2echocardiography 2009
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Echocardiograp hy Anatomy and patology Dott. Mirco Baccino Cardiologia Ospedale Santa Corona
Echocardiography is a group of interrelated applications of ultrasound to detect and check dimension and movement of the
ECHOCARDIOGRAPHY Preceded by clinical estimation - EKG - Specific issues - Targets -
ECHO
ECHOCARDIOGRAPHY
Patients without well-known cardiopathy:
The goal is to highlight a cardiopathy in high risk subjects
ECHOCARDIOGRAPHY Patients with well-known cardiopathy The goal is to highlight the clinical pattern and to check it
ECHOCARDIOGRAPHY
Sensible parameters: - morphology - ejection fraction - contractility - ventricular diameters - ventricular performance - flow calculations by Doppler - regurgitations - gradients
ECHOCARDIOGRAPHY
Coronary artery disease Cardiomyopathies (dilated, hypertrophic, restrictive, infiltrative) Hypertension Congenital heart disease Valvular heart disease Pericardial effusion and tamponade Endocarditis
ECHO
Parasternal view (long and short axis) Apical view Subxifoid view
ECHOCARDIOGRAPHY
Transthoracic echocardiography (B-mode ed M-mode) Doppler examination (PW e CW) Doppler tissue characterization (TDI) Stress test echocardiography (dipiridamolo o dobutamine)
WINDOWS
WINDOWS
Apical position Four chambers view
Parasternal position long axis view
Parasternal Short axis view
Subxiphoid position
Parasternal long axis view
ANTERIOR SEPT iva
POSTERIOR WALL cx
Parasternal long axis view Ventruclar values Valvular disease CAD Cardiomyopathies
LVOT patology HCM Sub-ao stenosis
AORTA ASC. Aneurismi Dissezione Aortic valve Stenosis Regurgitation
Ventricular values Systemic Hyperthension Aortic stenosis Diabetes HCM Coronary artery disease Iva/cx
Mitral valve Regurgitation Stenosis
Left Atrium: Mitral disease Left ventricular failure Atrial fibrillation Mixoma
Parasternal short axis view-left ventricle ANTERIOR
ANTERIOR WALL iva
SEPTUM iva
LATERAL WALL
INFERIOR cd
cx
POSTERIOR WALL cx-cd
INFERIOR WALL cd
Parasternal short axis view
AMI location
ISCHEMIA check in ECO STRESS
LEFT VENTRICULAR VALUES FLATTENING OF THE VENTRCIULAR SEPTUM IN PULMONARY HYPERTHENSION
Parasternal shot axis view Great vessel EVDx Morfologia (2d) Dimensioni (m,2d) Cinesi (m,2d) TRICUSPID VALVE Leaflets (2d) Morphology (2d) Rigurgitation (color) PAPs (cwd) AORTA N° cuspidi (2d) Morfologia (2d) Area planim. (2d)
PULMONARY VALVE Morfologia (2d) Rigurgito (color) PVR (pwd)
PULMONARY ARTERY Dimensioni (2d) Masse (2d)
ATRIAL SEPTUM Morfologia (2d) Movimento (2d) Shunt ?
