Learning objectives
Key terminology
Pre-procedure considerations

Basic physiology of the heart

• Basic cardiac physiology

  The function of the heart is to maintain blood flow throughout the body through a coordinated series of events that results in deoxygenated blood returning to the right atrium and being transferred to the pulmonary circulation. Blood then returns to the left atrium through four main pulmonary veins, and passes through the mitral valve into the left ventricle, from where it is pumped through the aortic valve into the aorta and throughout the body.

• The cardiac cycle

  The Wiggers diagram summarizes the electrical, pressure, and volume changes that occur in the heart during the normal cardiac cycle. A cardiac cycle is the time from one heartbeat to the next, and is similar to the R-R interval on an ECG. A cardiac cycle includes one period of systole and one period of diastole.

  
  Cardiac cycle

  The segments of the myocardium contract and move in a longitudinal direction, producing a piston-like motion contributing to most of the cardiac heart motion. The apex is the fixed point. The longitudinal fibers are the first ones to become ischemic.

Principles of Doppler imaging

Doppler echocardiography is used to assess blood flow through various chambers in the heart and across valves. Doppler ultrasound is different from other forms of imaging, since it focuses on the change in frequency that occurs when transmitted sound waves are reflected off a moving object.

Three types of Doppler are used commonly in echocardiography to assess blood flow: color, continuous wave, and pulsed wave Doppler. A fourth type of Doppler, tissue Doppler imaging, is used to assess the movement of the myocardium during systole and diastole (rather than movement of red blood cells).

Color Doppler
Color Doppler is used to provide information about the direction and the mean velocity of blood flow across a valve or in a blood vessel. This information is displayed in a color box superimposed over the 2D image using two colors. These colors indicate the direction of the blood flow relative to the transducer. Negative velocities are those moving away from the transducer and are generally represented as blue. Positive velocities are those moving towards the transducer and are generally represented as red (The mnemonic is 'BART': blue away, red towards). Higher velocities are displayed in lighter shades of these two colors. The ultrasound machine has a number of color maps available for selection. Care must be taken to select the color PRF (positive/negative) in the same orientation.

Color coding

A wall filter is used to eliminate low-frequency velocities that arise from the heart walls and valves.

Color Doppler provides qualitative information about blood flow, and therefore the selection of a Doppler angle is not as critical compared to pulsed wave (PW) or continuous wave (CW), because there are no angle-dependent quantitative measurements involved in color Doppler.

Main uses:

• assessing the presence of regurgitation and shunts
• positioning the cursor for M-mode and spectral Doppler

Continuous Wave (CW) Doppler
Continuous wave Doppler measures high blood velocities along the length or width of any selected cursor position and is recorded as a velocity against time on a spectral Doppler trace.

Two transducers are used: one for sending signals and one for receiving signals.

• Advantage
  The greatest advantage is the ability to accurately measure high velocities (such as those found in the heart).
• Disadvantage
  The main disadvantage is the inability to determine the exact location of the moving blood. This limitation is known as range ambiguity.

Main uses:

• assessing the severity of valvular stenosis and regurgitation
• assessing velocity of flow in shunts

• Advantage
  The main advantage is freedom from the limitation of range ambiguity, because the time taken for a signal to return to the transducer enables accurate information about location to be recorded.
• Disadvantage
  The main disadvantage is inaccurate measurement of high velocities, due to the possibility of aliasing.

Main uses:

• determining normal valve flow patterns
• assessing LV diastolic function
• measuring stroke volume and cardiac output

Tissue Doppler imaging
Tissue Doppler imaging (TDI) measures the longitudinal velocities and timing of the myocardium during systole and diastole.

TDI targets the myocardial tissue (not blood flow, as in traditional Doppler). The signal is adjusted to record the low-velocity, high-intensity signals from the myocardium. This technique can examine the electro-mechanical delay (EMD), which is the pause between the QRS (electrical activity) complex and the onset of mechanical activity. This is usually displayed using PW, and is measured at the base of the mitral annulus at the septal and lateral segments.

TDI is used in standard echocardiography for assessing dyssynchrony.

Other names for TDI are tissue velocity imaging (TVI), quantitative tissue velocity imaging (QTVI), and Doppler tissue imaging (DTI).

Ultrasound image of
trace Doppler imaging

Features of a Doppler tracing

Spectral Doppler analysis demonstrates information on velocity, direction of blood flow, timing of the blood flow, and intensity of the waveform.

• Velocity is displayed on the y axis, and this is calculated using the Doppler equation with the angle of incidence.
• Flow direction is displayed on the y axis as a positive or negative Doppler shift.
• Intensity of the signal is displayed by the brightness of the signal. 
• Timing of the signal is displayed along the x axis with the ECG pacing. Velocity, direction of the flow, and the intensity of the signal can therefore be assessed throughout the cardiac cycle.
• The baseline represents zero frequency shift. 
• A wall filter eliminates the low-frequency shifts due to wall and valve motion.
• The ultrasound beam is aligned parallel to the blood flow, using an optimum zero degree angle of incidence in all echocardiography.
  

  Red blood cells moving towards and away from the transducer

  Red blood cells moving towards and away from the transducer

• A positive frequency shift is towards the transducer and is displayed above the baseline (zero) in red; a negative shift is away from the transducer and is displayed below the baseline in blue (mnemonic - BART blue away and red towards).
• Amplitude of the Doppler signal is relative to the number of red blood cells in the sample volume, and not the velocity. The more red blood cells in the sample, the brighter the signal in the display.
  

  
  Doppler trace

We acknowledge that there may be variations in the technique presented.

You should perform this procedure under the supervision of an appropriately skilled supervisor until you are confident and competent enough to do it on your own.

Before using any medication or equipment in this procedure, please read the approved product information for instructions, contraindications, adverse effects, and warnings. Familiarize yourself with the equipment. The equipment or medication available to you may differ from what is used in this demonstration. You must inquire with a supervisor or instructor if there are variations or questions related to the equipment, medication, or procedures.

Ensure that all the equipment is plugged in and turned on before beginning with the patient. Typically, all equipment, including ultrasound machines, gel warmers, and power beds, are turned off but left plugged in at the end of the day. The gel warmer and power bed should be turned on and left on during the day. This keeps the gel warm and the bed operational.

Turn on the computer system, workstation, and printer. Select the storage media.

Ensure that there is adequate linen on the bed, and a good supply of additional linen and cloths.

Obtain a sonographer's worksheet on which to write the examination findings.

Perform the standard introductions with the patient. Check that the patient is appropriately dressed for the examination.

Confirm the patient's details and clinical information. Briefly explain the procedure to the patient, indicating how long the scan is expected to take, and obtain verbal consent.

Confirm the patient's identification, using name and date of birth. Enter the patient details into the ultrasound machine.

Obtain a brief medical history:

• pain: its location and duration, if present
• history of cardiac surgery or interventions
• history of echocardiography procedures, pathology, or disease
• any recent tests or imaging procedures 
• height and weight, if not provided

Explain to the patient that they may be asked to suspend breathing or to inhale deeply during the ultrasound scan.

Ask the patient to lie down on the bed and to roll over onto their left side, into the left lateral decubitus position.

Instruct the patient to raise their left arm above the level of the shoulder, bent at the elbow.

Left lateral
patient position

Expose the chest area.

Apply the 3-lead ECG electrodes (and wires) to the chest wall in the appropriate positions.

ECG lead placement

Ensure that the ECG cable is securely plugged into the ultrasound machine. Observe the ECG tracing to ensure that a clear ECG signal is obtained with a positive R wave of reasonable size. Adjust the ECG gain or reposition the ECG leads, if necessary.

Take standard precautions.

Sit on the patient's left-hand side, with the patient facing the sonographer (in the left lateral decubitus position), and with the ultrasound machine beside the right upper end of the bed (on the patient's left side). Manipulate the transducer in the left hand, and operate the machine settings with the right hand.

Patient and machine
positioning

Select the appropriate ultrasound transducer with the left hand.

Using the right hand, confirm the correct transducer selection on the ultrasound machine, and select the appropriate preset for adult echocardiography.

With the transducer in the left hand, apply pre-warmed acoustic gel directly onto the transducer face.

Obtain a left parasternal long axis view (PSLA).

Left parasternal area

Press the color button on the ultrasound machine control panel.

Adjust color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the mitral valve, ensuring that both leaflets are fully encapsulated within the box.

Left parasternal long
axis mitral valve
color box

Make minor adjustments to the transducer angle to optimize the color.

Zoom the image for a more detailed visualization.

