Formal echocardiography

Diagnostic Pearls

• Normal directional flow in CW and PW in apical, parasternal short:
  • Below the line for pulmonic and aortic valves (systole)
  • Above the line in tricuspid and mitral valves (diastole)
• Coronary artery distributions
  • LAD, circumflex, RCA
  • Left marginal = obtuse marginal
  • Right marginal

LV Coronary Artery Distributions

Coronary Artery Distribution, Grayscale

Parasternal long

• Assess for mitral valve prolapse, systolic anterior motion
• Differentiate pleural effusion from pericardial effusion
  • Pericardial effusion is anterior to descending aorta
  • Pleural effusion posterior to descending aorta

Pericardial effusion vs. pleural effusion

• Wall motion assessment obtains LAD and Circumflex coronary artery distributions

Parasternal Long Wall Motion

• EPSS, E-Point Septal Separation in PSL view
  • M-mode distance in mm between anterior leaflet of MV and septum in diastole
  • E-point is shortest distance
  • LVEF = 75.5 - 2.5 x EPSS in mm
    • EPSS and MRI LVEF correlated ~0.80 in study that generated equation
    • Excluded MV prostheses, asymmetrical septal hypertrophy, significant aortic regurgitation
  • Values as calculated by above study
    • < 5 mm, normal
    • > 7 mm, EF < 50%
    • > 18 mm, EF < 30%
  • Falsely elevated EPSS in:
    • Mitral stenosis, rheumatic heart disease
    • Mitral calcification
    • Aortic regurgitation
    • LV dilation

Parasternal short

• See Aortic stenosis regarding evaluation of cuspidity
• Evaluate kinetics of LV motion anatomically by coronary artery flow

Parasternal Short Wall Anatomy

Coronary Artery Distribution in PSS Axis

Apical

• Best obtained in left lateral decubitus with left arm above head to open up ribs
• EF estimation
  • LVEF by Simpson, LV volume change
  • LVEF by Teichholz method, using M-mode (estimation of LV volume by diameter measured just beyond mitral tips in diastole)
  • EF visual assessment:
    • >65% = hyperdynamic
    • 55-65% = normal
    • 45-54% = mildly depressed
    • 30-44% = moderately depressed
    • <30% = severely depressed
• Evaluation for wall motion abnormality

Apical Wall Motion and Coronary Artery Distribution (red box in PSS view in left image representative of apical 4 chamber window)

Apical Two Chamber View

• Infrequently used unless concern exists for full evaluation of wall motion abnormality in LV
• Obtains better views of RCA and LAD distribution

Apical Two Chamber with RCA and LAD Distribution

Aortic Stenosis

• See Aortic stenosis for formal echo evaluation

Mitral Stenosis

• See Mitral stenosis for formal echo evaluation

Diastolic Function

• Worsening diastolic dysfunction corresponds to less fluid responsive hypotension and more volume overload
  • Septic/hypotensive patients with baseline diastolic dysfunction will not have reliable IVC ultrasounding for fluid responsiveness
  • Pts in impaired relaxation states can stand to be volume resuscitated just until impaired relaxation becomes pseudonormal
  • Otherwise seen as the E wave ≈ A wave (give fluids until E wave increases up to A wave)
  • If still hypotensive at that point, pt volume resuscitated, then start vasopressors
  • Patients with pseudonormal or worse diastolic dysfunction require vasopressors, not more fluids
• Measure E and A waves, then e' and a' waves with tissue doppler
  • PW Doppler across MV in apical view bisecting across MV tips during opening, diastole
  • Tissue doppler at MV annulus (base) at either septum or lateral position to measure tissue velocity
  • E/e' ratio ≅ LVEDP (PCWP)

PW across Mitral Valve Opening and Tissue Doppler of Mitral Valve Annulus

• The following rules will apply to most patients(Video)

1. Rule 1: Normal diastolic function if echo normal, age<45 yrs, E>A
2. Rule 2: Impaired relaxation if A>E, with E/A<1
3. Rule 3: Pseudonormal if echo abnormal (LVH), age>65, E>A, E/A>1
4. Rule 4: Restrictive filling if E/A>2

Diastology Chart

Comprehensive Diastology Chart

• Evaluate the E' and A' in tissue doppler to differentiate normal diastolic function from pseudonormalization
  • Septal MV annulus TD, E' magnitude less than 8 cm/s suggestive of diastolic dysfunction
  • Lateral MV annulus TD, E' < 10 cm/s suggestive of diastolic dysfunction

	Normal	Impaired	Pseudonormal	Restrictive
LVEDP	< 15 mmHg	< 15 mmHg	15-25 mmHg	> 25 mmHg
E velocity	Normal	Stays Same	~ 100 cm/s	~150 cm/s
A velocity	Normal	↑	↓	↓↓
E/A	> 1	< 1	> 1	> 2
TDI	e' > a'	a' > e'	a' > e'	a' ≈ e'
E/e'	< 15	< 15	> 15	> 15
e' (septal)	> 8 cm/s	< 8 cm/s	<< 8 cm/s	<<< 8 cm/s

See Also

• Aortic stenosis for CW Doppler measurements
• ECHOpedia Diastolic Dysfunction

External Links

• Critical USG - Echocardiographic evaluation of left ventricular systolic function

References

Authors

Kevin Lu