You are on page 1of 6

Recommendations for Standards in

Transthoracic Two-Dimensional
Echocardiography in the Dog and Cat
William P. Thomas, DVM, Cathy E. Gaber, DVM, Gilbert J. Jacobs,
DVM, Paul M. Kaplan, DVM, Christophe W. Lombard, Dr Med Vet,
N. Sydney Moise, DVM, and Bradley L. Moses, DVM
(The Echocardiography Committee of The Specialty of Cardiology,
American College of Veterinary Internal Medicine)

Recommendations are presented for standardized imaging planes and display conventions for two-dimensional echocardiography in the dog and cat. Three transducer locations (windows) provide access
to consistent imaging planes: the right parasternal location, the left caudal (apical) parasternal location,
and the left cranial parasternal location. Recommendations for image display orientations are very
similar to those for comparable human cardiac images, with the heart base or cranial aspect of the heart
displayed to the examiners right on the video display. From the right parasternal location, standard
views include a long-axis four-chamber view and a long-axis left ventricular outflow view, and short-axis
views at the levels of the left ventricular apex, papillary muscles, chordae tendineae, mitral valve, aortic
valve, and pulmonary arteries. From the left caudal (apical) location, standard views include long-axis
two-chamber and four-chamber views. From the left cranial parasternal location, standard views include
a long-axis view of the left ventricular outflow tract and ascending aorta (with variations to image the
right atrium and tricuspid valve, and the pulmonary valve and pulmonary artery), and a short-axis view of
the aortic root encircled by the right heart. These images are presented by means of idealized line
drawings. Adoption of these standards should facilitate consistent performance, recording, teaching, and
communicating results of studies obtained by two-dimensional echocardiography. (Journal of Veterinary
Internal Medicine 1993; 7:247-252. Copyright 0 1993 by the American College of Veterinary Internal
Medicine.)

ECHOCARDIOGRAPHY has been used for clinical


and experimental cardiac imaging and evaluation for
over a decade, and has become an indispensable tool in
the specialty practice of veterinary cardiology. The Specialty of Cardiology of the American College of Veteri-

From the Department of Veterinary Medicine, University of California, Davis (Thomas), Department of Small Animal Clinical Sciences,
Michigan State University (Gaber),Department ofSmall Animal Medicine, University of Georgia (Jacobs), 8C Old Colony Drive, Westford,
MA (Kaplan), Department of Clinical Sciences, Cornell University
(Moise), Roberts Animal Hospital, Hanover, MA (Moses), and Klinik
Fur Kleine Haustiere, Tierspital der Universitat Bern, Switzerland
(Lombard).
Accepted April 5 , 1993.
Reprint requests: Dr. William P. Thomas, DVM, Dept. ofVM:Medicine, University of California, Davis, CA 956 16.
Copyright 0 1993 by the American College of Veterinary Internal
Medicine
089 I -6640/93/0704-0008$3.00/0

247

nary Internal Medicine (ACVIM) has recognized the


need to adopt profession-wide standards for nomenclature, display and recording, interpretation, communication, and publication of images obtained using this technology. Accordingly, a Committee on Echocardiography, composed of experienced veterinary cardiac
ultrasonographers, was formed to produce a report of
recommendations for standards in veterinary echocardiography. This report, one of several to be developed by
the committee, contains recommendations for standards
for routine transthoracic two-dimensional echocardiography (2DE) in the dog and cat. The principles are generally applicable to other species, including horses and
other farm animals, but more study and experience will
be required before detailed recommendations can be
made for these species. The recommendations presented
in this report have been reviewed and approved by consensus of the diplomates of the Specialty of Cardiology of

248

THOMAS ET AL

the ACVIM and the executive committee of the Academy of Veterinary Cardiology.
Introduction
The following qualifications must be considered in using
the techniques recommended in this article:
1. The imaging planes and orientations described here

(the figures were developed from canine images) are


applicable to most normal dogs and cats and most
animals with cardiac disease.-4However, there may
be significant individual variability related to body
habitus, size and location of the available imaging
window, and type and severity of disease. Fine adjustments of transducer position and angulation and
image plane orientations are necessary in most animals to obtain an optimal image of some cardiac
structures.
2. The image planes and movements of the beam are
described using the following terms for each of the
three planes of the body: right-left, cranial-caudal,
and dorsal-ventral. Rotation of the beam is described
as clockwise-counterclockwise as viewed in the direction the transducer and beam are pointed, whether
the examination is performed from the side of an
upright patient, or from above or below a laterally
recumbent patient.
3. To maintain consistency with standards established
for human 2DE, our recommendations for imaging
planes, display conventions, and nomenclature are
very similar to those for human examination^.^
Where our recommendations differ from those for
human 2DE, it is acknowledged in the article.
4. The 2DE examination, despite its value in ascertaining cardiac anatomy and physiology, is not infallible.
It is most valuable when viewed as part of a complete
noninvasive cardiac evaluation that includes the medical history, physical examination, resting electrocardiogram, thoracic radiographs, and other appropriate
laboratory tests. Indications for 2DE examination
should be based on findings from these examinations,
and the results of 2DE must be interpreted in light of
other aspects of the cardiovascular evaluation.
5. The present recommendations may require modifications in the future, based on additional studies and
continuing clinical experience.

