Adult Echocardiography Protocol

 Patient Position

o For parasternal and apical views have the patient lie in the left lateral decubitus
(LLD) position with left arm raised above the head. Obtain an adequate ECG which
includes visualization of the P wave, QRS complex, and T wave.

o For subcostal view have the patient lay on their back and bend their knees to soften
the abdominal muscles.

o For suprasternal notch view have the patient lay on their back with a pillow under
their shoulders to allow for the probe to be rotated correctly

 Cardiac Heart Beats

o Capture 2 cardiac heart beats per cine loop unless an abnormal rhythm is present

o Change the number of cardiac heart beats captured from 2 to 4-5 for patients with
the following abnormalities: atrial fibrillation, significant arrhythmias, rapid heart
rate (with a R wave to R wave greater than 500 m/sec on the ECG)

 Gray Scale Imaging

o Adjust overall gain and TGC so that the ventricular and atrial cavities are anechoic

 Color Doppler

o Adjust color gain until Doppler noise is seen, then decrease the gain down just
enough to eliminate the noise.
Too Correct
o Keep your color box narrow for better resolution wide

 Spectral Doppler

o The angle of incidence should be less than 20°

o Obtain 3 consecutive waveforms, measuring the middle waveform

 Continuous wave Doppler

o Perform continuous wave Doppler tracing on all valves with a velocity greater than
2m/sec

 For the mitral valve, include the pressure ½ time

o Perform continuous wave Doppler tracing on all valve replacements and repairs

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Adult Echocardiography Protocol
 *Asterisk within the protocol indicates images or measurements may not be
utilized at all clinical sites. Students are still responsible for knowing how to
correctly obtain the images or measurements.

Parasternal Window from the Long Axis Scan Plane

Structure Image Stored

Left Acquire cine loop 2D image at a depth of 15-20cm
Ventricle
(LV)

Left Acquire cine loop 2D image at a reduced depth so image fills field of view
Ventricle
(LV)

Aortic Valve M-mode sweep of aortic valve freeze and acquire DO NOT UNFREEZE THIS
(AV) IMAGE

Aortic Valve *Measure the following on the aortic valve M-mode:
(AV)  Aortic root end-diastolic dimension
 Measure the vertical distance from the outer edge of the anterior
aortic root to the inner edge (leading edge to leading edge) of the
posterior aortic wall at end-diastole.
 Normal range 2.0-3.7 cm
 LA end-systolic dimension
 Measure greatest vertical distance between the anterior side of the
posterior aortic wall and the anterior side of the posterior left atrial
wall (leading edge to leading edge) at end ventricular systole when
the aorta is in its maximal anterior position.
 Normal range 1.9-4.0cm
 Aortic valve systolic separation
 Measure the maximal opening of the aortic valve cusps during the
initial part of ventricular systole, using the internal borders of the
aortic cusps.
 Normal range 1.5-2.6 cm
Mitral Valve M-mode sweep of mitral valve freeze and acquire DO NOT UNFREEZE THIS
(MV) IMAGE

Mitral Valve *Measure the following with the mitral valve M-mode:
(MV)  E-F slope
 Measure the distance of the steepest initial portion of the anterior
MV leaflet by placing a caliper on the steepest point of early
diastole and then place a caliper at the end of the slope.
 Normal range is 70-150 mm/s.
 E Point Septal Separation (EPSS)
 Measure the vertical distance from the MV E point to the lowest
point of the IVS.
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Adult Echocardiography Protocol
 Normal range is 2-7 mm.

