DEPARTMENT NAME
TRANSTHORACIC ECHOCARDIOGRAPHY (TTE)
Angela Gooden RN, MSN, CPNP-PC/AC
Director, Advanced Practice
Cardiology Nurse Practitioner
Instructor, Baylor College of Medicine
DEPARTMENT NAME
• Describe basic principles
• Review limitations
• Describe the various methods
• Identify common views
• Review reasons to obtain an echo
• Identify normal findings
OBJECTIVES
DEPARTMENT NAME
Basic principlesUtility
INTRO TO ECHO
DEPARTMENT NAME
BASIC ECHO PRINCIPLES
• Non-invasive imaging • A transducer placed on the
chest emits sound waves that are used to create images
• No known adverse effects at clinical imaging frequencies
• Sound wave reflection determines image brightness
Sound wave reflection• High (white) = Air, bone, tissue
• Low (black) = body fluids, e.g. blood
DEPARTMENT NAME
UTILITY OF ECHO IMAGING• Quantitative and qualitative
evaluation of cardiac anatomy, hemodynamics, and function• Chamber size• Systolic, diastolic function• Valve motion, function• Masses, fluid collections• Hemodynamics
• Data is influenced by height, sex, age, ethnicity, body habitus, and athleticism
DEPARTMENT NAME
ScreenWindowsPlanesProtocol
IMAGING ORIENTATION
DEPARTMENT NAME
SCREEN ORIENTATION
Transducer
L: Medial/right structures
R: Lateral/left structures
D: Distant anatomy
L R
D
DEPARTMENT NAME
IMAGING WINDOWS• Suprasternal
• Parasternal
• Apical
• Subcostal
DEPARTMENT NAME
IMAGING PLANES• Long axis
• Short axis
• Apical
DEPARTMENT NAME
• Parasternal, long axis• Parasternal, short axis• Apical• Situs View• Subcostal, long axis• Subcostal, short axis• Suprasternal (arch views)• Ductal view• Pulmonary veins (crab view)
BASIC IMAGING PROTOCOL
DEPARTMENT NAME
2DM-ModeDoppler
ECHO TECHNIQUES
DEPARTMENT NAME
ECHO TECHNIQUE, 2D
Two-dimensional (2-D)• Cross-sectional• Snapshot, provides real-time
imaging in quick succession
Usefulness• Assessment of cardiac
structure
• Assessment of chamber & vessel size and volume
• Quantitative assessment of LV function and ejection fraction
DEPARTMENT NAME
DEPARTMENT NAME
ECHO TECHNIQUE, M-MODE
Motion mode (M-mode)• Ultrasound signal transmission
along one line• Graphs represent depth and
strength of ultrasound signal• High sensitivity to recording rapidly
moving structures, e.g. valve leaflets• Useful in providing dimension
measurements, e.g. shortening fraction
DEPARTMENT NAME
Continuous wave (CW)• Doppler continuously sends and receives
signals across moving blood flow
• Detects high velocity flows: Blue, Away-Red, Toward-Turbulence, Green
• Measures severity of stenosis, regurgitation in valves, shunts, conduits, etc.