Journal of Veterinary
Internal Medicine

effects of this and other sedatives on the 2DE examination of dogs and cats have not been reported. Ideally,
hair is clipped over the left and right precordial transducer locations. However, satisfactory images can also
be obtained in many animals by parting the relatively
thin hair coat at these points and by liberal use of coupling gel.
Dogs and cats may be examined in upright (standing,
sitting, sternal) or lateral recumbent positions without
substantial alteration of examination technique. In most
patients, however, lung interference will be minimized
and image quality enhanced by positioning the animal in
lateral recumbency on a table, stand, or other device that
allows transducer manipulation and examination from
beneath the animal.
Transducer Locations
There are three general transducer locations (windows) that provide access to consistent imaging planes
(Fig 1). The right parasternal location is located between
the right 3rd and 6th intercostal spaces (usually 4th to
5th) between the sternum and costochondral junctions.
The left caudal (apical) parasternal location is located
between the left 5th and 7th intercostal spaces, as close to
the sternum as possible. The left cranial parasternal loca-

Right Parasternal Window

Left Parasternal Windows

Patient Preparation and Positioning


Dogs and cats usually require little or no advance preparation for echocardiographic examination. Sedation is
not required nor desirable except in uncooperative patients. If sedation is used, the potential influence of the
drug(s)on heart rate, chamber dimensions, and ventricular motion compared with the unsedated state must be
considered in the interpretation. The effects of ketamine
hydrochloride on the feline M-mode echocardiogram
have been studied, but although probably similar, the

FIG. 1. Diagram of the thorax showing the approximate areas of the


three transducer locations (windows) used for 2DE examination in
dogs and cats.

Vol. 7

. NO.4, 1993

TRANSTHORACIC TWO-DIMENSIONAL ECHOCARDIOGRAPHY

tion is located between the left 3rd and 4th intercostal


spaces between the sternum and costochondral junctions. The optimum transducer locations vary in individual animals and must be determined during the course of
the examination. Other transducer locations do not provide consistently high-quality images, but may be useful,
especially for Doppler examination, in some animals.
Although images of the heart can be obtained from a
transducer location just caudal to the xiphoid (subcostal
location), the images often lack the clarity and anatomic
detail of the right and left intercostal locations. In most
animals, because of lung interference, it is not possible to
obtain high-quality cardiac images from a transducer location at the thoracic inlet (suprasternal notch location),
although vessels in the cranial mediastinum and thoracic
inlet may be visible.
Image Plane Identification
Imaging planes obtained from each transducer location
are named with respect to their orientation with the left
side of the heart, especially the left ventricle and ascending aorta. A plane that transects the left ventricle parallel
to the long axis of the heart from apex to base is called a
long-axis (longitudinal) plane. A plane that transects the
left ventricle or aorta perpendicular to the long axis of
the heart is called a short-axis plane. Individual planes
are further referred to in some cases by the region of the
heart or number of chambers imaged (see below). Variable oblique, angled views, which are modifications of
long-axis or short-axis planes, may be necessary in individual animals to optimally image some structures. Standardized, consistently obtainable imaging planes for
each of the three transducer locations are outlined
below.

base or the cranial portion of the heart will be displayed


to the examiners right on the video display. The exception to this rule is the left caudal (apical) four-chamber
view (see below). Proper image orientation can be maintained using the right-left image selection switch, and
regardless of the position of the index mark, the orientation of the images on the display and when recorded or

ABBREVIATIONS
FOR FIGURES
2 THROUGH
7
RA
RAu
RV
RVO
TV
PV
LPA
RPA
CaVC
VS
LA
LAu
LV
LVO
LVW
PM
CH
MV
AMV
PMV
A0
LC
RC
NC
0

Right atrium
Right auricle
Right ventricle
Right ventricular outflow tract
Tricuspid valve
Pulmonary valve
Left pulmonary artery
Right pulmonary artery
Caudal vena cava
Ventricular septum
Left atrium
Left auricle
Left ventricle
Left ventricular outflow tract
Left ventricular wall
Papillary muscle
Chorda tendineae
Mitral valve
Anterior mitral valve cusp
Posterior mitral valve cusp
Aorta
Left coronary cusp
Right coronary cusp
Noncoronary cusp
Transducer index mark