Parasternal Window from the Long Axis Scan Plane

Structure Image Stored

Left M-mode sweep of left ventricle freeze and acquire DO NOT UNFREEZE THIS
Ventricle IMAGE
(LV)

Left *Measure the following with the left ventricle M-mode:
Ventricle  Interventricular Septum in diastole (IVSd)
(LV)  Measure the diastolic thickness of the IVS as the vertical distance
from the RV side of the IVS to the LV side of the IVS in end-diastole
at a point corresponding to the onset of the QRS complex.
 Normal range 0.6-1.1 cm
 Left Ventricle Inner diameter in diastole (LVIDd)
 Measure the vertical distance from the endocardium of the IVS to
the endocardium of the PWLV in end-diastole at a point
corresponding to the onset of the QRS complex.
 Normal range 3.7 – 5.6 cm
 Left Ventricle Posterior Wall in diastole (LVPWd)
 Measure the vertical distance from the endocardium of the LVPW to
the epicardium in end-diastole at a point corresponding to the onset
of the QRS complex.
 Normal range 0.6 – 1.1 cm
 Interventricular Septum in systole (IVSs)
 Measure the systolic thickness of the IVS as the maximal vertical
distance that occurs between the RV and LV sides of the IVS at
ventricular systole
 Left Ventricle Inner Diameter in systole (LVIDs)
 Measure the vertical distance from the endocardium of the IVS at
the lowest point of the septal motion to the endocardium of the
LVPW in end-systole.
 Normal range 2.0 – 3.8 cm
 Left Ventricle Posterior Wall in systole (LVPWs)
 Measure the systolic thickness of the LVPW at the maximal vertical
distance that occurs between the endocardium and epicardium at
end-ventricular systole

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Adult Echocardiography Protocol
Left Freeze 2D image of left ventricle:
Ventricle Scroll back to end diastole and measure the following:
(LV)  *Right Ventricular Minor Axis in diastole (RVIDd)
 Measure the inner edge to inner edge dimension is measured at the
same level as the LV minor axis dimensions parallel to this
measurement.
 Normal range is 1.9-3.8 cm
 Interventricular Septum in diastole (IVSd)
 Measure the vertical distance from the RV side of the IVS to the LV
side of the IVS at end-diastole.
 Normal range is 0.6 – 1.2cm
 LV minor axis end-diastole (LVIDd)
 Measure the vertical distance from the endocardium of the IVS to
the endocardium of the LVPW at end-diastole.
 Normal range is 3.5 – 5.6 cm.
 LV Posterior Wall Diastolic Thickness (LVPWd) = Measure the vertical
distance from the endocardium of the LVPW to the epicardium at end-
diastole.
Normal range is 0.6 – 1.2cm
 Acquire still frame DO NOT UNFREEZE THE IMAGE!
From the previous frozen image, scroll forward to end systole and measure the
following:
 LV minor axis end-systole (LVIDs)
 Measure the vertical distance from the endocardium of the IVS to the
endocardium of the PWLV at end-systole.
 Normal range is 2.0-4.0 cm.
 LA end-systole (LAs)
 Measure the LA at the aortic valve plane, also perpendicular to the
aortic root. This is an inner edge to inner edge measurement.
 Normal range is 2.3 – 3.8 cm.
 Acquire still frame
Aortic Valve Freeze 2D image of aortic valve
Zoomed Scroll back to end diastole
 Measure aortic root at end-diastole with the valve plane perpendicular to
the wall of the aortic root at the sinus of Valsalva. Measure inner edge to
inner edge.
 Normal range 2.1 – 3.5 cm
 Acquire still frame w/measurement DO NOT UNFREEZE THE IMAGE!
Aortic Valve From the previous frozen image, scroll forward to mid systole:
Zoomed  Measure left ventricular outflow track diameter (LVOT) from the base of
the aortic valve RCC leaflet to the base of the anterior MV leaflet.
 Normal measurement 2.cm
 Acquire still frame w/measurement
Mitral Valve Acquire cine loop of 2D image of mitral valve
Zoomed

Aortic and Acquire cine loop of Color Doppler across both mitral valve & aortic valve

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Adult Echocardiography Protocol
Mitral Valve

Parasternal Window from the Long Axis Scan Plane

Structure Image Stored

RVIT Right ventricular inflow track (RVIT)
Acquire cine loop of 2D image of right ventricular inflow track (RVIT)
RVIT Acquire cine loop of color Doppler across the tricuspid valve(TV)

RVIT Acquire continuous wave Doppler across the tricuspid valve IF tricuspid
regurgitation present
*RVOT Right ventricular outflow track (RVOT)
Acquire cine loop of 2D image of right ventricular outflow track (RVOT)
*RVOT Acquire cine loop of color Doppler across the pulmonary valve (PV)

