing radius from first blue / red aliasing interface to regurgitant orifice (PISA shell) in the frozen color Doppler image
Obtain peak Mitral Regurgitant Velocity from CW of mitral regurgitation
Pulmonary venous flow obtained if possible with emphasis on systolic flow component
Prosthetic Mitral Valves
Type and size of prosthesis (from chart, op note or patient card)
Peak and mean gradient by CW
Calculation of MV area by Continuity Equation
Search for MR in multiple view
Pay attention to the morphology and mechanism of TR (RV dilatation, prolapse, flail, etc.) including jet direction
Show presence of Tricuspid Regurgitation with color flow
If severe regurgitation, obtain pulse wave Doppler of the hepatic vein in the Subcostal View for Systolic Flow Reversal
Pulmonary Systolic Artery Pressure Calculation
Measure Tricuspid regurgitation velocity using imaging CW (RV inflow, parasternal short-axis, A4C and Subcostal) and Pedoff probes from apical window as needed. Use highest velocity obtained to estimate RV-RA gradient, using the modified Bernoulli equation.
If IVC is normal and collapses add 5 mm Hg to the above equation
If IVC is dilated and partially collapses (less than ½), add 10 mm Hg to the above equation
If IVC is dilated and doesn’t collapse add 15 mm Hg to the above equation
Look for RV collapse and RA collapse using 2D mode and M-mode in multiple views (parasternal, apical and subcostal views
M-mode through RV at mitral valve level in short axis- run at 100 cm/min speed
M-mode RV in the Parasternal Long Axis as needed
Pulse mitral inflow at 25-50 mm/min speed to look for changes with inspiration and expiration
Perform 2D and Pulsed Doppler of the Hepatic Vein / the Inferior Vena Cava flow. Dilation of hepatic venous flow indicates increase in RA pressure.
Pay attention to LV thickness including maximal septal thickness, SAM and eccentric mitral regurgitation caused by SAM.
Pulse along the LVOT to show acceleration (dagger shape) to elicit location of pressure gradient if possible (sample volume should be placed at the site of obstruction, view frozen and image acquired at each level of LV to actually show the exact site of the obstruction