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4 echo study
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●
PART 2: CARDIAC IMAGING TECHNIQUES
thromboembolism
● neurological disorders (with cardiac involvement)
● arrhythmias (with suspected/possible structural heart disease)
● syncope (with suspected/possible structural heart disease)
● hypertension (if left ventricular hypertrophy (LVH)/dysfunction or
aortic coarctation are suspected)
● aortic disease (e.g. monitoring of aortic root dimensions in Marfan
syndrome)
● known or suspected congenital heart disease.
It is essential that echo requests contain adequate clinical data both to judge
the appropriateness of the request and also to allow the sonographer to
place the echo findings into an appropriate clinical context (see the box
‘Sensitivity, specificity and Bayesian analysis’). Echo requests should
therefore carry appropriate clinical details and must contain information
about known cardiac diagnoses or previous cardiac interventions/surgery
(e.g. prosthetic valves). Clinicians requesting echo studies should be
encouraged to include specific questions with their request (e.g. ‘Does this
patient have pulmonary hypertension?’), as this provides a clear focus for
the echo study and ensures that the sonographer can address the specific
concerns of the clinician.
● Sensitivity is the degree to which a test will identify all those who
have a particular disease – if 100 people with disease ‘X’ undergo
a test with 90 per cent sensitivity, the test will detect the disease
in 90 of them (but will produce a false negative in 10)
● Specificity is the degree to which a test will identify all those
without a particular disease – if 100 people without disease ‘X’
undergo a test with 90 per cent specificity, the test will be
normal in 90 of them (but will produce a false positive in 10).
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Transthoracic echo study
The number of people who receive false positive/negative results
is determined not only by the sensitivity and specificity of the test,
but also by the population prevalence of the disease in question.
Screening a large number of normal individuals for a rare disease
using a test with imperfect specificity will produce a relatively
large number of false positive results.
● Patient preparation
Patients attending for an echo study may feel anxious, not only about having
the test itself but also about any abnormalities that it may reveal. To help
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PART 2: CARDIAC IMAGING TECHNIQUES
reduce anxiety the test should be described to patients in clear and reassuring
terms – patients should have an explanation of why they are having an echo,
whether any special preparation is needed before they attend, what happens
during the scan and how long it will take. Patients should be reassured that
having an echo is safe and painless. Patients can eat and drink normally before
attending for a standard TTE, and they can take their medication as usual.
It is good practice to offer patients an information leaflet before they attend
(and to make available large print/Braille and translated versions as
appropriate). The patient information leaflet and/or appointment letter can
also invite the patient to bring a friend or relative if they wish to have
someone accompany them during the echo. If a friend or relative does not
accompany the patient when they attend, the patient should be offered
a chaperone in line with hospital policy.
Once the patient is in the echo room and you have checked that they
understand the test that is about to be performed, you should ask them to
undress to the waist for the echo study. Female patients should always be
offered a gown to wear during the echo (even if the sonographer is female).
Ask the patient to sit on the echo couch and recline at 45°, rolling on to their
left side. The patient should then raise their left arm and place their left
hand behind their head. Be sure to check if the patient has any physical
limitations that may make it difficult or uncomfortable for them to adopt
this position. If so, you may need to adapt the patient’s position until they
are comfortable. Sonographers who prefer to scan left-handed will also need
to adapt the patient’s positioning accordingly.
When the patient is in a comfortable position, apply the ECG electrodes and
ensure that a clear ECG tracing is visible on the screen of the echo machine.
You may need to adjust the electrodes and/or the ECG gain setting to obtain
a good trace. Ensure that the correct patient identification and clinical details
are entered into the echo machine, and then perform and report the study as
described in the sections that follow. At the end of the study, explain to the
patient that you will be writing a report which will be sent to the referring
clinician. Patients may ask you what the study has shown, but you should not
discuss the study findings at this stage and it is usually better to redirect
persistent requests for information to the referring clinician.