Parasternal short axis view Great vessel
TRYCUSPID VALVE RV Disfunctione Ebstein
AORTIC VALVE Stenosis Regurgitation
RVOT
Fallot Arrythmogenic RV cardiomyopathy Homograft polmonare Pre-Ross
PULMONARY ARTERY Pulmonary Embolism clots
FISTULA ATRIAL SEPTUM Oval fossa defect Interatrial seprum defects
APICAL 4-5 CHAMBER VIEW SEPTUM cd, iva motion (m,2d)
LATERAL WALL cx motion (m,2d)
APICAL 4-5 CHAMBER RV MORPHOLOGY/FUNCTION
LV FUNCTION Systolic/dyastolic ISCHEMIA/ AMI Septum-lateral wall MITRAL valve PATHOLOGY
TRYCUSPID Valve and PuLMONARY HYPERTENSION AORTIC Valve PATHOLOGY HOCM
ATRIUM PATHOLOGY
APICAL 2 CHAMBER APICAL WALL Iva
INFERIOR WALL Cd
ANTERIOR WALL Iva
APICAL 2 CHAMBER
LV SYSTOLIC FUNCTION
ISCHEMIA/AMI Anterior-inferior
B-mode ed M-mode
M-mode
Parasternal M-mode view
Transesophageal
Doppler CW e PW
Doppler Pressure
gradient by Bernoulli equation: ΔP = 4V22
Continuity
equation: CSA2 = CSA1 * V1/V2
MAJOR CORONARY ARTERIES AREAS OF OVERLAP
MAJOR CORONARY ARTERY IVA CX CD
PATHOLOGY
Apical 4-5 chamber view
MECHANICAL COMPLICATON
IVS BREACH
Biventricular acute overloaded
TRYCUSPID Valve REGURGITATION
RV ACUTE OVERLOADED
Patent Fossa Ovale
B. ISCHEMIA Shunt
Ventricular Aneurysm
Ejection fraction OperatorDependent
Ejection fraction
CRT - remodelling PRE
POST
FAVORABLE REMODELING
RESPONDER
30% = NO RESPONDER
PULMONARY ARTERIAL PRESSURE 2. SPEED (m/sec)
1. CWD on TRR
3. PRESSURE GRADIENT SOFTWARE Equazione di Bernouilli modificata
apical 4C view
4. PLUS 10 mmHg
LEFT ATRIUM
Valore normale Indicizzato < 25 cmq
50 ml about
LEFT ATRIUM
MITRAL VALVE STENOSIS
MITRAL REGURGITATION
ATRIAL COMPLIANCE
ATRIAL FIBRILLATION
LEFT ATRIUM ATRIUM DIMENSIONS
ATRIAL FIBRILLATION
CLOTS
MAZE
SPONTANEOUS ECHOCONTRAST
1 – LOW FLOW 2 - CLOTS
VERY IMPORTANT TO DETECT
CLOTS IN LEFT ATRIUM ETE
PARASTERNAL LONG AXIS VIEW
Mitral Stenosis
1. THICK LEAFLETS
2. ATRIUM EXPANSION
3. VALVE MELTING
PARASTERNAL SHORT AXIS VIEW
Mitral Stenosis
1. THICK LEAFLETS
2. MELTING Postmed
Antlat
REDUCED VALVE AREA
APICAL 4 CHAMBERS
Mitral Stenosis
1. SICK VALVE
2. LEFT ATRIUM EXPANSION
GRAVITY RV FUNCTION
Mitral Stenosis
STENOSIS DEGREE
PULMONARY PRESSURE LEFT ATRIUM VOLUME
MITRAL STENOSIS
PARASTERNAL SHORT AXIS VIEW
VALVE AREA
APICAL 4C
- DOPPLER AREA - GRADIENT
STENOSIS GRAVITY Doppler valve area and gradient
Mitral Stenosis
1. DOPPLER 2. GRADIENT BY SOFTWARE
