STANDARD PARASTERNAL TTE VIEWS STANDARD APICAL TTE VIEWS ASSESSMENT OF SYSTOLIC FUNCTION

BEFORE YOU START AN ECHOCARDIOGRAPHIC EXAMINATION:

Four Chamber Two Chamber Long Axis
First insert patient ID.
Make sure you have a stable ECG recording with positive QRS.

4-1
PX
Ask the patient to turn to the left side. LV
Make sure you set the total gain and depth for optimal visualisa- RV AMVL

tion of the endocardium.

PX4-1

4-1
PX
RA LA
STANDARD EXAMINATION
1. Start with the parasternal long axis (PLAX) showing the mitral Parasternal Subcostal Apical 4-1

valve(MV) and the aortic valve(AV). The aorta should be open. A4C
PX

probe position probe position probe position

2. Record the MV and AV with color. When using color decrease
the total gain. Aortic valve in PSAX
Base Mid Apex
3. Record MMode, perpundicular to the ventricular septum just RCC
below the tips of the MV leaflets for dimensions or measure 2D. LCC LV
NCC
4. Rotate the probe 90 ° clockwise for the short axis (PSAX) and AMVL
record on aortic level, tilting the probe cranially for the MV, papil- Aorta level
lary muscle and apical levels. Record color in the pulmonic palve Apical
PMVL
(PV), AV and tricuspid valve(TV). RV LA
Scoring: 0: Not visualized
5. Record the apical 4 chamber (A4C). LV RA
RA 1: Normokinesia 1
6. Tilt the probe for the 5 chamber view with the aorta(A5C). Mid papillary Papillary
A2C
PX
4-1

2: Hypokinesia 7
7. Rotate the probe to the 2 chamber view (A2C). LA 3. Akinesia 2
8
13 12
6

8. Rotate the probe to the 3 chamber view (A3C) (same struc- 4. Dyskinesia 14 17 16
tures visible as PLAX). 5. Aneurysmatic 9 11
15 5
9. Record color in the MV and AV in the A3C, the MV in the A2C Anterolateral papillary muscle
3
10
and the MV, AV, TV in A4C and A5C. Posteromedial papillary muscle LV 4
RV
10. Record a pulsed wave(PW) doppler just at the tips of the MV 1. basal anterior 7. mid anterior 13. apical anterior
leaflets for E/A ratio and record an PW tissue velocity imaging 2. basal anteroseptal 8. mid anteroseptal 14. apical septal
SUBCOSTAL VIEW 3. basal inferoseptal 9. mid inferoseptal 15. apical inferior
signal(TVI) of the interventricular septum. 4. basal inferior 10. mid inferior 16. apical lateral
LA 5. basal inferolateral 11. mid inferolateral 17. apex
11. Record a continuous wave(CW) in the AV.
4-1
PX

6. basal anterolateral 12. mid anterolateral

12. Record a tricuspid annular plane systolic excursion (TAPSE) AO
Coronary Territory
for right ventricluar function. M-Mode through A3C
13. Record a subcostal view. Inferior Caval Vein LAD: Segments 1, 7, 8, 9, 13, 14, 15, 16, 17
RCX: Segments 5, 6, 11, 12
14. Record the Inferior Caval Vein and ask the patient to sniff. 
 RCA: Segments 2, 3, 4, 10
15. Record more on indication.
  



If you have any comments please e-mail to Ivo van der Bilt: vanderbilt@cardionetworks.org This reference card is for education purposes only. When in doubt consult a Cardiologist. For more information: www.echopedia.org.
 ASSESSMENT OF DIASTOLIC FUNCTION AORTIC VALVE STENOSIS SEVERITY MITRAL VALVE REGURGITATION SEVERITY MITRAL VALVE STENOSIS WILKINS SCORE

Mild Diastolic Moderate Diastolic Severe Diastolic Dysfunction

Normal Diastolic
Dysfunction Dysfunction Reversible Fixed
Sclerosis Mild Moderate Severe Mild Moderate Severe Grade Mobility Leaflet Calcification Subvalvular
Function
Impaired Relaxation Pseudonormal Restrictive Restrictive Thickening thickening
Aortic jet velocity(m/s) ≤2.5 2.6-2.9 3.0-4.0 >4 Specific Small central jet <4 Signs of V. contracta ≥ 0.7cm,
0.75<E/A<1.5 E/A≤0.75 0.75<E/A<1.5 E/A>1.5 E/A>1.5
Mean gradient (mmHg) - >20 20-40 >40 cm2 or <20% of LA MR>mild central MR jet(area < 1 Mobile valve, only 4-5 mm Single aea minimal
DT>140 ms DT>140 ms DT<140 ms DT<140 ms
2.0 area2 present but 40% of LA) or with a wall- leaflet tip restricted
AVA(cm2) - >1.5 1.0-1.5 <1
Velocity, m/s

E Vena contracta width no criteria for impinging jet, swirling

Mitral Inflow
A AVI=AVA/BSA(cm2/m2) - >0.85 0.6-0.85 <0.6 <0.3 cm severe MR in LA2. 2 Leaflet mid and 5-8 mm, Scattered Extending 1/3 of
0
No or minimal flow Large flow convergence5 basal normal midleaflet areas chordal length
Adur
AORTIC VALVE REGURGITATION SEVERITY convergence Syst. pulm. vein reversal normal

2.0
ΔE/A<0.5 ΔE/A<0.5 ΔE/A≥0.5 ΔE/A≥0.5 ΔE/A<0.5 Supportive Systolic dominant Intermediate Dense, triangular CW 3 Valve continues 5-8 mm, Calcium ex- Extending to
Velocity, m/s

