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About

TTE Main Page

  1. Transthoracic echocardiography (TTE) is the most commonly performed cardiac ultrasound examination. A high quality transthoracic echocardiogram can be performed quickly at the bedside and has the potential to comprehensively evaluate left and right ventricular systolic and diastolic function, regional wall motion, valvular heart disease, and diseases of the pericardium. The transthoracic echocardiogram has been largely standardized across institutions, such that images are generally obtained from at least 4 separate standard transducer positions which allow for different portions of the heart to be visualized in detail. These standard positions are the parasternal position (which has both long axis and short axis views), apical position , subcostal position and the suprasternal notch position. These transducer positions and the multiple views obtained from each position are described in detail on the individual section pages. Click on the tabs above to view these pages. In addition to appreciating the power of a transthoracic echocardiogram, after performing transthoracic echocardiograms you will also come to realize the limitations of this technique. Many patients will have suboptimal or in some cases minimal acoustic windows for ultrasound examination and this has been a source of much frustration for technologists and cardiology fellows. For example, patients who are obese, those who have chronic lung disease, who are imaged supine or on a ventilator, or those who are recently post-op from cardiac or thoracic surgery will often have limited windows and possibly uninterpretable images no matter how skilled the sonographer. Some of these limitations can be overcome with off axis imaging, use LV contrast or with transesophageal imaging if needed.

 

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Parasternal Long Axis

PLAX Main Page

  1. The parasternal long axis view is generally the first view obtained in a routine transthoracic echocardiogram. It is the standard view for making M-mode and 2D measurements of the left ventricle, aortic root and left atrium. The patient is best imaged lying on their left side, with their left arm under their head.

Transducer Position: The transducer is placed 2-3 inches to the left of the sternum in the 4th or 5th rib interspace. The notch on the transducer should be facing towards the 10 o’clock position toward the right shoulder.  From this position, the standard view can be obtained. By manipulating the tip of the transducer, the RV inflow view and PA long axis view can also be obtained as shown on the additional tabs above.

 

 

 

 

 

 

 

 

 

 If the heart is viewed anteriorly, this is how it would appear to lie in the chest. The light blue trapezoid demonstrates how the ultrasound beam slices through the heart to obtain a 2D image.

As one can see, the most anterior structure is the right ventricular outflow tract here, just below the PA and in the far field we have the left ventricle, left atrium and descending aorta.


Standard Parasternal Long Axis View

In the appropriate standard view shown above, the apex should not be visible. The left ventricle should be oriented almost horizontally. The right ventricular outflow tract, left ventricular anteroseptum and inferolateral wall are visualized here as shown above with other key structures labeled. Note the RVOT is seen, and not the right ventricle. Posterior to the left atrium one can sometimes see the proximal descending thoracic aorta. RVOT – right ventricular outflow tract, AML - anterior mitral valve leaflet, PML - posterior mitral valve leaflet, LA - left atrium, LV – left ventricle, AV – aortic valve, and DA - descending aorta.

 

Zoomed in View of Aortic and Mitral Valve



Similarly zooming in on specific structures such as the aortic valve and mitral valve allows for better visualization of leaflet structures. Typically the right and non coronary cusps of the aortic valve are seen here, however with off-axis imaging, the left coronary cusp may also be seen. RCC - right coronary cusp, NCC - non coronary cusp, AML - anterior mitral valve leaflet.

 

Ascending Aorta View

By moving the transducer up an interspace, one can see the proximal ascending aorta. This is useful in those who have dilated or calcified aorta root and enlarged ascending aorta.

 

M-mode and 2D measurements

The parasternal long axis view is used to make a standardized set of measurements. We use both M mode and 2D to make these measurements.

M-mode measurements

M-mode scans one line across time. These measurements are thus very dependent upon lining up your M-mode correctly with the LV. The convention for all M- mode measurements is to measure from leading edge to leading edge. That is, the measurement starts at the top (or leading edge) of the line that makes up a structure and goes to the top of the next line where the measurement ends. Looks closely at the two measurements below for some example

Aortic Root Measurement

For the aortic root and LA measurements, place the cursor over the coaptation zone of the aortic valve cusps. Identify diastole using the start of the QRS on the EKG tracing, right before the aortic valve opens and measure the aortic root size

 

LA diameter measurement

Find peak systole with the largest dimension of the left atrium and measure leading edge to leading edge to obtain the LA diameter as shown above.

Ideally the M-mode cursor for LV measurements should be perpendicular to the LV septum. Otherwise LV dimensions can sometimes be overestimated when off axis. Try to measure the septum and posterior wall thickness at diastole (largest cavity size) which is usually right at the QRS onset and then measure these at systole (smallest LV cavity size). In addition measure the internal cavity dimension. In the M-mode below, the LV diastolic measurement is 4.7cm and the systolic measurement is 2.8cm, both of which are normal.

2-D measurements

Because of issues with difficulty in proper alignment with the M-mode cursor, the majority of measurements are now made with 2D imaging. Choose the best diastolic frame with the largest LV cavity (as shown below on the left) and measure the septal and posterior wall thickness as well as the LV diastolic cavity. This is also the appropriate frame in which to measure the aortic root diameter. Then chose a systolic frame (as shown below on the right) to measure LV dimensions as well as the left atrial diameter. With 2 D measurements the blood/tissue interface can be seen using modern equipment and a trailing edge to trailing edge measurement is appropriate.