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used when other views are suboptimal or when additional information is
Suprasternal
Right Left
parasternal parasternal
Apical
Subcostal
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Parasternal long axis view
PART 2: CARDIAC IMAGING TECHNIQUES
The parasternal long axis (LAX) view is shown in Fig. 6.2. To obtain the view
with the probe in the left parasternal window, rotate the probe so that the
probe’s ‘reference point’ (sometimes a ‘dot’) is pointing towards the
patient’s right shoulder.
LV antero-
septal wall
Aortic valve
RVOT (right coronary
Mitral valve
cusp)
LV posterior Ao
LVOT Aortic valve
wall
LV (non-coronary
cusp)
LA
Fig. 6.2 Normal parasternal long axis view (Ao aorta; LA left atrium;
LV left ventricle; LVOT left ventricular outflow tract; RVOT right
ventricular outflow tract)
For an optimal view, aim to position the probe so that the view cuts through
the centre of mitral and aortic valves, without foreshortening the left
ventricle (LV) or ascending aorta. In this view:
● Use 2-D M-mode to:
䊊 assess structure and mobility of the aortic valve. The right and
non-coronary cusps are visible and normally have a central closure
line – an eccentric closure line suggests bicuspid aortic valve
䊊 measure the aortic root dimensions and inspect the ascending aorta;
do not forget to look at the descending aorta as it runs behind the
left atrium (LA) – this is a useful landmark for assessing a
pericardial/pleural effusion
䊊 assess structure and mobility of the mitral valve – in this view, the
A2 and P2 segments are visible
䊊 measure LA dimensions
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Transthoracic echo study
䊊 measure LV dimensions and assess function (anteroseptum and
posterior (also known as inferolateral) wall)
䊊 measure RV dimensions and assess function
䊊 assess the pericardium and check for any pericardial (or pleural)
effusion.
● Use colour Doppler to:
䊊 assess the aortic valve for stenosis or regurgitation
䊊 examine mitral valve inflow and check for regurgitation
䊊 check for flow acceleration in the left ventricular outflow tract
(LVOT) in association with septal hypertrophy
䊊 check the integrity of the interventricular septum (IVS).
Tricuspid valve
- anterior leaflet
- posterior leaflet
RV
RA
Fig. 6.3 Normal right ventricular inflow view (RA right atrium; RV right
ventricle)
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PART 2: CARDIAC IMAGING TECHNIQUES
䊊 assess the structure of the RA. In this view it may be possible to see
the coronary sinus and the inferior and superior vena cavae as they
join the RA. There may be a prominent Eustachian valve at the
junction with the inferior vena cava (IVC)
䊊 assess the size and function of the RV.
● Use colour Doppler to examine tricuspid valve inflow and check for
regurgitation.
● Use continuous wave (CW) and pulsed wave (PW) Doppler to assess
tricuspid valve function. If tricuspid regurgitation is present, measure
the maximum velocity to assess RV systolic pressure.
Pulmonary valve
RV
PA
Fig. 6.4 Normal right ventricular outflow view (PA pulmonary artery;
RV right ventricle)
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● Use colour Doppler to examine the pulmonary valve for stenosis or
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PART 2: CARDIAC IMAGING TECHNIQUES
LA
Fig. 6.5 Normal parasternal short axis view (aortic valve level) (LA left
atrium; RV right ventricle)
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Transthoracic echo study
Mitral valve
RV
Fig. 6.6 Normal parasternal short axis view (mitral valve level) (RV right ventricle)
● At the papillary muscle level (Fig. 6.7), use 2-D M-mode to:
䊊 assess structure of the posteromedial and anterolateral papillary
muscles
Anterolateral
papillary muscle
Posteromedial
papillary muscle RV
Fig. 6.7 Normal parasternal short axis view (papillary muscle level) (RV right
ventricle)
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PART 2: CARDIAC IMAGING TECHNIQUES
Apical window
The apical window is located at the LV apex. This is normally in the mid-
clavicular line and the fifth intercostal space, but may be displaced
downwards and to the left if the heart is enlarged. From the apical window
a number of views can be obtained.