Long-Axis 4-Chamber View

Image Orientation
As recommended for human examinations, the index
mark on the two-dimensional transducer (which marks
the edge of the imaging plane) should normally be oriented to indicate the part of the cardiac image that will
appear on the right side of the image display. The transducer index mark should then be pointed either toward
the base of the heart (long-axis views) or cranially toward
the patients head (short-axis views). Because most
current two-dimensional echocardiographs have leftright image reversal capability, individual examiners
may prefer to reverse the orientation of the transducer
index mark, especially when performing studies with the
transducer directed upward through holes or notches in
the examination table. In these studies, many operators
may find it easier to rotate the beam counterclockwise to
change from right intercostal long-axis to short-axis
views, resulting in an index mark directed caudally instead of cranially. Regardless of the orientation of the
index mark, however, the general rule is that the heart

249

Long-Axis LV Outflow View

FIG. 2. Right parasternal location, long-axis views.

250

Journal of Veterinary
Internal Medicine

THOMAS ET AL.

Short-Axis Views

FIG. 3. Right parasternal location, short-axis views. Sections A to F


show progressive views at the level ofthe apex (A), papillary muscle (B),
chorda tendineae (C), mitral valve (D),aorta (E), and pulmonary arteries (F), respectively (see abbreviations list above).

heart, and with the transducer index mark pointing cranially (or cranioventrally), an orientation obtained by
90" clockwise rotation of the beam plane from the longaxis views, a series of short-axis views are obtained.
Proper short-axis orientation is identified by the circular
symmetry of the left ventricle or aortic root. Short-axis
planes at the level of the left ventricular apex, papillary
muscles, chordae tendineae, mitral valve, and aortic
valve should be obtained, respectively, by angling of the
beam plane from apex (ventral) to base (dorsal). Proper
short-axis alignment at the aortic valve level often requires additional slight clockwise rotation of the beam
plane. In some animals, further dorsal angulation allows
imaging of the proximal ascending aorta, right atrium,
and right pulmonary artery. The images should be displayed with the cranial part of the image to the right and
the right heart encircling the left ventricle and aorta
clockwise (right ventricular outflow tract and pulmonary
valve to the right) (Fig 3).

Left Caudal (Apical) Parasternal Location


Left Apical Two-chamber Views

printed should follow the recommendations in this article. In addition, the images should be displayed so that
the transducer artifact and near field echoes appear at
the top and the far field echoes toward the bottom of the
display. Inversion of the image so that the near field
echoes appear at the bottom of the display (an orientation favored by many pediatric cardiologists), may be
preferred by individual examiners, but is not recommended for routine recording and publication of images.

With the beam plane nearly perpendicular to the long


axis of the body, parallel to the long axis of the heart, and
with the transducer index mark pointing toward the
heart base (dorsal), a two-chamber view of the left heart,

Long-Axis 2-Chamber View

Imaging Planes and Orientations


For each of the three principle transducer locations there
are two primary imaging planes and one or more minor
planes (also called views). The following imaging planes
can be consistently obtained in most dogs and cats:

Right Parasternal Location


Long-Axis Views

With the beam plane oriented nearly perpendicular to


the long axis of the body, parallel to the long axis of the
heart, and with the transducer index mark pointing toward the heart base (dorsal), two views are usually obtained. The first is a four-chamber view with the cardiac
apex (ventricles)displayed to the left and the base (atria)
to the right (Fig 2). The second, obtained by slight clockwise rotation of the transducer and beam plane from the
four-chamber view into a slightly more craniodorsal to
caudoventral orientation, shows the left ventricular outflow tract, aortic valve, and aortic root.

Long-Axis LV Outflow View

Short-Axis Views

With the beam plane oriented at a small angle to the long


axis of the body, perpendicular to the long axis of the

FIG. 4. Left caudal (apical) parasternal location, two-chamber views


(see abbreviations list above).