Because there maybe discrepancies between M-mode and 2D measurements given that M-mode measurements may be off axis or in a different position, large differences should be reconciled before reporting to avoid confusion.


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PLAX: RV inflow view

  1. The RV inflow view is obtained by tilting the head of the transducer down and to the left without moving the probe off the chest from the main parasternal long axis position.
  2. MB - moderator band, CS - coronary sinus, RA - right atrium, PL - posterior leaflet, AL - anterior leaflet, RV - right ventricle, IVC - inferior vena cava

 


In this view, the right atrium, right ventricle, tricuspid valve and sometimes the IVC can be seen. A proper inflow view shows only the RV and not the LV. This in the only transthoracic view which shows the posterior leaflet of the tricuspid valve. If part of the LV is seen, it is not a pure RV inflow view and instead of the posterior leaflet you will be seeing the septal leaflet. The view is otherwise useful for evaluating tricuspid regurgitation and assessing RV inflow and outflow paradox, particularly if apical views are limited in cardiac tamponade. RV - right ventricle, RA - right atrium, TV - tricuspid valve, EV - eustachian valve, SVC - superior vena cava (coming out of the page toward you), IVC - inferior vena cava.

 

Doppler of the Tricuspid Valve

Color Doppler is typically used to first assess for any evidence of tricuspid regurgitation. This individual below, for example has trace tricuspid regurgitation. Note the inflow (red-orange color) from the IVC.



Thereafter spectral Doppler is used: pulsed wave (PW) Doppler above (right) and below (left) the tricuspid valve in this view.




 This is followed by continuous wave (CW) Doppler to measure the tricuspid regurgitation (TR) gradient which is indirectly used to calculate PA pressure. Position the cursor over the area where the TR jet is easiest to see.




CW Doppler can be used to calculate the pressure gradient across the tricuspid valve when there is TR to estimate the PA systolic pressure (because it is equal to the RV systolic pressure in most people) when there is no significant pulmonic stenosis. Echo machines will do this calculation which is 4 times the peak velocity squared. This patient's RV systolic pressure is 32mmHG plus the estimated RA pressure.

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PLAX: PA long axis view

  1. By tilting the head of the transducer up from the normal parasternal long axis position, the pulmonary artery and pulmonic valve can usually be seen in long axis. This view is useful for evaluating pulmonic stenosis and insufficiency, and for estimating cardiac output through the lungs. It is the best view to see the pulmonic valve, however, the PA bifurcation is rarely seen from the long axis view.
  2.  

  3. This is how the view looks in real time:

  4. Additional evaluation with color Doppler is usually performed in this view. It is quite common to see trace or mild pulmonic regurgitation as shown below in diastole (left picture) with the red color jet.

     

    Diastole                                                                 

     

  5. Systole

  6.  

  7. Next use pulsed wave Doppler above and below the valve assess whether there is evidence of pulmonic stenosis. As shown below the peak velocity above (right) and below (left) the valve are similar, suggesting there is no stenosis. There is also nice laminar flow as outlined by the pulsed wave Doppler jet.

     

    Continuous Wave Doppler of the Pulmonic Valve

    CW Doppler of the pulmonic valve is useful if you see high flow velocities or to calculate a PA diastolic pressure if you see some pulmonic regurgitation In this case the systolic velocity flow (below the baseline envelope) and diastolic regurgitation jet (above the baseline envelope) are seen and can be evaluated. The velocity at the end of the pulmonary regurgitation jet (at end diastole) can be used to estimate the PA diastolic pressure after adding the RA pressure. Just use 4 x peak velocity squared + RA pressure. Here the end diastolic velocity is about 1m/s. 


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Parasternal Short Axis

  1. This position encompasses several different views of the LV in short axis that differ in how basal or apical the probe is. The most basal window lays out the aortic valve, pulmonic valve, and tricuspid valve. Other standard views include the LV at the mitral valve level, the mid ventricle level and apex all shown sequentially below.

Transducer position: To obtain the short axis view, turn the probe clockwise until you are almost perpendicular to the long axis plane. Typically the probe marker is now oriented at 2 o’clock (toward the patient's left shoulder). From here, tilting probe handle up and down allows one to scan up and down the ventricle to obtain apical and basal views. In those with large hearts moving the probe up and down and interspace may be needed.

 

 

The figure below shows the different parasternal short axis views obtained just by tiling the probe from base to apex. It is important to obtain all the views shown below in order to assess 16 of the 17 different segments of the left ventricle (note that the 17th segment, the apex, can only be seen from an apical window) 

 

 

 

 

Short Axis: Aortic, Tricuspid and Pulmonic Valve Level

 

This is the most basal short axis view that lays out the 2 atria, 3 valves and the RV outflow tract. Repeat PW and CW across the tricuspid valve is usually done here. TV - tricuspid valve, RA - right atrium, LA - left atrium, AV - aortic valve, PV - pulmonary valve, RVOT - right ventricular outflow tract, PA - pulmonary artery

 

 

Short Axis: Zoom in on the Aortic Valve

 

It is quite useful to zoom in on the aortic valve to try to assess whether it is trileaflet. Color Doppler here can also help tell the origin of a regurgitant jet. The cusps can always be identified as follows, whether in this view, the subcostal view or via TEE: the intra-atrial septum always intersects the non coronary cusp; the right coronary cusp is the most anterior and abuts the right ventricular outflow tract. The left coronary cusp is therefore the one that is left. Sometimes slight angulation will allow visualization of the left main and right coronary arteries. RCC - right coronary cusp, LCC - left coronary cusp, NCC - non coronary cusp.