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Transthoracic echo study
LV infero-septal wall
LV lateral wall
Tricuspid valve
- septal leaflet LV
- anterior leaflet RV Mitral valve
RA LA
Fig. 6.8 Normal apical 4-chamber view (LA left atrium; LV left ventricle;
RA right atrium; RV right ventricle)
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PART 2: CARDIAC IMAGING TECHNIQUES
LVOT
LV
Aortic valve RV
RA Ao LA
Fig. 6.9 Normal apical 5-chamber view (Ao aorta; LA left atrium;
LV left ventricle; LVOT left ventricular outflow tract; RA right atrium;
RV right ventricle)
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Transthoracic echo study
LV anterior wall
LV inferior wall
Mitral valve
LV
LA
Fig. 6.10 Normal apical 2-chamber view (LA left atrium; LV left ventricle)
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PART 2: CARDIAC IMAGING TECHNIQUES
LV antero-
septal wall
LV posterior
wall Aortic valve
Mitral valve LV
Ao
LA
Subcostal window
The subcostal window is obtained with the patient lying supine with their arms
by their sides. It is important that the abdominal wall is relaxed, and asking the
patient to lie with their knees bent can help this. The probe should be placed
just below the xiphisternum and angled up towards the heart, with the ‘dot’ to
the patient’s left. From the subcostal window a number of views can be
obtained.
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Subcostal long axis view
RV
Interatrial septum
RA
LV
LA
Fig. 6.12 Normal subcostal long axis view (LA left atrium; LV left
ventricle; RA right atrium; RV right ventricle)
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PART 2: CARDIAC IMAGING TECHNIQUES
IVC
Fig. 6.13 Normal subcostal short axis (inferior vena cava (IVC)) view
Suprasternal window
The suprasternal window is located in the suprasternal notch. Ask the
patient to lie supine and to raise their chin. Place the probe in the notch and
angle it downwards into the chest. Be mindful that some patients find this
uncomfortable. This view shows the aortic arch in LAX (Fig. 6.14). A similar
view can, if needed, be obtained from the right supraclavicular position.
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Transthoracic echo study
Left carotid
Ascending aorta artery
Left subclavian
artery
Descending
Right pulmonary
aorta
artery
Modality 2-D
Aorta view
● Use 2-D to assess the appearances and dimensions of the aortic arch.
● Use colour Doppler to assess flow in the aorta, looking in particular for
evidence of coarctation or persistent ductus arteriosus.
● Use CW and PW Doppler to:
䊊 assess flow in the ascending aorta in the presence of aortic stenosis
䊊 assess flow in the descending aorta in the presence of a coarctation.
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PART 2: CARDIAC IMAGING TECHNIQUES
would be the patient’s National Health Service (NHS) number). The
patient’s age (or date of birth) and gender should be stated. The report
must also identify the referring clinician and the sonographer and state
the indication for the echo request and the date on which the study was
performed.
Detailed findings
The main body of your echo report should contain systematic descriptions
of each of the main cardiac structures (chambers, valves, great vessels and
pericardium). For each structure you need to describe its appearance and
also its function, grading any abnormalities as mild, moderate or severe
where possible (and supporting these statements with measurements
where appropriate).
It is usually easiest to set out your study findings by anatomical structure
(e.g. mitral valve, LV, etc.) rather than by echo window or modality (which
can make the report confusing and repetitive). You can simply describe the
findings relating to each anatomical structure in turn, or you may prefer to
adapt the list of findings so that the most significant abnormalities appear
at the start. Any relevant measurements (M-mode, 2-D and Doppler) and
calculations can be included in the descriptive text of each anatomical
structure, or if you prefer as a separate section.
The BSE Minimum Dataset for a Standard Adult Transthoracic
Echocardiogram describes the essential information you need to include in
a standard echo report (see Further Reading). It is important to use
standardized terminology in your report to minimize variability between
studies performed at different times and by different sonographers. The
BSE and ASE reporting guidelines contain tables of recommended
descriptive terms and diagnostic statements and it can be very helpful to
use these guidelines as a reference when writing up your study findings.
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