Left parasternal long
axis mitral valve
zoom box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Left parasternal long
axis mitral valve
color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin anterior and posterior leaflets
• leaflets move freely
• anterior leaflet is longer and larger than the posterior leaflet
• chordae tendinae appear as thin string-like fixtures
• uniform and cone-like papillary muscles
• color flow is seen in diastole
• flow is from the left atrium to left ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Pathology of the mitral valve

A) Mitral regurgitation

Mitral regurgitation, or insufficiency, may be acute or chronic. The condition can occur with dysfunction in any component of the mitral valve (leaflets, chordae tendineae, or papillary muscles). It results in the leaking of blood from the left ventricle to the left atrium through the mitral valve when the ventricle contracts during systole.

As blood leaks back into the left atrium, the blood volume and pressure in the left atrium increases. Volume changes lead to pressure changes, which result in atrial hypertrophy. The increased pressure may be transmitted backwards through the circulation into the pulmonary veins, leading to pulmonary edema. The left ventricle also enlarges as it chronically pumps harder to the aorta, to compensate for the blood being lost to the atrium. In mitral stenosis, enlargement occurs only in the left atrium and not in the left ventricle.

Common causes of mitral regurgitation include: mitral valve prolapse, mitral annulus abnormalities, chordate and papillary muscle abnormalities and dysfunctions, and myocardial infarction. Rheumatic heart disease is also a known cause of mitral valve disease, but the incidence is low in the US.

Acute mitral regurgitation may arise due to damage to the chordae tendinae or papillary muscles, due to cardiac trauma, myocardial infarction, or endocarditis.

Chronic mitral regurgitation may arise due to mitral valve prolapse, or cardiac remodeling due to heart failure or coronary artery disease.

i) Mitral valve prolapse

Mitral valve prolapse describes a condition where the mitral leaflets degenerate (ie, myxtomatous degeneration) and fall back posteriorly into the left atrial cavity during ventricular systole.

Mitral valve prolapse

Ultrasound image of mitral valve prolapse

Prolapse can be caused by rupture of the chordae tendinae, or thickening (the result of infection and fibrin deposits) on either or both the valve leaflets. Other conditions like Marfan's syndrome can also cause mitral valve prolapse. Mitral valve prolapse intensifies mitral regurgitation and often occurs with connective tissue disease and other pathologies or conditions such as hyperthyroidism.

ii) Flail mitral valve

Flail mitral valve is similar to mitral valve prolapse. The valve has lost its supporting structures (ie, the chordae tendinae or papillary muscle has ruptured or the leaflet tip has turned outwards), resulting in the valve being left to flap in the blood stream. Mitral regurgitation may also be present.

iii) Systolic Anterior Motion

Systolic anterior motion (SAM) is a phenomenon which causes a sucking effect of the anterior mitral valve leaflets into the left ventricular outflow tract during the mid to late systole phase. It is usually due to an enlarged septum (hypertrophic cardiomyopathy) but can also happen in patients with a low fluid volume, post operatively.

Clinical signs and symptoms

• dyspnea
• fatigue
• palpitations
• arrhythmias
• systolic heart murmur
• symptoms of heart failure
• asymptomatic, if the condition is mild

Echocardiography objectives
An echocardiogram can detect and quantify the severity of the leak.

Color Doppler findings

• Mild
  • regurgitant jet area that covers < 20% of LA area
  • anterior, central, posterior, or complex jet direction 
  • vena contracta width < 0.3 cm
• Moderate
  • regurgitant jet area that covers 20 to 40% of LA area
  • vena contracta width 0.3 to 0.7 cm
• Severe
  • regurgitant jet area that covers > 40% of LA area
  • vena contracta width >0.7 cm
  • focal increase in color flow or turbulent jet identified adjacent to the septal edge of the left ventricular outflow tract (known as systolic anterior motion [SAM]) 

Differential diagnoses

• mitral combined stenosis and incompetence
• flail mitral valve
• rheumatic heart disease
• mitral valve prolapse
• annular calcification

B) Mitral stenosis

Mitral stenosis is a narrowing or constriction of the mitral valve orifice and thickening of the mitral leaflets. This thickening may extend towards and include the chordate tendinae. The condition may be congenital or acquired, and restricts the blood flow from the left atrium to the left ventricle during diastole.

The left atrium enlarges as it pumps blood into the left ventricle against resistance. Because blood is unable to flow efficiently through the heart, back pressure can result in pulmonary edema. When the mitral valve orifice is reduced from approximately 5 cm² to 2 cm², the patient usually experiences symptoms.

The most common cause of acquired mitral stenosis is rheumatic fever, which results in a hockey-stick appearance of the anterior mitral valve leaflet and a short immobile posterior leaflet.

Clinical signs and symptoms

• exertional dyspnea
• syncope
• pulmonary congestion
• diastolic murmur
• palpitations
• arrhythmias
• symptoms of heart failure
• asymptomatic, if the condition is mild

Echocardiography objectives
An echocardiogram can detect and quantify the severity of the narrowing.

Color Doppler findings

• turbulent high velocity dense jet
• possible mitral regurgitation

Differential diagnoses

• rheumatic heart failure
• mitral annular calcification
• congenital abnormalities
• connective tissue disorders

C) Infective endocarditis

Infective endocarditis is infection of the endocardial (inner) surface of the heart, which includes the heart valves. Endocarditis is usually caused by bacteria or fungi.

Infective endocarditis

The endocardium is constantly exposed to blood flow and therefore to any pathogen travelling in the blood. Surgical, medical, or dental procedures may allow bacteria to enter the blood stream and cause infective endocarditis. Any pre-existing damage to the endocardial lining predisposes the heart to endocarditis, with infective endocarditis being either acute or sub-acute. The development of vegetations on the valve leaflets is a characteristic finding in infective endocarditis.

i) Acute bacterial endocarditis
Staphylococcus aureus is the most likely causative pathogen. Onset is rapid, developing within a few days, and the condition may be life-threatening, with rapid destruction of the valves. Valves need not be previously damaged; normal valves are often affected, with rapid progression to heart failure, sometimes within a week. The precipitating factor is often intravenous drug use. Thrombi are produced on the valves by bacteria and embolization, abscess formation, and neurological involvement are common complications.

ii) Sub-acute bacterial endocarditis
Streptococcus viridians is the most likely causative pathogen. Onset is more gradual, and the disease takes an extended course, developing gradually over weeks or months. Bacteria are deposited on previously damaged valves, and invade pre-existing thrombi rather than producing them. Heart failure occurs over a period of weeks to months. The precipitating factor is often dental therapy, and complications are usually from embolization and slow valve damage.

Clinical signs and symptoms

i) Acute bacterial endocarditis:

• rapid onset
• high fever
• tachycardia
• fatigue
• characteristic heart murmurs caused by rapid valve destruction
• signs of heart failure from valvular insufficiency
• splinter hemorrhages from septic emboli

ii) Sub-acute bacterial endocarditis:

• gradual onset
• mild fever or afebrile
• mild tachycardia
• fatigue
• weight loss
• anemia
• splinter hemorrhages from septic emboli
• micro abscesses
• Osler nodes or Janeway lesions
• characteristic heart murmurs caused by valve destruction
• signs of heart failure from valvular insufficiency

Investigations

• Laboratory tests:
  • blood cultures

Echocardiography objectives
Echocardiography shows the presence, size, and location of vegetations, and demonstrates valve function. Transesophageal echocardiography (TEE) is the most sensitive technique, and detects 90% of cases. Small vegetations may be missed on transthoracic echocardiography and TEE may need to be performed.

Color Doppler findings

• mild
  • regurgitant jet area that covers < 20% of LA area
  • anterior, central, posterior, or complex jet direction
  • vena contracta width < 0.3cm
• moderate
  • regurgitant jet area that covers 20 to 40% of LA area
  • vena contracta width 0.3-0.7 cm
• severe
  • regurgitant jet area that covers > 40% of LA area
  • vena contracta width > 0.7cm
• possible valve stenosis
• possible continuous color flow pattern; this may indicate perforations in the valve
• continuous flow pattern may be seen within an abscess site
• turbulent flow due to shunting from fistula formation (ie, left ventricular outflow tract to right atrium fistula)

Differential diagnoses

• acute rheumatic fever
• malignancy
• connective tissue disease

Make minor adjustments to optimize the view of the aortic valve.

Press the color button on the ultrasound machine control panel.

Adjust color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the aortic valve, ensuring that the leaflets are fully encapsulated within the box.

Left parasternal long
axis aortic valve
color box

Make minor adjustments to the transducer angle to optimize the color.

Zoom the image for a more detailed visualization.

Left parasternal long
axis aortic valve
zoom box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Left parasternal long
axis aortic valve
color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin parallel lines of the aortic root
• thin right and non-coronary artery leaflets
• leaflets move freely
• a central closure of the leaflets is visualized 
• color flow is seen in systole, along with open valves
• flow is from the left ventricle to aortic root
• velocity of flow < 2 m/s
• small flash of color reversal demonstrates physiological regurgitation

Pathology of the aortic valve

A) Aortic regurgitation

Aortic regurgitation, or insufficiency, occurs when blood leaks from the aorta into the left ventricle when the ventricle relaxes during diastole.

