G. AORTIC STENOSIS (AS)

G. AORTIC STENOSIS (AS) DEFINITION AORTIC STENOSIS: THE FACTS Aortic stenosis (AS) is a narrowing, thickening, and/or obstruction of the aortic valve (AOV) that impedes systolic blood flow traveling from the left ventricle, through the AOV, into the aorta. There is a difference between aortic stenosis and aortic sclerosis. Aortic stenosis is a thickened AOV that does not open well with a peak velocity > 2 m/sec. Aortic sclerosis is a thickened AOV that does open well with a peak velocity < 2 m/sec that may/may not become stenotic in the future. MUMUR The AS murmur is a systolic crescendo decrescendo murmur best heard at the right upper sternal border that may radiate up to the carotids. CAUSES CONGENITAL AS (subvalvular, valvular, or supravalvular) a. Subvalvular congenital AS may be due to a congenital membrane across the left ventricular outflow tract. b. Valvular congenital AS due to a bicuspid AOV. Normally the AOV has three cusps. A bicuspid AOV has two cusps that appear as a football-shaped opening when viewed from the short axis view. A raphe (underdeveloped aortic cusp) may be present. The raphe may give the appearance of a third cusp; however, it does not open it is fused to one of the other AOV cusps. Bicuspid AS usually becomes symptomatic between the ages of 20 50 years. Evaluate the patient for a co-existing aortic coarctation. Refer to Congenital Anomalies: Aortic Coarctation for details. c. Supravalvular congenital AS due to an aortic coarctation. A coarctation is a narrowing of the aorta, usually in the vicinity of the aortic isthmus, that obstructs blood flow. Approximately 50% of patients with aortic coarctations have a co-existing bicuspid AOV. DEGENERATIVE AS a. Age 65+ years. b. The AOV has a fibrocalcific nature. The stenosis originates at the sinuses of Valsalva and extends medially to the AOV cusps (i.e. the stenosis starts at the sinuses and moves in toward the cusps). RHEUMATIC AS a. AOV cusps become fibrotic and contract, with fusion of the commissures, and later calcification. b. The stenosis originates at the AOV cusps and moves out toward the commissures (opposite etiology of degenerative AS). PROSTHETIC VALVE DYSFUNCTION Dysfunctional AOV prosthesis obstructs blood flow. ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 170

COMPLICATIONS AORTIC STENOSIS: THE FACTS (continued) SIGNS AND SYMPTOMS a. Left ventricular pressure overload creates left ventricular hypertrophy. b. The stenotic AOV provides a perfect environment for infective endocarditis due to the turbulent flow and abnormalities of the cusps. TREATMENT a. The AS patient typically undergoes serial echos in order to track changes in the degree of AS left ventricular hypertrophy systolic function diastolic function chamber size b. AOV replacement is performed if the patient develops symptoms and/or experiences progressive left ventricular hypertrophy. Ideally, the replacement should be performed before the patient goes into heart failure. The patient may experience: decreased cardiac output, chest pain, syncope, myocardial or cerebral infarct, heart failure, pulmonary edema, dysrhythmias, and sudden death. ADVANCED TECHNOLOGY! a. The mini-thoracotomy is a robotically assisted surgery that offers a minimally invasive method (small incision between the ribs) used for valvular procedures, atrial septal defect repair, aortic aneurysm repair, AOV replacement, and coronary artery bypass grafting without the aid of cardiopulmonary bypass (CPB). This reduces post-operative discomfort, scarring, and recovery time. b. Percutaneous AOV replacement involves a balloon catheter with a stent-mounted valve crimped on its tip. The catheter is threaded from the femoral artery in the groin into the aorta and across the AOV (in the opposite direction to normal blood flow). Once the compressed valve is put into place over the diseased AOV, the balloon at the end of the catheter is inflated. The expanded valve pushes aside the diseased leaflets and becomes anchored in the valve opening. In patients with significant atherosclerotic plaque, the valve can be implanted via the mini-thoracotomy (through a small incision in the chest and a puncture in the left ventricular apex). INTERESTING FACT Another AOV congenital anomaly, although rare, is the quad AOV with four cusps. Last I heard there were 186 documented cases in the world. Associated AS is rare. On the contrary, the quad AOV opens well and 16% have normal function. As expected, 75% have associated aortic insufficiency. NOTES ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 171

2D ECHO: CONGENITAL AS AORTIC STENOSIS: 2D ECHO (1-2) SKETCH: BICUSPID AOV (1) Congenital AS due to a bicuspid AOV results in a football-shaped opening with thickened, doming cusps. The cusps will appear thickened and may have systolic and diastolic "doming" (AOV prolapse). (2) Presence of a raphe (underdeveloped cusp). OPEN BICUSPID AOV CLOSED BICUSPID AOV 2D ECHO: DEGENERATIVE AS/RHEUMATIC AS (3-8) SKETCH: AS (3) AOV cusps appear thickened and calcified with doming and decreased excursion. (4) Mitral annular calcification. (5) Left atrial enlargement due to volume and pressure overload. (6) The AS increases the afterload (resistance the heart must pump against). Therefore, the left ventricle must contract more forcefully in order to propel blood from the heart. This increased contraction and workload causes left ventricular hypertrophy. (7) Left ventricular enlargement with decreased left ventricular systolic function may develop long term. (8) Post stenotic dilatation of the aortic root and/or ascending aorta due to the high velocity jet striking the aortic root wall. ADDITIONAL FINDINGS of AS (not seen in this diagram) may include: AO coarctation. Later stages: possible left ventricular failure due to the added stress on the left ventricle and decreased left ventricular compliance. ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 172