Vol. 7

. NO.4, 1993

TRANSTHORACIC TWO-DIMENSIONAL ECHOCARDIOGRAPHY

4-Chamber (Inflow) View

25 1

the left on the screen. In some animals, especially cats,


the available window allows imaging through the lateral
left ventricular wall, rather than the apex, resulting in an
image tilted horizontally (apex to the upper left, base to
the lower right). Slight cranial tilting of the beam from
the four-chamber view brings the left ventricular outflow
region into view, and in some animals it is possible to
simultaneously image all four cardiac chambers, both
atrioventricular valves, the aortic valve, and proximal
aorta (sometimes referred to as a five-chamber view).
Left Cranial Parasternal Location
Long-Axis Views

5-Chamber (LV Outflow) View

With the beam plane oriented approximately parallel to


the long axis of the body and to the long axis of the heart,
and with the transducer index mark pointing cranially, a
view of the left ventricular outflow tract, aortic valve,
and ascending aorta is obtained (Fig 6, view 1). The
image is displayed with the left ventricle to the left and
the aorta to the right. This view, which is similar to the

Lonq-Axis View 1
FIG. 5. Left caudal (apical) parasternal location, four-chamber views
(see abbreviations list above).

including left atrium, mitral valve, and left ventricle, is


obtained (Fig 4). Slight counterclockwise rotation of the
transducer and beam plane into a more craniodorsal to
caudoventral orientation results in a long-axis view of
the left ventricle, outflow tract, aortic valve, and aortic
root. Both of these views should be displayed with the
left ventricular apex to the left and the left atrium or
aorta to the right.

Long-Axis View 2

Left Apical Four-Chamber Views

With the beam plane placed into a left-caudal to rightcranial orientation and then directed dorsally toward the
heart base, and with the transducer index mark pointing
caudally and to the left, a four-chamber view of the heart
may be obtained (Fig 5). Note that this is the only view in
which the transducer index mark is pointing caudally
and to the left, opposite the normal convention. Depending on the exact location of the caudal (apical) window, the appearance of this view varies between animals
more than most other views. The image should show the
ventricles in the near field closest to the transducer and
the atria in the far field, with the heart oriented vertically. The left heart (left ventricle, mitral valve, and left
atrium) should appear to the right and the right heart to

Long-Axis View 3

FIG.6. Left cranial parasternal location. long-axis views (see abbreviations list above).

252

Journal of Veterinary
Internal Medicine

THOMAS ET AL.

Short-Axis View

FIG. 7. Left cranial parasternal location, short-axis view at the level of


the aortic root, showing the right ventricular inflow and outflow tracts
(see abbreviations list above).

two-chamber outflow view obtained from the left caudal


(apical) location (Fig 4),shows the right ventricular outflow tract, aortic valve, and ascending aorta better than
the corresponding caudal (apical) view. From this beam
orientation, angling of the beam ventral to the aorta produces an oblique view of the left ventricle and the right
atrium, tricuspid valve, and inflow region of the right
ventricle (view 2). In this view the left ventricle is displayed to the left and the right auricle to the right. Angling of the transducer and beam plane dorsal to the
aorta produces a view of the right ventricular outflow
tract, pulmonary valve, and main pulmonary artery
(view 3).
Short-Axis View

With the beam plane oriented approximately perpendicular to the long axis of the body and to the long axis of

the heart, and with the transducer index mark pointing


dorsally, an orientation obtained by 90" clockwise beam
rotation from the long-axisviews, a short-axis view of the
aortic root encircled by the right heart is obtained (Fig 7).
The image, which is similar to the short-axis view at the
aortic valve level obtained from the right side (Fig 3), is
displayed with the right heart encircling the aorta clockwise, with the right ventricular inflow tract to the left and
the outflow tract and pulmonary artery to the right.
The Specialty of Cardiology of the ACVIM and the
Academy of Veterinary Cardiology recommend adoption of these imaging standards for the performance, display, recording, and publication of transthoracic 2DE
images in dogs and cats. In verbal, visual, and written communications (including publications), images
should be identified by transducer location (right, left
caudal, left cranial), major beam plane orientation (longaxis, short-axis, angled/oblique), and minor beam plane
orientation (four-chamber, two-chamber, outflow, inflow, etc.). Adoption of these standards should facilitate
consistent performance, recording, teaching, and communicating results of studies obtained by 2DE.
References
1. DeMadron E, Bonagura JD, Hemng DS. Two-dimensional echo-

cardiography in the normal cat. Vet Radiol 1985; 26:149-158.


2. Thomas WP. Two-dimensional, real-time echocardiography in
the dog. Technique and anatomic validation. Vet Radiol 1984;
2550-64.
3. O'Grady MR, Bonagura JD, Powers JD, et al. Quantitative crosssectional echocardiography in the normal dog. Vet Radiol
1986; 27:34-49.
4. Moise NS. Echocardiography. In: Fox PR, ed. Canine and Feline
Cardiology. New York: Churchill Livingstone, 1988; 1 13- 156.
5. Henry WL, DeMaria A, Gramiak R, et al. Report ofthe American
Society of Echocardiography committee on nomenclature and
standards in two-dimensional echocardiography. Circulation
1980; 62:2 12-2 17.