Aortic regurgitation

In diastole, the left ventricle relaxes, allowing blood to flow in naturally from the left atrium. However, if at the same time, blood leaks back from the aorta, the volume and pressure in the left ventricle increases. Over time, the ventricle muscle wall hypertrophies, and the overloaded chamber compensates for the extra volume by dilating. Systolic function usually remains within the normal range.

Aortic regurgitation may be congenital (a bicuspid aortic valve), or result from another condition, such as aortic root dilation or dissection. Rheumatic heart disease is also a known cause of aortic regurgitation, but the incidence of this is low in the US.

Clinical signs and symptoms

• asymptomatic, if the condition is mild 
• chest pain
• exertional dyspnea
• symptoms of heart failure, earlier in the disease
• diastolic murmur

Echocardiography objectives
An echocardiogram can detect and quantify the severity of the leak.

Color Doppler findings

• Mild
  • jet density is faint or incomplete
  • jet width is < 25% of the LVOT diameter
• Moderate
  • jet density is dense
  • jet width 25 to 64% of LVOT diameter
• Severe
  • jet density is dense
  • jet width > 65% of the LVOT diameter

Differential diagnoses

• combined stenosis and regurgitation of the aortic valve
• infective endocarditis
• rheumatic heart disease
• congenital (bicuspid, sub-aortic, and supra-aortic stenosis)
• dissection
• trauma
• hypertension
• bicuspid aortic valve, accompanied by aortic regurgitation
• ascending aortic aneurysm
• aortic valve prolapse (rare)

B) Aortic stenosis

Aortic stenosis is a narrowing of the aortic valve orifice, which increases resistance to blood flow from the left ventricle to the aorta during systole.

Aortic stenosis is characterized by the degeneration, calcification, and reduced motion of the leaflets, with commissural fusion at the junction of some leaflets. Aortic stenosis may be age-related, pathological (syphilis), or congenital (a bicuspid aortic valve).

Long-term effects include symmetrical left ventricular hypertrophy, and eventually,  left ventricular dysfunction. The thicker walls reduce the filling space inside the ventricle, so less blood is pumped out. Patients may report exercise-related fainting, but their resting cardiac output could appear normal. Eventually, the coronary arteries cannot adequately supply the thickened and overworked heart muscle, so myocardial ischemia, then heart failure, can result.

Aortic stenosis

Clinical signs and symptoms

• exertional dyspnea
• exercise-related syncope 
• angina pectoris
• palpitations 
• ejection systolic murmur
• symptoms of congestive heart failure 
• sudden death in hyperdynamic or increased flow states (ie, heavy exercise)
• asymptomatic if the condition is mild

Echocardiogram objectives
An echocardiogram can detect and quantify the severity of the stenosis.

Color Doppler findings

• turbulent high velocity dense jet, typically located centrally
• subvalvular, valvular, or supravalvular (coarctation) stenosis 
• post-stenotic turbulence may be identified

Differential diagnoses

• combined stenosis and regurgitation of aortic valve
• aortic sclerosis
• coarctation of the aorta
• congenital heart disease (bicuspid aortic valve)
• atherosclerosis
• rheumatic heart disease
• trauma
• infective endocarditis
• subaortic stenosis
• prosthetic valve replacement

C) Infective endocarditis

Color Doppler findings

• high velocity color jet
• post-stenotic turbulent/disturbed color flow

Obtain a left parasternal short axis view (PSSA).

Angle the transducer superiorly and laterally until the aortic valve appears.

Rock and rotate the transducer until a circular aortic valve annulus is seen with all three leaflets in the middle, with the characteristic "Y" shape and closure point.

PSSA: aortic valve

If only some of the leaflets are visible, rotate the transducer in either direction slightly.

If no leaflets are visible, angle back towards the apex slightly.

Once the structures are displayed correctly, optimize the image for the aortic valve, with the focus at the level of the aortic valve.

Press the color button on the ultrasound machine control panel.

Adjust color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the aortic valve, ensuring that the leaflets are fully encapsulated within the box.

Parasternal short
axis aortic valve
color box

Make minor adjustments to the transducer angle, to optimize the valve leaflets and the color.

Zoom the image for a more detailed visualization.

Parasternal short
axis aortic valve
zoom box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Parasternal short
axis aortic valve
color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin right, left, and non-coronary leaflets
• leaflets move freely
• color flow is seen in systole, along with open valves
• "Y"-shaped appearance of closed valve 
• flow is from the left ventricle to aortic root
• small flash of color reversal demonstrates physiological regurgitation

Make minor adjustments to optimize the view of the tricuspid valve.

Angle the transducer superiorly and laterally until a wide, open tricuspid valve annulus is seen, and two of the tricuspid valve leaflets are clearly displayed.

Optimize the image for the tricuspid valve, with the focus at the level of the tricuspid valve.

Press the color Doppler button on the ultrasound machine control panel.

Adjust color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the tricuspid valve, ensuring that the leaflets are fully encapsulated within the box.

Parasternal short
axis tricuspid valve
color box

Make minor adjustments to the transducer angle to optimize the valve leaflets and the color.

Zoom the image for a more detailed visualization.

Parasternal short
axis tricuspid valve
zoom box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Parasternal short
axis tricuspid valve
color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin anterior and posterior leaflets
• leaflets move freely
• anterior leaflet is normally longer and larger than the posterior leaflet
• limited view of chordae tendineae and papillary muscles
• color flow is seen in diastole
• flow is from the right atrium to right ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation
• tricuspid leaflets open into right ventricle

Press the pulsed wave (PW) button.

Set the sample volume size at 2 mm.

Align the sample volume with the tips of the tricuspid valve leaflets in the right ventricle.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Parasternal short axis
tricuspid valve pulsed
wave cursor alignment

Obtain a spectral trace through the tricuspid valve, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and place the first cursor on the tip of the first peak, to measure the E wave.

Place the second cursor on the tip of the second peak, to measure the A wave.

Review and save the image, if satisfied.

Parasternal short axis
tricuspid valve
pulsed wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin anterior and posterior leaflets
• leaflets move freely
• anterior leaflet is normally longer and larger than the posterior leaflet
• limited view of chordae tendinae and papillary muscles
• color flow is seen in diastole, along with open valves
• flow is from the right atrium to right ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation
• tricuspid leaflets open into right ventricle

Press the continuous wave (CW) button, and align the cursor with the brightest color hue.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Parasternal short axis
tricuspid valve
continuous wave
cursor alignment

Manipulate the transducer and cursor to obtain a spectral trace through the highest peak velocity flow, displaying a minimum of three cardiac cycles.

Press the freeze button to capture the spectral Doppler trace.

To perform spectral Doppler measurements, press the caliper button. To assess the peak velocity place the cursor on the highest peak of the tricuspid regurgitation or tricuspid stenosis waveform.

Review the image and press the save button again, if the quality of the image is satisfactory.

Parasternal short axis
tricuspid valve
continuous wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin anterior and posterior leaflets
• leaflets move freely
• anterior leaflet is normally longer and larger than the posterior leaflet
• limited view of chordae tendineae and papillary muscles
• color flow is seen in diastole, along with open valves
• flow is from the right atrium to right ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation
• tricuspid leaflets open into right ventricle

Manipulate the transducer to obtain a long axis of the pulmonary artery and its bifurcation into left and right pulmonary arteries (ie, a "trouser leg" view).

Trouser-leg lumen

With the transducer in the left parasternal short axis, angle the transducer superiorly and laterally. Rock and rotate the transducer until a wide, open main pulmonary artery is seen, and the pulmonary valve leaflets are clearly displayed (if possible).

Rotate the transducer a further 10 to 20 degrees clockwise, until the branches of the pulmonary artery are shown.

Optimize the 2D image, adjusting the sector width, focus, and depth of field of view.

Press the color Doppler button on the ultrasound machine control panel.

Adjust color Doppler velocity scale to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the pulmonary valve, ensuring that both leaflets are fully encapsulated within the box.

Parasternal short axis
pulmonary valve
color box

Make minor adjustments to the transducer angle to optimize the pulmonary artery and the color.

Zoom the image for a more detailed visualization.

Parasternal short axis
pulmonary valve
zoom box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Parasternal short axis
pulmonary valve
color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform leaflets
• leaflets move freely
• leaflets when open are parallel to the artery wall
• color flow is seen in systole, along with open valves
• flow is from the right ventricle to right pulmonary artery
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation
• "trouser-leg" lumen is demonstrated, showing bifurcation of right and left pulmonary artery branches

Modify the parasternal short axis view to demonstrate the pulmonary artery.

Optimize the 2D image, adjusting the sector width, focus, and depth of field of view.

Make minor adjustments to the transducer angle to optimize the pulmonary valve.

Press the pulsed wave (PW) button.