PLANIMETRY OF THE AORTIC VALVE METHOD Acquire planimetry from the SAX at the level of the AOV. Zoom in, freeze, and trace the AOV orifice during the maximum opening at early systole. This diagram displays a diminished AOV opening due to valvular AS. The ultrasound unit calculates the AOV area (AVA) once planimetry is complete. This method is particularly useful during TEE examinations when it is difficult to obtain the optimum Doppler angle. Useful for all types of valvular AS but can be technically difficult. SKETCH: PLANIMETRY M-MODE: BICUSPID AS AORTIC STENOSIS: M-MODE (1-2) SKETCH: BICUSPID AS (1) Eccentric closure. Normally, the closure line of the AOV is located at the center of the box. The bicuspid AOV often displays an eccentric closure line. It is typically located off-center due to the difference in the size of the two cusps. However, 25% of bicuspid aortic valves will have a normal closure by M-mode. (2) Thickened cusps with decreased aortic cusp separation (ACS). M-MODE: DEGENERATIVE AS/RHEUMATIC AS (3) Bright, thick, dense AOV cusps. (3-6) SKETCH: DEGENERATIVE AS/ RHEUMATIC AS (4) Decreased excursion of the aortic cusps or aortic cusp separation (ACS) < 1.5 cm. The normal ACS = 1.5 2.6 cm. (5) Example of normal systolic flutter of the AOV cusps when the cusps are thin, delicate, and open freely. (6) AS lacks normal systolic flutter due to the thick, calcified leaflets. ADDITIONAL FINDINGS of AS (not seen in this diagram) may include: Left ventricular hypertrophy. Left ventricular enlargement. Left atrial enlargement. Post-stenotic dilatation of the aortic root and/or ascending aorta. ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 173

AORTIC STENOSIS: CALCULATIONS Doppler echo is the method of choice in the diagnosis of valvular AS. From my experience, the most common AS calculations include the peak velocity, maximum pressure gradient (max PG), mean pressure gradient (mean PG), and AOV area (AVA). In order to detect the absolute peak velocity of the AS, it is very important to properly position the patient, optimize the Doppler angle, and utilize the proper equipment; otherwise the AS calculations may be underestimated. According to the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL), For aortic stenosis, the systolic velocity must be evaluated from multiple transducer positions (e.g. apical, suprasternal and right parasternal). This must include interrogation from multiple views with a dedicated nonimaging continuous wave Doppler transducer (at least one clear envelope must be obtained). This quote was approved and permitted by the ICAEL. Please refer to Transthoracic Echocardiogram: The Introduction for a review on nonimaging CW Doppler (PEDOF). Steerable CW Doppler (on the imaging transducer) is certainly quicker and easier making it a tempting choice during a busy day. However, nonimaging CW Doppler frequently acquires the absolute peak velocity making it a more reliable source of information. If preferred, start with steerable CW Doppler and then switch to nonimaging CW Doppler. The steerable CW Doppler transducer will give you an idea of the window location, transducer angle, and the potential peak velocity. Utilize the apical window, suprasternal window, and right parasternal window. The right parasternal window is generally located at the right, fourth intercostal space while the patient is in the right lateral decubitus position. Similar to the suprasternal window, the right parasternal AS waveform will appear above the baseline as the flow travels toward the transducer. Record/store the peak AS velocity from each window to document your attempts. Once you locate the absolute peak velocity and you have a good, clear envelope, proceed with the measurements and calculations. MAX PG, MEAN PG, AND PEAK VELOCITY: AS (1) Once you acquire the absolute peak velocity with a clear envelope, preferably with the opening and closing snaps, freeze the image. (1 2) SKETCH: PEAK VELOCITY, MAX PG & MEAN PG AS Doppler waveform acquired from the suprasternal or right parasternal window so the flow is traveling toward the transducer. (2) Use the calculations package and perform planimetry of the AS envelope. Be sure to start and finish at zero baseline. Once the envelope is traced, the max PG, mean PG, and peak velocity are calculated by the ultrasound machine. REVIEW: Doppler echo provides the instantaneous PG, while the catheterization lab provides the peak-to-peak PG. It is recommended that the echo and cath results be correlated. Please refer to the Cardiac Catheterization chapter for a review. (3) For a quick max PG, utilize the Modified Bernoulli s Equation where V = peak AS velocity. (3) SKETCH: PEAK VELOCITY AS Doppler waveform acquired from the apex so the flow is traveling away from the transducer. Modified Bernoulli s Equation = 4(V) 2 For example, if the peak velocity through the AOV = 4 m/sec, then the max PG = 4 (4 m/sec) 2 = 4 (4x4) = 4 (16) = 64 mmhg. More examples Peak velocity of 3 m/sec, PG = 4 (3) 2 = 4 (3x3) = 36 mmhg. Peak velocity of 5 m/sec, PG = 4 (5) 2 = 4 (5x5) = 100 mmhg. Peak velocity of 6 m/sec, PG = 4 (6) 2 = 4 (6x6) = 144 mmhg. ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 174