 

Pulmonary Artery View

 

Slight angulation superiorly will show the pulmonary artery and sometimes past the bifurcation. This is the view that is useful for seeing a PDA with color Doppler (usually a jet seen along the left PA). Also note the geometry of the pulmonary valve and artery, more anterior and almost perpendicular to the aortic valve plane. It is important to use PW Doppler above and below the pulmonic valve. Sometimes PW Doppler can be done separately in each pulmonary artery branch if stenosis or a mass is seen. Note that this individual is in atrial flutter during the echocardiogram. PA - pulmonary artery, PV - pulmonic valve.


Short Axis: Mitral Valve Level


Tilting the probe tip downward the view of the base of the LV and mitral valve can be seen. The ventricle in this view should be round and not oval when done properly. In this view and the next two, many of the 17 different segments of the LV wall can be assessed individually. Note it is the RV insertion site anteriorly which separates septum from anterior wall and the RV insertion site inferiorly which separates septum from the inferior wall. Simply assuming the the 12 o’clock position on the LV identifies the anterior wall will not always be correct, especially in hearts that are rotated. AML - anterior mitral leaflet, PML - posterior mitral leaflet

 

Short Axis: Mid Ventricle Level

 

The mid ventricle level is identified by the presence of the two papillary muscles, which should not be confused for masses or thrombi. ALPM - anterolateral papillary muscle. PMPM - posteromedial papillary muscle.


 

Short Axis: Left Ventricular Apex

 

Tilting the probe even more inferiorly allows one to see the very apical segment which has no clear papillary muscle structures.

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Apical Main Page

  1. The apical views are obtained by placing the probe at the point of maximal impulse. There are numerous views that are obtained from this position including the 4 chamber view , the 5 chamber view which includes the LV outflow tract, the 2 chamber view and the apical long axis view (sometimes called the 3 chamber view) all by rotation and minor manipulation of the probe. The apical windows are the most useful for: 1) Assessing flow across the aortic, tricuspid and mitral valves with Doppler as flow across them is parallel to the direction of the ultrasound beam. This information can be used directly to assess for degree of stenosis and regurgitation as well as respiratory inflow paradox across the valves which is sometimes seen in cardiac tamponade and constriction. 2) Assessment of diastolic function, including use of tissue Doppler and pulsing across the pulmonary veins, up to 3 of which may be visible in this position. 3) Assessment of RV size and function including use of tricuspid annular plane systolic excursion (TAPSE) 4) Evaluation of LV segmental wall motion and evaluation of LV thrombus (the apex is in the near field), sometimes with help of an IV echo contrast agent. 5) Assessment for a PFO or ASD in conjunction with the use of saline contrast..

 

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Apical 4 Chamber

Transducer position: The apical views are obtained by placing the transducer at the point of maximal impulse. The 4 chamber view is usually obtained first with the probe indicator at 3 o’clock (toward the patients left side).

 

 

Standard 4 Chamber View

The probe slices through the apex, and right and left ventricles in this view. The atria are in the far field.

 

The field cut of view is such that the aortic root and aortic valve are not seen in this plane.

 

RV - right ventricle, LV - left ventricle, DA - descending aorta, TV - tricuspid valve, MV - mitral valve, RA - right atrium, LA - left atrium


 

The actual live echo window looks like this:




In the standard 4 chamber, all four major chambers of the heart can be seen as shown above. The LV lateral wall, apex and septum are typically laid out. In the appropriate orientation, the septum lines up vertically near the center of the screen. The LV and LV apex should be vertically oriented and the LV should be parabolic in shape as shown. If the LV apex appears round or is off center in only this view and not others then you are likely "off axis" which can affect interpretation. This view is also used to assess RV size and function, atrial size, abnormal intra-atrial and interventricular septal movement, as well as diastolic function. A few institutions have standardized this view in right-left reverse with the left ventricle on the left side of the screen and the right ventricle on the right of the screen. The majority of hospitals otherwise use the convention we show above. LV - left ventricle, RV - right ventricle, LA - left atrium, RA - right atrium, TV - tricuspid valve, and MV - mitral valve.

the septum should be oriented vertically in the center of the screen and the LV and LV apex should be vertically oriented and parallel to the direction of the sound beams.

 

Zoomed in view of the Left Ventricle

It is important attempt to get a good look at all of the walls of the left ventricle. In this view the inferoseptum, lateral wall and apex can be seen. The lateral wall is usually the least well seen here because the wall itself is parallel with the ultrasound beam.



In addition to LV function assessment, below are some examples of what additional information can be gathered in this view. In the apical 4 chamber view it is important to use color Doppler to assess the mitral valve, the tricuspid valve and the pulmonary veins. Spectral Doppler should also be used to assess for the filling pattern of both valve, and to help quantify regurgitation as well as diastolic function. Tissue Doppler is frequently used at the lateral and septal mitral annulus to help assess diastolic function as well. This is discussed further in the diastolic function section.