Set the sample volume size at 2 mm.

Position the PW Doppler sample volume in the pulmonary artery 1 cm below the pulmonary valve leaflets.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Parasternal short axis
pulmonary valve
pulsed wave
cursor alignment

Obtain a spectral trace through the highest peak velocity flow, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and use the trackball to place the cursor on the tip of the highest peak to assess the velocity.

Review and save the image if satisfied.

Parasternal short axis
pulmonary valve
pulsed wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform leaflets
• leaflets move freely
• leaflets when open are parallel to the artery wall
• color flow is seen in systole, along with open valves
• flow is from the right ventricle to right pulmonary artery
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation
• "trouser-leg" lumen is demonstrated showing bifurcation of right and left pulmonary artery branches

Press the CW button and align the cursor with the centre of the pulmonary artery.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Parasternal short axis
pulmonary artery
continuous wave
cursor alignment

Obtain a spectral trace through the highest peak velocity flow, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button. To assess the peak velocity, place the cursor on the highest peak of the pulmonary regurgitation or pulmonary stenosis waveform.

Review and save the image, if satisfied.

Parasternal short axis
pulmonary artery
continuous wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform leaflets
• leaflets move freely
• leaflets when open are parallel to the artery wall
• color flow is seen in systole, along with open valves
• flow is from the right ventricle to right pulmonary artery
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation
• "trouser-leg" lumen is demonstrated showing bifurcation of right and left pulmonary artery branches

Modify the parasternal short axis view to demonstrate the right ventricular outflow tract (RVOT).

PSSA: right ventricular
outflow tract view

Optimize the 2D image, adjusting the sector width, focus, and depth of field of view.

Make minor adjustments to the transducer angle to optimize the RVOT.

Press the pulsed wave (PW) button.

Set the sample volume size 2 mm.

Position the PW Doppler sample volume in the RVOT above 1 cm (proximal) to the pulmonary valve leaflets.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Parasternal short axis
RVOT pulsed wave
cursor alignment

Obtain a spectral trace through the highest peak velocity flow, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and use the trackball to place the cursor on the tip of the highest peak to assess the velocity.

Review and save the image, if satisfied.

Parasternal short axis
RVOT pulsed wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform pulmonary leaflets
• pulmonary leaflets move freely
• pulmonary leaflets, when open, are parallel to the artery wall
• color flow is seen in systole, along with open valves
• flow is from the right ventricle to the RVOT
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Press the CW button and align the cursor through the centre of the RVOT.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Parasternal short axis
RVOT continuous wave
cursor alignment

Obtain a spectral trace of the highest peak velocity flow, displaying a minimum of three cardiac cycles.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and use the trackball to place the cursor on the tip of the highest peak to assess the velocity.

Review and save the image if satisfied.

Parasternal short axis
RVOT continuous
wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform pulmonary leaflets
• pulmonary leaflets move freely
• pulmonary leaflets, when open, are parallel to the artery wall
• color flow is seen in systole, along with open valves
• flow is from the right ventricle to the RVOT
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Pathology of the tricuspid valve, pulmonary valve, and aortic valve

A) Aortic regurgitation

Color Doppler findings

• Mild
  • jet density is faint or incomplete
  • central, right coronary cusp, left coronary cusp, or non-coronary cusp commissures jets
• Moderate
  • jet density is dense
  • central, right coronary cusp, left coronary cusp, or non-coronary cusp commissures jets
• Severe
  • jet density is very dense
  • central, right coronary cusp, left coronary cusp, or non-coronary cusp commissures jets

B) Tricuspid regurgitation

Tricuspid regurgitation is the leaking backwards of blood from the right ventricle to the right atrium, due to the incompetence of the tricuspid valve during systole. Tricuspid valve prolapse results in tricuspid regurgitation.

Several conditions, including connective tissue disease and endocarditis can lead to tricuspid regurgitation, but it usually results from right ventricle dilation combined with a dysfunctional valve. However, tricuspid regurgitation is commonly a benign condition.

Clinical signs and symptoms

• fatigue
• dyspnea
• peripheral edema
• ascites
• hepatic congestion
• jugular vein distention
• asymptomatic, if the condition is mild
• symptoms of right heart failure

Echocardiography objectives
An echocardiogram can detect and quantify the severity of the leak.

Color Doppler findings

• Mild
  • jet area < 5 cm²
  • jet density is soft
  • parabolic shape to jet
• Moderate
  • jet area 5 to 10 cm²
  • jet density is variable
  • variable shape to jet
• Severe
  • jet area > 10 cm²
  • jet density is dense
  • triangular shape to jet

Continuous wave Doppler findings

• Increased strength of the tricuspid regurgitation velocity signal
• Mild
  • parabolic shape to jet using CW
• Moderate
  • variable shape to jet
• Severe
  • triangular shape to jet

Differential diagnoses

• ruptured chordae tendinae
• tricuspid valve prolapse
• rheumatic heart disease
• trauma from pacemaker wire
• papillary muscle dysfunction

C) Tricuspid stenosis

Tricuspid stenosis is a restriction of blood flowing into the right ventricle from the right atrium, due to the tricuspid orifice becoming narrowed.

The right atrium may become enlarged, and blood is less effectively pumped to the pulmonary vasculature. Tricuspid stenosis is frequently accompanied by tricuspid regurgitation and mitral valve stenosis.

Clinical signs and symptoms

• fatigue
• abdominal pain in the right upper quadrant (related to liver enlargement)
• sensation of "flutter" in the neck
• prominent jugular vein

Echocardiography objectives
Echocardiography detects and quantifies the severity of the narrowing.

Color Doppler findings

• turbulent flow
• possible tricuspid regurgitation

Continuous wave Doppler findings

• increased mean pressure gradient
• elevated E velocity > 1 m/s
• decreased tricuspid tracing E-F slope

  E-F slope of
  tricuspid stenosis

• increased pressure half time

Differential diagnoses

• rheumatic fever
• carcinoid
• congenital (Ebstein's anomaly)
• inflow obstruction secondary to tumors, vegetations, or thrombus
• prosthetic valve replacement
• right-sided endocarditis (intravenous drug users)

D) Pulmonary regurgitation

Pulmonary regurgitation (insufficiency) occurs when blood leaks backwards from the pulmonary artery into the right ventricle during diastole, due to the malfunctioning of the pulmonary valve. The condition may be acute or chronic.

Pulmonary hypertension is usually the cause of pulmonary regurgitation, but infective endocarditis is also a predisposing factor.

Severe pulmonary regurgitation may lead to right ventricular hypertrophy and/or dilation, and may result in right-sided heart failure. Mild pulmonary regurgitation can be expected in all elderly people and is mainly clinically insignificant.

Clinical signs and symptoms

• dyspnea
• pulmonary hypertension
• fatigue
• dizziness
• in isolated cases, the symptoms are those of right ventricle-related heart failure, with right upper quadrant pain and an ascites-related bulging abdomen, in the more serious cases
• very commonly asymptomatic

Echocardiography objectives
An echocardiogram can detect and quantify the severity of the leak.

Color Doppler findings

• Mild
  • jet size using color is narrow and jet length is < 10 mm
  • soft jet density
• Moderate
  • jet size using color is intermediate in size
  • jet density is dense
• Severe
  • jet size using color is large and has a wide origin
  • jet density is very dense

Continuous wave Doppler findings

• increased strength of the PR velocity signal when compared with the density of the inflow
• Mild
  • slow deceleration rate

    
    Slow deceleration
    rate for pulmonary
    regurgitation

• Moderate
  • variable deceleration rate

    
    Variable deceleration
    rate for pulmonary
    regurgitation

• Severe
  • steep/short deceleration rate (short pressure half time)

    
    Steep deceleration
    rate for pulmonary
    regurgitation

Differential diagnoses

• infective endocarditis
• congenital heart disease
• trauma
• carcinoid
• rheumatic heart disease

E) Pulmonary stenosis

Pulmonary stenosis is a congenital abnormality where blood flow through the pulmonary valve is restricted. Volume and pressure overload of the right ventricle occur, causing right ventricular dilation. The condition may also be associated with exposure to rubella in utero, particularly during the first trimester; however the patient might not show symptoms for years.

Clinical signs and symptoms

• reduced exercise tolerance
• cyanosis
• peripheral edema
• systolic heart murmur

Echocardiography objectives
Echocardiography will detect and quantify the severity of the narrowing.

Color Doppler findings

• stenosis located in valvular or subvalvular site
• color will detect associated pulmonary regurgitation

Continuous wave Doppler findings

• possible pulmonary regurgitation

F) Infective endocarditis

Color Doppler findings

• Mild
  • regurgitant jet area that covers < 20% of LA area
  • anterior, central, posterior, or complex jet direction
  • vena contracta width < 0.3 cm
• Moderate
  • regurgitant jet area that covers 20 to 40% of LA area
  • vena contracta width 0.3 - 0.7 cm
• Severe MR
  • regurgitant jet area that covers > 40% of LA area
  • vena contracta width > 0.7cm
• possible stenosis of the valves
• possible continuous color flow pattern; this may indicate perforations in the valve
• continuous flow pattern can be seen within an abscess site
• turbulent flow due to shunting from fistula formation (ie, left ventricular outflow tract to right atrium fistula)

Locate the apical window.