1. MVA 2. PHT 3. DOPPLER VALVE AREA BY SOFTWARE
Aortic Stenosis
GRADIENT
VALVE AREA PLANIMETRY
Apical 5c
CONTINUITY EQUATION
Parasternal short axis view
GRADIENT
Aortic Stenosis 2. CWD LVOT
1. APICAL 5C 3. SISTOLIC SPEED -> Bernouilli’s Equation GRADIENT
by trackball
VALVE AREA TT PLANIMETRY
Aortic Stenosis
PARASTERNAL SHORT AXIS VIEW
base PLANIMETRY
apice
VALVE AREA TEE PLANIMETRY
Aortic Stenosis
VALVE AREA BY PLANIMETRY
VALVE AREA GRAVITY
Aortic Stenosis
LIGHT MODERATE SEVERE
AVA
AVA Index
(cm2) > 1.5
(cm 2/m2) > 0.9
> 1-1.5
> 0.6-0.9
<1
< 0.6
Aortic Stenosis
Aortic Stenosis
Aortic Regurgitation
DIAGNOSIS COLOR DOPPLER
arasternale asse lungo apical 5C and long axis view
Parasternal short axis view
DIASTOLIC JET
Aortic regurgitation
Aortic regurgitation
Aortic Regurgitation
DIAGNOSIS COLOR DOPPLER SISTOLIC JET: APICAL 4C
PARASTERNAL LONG AXIS VIEW
Mitral regurgitation
DIAGNOSIS IN NORMAL MORPHOLOGY TOO
NO NECESSARY BILLOWING
Mitral regurgitation
Mitral regurgitation
Mitral prolapse
SUBXIFOID VIEW VEIN FlOW (pwd)
CAVA VEIN Dimensions (m,2d) Variaz resp (m,2d) Masse (2d) PERICARDIUM Morfology (2d) Effusion (2d)
ATRIAL SEPTUM Morfology (2d) Movement (2d)
EVDx RV pathology Pulmonary embolism
SUBXIFOID VIEW
CAVA VEIN Vein Pressure Embolism Tumor PERICARDIUM Effusion/clots
ATRIAL SEPTUM Aneurysm Defects Shunts
RV Function Dimensions
SUBXIFOID VIEW
CAVA VEIN INFERIOR Diameter
ATRIAL SEPTUM Morfology
SUBXIFOID VIEW
PERICARDIAL EFFUSION
Rv DIMENSIONS
VEIN
VOLUME
RV MOVEMENT
RV clots
CENTRAL VEIN PRESSURE 1) Subxifoid view diameters
IVC
SNIFF
RAP mm Hg
< 1.5
collasso
0-5
1.5-2.5
> 50% < 50%
5-10 10-15
> 2.5
< 50% > 50%
15-20 > 20%
DIMENSIONS - MOVEMENT
TDI ANULUS TV
RIGHT VENTRICLE FUNCTION
TAPSE
ITR
DIMENSIONS: edd > 3.5 cm
TAPSE: <1.5 cm: moderata <1.0 cm: severa
RIGHT VENTRICUL DISFUNCTION TDI: S < 8 cm/s
ITR: 3-4
ARRHITHMOGENIYC CARDIOMYOPATHY RVOT > 30 mm
Aneurysm
PULMONARY SYSTOLIC PRESSURE
APICAL 4C
APICAL 4C VIEW
CWD
CWD
SPEED’
Arrhithmogenyc cardiomyopathy: MRI
1) EXPANSION
2) FAT WALL
ARRHYTHMOGENIC CARDIOMYOPATHY
ANEURYMS
RIGHT DISFUNCTION RV EXPANSION - ATRIAL SEPTUM INCORRECT MOVEMENT
PULMONARY HYPERTENSION 1) CWD trans-tricuspid valve 2) GRADIENT trans-tricuspid valve
3) PVC PAPs = gradient + pvc 30-40: lieve 40-50: moderate > 50: severe
RV PERFORMANCE
1) m-MODE TV ANULUS lat. TAPSE
2) TDI TV ANULUS lat.