 

Assessment of valvular regurgitation

Use of color Doppler below shows the presence of tricuspid valve (left) and mitral valve (right) regurgitation. Quantification of mitral regurgitation requires use of spectral Doppler and is discussed elsewhere.






 

Assessment of diastolic function

This involves a combination of assessment of mitral valve inflow, pulmonary vein flow and tissue Doppler Normal examples are shown below. Diastolic function is covered in more detail in another section.


Normal Mitral Valve Inflow Pattern

The E wave represents early passing filling and the a wave represents atrial contraction. Under normal circumstances the E wave is larger than the a wave and the deceleration time is not markedly prolonged or shortened.


Normal tissue Doppler of the septal (left) and lateral (right) mitral annulus.

The E' and A' waves res present the same parts of the cardiac cycle as above, but the ' denotes that we are talking about tissue velocity movements and not blood flow. Note that the velocity of tissue is much lower than blood. The peak E' velocity if about 15cm/s, whereas the peak E wave velocity using PW Doppler above was about 80 cm/sec. Normally the peak E' velocities are 10 cm/s and 15 cm/s at the septal and lateral mitral annulus, respectively. This pictures above therefore show normal tissue Doppler velocities.


Normal pulmonary vein color Doppler and inflow pattern.

Normal pulmonary vein flow pattern has 3 main components, an S wave that represents systole, a D wave that represents diastole and an A wave that represents reversal of flow during atrial contraction. Normally the S wave is larger than the D. Other nuances of pulmonary vein flow are covered elsewhere.


 

Assess right ventricular function

Tricuspid annular planar systolic excursion or TAPSE is another optional measurement that is not common in many protocols, but is worth being familiar with. It is performed in the apical 4 chamber. It is basically M-mode assessment of RV function where the M mode cursor is placed through the TV lateral wall annulus. The distance of excursion in systole (how much the annulus moves toward the probe) is measured. In the above view a diagonal tracing is made from base to peak and the VERTICAL distance is what is measured in the M mode. A normal TAPSE value is greater than 2 cm, which in the video above on the left represents the vertical distance the annulus travels from base to apex in systole. Additional measures of RV function, such as the fractional area change, can also be calculated from the four chamber view, if desired.

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Apical 5 Chamber

  1. By tilting the head of the probe upwards you move to more anterior structures and create the apical 5 chamber position, the LVOT, aortic valve and proximal aorta can be seen. It is called the 5 chamber view because the ascending aorta is now also seen in addition to the two ventricles and two atria.

Note that with the probe tilted anteriorly the ultrasound beam place slices through the aortic valve and aortic root.

AV - aortic valve, RV - right ventricle, LV - left ventricle, RA - right atrium, LA - left atrium, MV - mitral valve, TV - tricuspid valve.


 

The live echo view is shown below:

 

Aortic Valve Assessment

To better assess the aortic valve and for the presence of stenosis and regurgitation, color Doppler and spectral Doppler are used.

It is important to assess for aliasing flow as there may be flow acceleration in the LVOT. When seen, aortic regurgitation is commonly overestimated in this view and hence it is not typically used in quantification assessment. The quantification of aortic regurgitation and stenosis are discussed elsewhere. The above video shown normal color Doppler profile across the aortic valve

 

Spectral Doppler of the Aortic Valve

Pulse wave Doppler at the LVOT (left picture) usually gives a peak velocity near 1 meter/second in most individuals. Above the aortic valve (right picture) if there is a significant increase in this peak velocity (usually over 2 meters/second) then this suggests possible aortic stenosis. Pulse wave Doppler usually will alias at this velocity and continuous wave Doppler is needed to get the peak velocity. Note that the PW above the valve the velocity is similar to that in the LVOT.

 

CW Doppler is now used, showing a similar peak velocity profile along the LVOT and across the aortic valve as seen with PW Doppler There is no evidence aortic stenosis. If one were to measure peak and mean gradients are shown here, they are nominal.

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Apical 2 Chamber

Transducer Position: By rotating the probe approximately 90 degrees counter clockwise from the apical 4 chamber position, the apical 2 chamber view can be obtained.

 

This view bisects the left ventricle, along the anterior and inferior wall

 

Sometimes the left atrial appendage can also be seen in this view.

 

 

A Standard 2 Chamber View

This view is excellent for assessing wall motion of the inferior wall, anterior wall and apex. It is another useful view for assessing the mitral valve. Note the descending thoracic aorta can also be visualized in this view if off axis imaging is used whereby the LV will appear more foreshortened, as shown below.


Off Axis Imaging to Bring in the Thoracic Aorta

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Apical Long Axis

Transducer Position: The apical long axis, sometimes called the three chamber view is obtained by rotation of the probe another 90 degrees counter-clockwise from the apical 2 chamber position. The probe is thus facing around 9 to 10 o'clock.

 

Rotating the probe from the two chamber position now bisects the aortic root and aortic valve.

The anteroseptum now comes into view. Compare this view plane to the parasternal long axis. It is virtually the same except the probe is in a different location

 

The live echo view is show below:

 This view shows similar structures to the parasternal long axis except now the LV apex is well visualized and is in the near field. The LV wall segments and views of the aortic and mitral valves are the same. Ao - aorta, AV - aortic valve, LA - left atrium, LV - left ventricle, PML - posterior mitral leaflet, AML - anterior mitral leaflet, and RVOT - right ventricular outflow tract.