Obtain an apical four-chamber view (A4C) and optimize the image by adjusting the machine settings.

Apical scanning area

Press the color button on the ultrasound machine control panel.

Adjust color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the mitral valve, ensuring that both leaflets are fully encapsulated within the box.

Apical four-chamber
mitral valve color
box

Make minor adjustments to the transducer angle to optimize the color.

Zoom the image for a more detailed visualization.

Apical four-chamber
mitral valve zoom
box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Apical four-chamber
mitral valve color
Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform mitral leaflets
• mitral leaflets move freely
• leaflets open into the left ventricle
• posterior leaflet extends from the lateral border, and anterior leaflet extends from septal border
• color flow is seen in diastole, along with open valves
• flow is from the left atrium to the left ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Press the PW button.

Set the sample volume size at 2 mm.

Align the sample volume with the tips of the mitral valve leaflets in the left ventricle.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Apical four-chamber
mitral valve pulsed
wave cursor alignment

Obtain a spectral trace through the mitral valve, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and place the first cursor on the tip of the first peak to measure the E wave.

Place the next cursor on the lowest clear edge of the deceleration slope.  

Place the last cursor on the tip of the second peak, to measure the A wave. 

Review and save the image, if satisfied.

Apical four-chamber
mitral valve pulsed
wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform mitral leaflets
• mitral leaflets move freely
• leaflets open into the left ventricle
• posterior leaflet extends from the lateral border, and anterior leaflet extends from septal border
• color flow is seen in diastole, along with open valves
• flow is from the left atrium to the left ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Press the CW button, and using color Doppler, align it with the color jet.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Apical four-chamber
mitral valve continuous
wave cursor alignment

Obtain a spectral trace of the highest peak velocity, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button. To assess the peak velocity, place the cursor on the highest peak of the mitral regurgitation or mitral stenosis waveform.

Review and save the loop, if satisfied.

Apical four-chamber
mitral valve
continuous wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform mitral leaflets
• mitral leaflets move freely
• leaflets open into the left ventricle
• posterior leaflet extends from the lateral border, and anterior leaflet extends from septal border
• color flow is seen in diastole, along with open valves
• flow is from the left atrium to the left ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Optimize the apical four-chamber (A4C) view and adjust the image to view the tricuspid valve.

Press the color button on the ultrasound machine control panel.

Adjust color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the tricuspid valve, ensuring that the leaflets are fully encapsulated within the box.

Apical four-chamber
tricuspid valve color
box

Make minor adjustments to the transducer angle to optimize the color.

Press the zoom button to bring up the zoom box, adjust the box size, and place the zoom box over the tricuspid valve, ensuring that both leaflets are fully contained within the zoom box.

Apical four-chamber
tricuspid valve zoom
box

Press the save/capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Apical four-chamber
tricuspid valve
color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform tricuspid leaflets
• tricuspid leaflets move freely
• leaflets open into the right ventricle
• anterior leaflet extends from the lateral border, and septal leaflet extends from medial border
• septal leaflet inserts 5 to 10 mm inferiorly than the anterior mitral leaflet
• color flow is seen in diastole, along with open valves
• flow is from the right atrium to the right ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Press the PW button.

Set the sample volume size at 2 mm.

Align the sample volume with the tips of the tricuspid valve leaflets in the right ventricle.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Apical four-chamber
tricuspid valve
pulsed wave
cursor alignment

Obtain a spectral trace through the tricuspid valve, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and place the first cursor on the tip of the first peak, to measure the E wave.

Place the second cursor on the tip of the second peak, to measure the A wave. 

Review and save the image, if satisfied.

Apical four-chamber
tricuspid valve
pulsed wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform tricuspid leaflets
• tricuspid leaflets move freely
• leaflets open into the right ventricle
• anterior leaflet extends from the lateral border, and septal leaflet extends from medial border
• septal leaflet inserts 5 to 10 mm inferiorly than the anterior mitral leaflet
• color flow is seen in diastole, along with open valves
• flow is from the right atrium to the right ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Press the CW button and, using color Doppler, align it with the color jet.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Apical four-chamber
tricuspid valve
continuous wave
cursor alignment

Obtain a spectral trace of the highest peak velocity, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button. To assess the peak velocity, place the cursor on the highest peak of the tricuspid regurgitation or tricuspid stenosis waveform.

Review and save the image, if satisfied.

Apical four-chamber
tricuspid valve
continuous wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin uniform tricuspid leaflets
• tricuspid leaflets move freely
• leaflets open into the right ventricle
• anterior leaflet extends from the lateral border, and septal leaflet extends from medial border
• septal leaflet inserts 5 to 10 mm inferiorly than the anterior mitral leaflet
• color flow is seen in diastole, along with open valves
• flow is from the right atrium to the right ventricle
• velocity of flow < 1 m/s
• small flash of color reversal demonstrates physiological regurgitation

Optimize the apical four-chamber (A4C) view.

Press the color button on the ultrasound machine control panel.

Decrease the color Doppler velocity scale (PRF) to visualize the lower flow in the pulmonary vein.

Adjust the color box size, using the trackball on the console to cover the right upper pulmonary vein and the posterior wall of the left atrium.

Apical four-chamber
pulmonary vein
color box

Select PW.

Set the sample volume size at 4 mm.

Position the sample volume 1 cm into the right upper pulmonary vein.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Apical four-chamber
pulmonary vein
pulsed wave cursor
alignment

Select low PRF technique when using PW Doppler at this depth.

Obtain a spectral trace from the right upper pulmonary vein, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and use the trackball to place the cursor in the region of interest.

There are three parts to the pulmonary vein flow:

• S wave: indicates the relaxation of the left atrium and ventricular systole, and is the largest wave
• D wave: found above the baseline, and represents the diastolic phase
• Atrial reversal (AR) wave: refers to the flow moving below the baseline, and indicates the flow back into the pulmonary veins (usually the smallest wave)

Measure the S, D, AR height and AR duration portions of the waveform.

Review and save the image, if satisfied.

Apical four-chamber
pulmonary vein
pulsed wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• three of the four pulmonary veins may be seen; these are echo-free tubular structures, inserting into the deep border of the left atrium
• the right upper pulmonary vein is seen at the supero-medial border, and the left upper and left lower pulmonary veins are seen at lateral border
• color flow is seen in systole and diastole, along with open valves
• flow is from the pulmonary veins to the left atrium
• velocity of flow < 1 m/s

Select the TDI button.

Set the sample volume to approximately 3 to 4 mm in size.

Move the sample volume to the septal annulus of the mitral valve.

Align the cursor so that it is parallel to the myocardial wall, maximizing the 0-degree optimum echocardiographic angle.

Apical four-chamber
septal annulus TDI
cursor alignment

Obtain a spectral trace through the myocardial septal annulus, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the TDI spectral Doppler trace at the septal annulus.

The waveform has a myocardial systolic phase, which is above the baseline, and is the "S" portion of the waveform. 

The E peak is a reflection of the atrial myocardial lengthening, and is below the baseline.

The third A peak is a reflection of the late diastolic myocardial phase, and is also displayed below the baseline and is normally less prominent.

Measure the E peak of the waveform.

Review and save the image, if satisfied.

Apical four-chamber
septal annulus TDI

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• cardiac crux is visualized as the center cross of the heart
• tricuspid and mitral valves move freely
• leaflets open into the ventricles
• tricuspid septal leaflet inserts 5 to 10 mm inferiorly than the anterior mitral leaflet
• myocardium has uniform echogenicity
• color flow is seen in diastole, along with open valves
• flow is from the atria to the ventricles
• velocity of flow < 1 m/s

Select the TDI button.

Set the sample volume to approximately 3 to 4mm in size.

Move the sample volume to the lateral annulus of the mitral valve.

Align the cursor so that it is parallel to the myocardial wall, maximizing the 0-degree optimum echocardiographic angle.

Apical four-chamber
lateral annulus TDI
cursor alignment

Obtain a spectral trace through the myocardial lateral annulus, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the TDI spectral Doppler trace at the lateral annulus.

The waveform has a myocardial systolic phase, which is above the baseline, and is the S portion of the waveform. 

The E peak is a reflection of the atrial myocardial lengthening, and is below the baseline.

The third A peak is a reflection of the late diastolic myocardial phase, and is also displayed below the baseline. It is normally less prominent.

Measure the E peak of the waveform.

Review and save the image, if satisfied.