PERFORMANCE: TAPSE
NORMALE LIGHT DISFUNCTION SEVERE DISFUNCTION
> 2 cm/sec 1.5-2 cm/sec < 1 cm/sec
PERFORMANCE: TDI
> 13 cm/s
> 12.7 cm/s
NORMAL
> 12 cm/s
LEFT VENTRICULE EXPANSION
Mitral Valve Vegetations
Right Ventricle expasion
HOCM
Left Ventricle Hypertrophy
Left Ventricle Hypertrophy
Cardiac Mass
Cardiac Mass
Ventricular Mixoma
Ebstein
Pericardial effusion
Pericardial effusion
Pericardial effusion
Pericardial effusion
Pericardial effusion
Pericardial effusion
Pericardial effusion
ETE - Clots in right atrium
ETE – Interatrium defect
Trydimensional Echocardiography
Trydimensional Echocardiogrphy
Trydimensional Echocardiography
Trydimensional Echocardiography
Santa Corona Hospital
Echocardiography is a group of interrelated applications of ultrasound to detect and check dimension and movement of the
ECHOCARDIOGRAPHY Preceded by clinical estimation - EKG - Specific issues - Targets -
ECHO
ECHOCARDIOGRAPHY
Patients without well-known cardiopathy:
The goal is to highlight a cardiopathy in high risk subjects
ECHOCARDIOGRAPHY Patients with well-known cardiopathy The goal is to highlight the clinical pattern and to check it
ECHOCARDIOGRAPHY
Sensible parameters: - morphology - ejection fraction - contractility - ventricular diameters - ventricular performance - flow calculations by Doppler - regurgitations - gradients
ECHOCARDIOGRAPHY
Coronary artery disease Cardiomyopathies (dilated, hypertrophic, restrictive, infiltrative) Hypertension Congenital heart disease Valvular heart disease Pericardial effusion and tamponade Endocarditis
ECHO
Parasternal view (long and short axis) Apical view Subxifoid view
ECHOCARDIOGRAPHY
Transthoracic echocardiography (B-mode ed M-mode) Doppler examination (PW e CW) Doppler tissue characterization (TDI) Stress test echocardiography (dipiridamolo o dobutamine)
WINDOWS
WINDOWS
Apical position Four chambers view
Parasternal position long axis view
Parasternal Short axis view
Subxiphoid position
Parasternal long axis view
ANTERIOR SEPT iva
POSTERIOR WALL cx
Parasternal long axis view Ventruclar values Valvular disease CAD Cardiomyopathies
LVOT patology HCM Sub-ao stenosis
AORTA ASC. Aneurismi Dissezione Aortic valve Stenosis Regurgitation
Ventricular values Systemic Hyperthension Aortic stenosis Diabetes HCM Coronary artery disease Iva/cx
Mitral valve Regurgitation Stenosis
Left Atrium: Mitral disease Left ventricular failure Atrial fibrillation Mixoma
Parasternal short axis view-left ventricle ANTERIOR
ANTERIOR WALL iva
SEPTUM iva
LATERAL WALL
INFERIOR cd
cx
POSTERIOR WALL cx-cd
INFERIOR WALL cd
Parasternal short axis view
AMI location
ISCHEMIA check in ECO STRESS
LEFT VENTRICULAR VALUES FLATTENING OF THE VENTRCIULAR SEPTUM IN PULMONARY HYPERTHENSION
Parasternal shot axis view Great vessel EVDx Morfologia (2d) Dimensioni (m,2d) Cinesi (m,2d) TRICUSPID VALVE Leaflets (2d) Morphology (2d) Rigurgitation (color) PAPs (cwd) AORTA N° cuspidi (2d) Morfologia (2d) Area planim. (2d)
PULMONARY VALVE Morfologia (2d) Rigurgito (color) PVR (pwd)
PULMONARY ARTERY Dimensioni (2d) Masse (2d)
ATRIAL SEPTUM Morfologia (2d) Movimento (2d) Shunt ?