AORTIC VALVE AREA (AVA) AORTIC STENOSIS: CALCULATIONS (continued) The AOV area (AVA) can be determined by a number of methods. The most common method is the Continuity Equation. This equation assumes that, Flow through a tube is constant. Flow is equal to VELOCITY multiplied by AREA. Therefore, if the area decreases (as is the case with aortic stenosis), the velocity must increase in order to maintain the flow. From this theory, the Continuity Equation is derived. The Continuity Equation (simplified version) = (VELOCITY 1 ) (AREA 1 ) = (VELOCITY 2 ) (AREA 2 ) or (V 1 ) (A 1 ) = (V 2 ) (A 2 ) In the case of the AOV, V 1 and A 1 refer to the left ventricular outflow tract (LVOT) and V 2 and A 2 refer to the AOV. When we substitute the terminology, we get the following equation: (V LVOT ) (A LVOT ) = (V AOV ) (A AOV ) In order to determine the AOV area (A AOV ), we move the V AOV to the other side of the equation by dividing both sides by V AOV. This cancels the V AOV out on the right side of the equation. In other words, A AOV = (V LVOT ) (A LVOT ) / (V AOV ) Finally, we add a constant that converts a diameter to an area (.785), square the LVOT diameter, and we have the AVA Continuity Equation, also written as AVA = (.785) (LVOT diameter) 2 (V1) / (V2) IN THE EQUATION,.785 is a constant that converts a diameter to an area LVOT diameter 2 = left ventricular outflow tract (LVOT) diameter 2 V1 = peak velocity of the LVOT (PW Doppler of the LVOT) V2 = peak velocity through the AOV (CW Doppler of the AOV) For example, if the LVOT diameter = 2.3 cm, V1 = 0.9 m/sec, and V2 = 3.5 m/sec, what is the AVA according to the Continuity Equation? AVA = (.785) (2.3 cm) 2 (0.9 m/sec) / (3.5 m/sec) = 3.7 / 3.5 = 1.1 cm 2 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 175

#1 LVOT DIAMETER CONTINUITY EQUATION: AORTIC VALVE AREA (AVA) a. The left ventricular outflow tract (LVOT) diameter is a critical measurement because the value is squared in the Continuity Equation. In other words, if you measure the LVOT incorrectly, your mistake will be squared! b. Obtain the optimum view of the AOV and LVOT from the LAX. The zoom feature is helpful. Freeze the image and utilize the cine loop for proper timing and optimum visualization. c. Open the AOV calculations package and utilize the calipers to measure the LVOT during early to mid ventricular systole from inner edge to inner edge. d. Obtain an average diameter from 2-3 different beats. If you acquire three very different measurements, start over accuracy is a must! 2D ECHO: LVOT DIAMETER #2 LVOT PEAK VELOCITY (V1) PW DOPPLER: LVOT a. From the 5C, place the PW Doppler gate in the LVOT. Make sure you are not in the AOV apparatus. It may be helpful to place the PW Doppler gate within the AOV then move into the LVOT. There should be a sudden decrease in velocity when the PW gate leaves the valve and enters the LVOT. b. Obtain the LVOT peak velocity. c. Open the AOV calculations package and enter the peak velocity of the LVOT. #3 AOV PEAK VELOCITY (V2) CW DOPPLER: AOV (apex) a. Utilize and compare the apical, suprasternal, and right parasternal windows. Acquire the absolute AS peak velocity and freeze the image. The opening and closing snaps should be visible. b. Start and finish at zero baseline and carefully trace the entire waveform. c. The max PG, mean PG, and peak velocity are calculated by the ultrasound machine if the calculations package is utilized while tracing the waveform. d. Once #1, #2, and #3 are in the AOV calculations package, the AVA is determined. EXAMPLE Assume the LVOT = 1.8 cm, V1 = 1.0 m/sec, and V2 = 4.5 m/sec, according to the Continuity Equation, the AVA = (.785) (LVOT) 2 (V1) / (V2) = (.785) (1.8 cm) 2 (1.0 m/sec) / (4.5 m/sec) = 2.5 / 4.5 = 0.6 cm 2 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 176

AORTIC STENOSIS: AORTIC VALVE AREA (continued) It is the Cardiac Sonographer s job to verify that the data makes sense. If the valve looks as if it is barely opening by 2D echo, then the AVA should be decreased and the PG should be elevated if not, double check all of the measurements! If you are sure that you are acquiring all of the measurements correctly, but the AS calculations still don t correlate with the 2D findings, consider these facts. AS can be overestimated by high cardiac output states, such as anemia, pregnancy, and aortic insufficiency. AS can be underestimated by low cardiac output states, such as mitral regurgitation and dysrhythmias. A poor Doppler angle will underestimate the peak velocity through the valve. Be careful not to confuse an MR jet with an AS jet. An MR jet is wider than an AS jet because MR includes the isovolumic contraction and relaxation phases, the AS jet does not. AORTIC STENOSIS: SEVERITY SCALE DEGREE OF AS MAX PG PEAK VELOCITY AVA Mild AS 16 36 mmhg < 3.0 m/sec > 1.5 cm 2 Moderate AS 36 50 mmhg 3.0 4.0 m/sec 1.0-1.5 cm 2 Severe AS > 64 mmhg > 4.0 m/sec < 1.0 cm 2 REFERENCE: 2006 ACC/AHA Guidelines COLOR FLOW AORTIC STENOSIS: COLOR FLOW AS creates turbulent systolic flow in the region of the stenosis that travels from the left ventricular outflow tract, through the AOV (while it is open), into the aortic root. ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 177