Apical four-chamber
lateral annulus TDI
cursor alignment

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• cardiac crux is visualized as the center cross of the heart
• tricuspid and mitral valves move freely
• leaflets open into the ventricles
• tricuspid septal leaflet inserts 5 to 10 mm inferiorly than the anterior mitral leaflet
• myocardium has uniform echogenicity
• color flow is seen in diastole, along with open valves
• flow is from the atria to the ventricles
• velocity of flow < 1 m/s

Pathology of regurgitation, stenosis, prolapse, and diastolic function

A) Mitral stenosis

Color Doppler findings

• turbulent high velocity dense jet
• possible mitral regurgitation

Spectral Doppler findings

• peak velocity, peak, and mean pressure gradient, and VTI levels increase with severity
• increased E velocity at the mitral valve tips > 1.3 m/s

B) Mitral regurgitation

Color Doppler findings

• mild
  • regurgitant jet area that covers < 20% of LA area
  • anterior, central, posterior, or complex jet direction
  • vena contracta width < 0.3cm
• moderate
  • regurgitant jet area that covers 20 to 40% of LA area
  • vena contracta width 0.3-0.7 cm
• severe
  • regurgitant jet area that covers > 40% of LA area
  • vena contracta width > 0.7cm
• possible stenosis of the mitral valve

C) Infective endocarditis

Color Doppler findings

• mild
  • regurgitant jet area that covers < 20% of LA area
  • anterior, central, posterior, or complex jet direction
  • vena contracta width < 0.3cm
• moderate
  • regurgitant jet area that covers 20 to 40% of LA area
  • vena contracta width 0.3-0.7 cm
• severe
  • regurgitant jet area that covers > 40% of LA area
  • vena contracta width > 0.7 cm
• possible valvular stenosis
• possible continuous color flow pattern; this may indicate perforations in the valve
• continuous flow pattern can be seen within an abscess site
• turbulent flow due to shunting from fistula formation (ie, left ventricular outflow tract to right atrium fistula)

D) Tricuspid stenosis

Color Doppler findings

• turbulent flow
• possible tricuspid regurgitation

Continuous wave Doppler findings

• elevated E velocity (> 1 m/s)
• decreased tricuspid tracing E-F slope
• increased pressure half time

E) Tricuspid regurgitation

Color Doppler findings

• mild
  • jet area < 5 cm²
  • jet density is soft
  • parabolic shape to jet
• moderate
  • jet area 5 to 10 cm²
  • jet density is variable
  • variable shape to jet
• severe
  • jet > 10 cm²
  • jet density is dense
  • triangular shape to jet

Continuous valve Doppler findings

• increased strength of the tricuspid regurgitation velocity signal
• mild
  • parabolic shape to jet using CW
• moderate
  • variable shape to jet
• severe
  • triangular shape to jet

F) Left ventricular diastolic dysfunction

Diastolic dysfunction is a disorder in the diastolic phase of the cardiac cycle. The diastolic phase is when the ventricles relax to allow blood to fill the chamber before the next beat. In the case of diastolic dysfunction, the ventricles do not relax, and less blood enters the ventricles to be pumped out.

Clinical signs and symptoms

• dyspnea with a varying degree of exertion

Tissue Doppler findings

• relaxation abnormality
  • systole >= diastole E/E' < 8
• pseudo-normalization
  • systole < diastole E/E' >= 10
• restrictive physiology
  • systole < diastole E/E' > 15

Differential diagnoses

• cardiomyopathies
• coronary artery disease

Obtain an apical five-chamber view; this gives a full view of the aortic valve and left ventricular outflow tract (LVOT).

Press the color button on the ultrasound machine control panel.

Adjust the color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box centering over the LVOT and including the aortic valve, ensuring that both are fully encapsulated within the box.

Apical five-chamber
LVOT and aortic
valve color box

Make minor adjustments to the transducer angle, to optimize the LVOT and aortic valve leaflets.

Zoom the image for a more detailed visualization.

Apical five-chamber
LVOT and aortic
valve zoom box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Apical five-chamber
LVOT and aortic
valve color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin parallel lines of the aortic root
• thin right and non-coronary artery leaflets
• leaflets move freely
• a central closure of the leaflets is visualized
• LVOT is visualized by the interventricular septum medially and the anterior mitral valve laterally
• vertical echogenic artery walls of the proximal ascending aorta
• color flow is seen in systole, along with open valves
• flow is from the left ventricle to aortic root
• small flash of color reversal demonstrates physiological regurgitation

Press the PW button on the ultrasound machine control panel.

Set the sample volume size to 2 to 3 mm.

Place the sample volume in the LVOT, 1 cm from the aortic valve leaflets on the left ventricle side.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Apical five-chamber
LVOT pulsed wave
cursor alignment

Obtain a spectral trace from the LVOT, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, select the cursor, and use the trackball to place the cursor in the region of interest.

Measure the highest peak velocity of the LVOT waveform.

Review and save the image, if satisfied.

Apical five-chamber
LVOT pulsed wave

Press the 2D button to return to the 2D imaging.

Normal sonographic findings

• thin parallel lines of the aortic root
• thin right and non-coronary artery leaflets
• leaflets move freely
• a central closure of the leaflets is visualized
• LVOT is visualized by the interventricular septum medially and the anterior mitral valve laterally
• vertical echogenic artery walls of the proximal ascending aorta
• color flow is seen in systole, along with open valves
• flow is from the left ventricle to aortic root
• velocity of flow < 1.5 m/s

Obtain an apical five-chamber view; this gives a full view of the aortic valve and left ventricular outflow tract (LVOT).

Press the color button on the ultrasound machine control panel.

Adjust the color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the aortic valve, ensuring that it is carefully encapsulated within the box.

Apical five-chamber
aortic valve color box

Make minor adjustments to the transducer angle to optimize the aortic valve leaflets.

Zoom the image for a more detailed visualization.

Apical five-chamber
aortic valve zoom box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Apical five-chamber
aortic valve color
Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin parallel lines of the aortic root
• thin right and non-coronary artery leaflets
• leaflets move freely
• a central closure of the leaflets is visualized
• LVOT is visualized by the interventricular septum medially and the anterior mitral valve laterally
• vertical echogenic artery walls of the proximal ascending aorta
• color flow is seen in systole, along with open valves
• flow is from the left ventricle to aortic root
• small flash of color reversal demonstrates physiological regurgitation

Press the CW button on the ultrasound machine control panel.

Align the cursor parallel to the walls of the aorta and move to the centre of the vessel. Blood flow occurs during the systolic phase. The "clicks" of the opening and closing of the valves are seen on the spectral trace.

Align the cursor so that it is parallel to blood flow maximizing, the 0-degree optimum echocardiographic angle.

Apical five-chamber
aortic valve
continuous wave
cursor alignment

Obtain a spectral trace through the aortic valve, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and use the trackball to place the cursor in the region of interest.

Select the highest waveform and place the cursor on the tip of this wave, to measure the peak velocity. Blood flow moves away from the transducer, and therefore the waveform is displayed below the baseline.

Review the spectral graph and press the save/capture button, if its quality is satisfactory.

Apical five-chamber
aortic valve
continuous wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• thin parallel lines of the aortic root
• thin right and non-coronary artery leaflets
• leaflets move freely
• a central closure of the leaflets is visualized
• LVOT is visualized by the interventricular septum medially and the anterior mitral valve laterally
• vertical echogenic artery walls of the proximal ascending aorta
• color flow is seen in systole, along with open valves
• flow is from the left ventricle to aortic root
• velocity of flow < 2 m/s
• small flash of color reversal demonstrates physiological regurgitation

Pathology of aortic valve/left ventricular outflow tract

A) Aortic stenosis

Color Doppler findings

• turbulent high velocity dense jet

Spectral Doppler findings

• continuous wave Doppler is used to determine the severity of the valvular stenosis
• pulsed wave Doppler is used to determine LVOT obstruction

Severity of aortic stenosis	Peak velocity	Peak pressure gradient	Mean pressure gradient
Mild stenosis	< 3 m/s	< 36 mmHg	< 20 mmHg
Moderate stenosis	3-4 m/s	36-50 mmHg	20-40 mmHg
Moderate to severe stenosis	-	50-64 mmHg	-
Severe stenosis	> 4 m/s	> 64 mmHg	> 40 mmHg

B) Aortic regurgitation

Color Doppler findings

• Mild
  • jet density faint or incomplete
  • jet width < 25% of the LVOT diameter
• Moderate
  • jet density is dense
  • jet width 25 to 64% of LVOT diameter
• Severe
  • jet density is dense
  • jet width > 65% of the LVOT diameter

Spectral Doppler finding

• Mild
  • pressure half time > 500 milliseconds
• Moderate
  • pressure half time 200 to 500 milliseconds
• Severe
  • pressure half time < 200 milliseconds

C) Infective endocarditis

Color Doppler findings

• possible aortic regurgitation
• possible aortic stenosis
• turbulent color flow throughout the cardiac cycle, in the case of perforations of the valve
• continuous flow pattern, in the case of an abscess

Spectral Doppler findings
Pulsed and continuous wave Doppler is used to determine the severity of the associated valvular regurgitation and stenosis.