Parasternal short axis view Great vessel
TRYCUSPID VALVE RV Disfunctione Ebstein
AORTIC VALVE Stenosis Regurgitation
RVOT
Fallot Arrythmogenic RV cardiomyopathy Homograft polmonare Pre-Ross
PULMONARY ARTERY Pulmonary Embolism clots
FISTULA ATRIAL SEPTUM Oval fossa defect Interatrial seprum defects
APICAL 4-5 CHAMBER VIEW SEPTUM cd, iva motion (m,2d)
LATERAL WALL cx motion (m,2d)
APICAL 4-5 CHAMBER RV MORPHOLOGY/FUNCTION
LV FUNCTION Systolic/dyastolic ISCHEMIA/ AMI Septum-lateral wall MITRAL valve PATHOLOGY
TRYCUSPID Valve and PuLMONARY HYPERTENSION AORTIC Valve PATHOLOGY HOCM
ATRIUM PATHOLOGY
APICAL 2 CHAMBER APICAL WALL Iva
INFERIOR WALL Cd
ANTERIOR WALL Iva
APICAL 2 CHAMBER
LV SYSTOLIC FUNCTION
ISCHEMIA/AMI Anterior-inferior
B-mode ed M-mode
M-mode
Parasternal M-mode view
Transesophageal
Doppler CW e PW
Doppler Pressure
gradient by Bernoulli equation: ΔP = 4V22
Continuity
equation: CSA2 = CSA1 * V1/V2
MAJOR CORONARY ARTERIES AREAS OF OVERLAP
MAJOR CORONARY ARTERY IVA CX CD
PATHOLOGY
Apical 4-5 chamber view
MECHANICAL COMPLICATON
IVS BREACH
Biventricular acute overloaded
TRYCUSPID Valve REGURGITATION
RV ACUTE OVERLOADED
Patent Fossa Ovale
B. ISCHEMIA Shunt
Ventricular Aneurysm
Ejection fraction OperatorDependent
Ejection fraction
CRT - remodelling PRE
POST
FAVORABLE REMODELING
RESPONDER
30% = NO RESPONDER
PULMONARY ARTERIAL PRESSURE 2. SPEED (m/sec)
1. CWD on TRR
3. PRESSURE GRADIENT SOFTWARE Equazione di Bernouilli modificata
apical 4C view
4. PLUS 10 mmHg
LEFT ATRIUM
Valore normale Indicizzato < 25 cmq
50 ml about
LEFT ATRIUM
MITRAL VALVE STENOSIS
MITRAL REGURGITATION
ATRIAL COMPLIANCE
ATRIAL FIBRILLATION
LEFT ATRIUM ATRIUM DIMENSIONS
ATRIAL FIBRILLATION
CLOTS
MAZE
SPONTANEOUS ECHOCONTRAST
1 – LOW FLOW 2 - CLOTS
VERY IMPORTANT TO DETECT
CLOTS IN LEFT ATRIUM ETE
PARASTERNAL LONG AXIS VIEW
Mitral Stenosis
1. THICK LEAFLETS
2. ATRIUM EXPANSION
3. VALVE MELTING
PARASTERNAL SHORT AXIS VIEW
Mitral Stenosis
1. THICK LEAFLETS
2. MELTING Postmed
Antlat
REDUCED VALVE AREA
APICAL 4 CHAMBERS
Mitral Stenosis
1. SICK VALVE
2. LEFT ATRIUM EXPANSION
GRAVITY RV FUNCTION
Mitral Stenosis
STENOSIS DEGREE
PULMONARY PRESSURE LEFT ATRIUM VOLUME
MITRAL STENOSIS
PARASTERNAL SHORT AXIS VIEW
VALVE AREA
APICAL 4C
- DOPPLER AREA - GRADIENT
STENOSIS GRAVITY Doppler valve area and gradient
Mitral Stenosis
1. DOPPLER 2. GRADIENT BY SOFTWARE
1. MVA 2. PHT 3. DOPPLER VALVE AREA BY SOFTWARE
Aortic Stenosis
GRADIENT
VALVE AREA PLANIMETRY
Apical 5c
CONTINUITY EQUATION
Parasternal short axis view
GRADIENT
Aortic Stenosis 2. CWD LVOT
1. APICAL 5C 3. SISTOLIC SPEED -> Bernouilli’s Equation GRADIENT
by trackball
VALVE AREA TT PLANIMETRY
Aortic Stenosis
PARASTERNAL SHORT AXIS VIEW
base PLANIMETRY
apice