TABLE OF CONTENTS SUBJECT PAGE I. NORMAL CARDIAC ANATOMY AND PHYSIOLOGY 1-36 OBJECTIVES 1 A. THE BIG PICTURE Cardiovascular System 2 Right Heart/Pulmonary Circulatory System 2 Left Heart/Systemic Circulatory System 2 DIAGRAM: NORMAL OXYGEN SATURATION/NORMAL PRESSURES 3 Arteries, Arterioles, Capillaries, and Venules 3 Veins 4 DIAGRAM: CARDIOVASCULAR SYSTEM: A FLOWCHART APPROACH 4 B. LOCATION AND TERMINOLOGY Terminology 5 DIAGRAM: TERMINOLOGY 5 C. PERICARDIUM AND HEART WALL Pericardium and Pericardial Space 6 Heart Wall (Epicardium, Myocardium, and Endocardium) 6 DIAGRAM: LAYERS OF HEART WALL 6 D. CHAMBERS, VESSELS, AND VALVES Cardiac Chambers Atria and Ventricles 7 Great Vessels Superior Vena Cava, Inferior Vena Cava, and Pulmonary Artery 7 Pulmonary Veins 7 Aorta 8 DIAGRAM: CARDIAC CHAMBERS AND GREAT VESSELS 8 Cardiac Valves 9 DIAGRAM: CARDIAC VALVE LOCATION 9 Atrioventricular Valves Tricuspid Valve and Mitral Valve 9 Semilunar Valves Pulmonic Valve and Aortic Valve 10 DIAGRAM: CARDIAC VALVES 10 E. ORDER OF FLOW DIAGRAM: NORMAL CIRCULATION 11 Superior Vena Cava and Inferior Vena Cava 12 Right Atrium 12 Cardiac Venous System 12 Tricuspid Valve 13 Right Ventricle 13 Pulmonic Valve 14 Pulmonary Artery 14 Pulmonary Veins 14 Left Atrium 14 Mitral Valve & DIAGRAM 15 Left Ventricle 15 Aortic Valve 16 Aorta 16 DIAGRAM: ANATOMY OF THE AORTA 17 Ascending Aorta and Coronary Artery System 18 DIAGRAM: CORONARY ARTERIES 19 Aortic Arch and Branches 19 Descending Thoracic Aorta 20 F. CARDIOVASCULAR PHYSIOLOGY Heart Sounds and Cardiac Cycle Isovolumic Contraction Time, Systole, 21 Isovolumic Relaxation Time, and Diastole DIAGRAM: CARDIAC CYCLE 22 DIAGRAM: DIASTOLE: ATRIOVENTRICULAR VALVES OPEN 23 DIAGRAM: SYSTOLE: ATRIOVENTRICULAR VALVES CLOSED 23 DIAGRAM: SYSTOLE: SEMILUNAR VALVES OPEN 24 DIAGRAM: DIASTOLE: SEMILUNAR VALVES CLOSED 24 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 178

F. CARDIOVASCULAR PHYSIOLOGY (continued) G. THE CONDUCTION SYSTEM: A QUICK REVIEW Systolic Function and Diastolic Function 25 Wall Motion Terminology 25 Cardiac Function Heart Rate, Stroke Volume, Cardiac Output, and Cardiac Index 26 Cardiac Function Equations 27 Blood Pressure 27 Preload 27 Left Ventricular End Diastolic Pressure 27 Frank-Starling Law (Length Tension Relationship) 27 Interval Strength Relationship 27 Post Extrasystolic Potentiation/Pre-Ventricular Contraction 27 DIAGRAM: POST EXTRASYSTOLIC POTENTIATION 27 Force Velocity Relationship 28 Afterload 28 Inotropic Force 28 Chronotropic Force 28 Autonomic Nervous System 28 Sympathetic Nervous System and Parasympathetic Nervous System 28 Maneuvers That Alter Cardiac Physiology 29 Valsalva Maneuver 29 Amyl Nitrite Inhalation 29 Additional Maneuvers (inspiration, expiration, squatting, standing) 29 Electrical Events 30 Electrical-Mechanical Delay 30 Conduction System 30 Property of Automaticity 30 Order of Contraction 30 Sinoatrial Node 30 Atrioventricular Node 31 Bundle Of His 31 Bundle Branches 31 Purkinje Fibers 31 Repolarization 31 DIAGRAM: CONDUCTION PATHWAY 31 DIAGRAM: THE ELECTROCARDIOGRAM EKG Paper, Waveform, Normal Values, Common Measurements DIAGRAM: ELECTRICAL + MECHANICAL = CARDIAC CYCLE 33 SUMMARY: ANATOMY AND PHYSIOLOGY 34-36 32 II. BASIC EMBRYOLOGY AND FETAL CIRCULATION 37-48 OBJECTIVES 37 A. BASIC EMBRYOLOGY WEEK 3: FIGURES 1 and 2 38 WEEK 4: FIGURES 3 and 4 39 WEEK 5: FIGURES 5, 6, and 7 40-41 WEEK 6 41 WEEK 7: FIGURES 8 and 9 42 B. FETAL CIRCULATION Duties of the Placenta, Pressure Differences, Shunting, and Oxygen Saturation 43 Fetal Circulation 43 DIAGRAM: FETAL CIRCULATION 45 C. CHANGES AT BIRTH First Breath 46 Fossa Ovalis, Ligamentum Arteriosum, Umbilical Arteries, Umbilical Vein, and Ligamentum Venosum Persistent Fetal Circulation 46 SUMMARY: BASIC EMBRYOLOGY AND FETAL CIRCULATION 47-48 46 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 179