Mitral Inflow at Mild Moderate Severe flow in pulmonary signs/findings Doppler MR jet to move forward extending tending into distal third of chords
Peak Valsalva E
A veins E-wave dominant mitral in diastole, mainly through en- mid portion
Maneuver Specific Central Jet, width>25% Signs of Central Jet, width ≥ A-wave dominant inflow (E >1.2m/s)4. from the base tire leaflet of leaflet
0 LVOT2 AR>mild 65% of LVOT2 mitral inflow4 Dilated LV/LA3.
Vena contracta <0.3 cm2 present but Vena contracta > Soft density, para- 4 No or minimal >8-10 mm Extensive Extensive, extending
Velocity, m/s

Doppler Tissue 0
E/e'<10 E/e'<10 E/e'≥10 E/e'≥10 E/e'≥10 No/brief early diastolic no criteria for 0.6cm2 bolic CW Doppler MR forward movement throughout to papillary muscle
Imaging of Mitral a'
flow reversal in descending severe AR signal of the leaflets in most of the
0.15
Annular Motion e' aorta Normal LV size1 diastole leaflet
S≥D S>D S<D or S<D or S<D or Supportive Pressure half time > 500 ms Intermediate Pressure half-time < Quantitave6
ARdur>Adur+30 ms ARdur>Adur+30 ms ARdur>Adur+30 ms
2.0
ARdur<Adur ARdur<Adur
Normal LV size1 values 200 ms EROA(cm2) <0.20 0.2-0.29/0.3-0.4 ≥0.40 LEFT VENTRICULAR FUNCTION
Velocity, m/s

Holodiastolic aortic RF (%) <30 30-39/40-49 ≥50

S D flow reversal in de-
Pulmonary R vol (ml/ <30 30-44/45-59 ≥60
ARdur
Venous Flow scending aorta beat) LV dysfunction Normal Mild Moderate Severe
0
AR Moderate or greater
Time, ms Time, ms Time, ms Time, ms Time, ms
LV enlargement3 Ejection Fraction(%) >54 45-54 30-44 <30
Left Ventricular Relaxation Normal Impaired Impaired Impaired Impaired
Left Ventricular Compliance Normal
Quantitave$ MITRAL VALVE STENOSIS SEVERITY Fractional Shortening
Normal to ↓ ↓↓ ↓↓↓ ↓↓↓↓
Atrial Pressure Normal
EROA$ <0.10 0.10-0.19 ≥0.30 Endocardial(%) 25-45 20-26 15-21 ≤14
Normal ↑↑ ↑↑↑ ↑↑↑↑
RF (%) <30 30-39/40-49 ≥50
Midwall(%) 12-23 12-14 10-12 ≤10
R vol (ml/ <30 30-44/45-59 ≥60
Septal e’ beat) Mild Moderate Severe
AVA, Aortic valve area; AR, Aortic regurgitation; EROA, effective regurgitant orifice area;
Lateral e’ Specific >1.5 1.0-1.5 <1.0 LV, left ventricle; L(R)VOT, left(right) ventricular outflow tract; R Vol, regurgitant volume;
LA volume REFERENCE VALUES Valve area(cm2) RF, regurgitant fraction; LVEDD, LV end diastolic diameter; TAPSE, tricuspid annular plane
systolic excursion; LA, left atrium; RA Right atrium; BSA, Body Surface Area. CW, Continu-
Septal e’ ≥ 8 Septal e’ ≥ 8 Septal e’ < 8 Supportive ous wave.
Lateral e’ ≥ 10 Lateral e’ ≥ 10 Lateral e’ < 10 Normal Normal Mean gradient(mmHg) <5 5-10 >10
LA < 34 ml/m2 LA ≥ 34 ml/m2 LA ≥ 34 ml/m2 Pulmonary artery 1
LV size applied only to chronic lesions.
Ejection Fraction(%) >55 pressure(mmHg) <30 30-50 >50 2
At a Nyquist limit of 50–60 cm/s.
E/A < 0.8 E/A 0.8-1.5 E/A ≥ 2 LV mass/BSA(g/m2) 43-95 LVOT(cm) 1.8-2.4 3
In the absence of other etiologies of LV dilatation.
DT > 200 ms DT 160-200 ms DT < 160 ms Septal thickness(mm) <12 RVOT(above AV)(cm) 2.5-2.9 4
Usually above 50 years of age or in conditions of impaired relaxation, without elevated
Av. E/e’ ≤ 8 Av. E/e’ 9-12 Av. E/e’ ≥ 13 Posterior wall thickness(mm) 0.6-1.0 TAPSE(cm) 1.5-2.0 LA pressure(MS).
Ar-A < 0 ms Ar-A ≥ 30 ms Ar-A ≥ 30 ms LV diast. vol/BSA(ml/m2) 35-86 LA volume/BSA(ml/m2) 22 ±6 5
Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and
Val ΔE/A < 0.5 Val ΔE/A ≥ 0.5 Val ΔE/A ≥ 0.5 LV syst. vol/BSA(ml/m2) 12-30 LA diameter/BSA(cm/m2) 1.5-2.3 ≤ 0.9 cm for central jets, respectively, with a baseline shift at a Nyquist of 40 cm/s; Cut-offs
LVEDD(cm) 3.9-5.9 RA diameter/BSA(cm/m2) 1.7-2.5 for eccentric jets are higher, and should be angle corrected (see text).
Normal. Normal function, LV diast. volume/BSA(ml/m2) 35-75 Aorta diameter (normal/
function Athlete’s heart, or
6
Quantitative parameters can help sub-classify the moderate regurgitation group into
Grade I Grade II Grade III LV syst. volume/BSA(ml/m2) 12-30 Marfan (mm)) <50/<45
constriction mild-to-moderate and moderate-to-severe as shown.