VALVE AREA TEE PLANIMETRY
Aortic Stenosis
VALVE AREA BY PLANIMETRY
VALVE AREA GRAVITY
Aortic Stenosis
LIGHT MODERATE SEVERE
AVA
AVA Index
(cm2) > 1.5
(cm 2/m2) > 0.9
> 1-1.5
> 0.6-0.9
<1
< 0.6
Aortic Stenosis
Aortic Stenosis
Aortic Regurgitation
DIAGNOSIS COLOR DOPPLER
arasternale asse lungo apical 5C and long axis view
Parasternal short axis view
DIASTOLIC JET
Aortic regurgitation
Aortic regurgitation
Aortic Regurgitation
DIAGNOSIS COLOR DOPPLER SISTOLIC JET: APICAL 4C
PARASTERNAL LONG AXIS VIEW
Mitral regurgitation
DIAGNOSIS IN NORMAL MORPHOLOGY TOO
NO NECESSARY BILLOWING
Mitral regurgitation
Mitral regurgitation
Mitral prolapse
SUBXIFOID VIEW VEIN FlOW (pwd)
CAVA VEIN Dimensions (m,2d) Variaz resp (m,2d) Masse (2d) PERICARDIUM Morfology (2d) Effusion (2d)
ATRIAL SEPTUM Morfology (2d) Movement (2d)
EVDx RV pathology Pulmonary embolism
SUBXIFOID VIEW
CAVA VEIN Vein Pressure Embolism Tumor PERICARDIUM Effusion/clots
ATRIAL SEPTUM Aneurysm Defects Shunts
RV Function Dimensions
SUBXIFOID VIEW
CAVA VEIN INFERIOR Diameter
ATRIAL SEPTUM Morfology
SUBXIFOID VIEW
PERICARDIAL EFFUSION
Rv DIMENSIONS
VEIN
VOLUME
RV MOVEMENT
RV clots
CENTRAL VEIN PRESSURE 1) Subxifoid view diameters
IVC
SNIFF
RAP mm Hg
< 1.5
collasso
0-5
1.5-2.5
> 50% < 50%
5-10 10-15
> 2.5
< 50% > 50%
15-20 > 20%
DIMENSIONS - MOVEMENT
TDI ANULUS TV
RIGHT VENTRICLE FUNCTION
TAPSE
ITR
DIMENSIONS: edd > 3.5 cm
TAPSE: <1.5 cm: moderata <1.0 cm: severa
RIGHT VENTRICUL DISFUNCTION TDI: S < 8 cm/s
ITR: 3-4
ARRHITHMOGENIYC CARDIOMYOPATHY RVOT > 30 mm
Aneurysm
PULMONARY SYSTOLIC PRESSURE
APICAL 4C
APICAL 4C VIEW
CWD
CWD
SPEED’
Arrhithmogenyc cardiomyopathy: MRI
1) EXPANSION
2) FAT WALL
ARRHYTHMOGENIC CARDIOMYOPATHY
ANEURYMS
RIGHT DISFUNCTION RV EXPANSION - ATRIAL SEPTUM INCORRECT MOVEMENT
PULMONARY HYPERTENSION 1) CWD trans-tricuspid valve 2) GRADIENT trans-tricuspid valve
3) PVC PAPs = gradient + pvc 30-40: lieve 40-50: moderate > 50: severe
RV PERFORMANCE
1) m-MODE TV ANULUS lat. TAPSE
2) TDI TV ANULUS lat.
PERFORMANCE: TAPSE
NORMALE LIGHT DISFUNCTION SEVERE DISFUNCTION
> 2 cm/sec 1.5-2 cm/sec < 1 cm/sec
PERFORMANCE: TDI
> 13 cm/s
> 12.7 cm/s
NORMAL
> 12 cm/s
LEFT VENTRICULE EXPANSION
Mitral Valve Vegetations
Right Ventricle expasion
HOCM
Left Ventricle Hypertrophy
Left Ventricle Hypertrophy
Cardiac Mass
Cardiac Mass
Ventricular Mixoma
Ebstein
Pericardial effusion
Pericardial effusion
Pericardial effusion
Pericardial effusion
Pericardial effusion
Pericardial effusion
Pericardial effusion
ETE - Clots in right atrium
ETE – Interatrium defect
Trydimensional Echocardiography
Trydimensional Echocardiogrphy
Trydimensional Echocardiography
Trydimensional Echocardiography
Santa Corona Hospital
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