III. TRANSTHORACIC ECHOCARDIOGRAM (TTE): THE INTRODUCTION 49-71 OBJECTIVES 49 A. THE FUNDAMENTALS Definition, Indications, Contraindications, and Advantages 50 How does ultrasound work? 50 B. TWO-DIMENSIONAL ECHO (2D ECHO) Transducers 51 Windows and Views 51 DIAGRAM: WINDOWS AND VIEWS 51 DIAGRAM: 2D IMAGING PLANES 52 DIAGRAMS: STANDARD TTE WINDOWS AND WINDOWS VERSUS VIEWS 53 Definition 54 DIAGRAM: 2D ECHO 54 DIAGRAM: 2D ECHO: ON-AXIS VERSUS OFF-AXIS 55 Standard Views 55 DIAGRAM: PARASTERNAL LONG AXIS (LAX) 56 DIAGRAM: PARASTERNAL SHORT AXIS (SAX) 56 DIAGRAM: SAX IN RELATION TO THE 4C, 2C, AND 3C 57 DIAGRAM: APICAL VIEWS (4C, 5C, 2C, 3C) 58 DIAGRAM: SUBCOSTAL VIEWS 59 DIAGRAM: SUPRASTERNAL VIEWS 60 C. MOTION MODE ECHO (M-MODE) Definition 61 DIAGRAM: M-MODE VERSUS 2D IMAGE 61 DIAGRAM: M-MODE GRAPH 62 M-mode Dimensions 62 DIAGRAM: M-MODE: OPTIMAL VERSUS SUBOPTIMAL 63 DIAGRAM: M-MODE: TIMING EVENTS OF THE CARDIAC CYCLE 63 D. DOPPLER ECHO Definition 64 DIAGRAM: DOPPLER: PARALLEL VERSUS PERPENDICULAR FLOW 64 Color Flow Doppler 65 DIAGRAM: COLOR FLOW DOPPLER 65 Spectral Doppler 66 DIAGRAM: SPECTRAL DOPPLER GRAPH 66 Pulsed Wave Doppler 67 DIAGRAM: PULSED WAVE DOPPLER 67 Continuous Wave Doppler 68 DIAGRAM: SPECTRAL DOPPLER 68 Nonimaging Continuous Wave Doppler 69 SUMMARY: INTRODUCTION TO ECHO 70 SUMMARY: STANDARD 2D ECHO VIEWS 71 IV. THE TRANSTHORACIC ECHOCARDIOGRAM (TTE) 72-124 OBJECTIVES 72 A. PREPARING FOR THE TTE Steps Prior to Performing the TTE 73 B. PARASTERNAL WINDOW Locating the Parasternal Window 75 DIAGRAM: PARASTERNAL TRANSDUCER ORIENTATION 75 Optimal Resolution 76 Parasternal Long Axis 76 DIAGRAM: LAX: 2D ECHO 77 DIAGRAM: LAX: 2D ECHO DIMENSIONS 78-79 DIAGRAM: LAX: M-MODE SCAN LINE 80 DIAGRAM: LAX: M-MODE DIMENSIONS 81 Ejection Fraction 82 DIAGRAM: LAX: MITRAL VALVE M-MODE 83 DIAGRAM: LAX: AORTIC ROOT, AORTIC VALVE, AND LEFT ATRIAL M-MODE 84 DIMENSIONS DIAGRAM: LAX: LVOT DIAMETER 85 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 180

B. PARASTERNAL WINDOW (continued) DIAGRAM: LAX: COLOR FLOW 86 DIAGRAM: LAX RVIT: 2D ECHO 86 DIAGRAM: LAX RVIT: COLOR FLOW 87 DIAGRAM: LAX RVIT: SPECTRAL DOPPLER 88 DIAGRAM: LAX RVOT: 2D ECHO 88 DIAGRAM: LAX RVOT: M-MODE 89 DIAGRAM: LAX RVOT: COLOR FLOW 89 DIAGRAM: LAX RVOT: SPECTRAL DOPPLER 90 Parasternal Short Axis (SAX) 90 DIAGRAM: SAX LV WALL SEGMENTS: 2D ECHO 91 DIAGRAM: SAX BASE: 2D ECHO 92 DIAGRAM: SAX BASE: COLOR FLOW 93 DIAGRAM: SAX BASE: SPECTRAL DOPPLER 93 C. APICAL WINDOW Locating the Apical Window 94 DIAGRAM: APICAL TRANSDUCER ORIENTATION 94 Apical 4 Chamber (4C) 95 DIAGRAM: 4C: 2D ECHO 95 DIAGRAM: 4C: COLOR FLOW 96 DIAGRAM: 4C: SPECTRAL DOPPLER 96 Diastolic Function 97 DIAGRAM: DIASTOLIC PARAMETER TOOLS 97 DIAGRAM: DIASTOLIC PARAMETERS (1-3): MITRAL FLOW 98 DIAGRAM: DIASTOLIC PARAMETERS (4-7): PULMONARY VENOUS FLOW 99 DIAGRAM: PSEUDONORMAL MITRAL FLOW 100 DIAGRAM: DIASTOLIC PARAMETER (8): ISOVOLUMIC RELAXATION TIME 101 DIAGRAM: DIASTOLIC PARAMETER (9): INFERIOR VENA CAVA DIAMETER 102 DIAGRAM: (1-9) DIASTOLIC FUNCTION GUIDELINES 103 DIAGRAM: DIASTOLIC PARAMETER (10): TISSUE DOPPLER IMAGING OF THE 104 MITRAL ANNULAR MOTION Apical 5 Chamber (5C) 105 DIAGRAM: 5C: 2D ECHO 105 DIAGRAM: 5C: COLOR FLOW 106 DIAGRAM: 5C: SPECTRAL DOPPLER (AORTIC VALVE) 107 DIAGRAM: 5C: SPECTRAL DOPPLER (LEFT VENTRICULAR OUTFLOW TRACT) 107 Apical 2 Chamber (2C) 108 DIAGRAM: 2C: 2D ECHO AND COLOR FLOW 108 Apical 3 Chamber (3C) / Apical Long Axis (Apical LAX) 109 DIAGRAM: 3C: 2D Echo 109 DIAGRAM: 3C: COLOR FLOW 110 D. SUBCOSTAL WINDOW Locating the Subcostal Window 111 DIAGRAM: SUBCOSTAL TRANSDUCER ORIENTATION 111 DIAGRAM: SUBCOSTAL OPPORTUNITIES 112 Subcostal Four Chamber (4C) 113 DIAGRAM: SUBCOSTAL 4C: 2D ECHO AND COLOR FLOW 113 Subcostal Short Axis (SUBCOSTAL SAX) 114 DIAGRAM: SUBCOSTAL SAX LV AND BASE: 2D ECHO 114 DIAGRAM: SUBCOSTAL IVC: 2D ECHO AND COLOR FLOW 115 DIAGRAM: SUBCOSTAL DAO: 2D ECHO AND COLOR FLOW 116 E. SUPRASTERNAL WINDOW Locating the Suprasternal Window 117 DIAGRAM: SUPRASTERNAL TRANSDUCER ORIENTATION 117 Suprasternal Long Axis (SUPRASTERNAL LAX) 118 DIAGRAM: SUPRASTERNAL LAX: 2D ECHO AND DOPPLER 118 Suprasternal Short Axis (SUPRASTERNAL SAX) 119 DIAGRAM: SUPRASTERNAL SAX: 2D ECHO AND COLOR FLOW 119 SUMMARY: TTE, STANDARD TTE PROTOCOL, AND DIASTOLIC FUNCTION 120-124 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 181

