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Chamber Quantification
Echocardiographic and Doppler Evaluation A. CARDIAC STRUCTURES The following cardiac and vascular structures are generally be evaluated as part of a comprehensive adult transthoracic echocardiography report: 1) Left Ventricle 2) Left Atrium 3) Right Atrium 4) Right Ventricle 5) Aortic Valve 6) Mitral Valve 7) Tricuspid Valve 8) Pulmonic Valve 9) Pericardium 10) Aorta 11) Pulmonary Artery 12) Inferior Vena Cava and Pulmonary Veins It should be emphasized that identification and measurement of some of the structures listed may not always be possible or necessary to provide a comprehensive, clinically relevant report. However it is important for the echocardiography report to include comments on the left ventricle, left atrium, mitral valve and aortic valve. When images of these structures cannot be recorded or interpreted, the report should state that imaging was suboptimal or impossible. In addition, the indication for a particular echocardiographic study may make it crucial to image a particular anatomic structure or to obtain specific
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Doppler recording(s). In this case, it is important for the report to comment on the crucial findings or to note that an adequate recording was not possible. B. MEASUREMENTS As a general rule, quantitative measurements are preferable. However, it is recognized that qualitative or semi-quantitative assessments are often performed and frequently adequate. The following types of measurements are commonly included in a comprehensive echocardiography report. 1) Left Ventricle: a) Size: Dimensions or volumes, at end-systole and end-diastole b) Wall thickness and/or mass: Ventricular septum and left ventricular posterior wall thicknesses (at end-systole and end-diastole) and/or mass (at end-diastole) c) Function: Assessment of systolic function and regional wall motion. Assessment of diastolic function 2) Left Atrium: Size: Area or dimension 3) Aortic Root: Dimension 4) Valvular Stenosis: a) For Valvular Stenosis: Assessment of severity. Measurements that provide an accurate assessment of severity include trans-valvular gradient and area. b) For Subvalvular Stenosis: Assessment of severity. Measurement of subvalvular gradient provides the most accurate assessment of severity and is, therefore,

recommended. 5) Valvular Regurgitation: Assessment of severity with semi-quantitative descriptive statements and/or quantitative measurements 6) Prosthetic Valves: a) Transvalvular gradient and effective orifice area b) Description of regurgitation, if present 7) Cardiac Shunts: Assessment of severity. Measurements of QP:QS (pulmonary-tosystemic flow ratio) and/or orifice area or diameter of the defect are often helpful.

Figure 1 Measurement of left ventricular end-diastolic diameter (EDD) and end-systolic diameter (ESD) from M-mode, guided by parasternal short-axis image (upper left) to optimize medial-lateral beam orientation.

Figure 2 Transesophageal measurements of left ventricular length (L) and minor diameter (LVD) from midesophageal 2-chamber view, usually best imaged at multiplane angle of approximately 60 to 90 degrees.

Figure 3 Transesophageal echocardiographic measurements of left ventricular (LV) minor-axis diameter (LVD) from transgastric 2-chamber view of LV, usually best imaged at angle of approximately 90 to 110 degrees after optimizing maximum obtainable LV size by adjustment of medial-lateral rotation.

Figure 4 Transesophageal echocardiographic measurements of wall thickness of left ventricular (LV) septal wall (SWT) and posterior wall (PWT) from transgastric shortaxis view of LV, at papillary muscle level, usually best imaged at angle of approximately 0 to 30 degrees.

Figure 6 Two methods for estimating LV mass based on area-length (AL) formula and the truncated ellipsoid (TE) formula, from short-axis (left) and apical four-chamber (right) 2-D echo views. Where A1 _ total LV area; A2 _

LV cavity area, Am _ myocardial area, a is the long or semi-major axis from widest minor axis radius to apex, b is the short-axis radius (back calculated from the short-axis cavity area) and d is the truncated semimajor axis from widest short-axis diameter to mitral anulus plane. Assuming a circular area, the radius (b) is computed and mean wall thickness (t) derived from the short-axis epicardial and cavity areas. See text for explanation.

Figure 7 Two-dimensional measurements for volume calculations using biplane method of disks (modified Simpsons rule) in apical 4-chamber (A4C) and apical 2-chamber (A2C) views at end diastole (LV EDD) and at end systole (LV ESD). Papillary muscles should be excluded from the cavity in the tracing.

Figure 8 Segmental analysis of LV walls based on schematic views, in a parasternal short- and long-axis orientation, at 3 different levels. The apex segments are usually visualized from apical 4-chamber, apical 2 and 3chamber views. The apical cap can only be appreciated on some contrast studies. A 16-segment model can be used, without the apical cap, as described in an ASE 1989 document.2 A 17-segment model, including the apical cap, has been suggested by the American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging.

Figure 9 Typical distributions of the right coronary artery (RCA), the left anterior descending (LAD),and the circumflex (CX) coronary arteries. The

arterial distribution varies between patients. Some segments have variable coronary perfusion

Figure 10 Methods of measuring right ventricular wall thickness (arrows) from M-mode (left) and subcostal transthoracic (right) echocardiograms.

Figure 11 Midright ventricular diameter measured in apical 4-chamber view at level of left ventricular papillary muscles.

Figure 12 Transesophageal echocardiographic measurements of right ventricular (RV) diameters from midesophageal 4-chamber view, best imaged after optimizing maximum obtainable RV size by varying angles from approximately 0 to 20 degrees

Figure 13 Measurement of right ventricular outflow tract diameter at subpulmonary region (RVOT1) and pulmonic valve annulus (RVOT2) in midesophageal aortic valve short-axis view, using multiplane angle of approximately 45 to 70 degrees.