In this view the color and spectral Doppler of the aortic valve and mitral valve should be performed. The probe may have better alignment with the flow through the LVOT and aortic valve in this view compared to the 5 chamber view. It is important to assess the velocity time profiles in both views.

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Subcostal Long Axis

Transducer Position: The patient is placed flat on their back. Sometimes it helps for the head to be slightly elevated or if the patient takes in a deep breath. It may also be helpful if the patient bends their legs.

  1. Scan under the subxyphoid process until a standard 4 chamber view is obtained. Increasing the depth is usually needed depending on how high up the heart is located..

 

The heart is now in the far field, and the ultrasound beam has to go through the liver first, before slicing through the right ventricle and then left ventricle.

 

 

The structures seen are roughly similar to the apical four chamber however now the ultrasound beam is more perpendicular to the atrial and ventricular septum.

 

This view is excellent for looking at the anterior RV free wall, to assess for RV thickness, and for the evaluation of pericardial effusions. It is also one of the most useful views for evaluating flow across the intra-atrial septum for the presence of a PFO or ASD. RV- right ventricle, LV - left ventricle, LA - left atrium, RA - right atrium, TV - tricuspid valve, and MV - mitral valve.

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Subcostal Short Axis

Short Axis View from the Subcostal Position*

  1. If the probe is rotated counterclockwise from the long axis position then short axis images of the LV, valves be obtained. Some fine tuning with tilting the head of the probe may also be needed depending on the orientation of the heart in the chest. Views in this plane very similar to the parasternal short axis views, however the heart ultrasound beam is now coming from an inferior direction. *Note that these views are useful to attempt in those who have poor parasternal windows in order to get the valves and left ventricle in short axis. One does not necessarily need these views if the parasternal short axis images are of high quality.

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Subcostal Great Vessels

Transducer Position: Rotate the probe 90 degrees counter clockwise from the 4 chamber subcostal view so that the probe is pointing toward the head at 12'o'clock. Tilting medially and laterally will help show the IVC and aorta



Abdominal Aorta: Color Doppler


The abdominal aorta can be found by tilting the probe medially until this pulsatile thick-walled structure is seen. This view assesses the abdominal aorta from which the celiac artery can sometimes be seen to arise. PW can be performed here although blood flow may sometimes be quite perpendicular to the transducer.


Subcostal View of the IVC


To get this view, tilt the probe more right lateral from the abdominal aorta view. Alternatively from the subcostal four chamber, visualize the right atrium and turn the probe from the 9 o'clock position to the 12 o'clock position. This view is used to assess RA pressures based on inspiratory collapse of the IVC. Lack of collapse suggests high RA pressures where as complete collapse suggests low RA pressures. Note the change here in IVC diameter with respiration. Sometimes an M mode through the IVC as shown above on the right can better help show respiratory changes with time. This topic is covered further in the hemodynamics section.

Color Doppler of the Middle Hepatic Vein



Slight angulation around the IVC position will show the middle hepatic vein, shown above with color Doppler PW can then be done to reveal the characteristic waveform which gives information about right sided pressures and hemodynamics as there is no valve between the middle hepatic vein and the right atrium. Shown are the A wave (atrial contraction), S wave (systole) and D wave (diastole). Reversal of the S wave may be seen with significant tricuspid regurgitation.

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Suprasternal Long Axis

Transducer Position: Have the patient lie completely flat without anything under the head. Ask them to lift their chin upward and look to the left. Then place the transducer in the suprasternal notch with the probe pointed at the left shoulder at about 2 o'clock. Sometimes you may need to tilt the probe to point downward.

Note that in this view the right pulmonary artery courses underneath the arch, therefore we see it in a short axis view here.

 

It is often difficult to see all 3 major branches from the aortic arch. The descending aorta is also less well seen in the far field in this view.

 

A an example of a live echo view is shown below

This view usually gives a nice look at the arch, from which the 3 major vessels may be seen to arise. The right pulmonary artery and brachiocephalic vein which empties into the SVC can also be seen. It is important to use color Doppler to assess flow in the ascending and descending aorta and then to use spectral Doppler as shown below.

 

Pulse wave Doppler in the ascending (right) and descending (left) aorta.

If there is an increase in the velocity of flow in the descending aorta (greater than 1.5 m/s) accompanied by flow turbulence on color Doppler imaging, then this may suggest the presence of aortic coarctation. CW Doppler should be used to assess for the maximal gradient.

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Suprasternal Short Axis

Transducer Position:Turn the probe clockwise to the 5 o'clock position, roughly perpendicular to the long axis view.

 

Now the probe is turned 90 degrees the aorta is cut in the short axis plane and the right pulmonary artery underneath is now shown in the long axis. Often the SVC is also bisected here.

In the far field, sometimes the left atrium can be seen, with all four pulmonary veins, the only TTE view in which all 4 veins may be seen.

 

The live echo view is show below:

Here the aorta is seen in in short axis and the right PA now in long axis. Sometimes in the far field the 4 pulmonary veins can be seen entering the left atrium.

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SVC view

Transducer Position: Place the probe near the base of the right sternocleidomastoid muscle with the tip at about 11 o'clock.

This is a challenging view to obtain in many individuals, and sometimes color Doppler is needed to direct you to the SVC. Flow should be blue, away from the probe since this is a venous structure going toward the heart.