V. THE TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE) 125-135 OBJECTIVES 125 A. TEE FUNDAMENTALS Definition 126 The Team 126 B. TEE WINDOWS, VIEWS, AND PROBES Key to a Successful TEE 127 Advantages of TEE 127 Disadvantages of TEE 127 Additional Materials 128 Indications for TEE 129 DIAGRAM: CONTRAST BUBBLE STUDY 130 Contraindications 131 Standard Windows 132 Omniplane Probe 132 DIAGRAM: OMNIPLANE TEE PROBE 133 DIAGRAM: OMNIPLANE TEE VIEWS (just a few ) 133 Biplane Probe and Single Plane Probe 134 Transnasal Probe 134 SUMMARY: TEE 135 VI. THE STRESS ECHOCARDIOGRAM (SE) 136-155 OBJECTIVES 136 A. SE FUNDAMENTALS Definition 137 B. SE ADVANTAGES, INDICATIONS, AND CONTRAINDICATIONS The Team 137 Key to a Successful SE 137 Cardiac Response to Stress 137 DIAGRAM: WALL SEGMENTS AND CORONARY ARTERY DISTRIBUTION 138-139 Criteria for a Positive SE 140 Wall Motion Index 140 DIAGRAM: 17 SEGMENT MODEL AND CORONARY ARTERY DISTRIBUTION 141 Advantages 142 Indications 142 Contraindications 143 C. SE INSTRUMENTATION Equipment 144 Common Views 144 DIAGRAM: THE QUAD SCREEN 144 Capturing Systolic Beats 145 Proofreading the Final Images 145 D. TYPES OF SE EXAMINATIONS Treadmill Stress Echo (TMSE) 146 Patient Education and Patient Prep 146 Rest Images 147 Breathing Exercises 147 Test Termination 147 Immediate Post Images 148 DIAGRAM: TREADMILL STRESS ECHO 148 Supine Bicycle Stress Echo (SBSE) 149 Double Product 149 Patient Education and Patient Prep 149 Rest Images 150 Peak and Immediate Post Images 151 DIAGRAM: SUPINE BICYCLE STRESS ECHO 151 Pharmacologic Stress Echo/Dobutamine Stress Echo (DSE) 152 Patient Education and Patient Prep 152 Five Stages 153 DIAGRAM: DOBUTAMINE STRESS ECHO 154 SUMMARY: STRESS ECHO 155 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 182