Figure 14 Measurement of right ventricular outflow tract at pulmonic valve annulus (RVOT2) and main pulmonary artery from parasternal short-axis view.

Figure 15 Measurement of left atrial diameter (LAD) from M-mode, guided by parasternal short-axis image (upperb right) at level of aortic valve. Linear method is not recommended.

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Figure 16 Measurement of left atrial (LA) volume from area-length (L) method using apical 4-chamber (A4C) and apical 2-chamber (A2C) views at ventricular end systole (maximum LA size). L is measured from back wall to line across hinge points of mitral valve. Shorter L from either A4C or A2C is used in equation.

Figure 17 Measurement of left atrial (LA) volume from biplane method of disks (modified Simpsons rule) using apical 4-chamber (A4C) and apical 2-chamber (A2C) views at ventricular end systole (maximum LA size).

Figure 18 Measurement of aortic root diameters at aortic

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valve annulus (AV ann) level, sinuses of Valsalva (Sinus Val), and sinotubular junction (ST Jxn) from midesophageal long-axis view of aortic valve, usually at angle of approximately 110 to 150 degrees. Annulus is measured by convention at base of aortic leaflets. Although leading edge to leading edge technique is demonstrated for the Sinus Val and ST Jxn, some prefer inner edge to inner edge method. (See text for further discussion.)

Figure 19 Measurement of aortic root diameter at sinuses of Valsava from 2-dimensional parasternal long-axis image. Although leading edge to leading edge technique is shown, some prefer inner edge to inner edge method. (See text for further discussion.)

Comprehensive Epicardial Echocardiography Examination

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Figure 1 Epicardial aortic valve (AV) short-axis (SAX) view (transthoracic echocardiographic parasternal AV SAX equivalent). A, Porcine anatomic specimen demonstrating ultrasound transducer oriented above AV annulus so that ultrasound beam can be aligned in SAX plane to AV. B, When orientation marker (indentation) on transducer is pointed toward patients left, right coronary cusp (R) will be at top of monitor screen, left coronary cusp (L) will be on right, and noncoronary cusp (N) will be on left side of screen adjacent to interatrial septum. PA, Pulmonary artery.

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Figure 2 Epicardial aortic (AO) valve (AV) long-axis (LAX) view (transthoracic echocardiographic suprasternal AV LAX equivalent). A, Porcine anatomic specimen demonstrating ultrasound transducer oriented along AO root, and directing ultrasound beam posteriorly to visualize left ventricular outflow tract (LVOT) and AV. B, AV and LVOT are well visualized. PA, Pulmonary artery.

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Figure 3 Epicardial left ventricle (LV) basal short-axis (SAX) view (transthoracic echocardiographic odified parasternal mitral valve [MV] basal SAX equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning for developing epicardial LV basal SAX view. B, MV annulus is well visualized with its typical fish mouth appearance. MV anterior leaflet (AL) appears on top of screen and posterior leaflet (PL) is underneath. When transducer orientation marker is directed toward patients left, MVanterolateral commissure will be on right and posteromedial commissure will be on left of screen. RV, Right ventricle.

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Figure 4 Epicardial left ventricle (LV) mid short-axis (SAX) view (transthoracic echocardiographic parasternal LV mid-SAX equivalent). A, Porcine anatomic specimen demonstrating proper epicardial probe positioning toward right ventricle apex for developing epicardial LV mid-SAX view. B, With transducer orientation marker directed toward patients left, LV anterolateral papillary muscle will be on right and posteriomedial papillary muscle will be on left of ultrasound sector displayed on monitor. Septal (S) wall of LV is displayed on left followed by anterior (A), lateral (L), and inferior (I) walls, respectively, in clockwise rotation. The right ventricle is not visualized in this image.

Figure 5 Epicardial left ventricle (LV) long-axis (LAX) view (transthoracic echocardiographic parasternal LAX equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning with ultrasound beam angled superiorly and toward patients left shoulder to obtain epicardial LV LAX view. B, Porcine

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anatomic specimen with resected anterior ventricular wall demonstrating visualization of LV and right ventricle (RV), left atrium (LA), LV outflow tract (LVOT), interventricular septum (IVS), aortic valve (AV), and mitral valve (MV). C, Corresponding epicardial LV LAX echocardiographic view.

Figure 6 Epicardial 2-chamber view (transthoracic echocardiographic modified parasternal long-axis [LAX] equivalent). A, Porcine anatomic specimen demonstrating proper probe positioning with ultrasound transducer rotated 90 degrees from epicardial left ventricle (LV) LAX view to obtain epicardial 2-chamber view. B, Porcine anatomic specimen with resected anterior ventricular wall demonstrating left atrium (LA), mitral valve (MV), and LV. To completely eliminate right ventricle, transducer must be placebo directly on LV, which is possible only in patients with severe LV dilation (not shown). C, Corresponding epicardial 2chamber echocardiographic image in a patient with LV dilation.

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Figure 7 Epicardial right ventricular (RV) outflow tract (RVOT) view (transthoracic echocardiographic parasternal short-axis equivalent). A, Porcine anatomic specimen with resected anterior ventricular wall demonstrating proper probe positioning for developing epicardial RV inflow tract/RVOT view. B, RVOT, pulmonic valve (PV), proximal main pulmonary artery, and aortic valve (AV) can be visualized.