• Associated mild regurgitation
  • pressure half time > 500 milliseconds
• Associated moderate regurgitation
  • pressure half time 200 to 500 milliseconds
• Associated severe regurgitation
  • pressure half time < 200 milliseconds
• Associated stenosis:

Severity of aortic stenosis	Peak velocity	Peak pressure gradient	Mean pressure gradient
Mild stenosis	< 3 m/s	< 36 mmHg	< 20 mmHg
Moderate stenosis	3-4 m/s	36-50 mmHg	20-40 mmHg
Moderate to severe stenosis	-	50-64 mmHg	-
Severe stenosis	> 4 m/s	> 64 mmHg	> 40 mmHg

D) Mitral regurgitation

Pulsed wave Doppler findings

• a focal increased flow or velocity is identified adjacent to the septal edge of the left ventricular outflow tract, known as systolic anterior motion (SAM)
• mitral regurgitation caused by SAM is seen as a change in shape of the CW Doppler waveform, which has a "dagger" or triangular-shaped appearance
• "dagger" appearance of the waveform is also seen in the midventricular obstruction without the presence of SAM

LVOT spectral
Doppler waveform
with dagger shape

Locate the subcostal window.

Transducer position
for subcostal views

Obtain the subcostal view of the inferior vena cava (IVC) and hepatic veins.

Subcostal area

Press the color button on the ultrasound machine control panel, to add color Doppler to the 2D image.

Adjust the color Doppler velocity scale (PRF) to visualize lower flows.

Adjust the color box size, using the trackball on the console. Place the color box over the IVC, ensuring that it is completely covered.

Subcostal IVC
color box

Make minor adjustments to the transducer angle to optimize the IVC color.

Zoom the image for a more detailed visualization.

Subcostal IVC
zoom box

Press the save or capture button to capture the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Subcostal IVC
color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• liver is identified at the top of the image; this has a fine homogeneous echotexture
• three hepatic veins can be visualized draining into the IVC
• IVC is adjacent and immediately deep to the liver
• IVC is seen expanding and collapsing with respiration
• IVC lumen is echo-free
• IVC can be seen draining into the right atrium
• color flow is seen in systole and diastole
• flow is from the IVC to the right atrium

Obtain the subcostal view of the aorta in the long axis.

Slide the transducer superiorly and angle to optimize the Doppler angle required.

Press the PW button.

Set the sample volume to 2 to 3 mm in size.

Place the sample volume in the centre of the abdominal aorta.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Subcostal descending
aorta pulsed wave
cursor alignment

Obtain a spectral trace through the abdominal aorta, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

To perform Doppler measurements, press the caliper button, and use the trackball to place the cursor on the peak velocity.

Review and save the image, if satisfied.

Subcostal descending
aorta pulsed wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• liver appears at the top of the image; this has a fine homogeneous echo-texture
• echogenic walls of the aortic artery are visualized immediately deep to the liver
• aortic lumen is absent of any echogenicity
• direction of the aorta is pointing deep to the sector of the image
• color flow is seen in systole, along with open valves
• flow is towards the feet
• velocity of flow < 1 m/s

Obtain a subcostal four-chamber view of the interatrial septum.

Press the color button on the ultrasound machine control panel.

Adjust the color Doppler velocity scale (PRF) to 40 to 50 cm.

Adjust the color box size, using the trackball on the console. Place the color box over the interatrial septum.

Subcostal interatrial
septum color box

Make minor adjustments to the transducer angle to optimize the four chambers and interatrial septum.

Zoom the image for a more detailed visualization.

Subcostal interatrial
septum zoom box

Press the save loop or capture button to save the color loop.

Review and press the save button again, if the quality of the loop is satisfactory.

Subcostal interatrial
septum color Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• mitral and tricuspid valves are thin and freely mobile
• right atrium and right ventricle are visualized at the top of the view adjacent to the liver
• left atrium and left ventricle are visualized at the bottom of the view
• interventricular septum is well-seen in this view, as it lies perpendicular to the ultrasound beam
• interatrial septum is also best visualized in this view, and is normally thinner than the interventricular septum
• no flow is identified across the septum
• color flow is seen in diastole, along with open valves
• flow is from the atria to the ventricles
• velocity of flow < 1 m/s

Pathology of the aorta, inferior vena cava, hepatic veins, and interatrial septum

A) Aortic stenosis

Pulsed wave Doppler findings

• tardus parvus pulse changes in the abdominal aorta with severe aortic stenosis

B) Aortic regurgitation

Pulsed wave Doppler findings

• pan-diastolic flow reversal in the abdominal aorta, in the case of severe regurgitation

C) Tricuspid stenosis

Color Doppler findings

• elevated flow reversal in the inferior vena cava and hepatic veins associated with severe tricuspid regurgitation

D) Tricuspid regurgitation

2D ultrasound findings

• an increase in right atrium pressure (RAP) due to tricuspid regurgitation can be measured by assessing the IVC diameter; this increases with increasing disease
• Criteria assess severity of right atrial pressure
  • IVC < 1.7 cm and reduces by more than half with inspiration
  • IVC < 1.7 cm and reduces by less than half with inspiration
  • IVC diameter does not change with respiration

Color Doppler findings

• elevated flow reversal in the IVC and hepatic veins, in the case of severe regurgitation

E) Pulmonary embolism

Pulmonary embolism occurs when a large thrombus (or thrombi) blocks the main pulmonary artery where it first branches. If the thrombi are smaller, they may obscure narrower vessels towards the surface of the lung.

Abnormal blood flow
due to pulmonary
embolism

As a result, blood flow to distal vessels is blocked. Disrupted flow and volume of blood through the heart may lead to failure of the right ventricle.

Elderly and immobilized patients have a higher risk of developing pulmonary embolism. Furthermore, trauma, especially severe burns and leg fractures, or surgery (including caesarean section) are risk factors for developing a pulmonary embolism.

Symptoms are frequently non-specific, leading to potentially fatal misdiagnosis. The assessment of pulmonary embolism relies on more than one criterion.

Clinical signs and symptoms

• chest pain (prominent feature)
• dyspnea, which may be progressive
• hemoptysis
• tachypnea
• tachycardia
• heart failure
• sudden death
• non-specific

Echocardiography objectives
Echocardiography will detect and quantify the severity of the obstruction.

Color and continuous wave Doppler findings

• increased velocity, due to a thrombus in the pulmonary artery
• possible artery regurgitation

Lab Findings

• increased d-dimer
• changes in blood gases; a low ventilation/perfusion ratio develops

Differential diagnoses

• pulmonary hypertension
• cardiac tamponade
• malignancy
• pulmonary embolism in transit
• right heart failure
• right ventricle systolic dysfunction

 F) Patent foramen ovale

Before birth, there is an opening between the left and right atria, allowing circulation of oxygen-rich blood from the placenta through the fetal body. Shortly after birth, when the newborn starts breathing, this opening closes and develops into a true wall between the atria. If the foramen ovale is not sealed shut, this is called a patent foramen ovale (PFO).

Clinical signs and symptoms

• asymptomatic, in many cases
• migraine, common
• embolic event

Color Doppler findings

• turbulent color flow moving from the left atrium to the right atrium, across the interatrial septum; best observed when the patient coughs, or when a Valsalva maneuver is performed

Differential diagnosis

• atrial septal defect

G) Atrial septal defect

An atrial septal defect is a congenital heart anomaly that occurs during the development of the heart. Atrial septal defects result in shunting of blood from the left to the right cardiac chambers.

Clinical signs and symptoms

• asymptomatic
• murmur
• dyspnea with a varying degree of exertion
• fatigue

Color Doppler findings

• turbulent color flow moving from the left atrium to the right atrium, across the interatrial septum

Differential diagnosis

• patent foramen ovale
• sinus venosus
• pulmonary stenosis

Obtain a suprasternal view and optimize the image by adjusting the machine.

Suprasternal area

Press the color button on the ultrasound machine control panel.

Adjust color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the ascending aorta and aortic arch.

Suprasternal aorta
color box ascending
aorta

Make minor adjustments to the transducer angle, to optimize visualization of the aorta.

Press the save loop or capture button to save the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Suprasternal aorta
color Doppler
descending aorta

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• 'candy-cane' appearance of the ascending aortic arch and descending aorta are visualized
• thin echogenic walls and echo-free aortic lumen is characteristic
• color flow is seen in systole, along with open valves
• flow is from the ascending aorta to the descending aorta
• velocity of flow < 1 m/s

Select the PW button.

Set the sample volume at 3 to 4 mm.