ECHO TECHNIQUE, DOPPLER
DEPARTMENT NAME
ECHO TECHNIQUE, DOPPLERPulsed wave (PW)• Intermittent signal
• Allows spatial localization
• Limited by velocity of flow
DEPARTMENT NAME
ECHO TECHNIQUE, DOPPLER
Color Flow
• Integrated with 2D image
• Displays blood flow timing, velocity, direction, and turbulence
DEPARTMENT NAME
Acquired images and demonstrated structures
IMAGING PROTOCOLS
DEPARTMENT NAME
PARASTERNAL LONG AXIS VIEW• Transducer at 3-4th intercostal
space
• Structures: LA, MV, LV, LVOT, AV, IVS, RV, Ascending aorta
• Tilt and rotate the transducer to see RVOT, PV, PA
LA
LV
RV
LA
RV
LV AV
MV
Asc Ao
IVS
DEPARTMENT NAME
PARASTERNAL SHORT AXIS VIEW (PSAX)• 90° rotation from long axis
view, tilted superiorly
• 1 dimensional assessment
• Structures: AV, LA, RA, TV, RVOT, PV, IAS
DEPARTMENT NAME
PSAX TRANSITION• 90° rotation from long axis
view, tilted superiorly
• Great vessel level—Focus on aortic valve
• Mitral valve level, anterior and posterior leaflets
• Left ventricle, papillary muscles, apex
DEPARTMENT NAME
PARASTERNAL SHORT AXIS TRANSITION
1: Great vessel level 2: Mitral valve level 3: Papillary muscle level
DEPARTMENT NAME
APICAL VIEW
Four chamber• Transducer at the cardiac apex
• Structures: LA, MV, LV, RV, TV, RA, interatrial septum, interventricular septum
LARA
LV
RV
DEPARTMENT NAME
APICAL VIEW
Five chamber• Transducer tilted anteriorly
towards the chest wall from the four chamber view
• Aortic valve and ascending aorta come into view
LVRV
LARA
AV
DEPARTMENT NAME
SUBCOSTAL VIEW• Transducer placed under the
xiphoid process
• Long axis: IVC, RA, IAS, hepatic veins
IVC RA
DEPARTMENT NAME
SUBCOSTAL VIEW, LONG AXIS
LV
LA
Liver
RA
• 4-chamber view
• Structures: RA, RV, LA, LV, IAS
RV
DEPARTMENT NAME
SUBCOSTAL VIEW, SHORT AXIS• Structures: RV, PA, LV
RV
PALV
DEPARTMENT NAME
SUPRASTERNAL VIEW• Transducer placed above the
suprasternal notch, ‘arch view’
• Ascending/descending aorta, arch, take-off of the great vessels, and right PA short axis
RPA
Asc Ao
Dsc Ao
DEPARTMENT NAME
PULMONARY VEINS• View from the suprasternal
notch, pulmonary veins and LA
• ‘Crab view’RPA
LA
Ao
1
23
4
SVC
DEPARTMENT NAME
IndicationsLimitationsFindings
ORDERING AN ECHO
DEPARTMENT NAME
INDICATIONS TO REQUEST AN ECHO
• Evaluate valve/ventricular function
• Evaluate for structural abnormalities
• Estimate intracardiac/vascular pressures
• Rule out cardiac source of embolism, e.g. stroke or TIA
• Evaluate for LVH with hypertension
• Evaluate pericardial effusions• Assess for intracardiac
vegetation, masses, or thrombi
DEPARTMENT NAME
LIMITATIONS OF ECHO IMAGING
• Poor acoustic windows: Obesity, chest wall deformities, chronic lung disease
• Excessive movement—sedation may be required
• Masses
• Apical lesions
• Aortic dissections
• Pericardial disease
DEPARTMENT NAME
VELOCITY DATA• The simplified Bernoulli
equation translates velocity data to pressure gradients
• Velocities toward the transducer are above the line, those away are below
• Flow color: laminar vs. turbulent
Valve Peak (m/s) Range (m/s)AV/Ao 1.3 0.9-1.7
LV 0.9 0.7-1.1MV 0.9 0.6-1.3TV 0.5 0.3-0.7
PV/PA 0.75 0.5-1.0
ΔP = 4V2
DEPARTMENT NAME
BERNOULLI EXAMPLE• ∆P = 4V2 = 4 x (5) 2 = 100 mmHg
• Interpret with caution when there are multiple levels of obstruction or small/long vessels
DEPARTMENT NAME
NORMAL FINDINGS• Mild mitral, tricuspid
regurgitation
• Chiari network• Embryological remnant of the
sinus venosus R valve
• Web-like, mobile structure in the RA
• Eustachian valve• Endocardial ridge or fold at the
RA/IVC junction
• Crista terminalis• Embryological remnant of RA
fusion
• Anterior muscular ridge passing from the SVC to IVC
DEPARTMENT NAME
COMMENTS/QUESTIONS?