Pulsed wave Doppler will show a classic pattern seen in JVP with an A wave, and X and Y descent. There is normally some variation with respiration
 

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Mass/Volume Calculations

It has become common practice in many echocardiography labs to report LV mass and volumes indexed to body size as well as atrial volumes and these provide more informative data than just standard LV dimensions. Measurements need to be performed with adequate apical and short axis views which are not distorted or foreshortened.

LV Volumes

4 chamber view diastole

 

 

4 chamber view systole

 

2 chamber view diastole

 

2 chamber view systole

The 4 and 2 chamber views are used to trace out the LV cavity in end systole and end diastole. Use simpson's method of disks, End diastolic and end systolic volumes are calculated which are then used to derive the EF (here shows as EF Biplace=65%). One should not inlude the papillary muscles and make sure to trace all the way out to the true apex. The volumes are then indexed by body surface area.



LV mass

Parasternal short axis, mid ventricle, diastole


 

4 chamber view diastole

There are two major methods to use 2 D measurements to calculate LV mass: the truncated ellipse (TE) method and the area length method. One needs needs endocardial and epicardial areas from the short axis view at the level of the mid ventricle at end diastole and also the length at the apical 4 chamber view in end diastole (shown as 9.0cm above). Again it is important to not include the papillary muscles

 

LA volumes

4 Chamber view systole

 

2 chamber view systole

 

 

Atrial measurements are done in peak systole in the 4 and 2 chamber views. Make sure not to trace into the pulmonary veins or to include the left atrial appendage. The volume is also inddexed to body surface area.

 

A1 and A2 are the two areas measured above. L is the shorter of the 2 lenghts measured above in the 4 and 2 chamber views from the mitral valve to the most superior portion of the left atrium. 


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Transesophageal Echocardiography

Transesophageal echocardiography improves image quality in many ways over transthoracic echo but at the expense of being an invasive procedure. The echo probe is placed within the esophagus and ultrasound is projected at the neighboring structures, such as the heart and aorta, which are in close proximity. Because of imaging at shallower depths, TEE can use higher frequency transducers (up to 7MHz).

Becoming familiar with obtaining standard tomographic views takes some time and practice working along side an experienced echocardiographer. The standard views can be divided by how far in the TEE probe is into the esophagus or stomach. Most of the information usually is obtained in the mid-esophageal view. The transgastric views shows the LV in short and long axis and helps one obtain aortic valve gradients. It is one of the best views to evaluate left ventricular function and pericardial effusions. The high esophageal view allows visualization of the great vessels. These are discussed on separate pages.


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Common Indications for TEE

1. Assessing for a cardiac source of embolus :This may be a common order in a neurology ward with frequent admissions for stroke, especially of unclear etiology and especially in younger patients. Careful assessment of all valves, the left atrial appendage, the intra-atrial septum and the aorta for large friable atheroma are all important components of this study..

2. Assessing for a cardiac source of infection : After an initial work-up for endocarditis TEE can be used sometime to help make a diagnosis in those with reasonable clinical suspicion or to help triage a case of known or suspected endocarditis to medical vs. surgical therapy, if for example an abscess is seen.

3. Imaging the heart before, during and after major cardiac surgery: Often immediately after cardiac surgery a transthoracic echo windows are often inadequate because of recent inflammation and chest tubes and TEE is needed. In those undergoing complicated bypass and/or valve surgery pre-op and intra-operative TEE can help guide surgical therapy.

4. Assessment of congenital heart disease and associated shunts. Certain congenital anomalies uniquely seen on TEE, such as a sinus venosus ASD or anomalous pulmonary venous return.

5. Pre-cardioversion in those with atrial fibrillation for flutter. Here the left atrial appendage and atrial and ventricular structures are close examined for the presence of thrombus before cardioversion.

6. Assessment of an intracardiac masses TEE can better characterize location of intracardiac masses seen initial on TTE. Cardiac MRI is also a convenient modality for this evaluation.

7. Examination for a proximal aortic dissection : When other imaging modalities are impractical because the patient has renal failure or not able to get an MRI, this becomes the test of choice.


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Contraindications for TEE

Common Contraindications

1. Known esophageal strictures, perforation, lacerations or large diverticula 2. Cervical spine instability 3. Inability to protect the airway (if not intubated). 4. Loose teeth (need a dental exam and possible extraction before proceeding)

Relative Contraindications for TEE

1. Dysphagia or odynophagia 2. Recent upper GI bleeding 3. Extensive radiation to the chest and mediastinum 4. Esophageal varices

Major Risks of TEE

Due to medications used for sedation:

1. Hypotension from sedating medications 2. Methemoglobinemia 3. Respiratory depression 4. Arrhythmia 5. Paradoxical reaction to sedating medications 6. Infection/Bleeding (from IV insertion site for IV medications) 7. Death (1/10,000)

Due to intubation and probe manipulation:

1. Esophageal trauma, tear or perforation (1/1000 patients) 2. Aspiration 3. Upper GI bleeding 4. Dental injury, aspiration of a loose tooth 5. Displacement of endotracheal and nasogastric tubes


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Mid-Esophageal Views

There are numerous mid-esophageal views. This page will review the most common ones you need to know as you get started, which are akin to transthoracic views. More complex views to target specific structures (for example, the left atrial appendage) are discussed elsewhere. As an overview below, they are listed below with the relevant anatomy labeled. The order in which images are acquired are based on the indication. For example if the interest is in assessing mitral valvular pathology and cause of regurgitation, then the initial images will focus on that, with the axiom that you should always try to answer the clinical question first then move to the rest of the exam.