Place the sample volume in the descending aorta, approximately 1 cm below the level of the left subclavian artery bifurcation.

Align the cursor so that it is parallel to blood flow maximizing, the 0-degree optimum echocardiographic angle.

Suprasternal aorta
pulsed wave cursor
alignment

Obtain a spectral trace through the descending aorta, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

Assess for reversal of the flow in the diastolic phase of the waveform.

Review and save the image if satisfied.

Suprasternal aorta
pulsed wave

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• 'candy-cane' appearance of the ascending aortic arch and descending aorta are visualized
• thin echogenic walls and echo-free aortic lumen is characteristic
• color flow is seen in systole
• flow is from the ascending aorta to the descending aorta
• velocity of flow < 1 m/s

Select the CW button and align the cursor with the center of the ascending/descending aorta.

Align the cursor so that it is parallel to blood flow, maximizing the 0-degree optimum echocardiographic angle.

Suprasternal aorta using
continuous wave cursor
alignment

Obtain a spectral trace through the descending aorta, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

Assess for reversal of the flow in the diastolic phase of the waveform.

Review and save the image if satisfied.

Suprasternal aorta using
continuous wave

Press the 2D button to return to 2D imaging.

 Normal sonographic findings

• 'candy-cane' appearance of the ascending aortic arch and descending aorta are visualized
• thin echogenic walls and echo-free aortic lumen is characteristic
• color flow is seen in systole
• flow is from the ascending aorta to the descending aorta
• velocity of flow < 1 m/s

Obtain a suprasternal view of the main pulmonary artery (MPA) in the long axis view. Rotate the probe through 90 degrees from the view of the aortic arch.

Press the color Doppler button on the ultrasound machine control panel.

Adjust the color Doppler velocity scale (PRF) to the maximum.

Adjust the color box size, using the trackball on the console. Place the color box over the main pulmonary artery.

Suprasternal main
pulmonary artery color
box

Press the save loop or capture button to save the color loop.

Review the loop and press the save button again, if the quality of the loop is satisfactory.

Suprasternal main
pulmonary artery color
Doppler

Press the 2D button to return to 2D imaging.

Normal sonographic findings

• aortic arch is seen in cross-section at the top of the image and appears as a circle
• right pulmonary artery is visualized as two echogenic linear lines immediately under the aorta
• right pulmonary artery lumen is echo-free
• color flow is seen in systole, along with open valves
• velocity of flow < 1 m/s

Select the Pedoff probe button on the ultrasound keyboard.

Place the probe on the skin in the suprasternal notch.

Pedoff placement

Direct the pedoff probe in the direct line of the ascending aorta. Listen for the highest peak.

Make minor adjustments to the transducer angle to optimize the Doppler trace and gain the maximum peak.

Obtain a spectral trace through the highest peak velocity, displaying a minimum of three cardiac cycles.

If aliasing is noted, adjust the appropriate factors.

Press the freeze button to capture the spectral Doppler trace.

Press the caliper button, and place the cursor on the tip of the highest waveform.

Review and save the image, if satisfied.

Suprasternal spectral
trace using Pedoff

Unfreeze the image.

Pathology of the aorta and main pulmonary artery

A) Aortic regurgitation

Color Doppler findings

• diastolic flow reversal in the aortic arch, in the case of severe aortic regurgitation

Pulsed wave Doppler findings

• Moderate
  • end-diastolic flow reversal > 0.6 m/s in the descending aorta
• Severe
  • end-diastolic flow reversal > 0.18 m/s in the descending aorta
  • diastolic flow reversal in the aortic arch

Continuous wave Doppler findings

• diastolic flow reversal in the aortic arch, in the case of severe aortic regurgitation

B) Aortic stenosis

Continuous wave Doppler findings (with Pedoff probe)
Continuous wave Doppler is used to determine the severity of the valvular stenosis.

C) Patent ductus arteriosus

Patent ductus arteriosus is a relatively common congenital heart defect. The ductus arteriosus is a blood vessel that connects the descending aorta with the pulmonary artery during fetal development. Usually, the ductus arteriosus closes in the first hours after birth when the newborn starts breathing, but complete closure may take two to three weeks after the birth. When the ductus arteriosus remains open (a patent ductus arteriosus) after birth, this produces a left-to-right shunt.

Patent ductus
arteriosus

The patent ductus arteriosus may be too small to notice until much later in life, or in the case of a larger and persistent shunt (particularly with a premature baby); the condition may be life-threatening. The perforation may be closed by surgery, if medication fails.

Clinical signs and symptoms

• asymptomatic, if the shunt is small
• chest pain, initial symptom in about 25% of adult cases
• atrial arrhythmia
• heart failure
• dyspnea
• fatigue

Color Doppler findings

• turbulent flow pattern visualized at the pulmonary artery bifurcation
• right to left, left to right, or bidirectional flow within the shunt

Differential diagnoses

• heart failure
• infective endocarditis
• pulmonary hypertension
• Eisenmenger's syndrome

Position the patient in the right lateral decubitus position, with their right arm raised above the shoulder.

Right lateral
decubitus position

Palpate the chest wall and place the pedoff transducer in the right parasternal window. This is the area to the right of and close to the midline, around the first or second intercostal space.

Right parasternal
window

Make minor adjustments to the transducer angle to optimize the spectral trace. To do so, look at the spectral trace and listen for the highest peak velocity.

Press the freeze button to capture the spectral Doppler trace, displaying a minimum of three cardiac cycles.

Press the caliper button, and place the cursor on the tip of the highest waveform.

Right parasternal
aorta Pedoff

Review and save the image if satisfied.

Pathology of aortic stenosis

A) Aortic stenosis

Continuous wave Doppler findings

Continuous wave Doppler is used to determine the severity of the aortic stenosis.

Post-procedure considerations

Bibliography

Web articles

Brusch J. Infective endocarditis. eMedicine.
Available at: http://emedicine.medscape.com/article/216650-overview
Accessed 3 March, 2010.

Dima C, Desser K, Balasundaram K. Mitral stenosis. eMedicine.
Available at: http://emedicine.medscape.com/article/155724-overview
Accessed 3 March, 2010.

Hanson I, Afonso I. Mitral regurgitation. eMedicine.
Available at: http://emedicine.medscape.com/article/155618-overview
Accessed 3 March, 2010.

Kamangar N, McDonnell M, Sharma S. Pulmonary embolism. eMedicine.
Available at: http://emedicine.medscape.com/article/300901-overview
Accessed 3 March, 2010.

Mancini M. Tricuspid regurgitation. eMedicine.
Available at: http://emedicine.medscape.com/article/158484-overview
Accessed 3 March, 2010.

McPherson J. Aortic stenosis. eMedicine.
Available at: http://emedicine.medscape.com/article/150638-overview
Accessed 3 March, 2010.

Tanser P. Tricuspid regurgitation. The Merck manual for healthcare professionals.
Available at: http://www.merck.com/mmpe/sec07/ch076/ch076i.html 
Accessed 3 March, 2010.

Tanser P. Tricuspid stenosis. The Merck manual for healthcare professionals.
Available at: http://www.merck.com/mmpe/sec07/ch076/ch076j.html
Accessed 3 March, 2010.

Thakkar B, Forker A, Schussheim A. Mitral valve prolapse. eMedicine.
Available at: http://emedicine.medscape.com/article/155494-overview
Accessed 3 March, 2010.

Wang S. Aortic regurgitation. eMedicine.
Available at: http://emedicine.medscape.com/article/150490-overview
Accessed 3 March, 2010.

Websites

Echocardiology.org. Echocardiography Tutorials. Valvular Disease.
Available at: www.echocardiology.org
Accessed April 13, 2010.

The American Society of Echocardiography. ASE Guidelines and Standards.
Available at: www.asecho.org
Accessed April 13, 2010.

U.S. Department of Health & Human Service. Health Information Privacy. The Health Insurance Portability Act of 1996 (HIPPA) Privacy Rule.
Available at: http://www.hhs.gov/ocr/privacy/index.html
Accessed March 4, 2010.

Textbooks

Anderson B. Echocardiography, the Normal Examination and Echocardiographic Measurements. 1st ed. Queensland, Australia: MGA Graphics; 2000.

Feigenbaum H, Armstrong F, Ryan T. Feigenbaum's Echocardiography. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2005.

Kaddoura S. Echo made easy. 2nd ed. St Louis, MO: Churchill Livingstone Elsevier; 2009.

Oh J, Seward J, Tajik A. The Echo Manual. 2nd ed. Philadelphia, PA: Lippincott-Raven; 1999.

Otto C. Textbook of Clinical Echocardiography. 2nd ed. Philadelphia, PA: WB Saunders Company; 2000.

Reynolds T. The Echocardiographer's Pocket Reference. 3rd ed. Phoenix, AZ: School of Cardiac Ultrasound; 2007.