VII. CARDIAC CATHETERIZATION (CATH): THE BASICS 156-169 OBJECTIVES 156 A. CATH FUNDAMENTALS Definition 157 Indications 157 Fluoroscopy Versus Digital 157 B. CATH PROCEDURES Procedures (Right Heart and Left Heart) 158 DIAGRAM: CORONARY ARTERIES 160 Intravascular Ultrasound (IVUS) 160 DIAGRAM: NORMAL CATH PRESSURE TRACINGS 161 Echo Pressure Gradient Versus Cath Gradient 161 DIAGRAM: CATH VERSUS ECHO 162 Stenotic Valves 162 DIAGRAM: AORTIC STENOSIS 163 DIAGRAM: MITRAL STENOSIS 164 Regurgitant Valves 165 Quality Assurance 165 DIAGRAM: AORTIC INSUFFICIENCY AND AORTIC STENOSIS 166 DIAGRAM: MITRAL REGURGITATION 167 C. CATH CONTRAINDICATIONS AND Contraindications 168 RISKS Risks 168 SUMMARY: CARDIAC CATH 169 VIII. VALVULAR HEART DISEASE (VHD) 170-214 OBJECTIVES 170 A. INTRODUCTION Incidence 171 Review: Normal Flow 171 DIAGRAM: LAMINAR VERSUS TURBULENT 171 Doppler 171 DIAGRAM: NORMAL VERSUS ABNORMAL FLOW 172 B. VALVULAR STENOSIS Definition 173 Proximal to the Stenotic Valve 173 At the Level of the Stenotic Valve 173 Distal to the Stenotic Valve 173 Consequences of Stenosis 174 Cardiac Sonographer s Role 174 Calculating the Area 174 Maximum Pressure Gradient 174 Correlation Between Cath and Echo 175 DIAGRAM: PRESSURE GRADIENTS (PG) 175 C. VALVULAR REGURGITATION Definition 176 Volume Overload Pattern 176 Side Effects 176 DIAGRAM: INTRODUCTION TO REGURGITATION 177 D. MITRAL STENOSIS (MS) THE FACTS (Definition, Murmur, Causes, Complications, Signs & Symptoms, 178-179 Treatment) 2D ECHO AND COLOR FLOW 180 M-MODE 181 MS WITH PULMONARY HYPERTENSION (PHTN): 2D ECHO AND M-MODE 182 DOPPLER 183 E. MITRAL REGURGITATION (MR) THE FACTS (Definition, Murmur, Causes, Complications, Signs & Symptoms, 184 Treatment, Advanced Technology) 2D ECHO AND M-MODE 185 COLOR FLOW DOPPLER AND SEVERITY SCALE 186 DOPPLER 187 PULMONARY VEIN IN THE PRESENCE OF MR: DOPPLER 188 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 183

F. MITRAL VALVE PROLAPSE (MVP) THE FACTS (Definition, Causes, Murmur, Complications/Signs & Symptoms, Treatment) 2D ECHO 190 M-MODE AND COLOR FLOW 191 G. AORTIC STENOSIS (AS) THE FACTS (Definition, Murmur, Causes, Complications, Signs & Symptoms, 192-193 Treatment, Advanced Technology) 2D ECHO 194 PLANIMETRY AND M-MODE 195 CALCULATIONS 196-197 AORTIC VALVE AREA 198-199 SEVERITY SCALE 199 COLOR FLOW 199 H. AORTIC INSUFFICIENCY (AI) THE FACTS (Definition, Causes, Murmur, Complications/Signs & Symptoms, Treatment) 2D ECHO AND M-MODE 201 DOPPLER AND SEVERITY SCALE 202-203 COLOR FLOW 203 I. TRICUSPID STENOSIS (TS) THE FACTS (Definition, Murmur, Causes, Complications, Signs & Symptoms) 204 2D ECHO, M-MODE, DOPPLER, AND SEVERITY SCALE 205 J. TRICUSPID REGURGITATION (TR) THE FACTS (Definition, Murmur, Causes, Complications/Signs & Symptoms, Treatment) 2D ECHO, M-MODE, AND COLOR FLOW 207 DOPPLER AND SEVERITY SCALE (PULMONARY HYPERTENSION) 208 K. PULMONIC STENOSIS (PS) THE FACTS (Definition, Murmur, Causes, Complications) 209 2D ECHO, M-MODE, DOPPLER, AND SEVERITY SCALE 210 L. PULMONIC INSUFFICIENCY(PI) THE FACTS (Definition, Murmur, Causes, Complications) 211 2D ECHO, M-MODE, AND DOPPLER 212 SUMMARY: VALVULAR HEART DISEASE 213-214 189 200 206 IX. INFECTIVE ENDOCARDITIS (IE) 215-220 OBJECTIVES 215 THE FACTS (Definition, Etiology, Types, Risk Factors, Prevention, Signs & 216-217 Symptoms, Complications, Treatment) 2D ECHO 218 M-MODE 219 SUMMARY: INFECTIVE ENDOCARDITIS 220 X. PROSTHETIC HEART VALVES 221-227 OBJECTIVES 221 ETIOLOGY AND SELECTION (Tissue Versus Mechanical) 222 BIOPROSTHETIC (TISSUE) VALVES (Types, Complications) 223 MECHANICAL VALVES (Types, Complications) 224 ECHO 225 SKETCHES 226 SUMMARY: PROSTHETIC HEART VALVES 227 XI. ISCHEMIC HEART DISEASE (IHD) 228-233 OBJECTIVES 228 THE FACTS (Ischemia, Injury, and Infarct; Causes, Signs & Symptoms, Risk 229-231 Factors, Treatment/Advanced Technology, Recognizing MI, Diagnostic Tests, Complications) ECHO 232 SUMMARY: ISCHEMIC HEART DISEASE 233 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 184