4 Chamber View, 0 degrees

This is the standard starting view for most studies, starting with the omni at 0 degrees and no rotation. Frequently, retroflexion is needed to get a non-forshortened 4 chamber view. This view is in part used to assess RV and LV function. Note the LV wall segments are similar to that seen in the apical 4 chamber on transthoracic images. Changes in rotation along with changing the probe depth can be used to assess the pulmonary veins in this view as well, as well as better visualize the atria, which are near field structures.

4 Chamber View, 0 degrees, Live 2D View

LA - left atrium, MV - mitral valve, LV - left ventricle, RV - right ventricle, RV - tricuspid valve, RA - right atrium.


5 Chamber View, 0 degrees

Antiflexion from the 4 chamber view will bring in the aortic root and left ventricular outflow tract. Here we are seeing the anteroseptum, similar to the 5 chamber view in transthoracic ECHO, however the apex here is farfield.


5 Chamber View, 0 degrees, Live 2D view

LVOT - left ventricular outflow tract, LA - left atrium, AV - aortic valve, LV - left ventricle, RA - right atrium, RV - right ventricle.




2 Chamber view, 90 degrees

By keeping the probe in the same position by just using omni to 90 degrees, you will get the 2 chamber view. This is similar to the Apical 2 chamber view where often the left atrial appendage in seen.

2 Chamber view, 90 degrees, Live 2D view

LA - left atrium, MV - mitral valve, LV - left ventricle, LAA - left atrial appendage, CS - coronary sinus.




Long Axis View, 120-140 degrees

Increasing the omni, while slightly rotating the probe counterclockwise brings in the long axis view, with similar structures seen as that in the parasternal long axis and apical long axis of transthoracic echo. This in the best view to look at the LVOT and anteroseptum as well as A2 and P2 of the mitral valve.

Long Axis View, 120-140 degrees, Live 2D view

RVOT - right ventricular outflow tract, AV - aortic valve, Ao - aorta, LV - left ventricle, MV - mitral valve, LA - left atrium.


Short Axis View, 30-60 degrees

This view is commonly found perpendicular to the long axis view. So if the ideal long axis view was found at 120 degrees, then a good short axis view typically is found between 30 and 60 degrees of omni. This view is similar to the parasternal short axis view at the aortic valve level, but with different orientation of the structures.


Short Axis View, 30-60 degrees, Live 2D view

Note again the non coronary cusp (NCC) is again interested by the intra-atrial septum. Look closely and in this video you will also see the left main coronary artery arising from the left coronary cusp (LCC). RCC - right coronary cusp, TV - tricuspid valve, RA - right atrium, IAS - intra-atrial septum, RVOT - right ventricular outflow tract, PV - pulmonic valve, LA - left atrium.


BiCaval View, 90-110 degrees

This is one important view which has no main equivalent in transthoracic echo like the other views shown above. Somewhere along 90-110 degrees, rotate the probe clockwise (toward the right sided structures) to obtain this view, which lays out the intra-atrial septum. This is a great view in which to look for PFOs, ASDs or to perform a bubble study. This is also an excellent view to evaluate the IVC, SVC, eustachian valve, and right atrial appendage.

BiCaval View, 90-110 degrees, Live 2D view

EV - eustachian valve, IAS - intra-atrial septum, RAA - right atrial appendage, LA - left atrium, RA - right atrium.


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Transgastric Views

The transgastric views are among the most important transesophageal views and are the best TEE views for evaluating left and right ventricular function. As such, transgastric views are commonly employed in operative TEE to assess ejection fraction and wall motion post-operatively. In addition, deep transgastric views are the best views in which one can obtain accurate gradients across the aortic valve to assess the degree of aortic stenosis or regurgitation.


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The transgastric short axis

The transgastric short axis views are obtained by advancing the probe into the stomach and gently anteflexing. These views are similar to an inverted parasternal short axis view with the anterior wall on the bottom of the screen and the inferior wall at the top. By advancing and withdrawing the probe, short axis slices can be obtained at mitral valve level, papillary muscle level and at the LV apex. In addition, short axis views of the right ventricle, tricuspid valve and RVOT can be obtained via clockwise rotation of the probe.

Transgastric short axis, 0 degrees: Left Ventricle, Live 2D View

The first short axis view typically obtained is the short axis view of the left ventricle. In this view the anterior, inferior and lateral walls are well visualized as well as the ventricular septum.


Transgastric short axis, 0 degrees: Papillary Muscle Level, Live 2D View

By withdrawing the probe further, a more basal view of the left ventricle can be obtained at the level of the papillary muscles. In some instances the LV is somewhat rotated such that electronically scanning to 30 degrees may be necessary to properly orient the left ventricle.


Transgastric Short Axis, 0 degrees: Mitral Valve Level, Live 2D View

Withdrawing further still, the anterior and posterior mitral leaflets can be visualized in short axis as well as the anterior and posterior commissures.


Transgastric Short Axis, 0-30 degrees: Tricuspid Valve, Live 2D View

By rotating the probe clockwise and electronically scanning to 30 degrees, the tricuspid valve can be seen in short axis. This a often a helpful TEE view to assess mechanism of tricuspid regurgitation due to restricted leaflet motion (such as pacemaker lead related scarring) vs. excess motion in a flail segment.



Transgastric Short Axis, 30-60 degrees: RV Outflow Tract

Electronically scanning further to 30-60 degrees, and advancing the probe the muscular right ventricular outflow tract and pulmonic valve can be visualized. This is one TEE view in which Doppler across the pulmonic valve is feasible to assess degree of PS or PR.



Transgastric Short Axis, 30-60 degrees: RV Outflow Tract, Live 2D view


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Transgastric Long Axis

For any given view obtained in the short axis, a similar long axis projection can generally be obtained by electronically scanning 90 degrees from the corresponding short axis plane. By electronically scanning to 90 degrees, one can see the entire anterior and inferior wall of the left ventricle as well as the LV apex to evaluate for left ventricular thrombus.


Transgastric Long Axis, 90 Degrees: Left Ventricle

Transgastric Long Axis, 90 Degrees: Left Ventricle, Live 2D view



Transgastric Long Axis, 90 Degrees: Mitral Valve, Live 2D view

At 90 degrees, withdrawing the probe gently allows visualization of the mitral valve leaflets, left atrium, left atrial appendage and subvalvular apparatus. This is an excellent view for evaluating mitral valve vegetations including chordal/papillary muscle involvement and for visualizing ruptured chords.


Transgastric Long Axis, 90 Degrees: RV Long Axis, Live 2D view

By carefully rotating the probe clockwise from the transgastric long axis view of the LV at 90 degrees, a long axis view of the RV can be obtained. This is another excellent view to assess RV function and to view the anterior wall of the RV.


Transgastric Long Axis, 110-130 Degrees: LVOT and Aortic Valve

By increasing the scanning angle to roughly 100-130 degrees, the left ventricular outflow tract and aortic valve can be visualized. This view is similar to an inverted parasternal long axis view.



Transgastric Long Axis, 110-130 Degrees: LVOT and Aortic Valve, Live 2D view


Transgastric Long Axis, 110-130 Degrees: LVOT and Aortic Valve, Doppler

From this view, one can Doppler across the aortic valve to assess degree of aortic stenosis and regurgitation, particularly if a deep transgastric view is technically limited (see panel at left)


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Deep Transgastric View

Deep Transgastric View, 0 Degrees

Deep transgastric views are the best TEE views for assessing aortic stenosis and regurgitation, because in general, the TEE probe can be oriented parallel to the direction of the LVOT and aortic valve. The deep transgastric views are obtained by advancing the TEE probe deep into the stomach (roughly 50-60 cm in most patients) and gently anteflexing. They can be challenging to obtain in some patients.

Deep Transgastric View, 0 Degrees - Live 2D View

The deep transgastric view is similar to the apical 5 chamber view obtained in transthoracic imaging. Note that the continuous wave cursor can be oriented essentially parallel to the aortic valve from this view (left panel) to allow accurate measurement of gradients across the aortic valve to assess degree of AS/AR.


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High esophageal views

High esophageal views are helpful for evaluating the great vessels including the aortic root and coronary arteries, ascending aorta and the pulmonary artery. A useful landmark for obtaining many of the high esophageal views is the mid-esophageal view of the aortic valve in short axis at 40-60 degrees. By withdrawing from the level of the aortic valve, the origin of the coronary arteries can be visualized.

This allows visualization of the origin of the left main coronary artery arising from the left coronary cusp of the aortic valve and in some instances the LAD and LCX (the latter running towards the left atrium in the AV groove).

By withdrawing further from the aortic valve level, the ascending aorta can be visualized in short axis and the pulmonary artery can be followed in long axis to the PA bifurcation.

The final high esophageal views generally obtained are views of the ascending aorta, aortic arch and proximal descending thoracic aorta. The proximal ascending aorta is best visualized from the long axis, roughly 100-110 degrees and with gentle anteflexion, withdraw the probe to see the ascending aorta until contact is lost. This is an excellent view for the assessment of Type A aortic dissection.

The descending aorta and distal arch can be seen in short axis at 0 degrees, by rotating toward the aorta from the mid esophageal position and slowly withdrawing the probe. In newer TEE systems with 3-D capabilities, x-plane is often used to view the aorta in both short axis (left) and long axis (right) to ensure that dissection and atherosclerotic plaque are not missed.

Withdrawing the probe further, the aortic arch and in some instances the head and neck vessels can be visualized. Again, it is often useful to use biplane to see the arch in long axis (left) and short axis (right). This view is helpful to evaluate the aortic arch in patients with cryptogenic strokes or suspected systemic emboli to exclude aortic arch atheroma. Note that grade III or IV atheroma (4mm thickness and/or mobile elements) discovered on TEE in patients with stroke is an indication for anticoagulation.


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If you are a cardiologist in practice, a fellow in training, an echo technologist, or a cardiac anesthesiologist, then this is the right place to help you learn and review principles of echocardiography..

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Disclaimer: This information on this site is meant to be purely educational and in no way should substitute for clinical judgment or be used as a means to make decisions regarding clinical care. Copyrights' For echocardiographer.org


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