XII. CARDIOMYOPATHY (CMO) 234-246 OBJECTIVES 234 DEFINITION AND CATEGORIES DEFINITION AND CATEGORIES (DILATED, HYPERTROPHIC, AND 235 RESTRICTIVE/INFILTRATIVE) A. DILATED CMO THE FACTS (Definition, Causes, Complications/Signs & Symptoms) 235 2D ECHO 236 M-MODE AND DOPPLER 237 B. HYPERTROPHIC CMO (HCMO) THE FACTS (Definition, Etiology, Treatment Options, Signs & Symptoms, 238-239 Complications, Additional Names, Types of Hypertrophic CMO) 2D ECHO AND COLOR FLOW 240 M-MODE 241 DOPPLER 242 C. RESTRICTIVE/INFILTRATIVE CMO THE FACTS (Definition, Signs & Symptoms, Treatment, Types) 243-244 ECHO 245 SUMMARY: DILATED CMO, HYPERTROPHIC CMO, AND RESTRICTIVE/INFILTRATIVE CMO 246 XIII. HEART FAILURE (HF) 247-250 OBJECTIVES 247 THE FACTS (Definition, Causes, Complications, Left and Right Sided Failure) 248-249 ECHO 250 SUMMARY: HEART FAILURE 250 XIV. MYOCARDITIS 251-253 OBJECTIVES 251 THE FACTS (Definition, Causes, Etiology, Signs & Symptoms, Treatment) 252 ECHO 253 SUMMARY: MYOCARDITIS 253 XV. PERICARDITIS/CONSTRICTIVE PERICARDITIS 254-257 OBJECTIVES 254 THE FACTS (Definition, Etiology, Types, Complications, Constrictive Pericarditis) 255 ECHO 256 RESTRICTIVE/INFILTRATIVE CMO VERSUS CONSTRICTIVE PERICARDITIS 256 SUMMARY: PERICARDITIS AND CONSTRICTIVE PERICARDITIS 257 XVI. PERICARDIAL EFFUSION AND TAMPONADE 258-266 OBJECTIVES 258 A. PERICARDIAL EFFUSION THE FACTS (Definition, Etiology, Signs & Symptoms, Differential Diagnosis) 259 2D ECHO 260 B. TAMPONADE THE FACTS (Definition, Size, Etiology, Clinical Diagnosis, Clinical Presentation, 261-262 Complications, Signs & Symptoms, Treatment) 2D ECHO 263 M-MODE 264 DOPPLER 265 SUMMARY: PERICARDIAL EFFUSION AND TAMPONADE 266 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 185

XVII. MYXOMAS, TUMORS, MASSES, AND MISSILES 267-273 OBJECTIVES 267 A. TUMORS PRIMARY BENIGN TUMORS (INTRACARDIAC): Myxoma 268 PRIMARY BENIGN TUMORS (INTRACARDIAC): Papillary Fibroelastoma, Lipoma, Fibroma, Rhabdomyoma PRIMARY MALIGNANT TUMORS (INTRACARDIAC): Angiosarcoma, Sarcoma 270 SECONDARY TUMORS (METASTATIC) 270 EXTRACARDIAC TUMORS 270 CARCINOID HEART DISEASE 270 B. THROMBUS THE FACTS (Definition, Types, Echo) 271 C. MISSILES THE FACTS (Definition, Side Effects, Echo) 272 SUMMARY: MYXOMAS, TUMORS, MASSES, AND MISSILES 273 269 XVIII. DISEASES OF THE AORTA 274-278 OBJECTIVES 274 A. AORTIC DISSECTION THE FACTS (Definition, Etiology, Types, Signs & Symptoms, Complications) 275 ECHO 276 B. ADDITIONAL DISEASES OF THE AORTA Sinus of Valsalva Aneurysm, Marfan Syndrome, Aortic Aneurysm, Coarctation of the Aorta SUMMARY: DISEASES OF THE AORTA 278 277 XIX. CONGENITAL ANOMALIES 279-296 OBJECTIVES 279 A. ATRIAL SEPTAL DEFECT Definition, Types, Hemodynamic Effect, After Birth, Echo, Qp/Qs Ratio 280 DIAGRAM: ATRIAL SEPTAL DEFECT: ECHO 281 DIAGRAM: Qp/Qs RATIO 282 B. VENTRICULAR SEPTAL DEFECT Definition, Types, Echo, Qp/Qs Ratio 283 DIAGRAM: VENTRICULAR SEPTAL DEFECT: ECHO, Qp/Qs RATIO 284 C. PATENT DUCTUS ARTERIOSUS Definition, Murmur, Echo, Qp/Qs Ratio 285 DIAGRAM: PATENT DUCTUS ARTERIOSUS: ECHO, Qp/Qs RATIO 286 D. ENDOCARDIAL CUSHION DEFECT Definition, Associated Findings, Signs & Symptoms & DIAGRAM 287 E. CLEFT MITRAL VALVE Definition and Associated Lesions & DIAGRAM 288 F. PULMONIC STENOSIS Definition, Types, Changes Over Time, Echo 289 G. COARCTATION OF THE AORTA Definition, Associated Findings, Types, Echo & DIAGRAM 290 H. EBSTEIN ANOMALY Definition, Associated Findings, Echo & DIAGRAM 291 I. TETRALOGY OF FALLOT Four Defects, Symptoms, Echo & DIAGRAM 292 J. TRANSPOSITION OF THE GREAT ARTERIES K. HYPOPLASTIC LEFT HEART SYNDROME Etiology, Dextro-TGA, Levo-TGA, Map of the Flow 293 DIAGRAM: TRANSPOSITION OF THE GREAT ARTERIES: SKETCH 294 Definition, Diagnosis, At Birth, Treatment Options, Echo 295 SUMMARY: CONGENITAL ANOMALIES 296 XX. 3D/RT3D (4D) ECHOCARDIOGRAPHY 297-303 OBJECTIVES 297 A. HISTORY OF 3D ECHO HISTORY AND ACQUISITION OF 2D IMAGES 298 B. REAL-TIME 3D (RT3D) ECHO (aka 4D Echo) CARTESIAN COORDINATE SYSTEM 298 QUALITY OF 3D RECONSTRUCTION 299 HISTORY, TRANSDUCER, ACQUISITION MODES, TECHNICAL FACTORS 300 PROTOCOL AND CLINICAL APPLICATIONS 301 REFERENCES AND SUGGESTED READING 304 ECHOCARDIOGRAPHY... From a Sonographer s Perspective: THE NOTEBOOK (6.5) 186