*RVOT Acquire pulsed wave Doppler across the pulmonary valve and measure peak
velocity
*RVOT Acquire continuous wave Doppler across the pulmonary valve IF pulmonary
regurgitation present

Parasternal Window from the Short Axis Scan Plane

Structure Image Stored

AV, TV, PV Acquire cine loop of 2D image of aortic valve, tricuspid valve, and pulmonary
valve
Pulmonary Acquire cine loop of color Doppler across the Pulmonary artery/valve
Valve

Pulmonary Acquire pulse wave at pulmonary leaflet tips & measure maximum velocity.
Valve Normal range 0.6-1.0 m/s

Pulmonary Acquire continuous wave through pulmonary valve for pulmonary valve flow and
Valve pulmonary insufficiency with measurements

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Adult Echocardiography Protocol
Aortic Valve Acquire cine loop of 2D image of the aortic valve & atrial septal wall
Zoomed

Aortic Valve Acquire cine loop of color Doppler across the aortic valve
not Zoomed

Tricuspid Acquire cine loop of color Doppler across the tricuspid valve for tricuspid
Valve regurgitation

Left Acquire cine loop of 2D image of left ventricle at level of the mitral valve
Ventricle &
Mitral Valve

Left Acquire cine loop of color Doppler of left ventricle at level of the mitral valve
Ventricle & across the septal wall & mitral valve
Mitral Valve

Left Acquire cine loop of 2D image of left ventricle at level of the papillary muscles
Ventricle &
Papillary
muscles
Apex of LV Acquire cine loop of 2D image of left ventricle apex

Apical Window 4 Chamber Scan Plane

Structure Image Stored

4 Chamber Acquire cine loop of 2D image showing all 4 chambers

4 Chamber Acquire cine loop of color Doppler of flow across mitral valve & left atrium for
mitral regurgitation
4 Chamber Acquire pulse wave Doppler at the tips of the mitral valve leaflets and freeze
image:
 Measure E to A & descending slope
 Acquire image with measurement
4 Chamber Acquire continuous wave Doppler across mitral valve and freeze image:
 Measure peak velocity of mitral regurgitation if present
 Acquire image with measurement
4 Chamber Acquire pulse wave Doppler at the opening of the pulmonary vein and freeze
image:
 Documenting the systolic and diastolic forward flow
Left Acquire 2D image with a decreased depth demonstrating the left ventricle and
Ventricle & 1/3 of the left atrium
Left Atrium

Left Acquire cine tissue Doppler imaging (TDI) of left ventricle and 1/3 of the left
Ventricle & atrium:
Left Atrium

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Adult Echocardiography Protocol
Left Using TDI acquire pulse Doppler from the lateral aspect of the mitral valve
Ventricle & annulus:
Left Atrium  Measure E prime
 Acquire image with measurement

Apical Window 5 Chamber Scan Plane

Structure Image Stored

5 Chamber Acquire cine loop 2D image of left atrium, left ventricle, aorta, right atrium, &
right ventricle
5 Chamber Acquire cine loop color Doppler across the aortic valve

5 Chamber Acquire continuous wave Doppler across the aortic valve:
 Measure peak velocity (If continuous wave Doppler gradient is over 2
m/sec trace the spectral envelope)
 Normal range is 1.0 – 1.7 m/s
 Acquire image with measurement
5 Chamber Acquire pulse wave Doppler of left ventricle outflow track:
 Measure peak velocity of the left ventricle outflow track.
 Normal range is 0.7 - 1.1 m/s
 Acquire image with measurement

Apical Window 4, 3, & 2 Chamber Scan Plane

Structure Image Stored

RV, TV, RA Acquire cine loop of color Doppler across the tricuspid valve

RV, TV, RA Acquire continuous wave Doppler across the tricuspid valve IF tricuspid
regurgitation:
 Measure tricuspid regurgitation
 Acquire image with measurement
4 Chamber *Biplane Simpson’s Method:
 Acquire an apical 4 chamber image and freeze
 Scroll to end-diastole and trace the LV cavity and store image
 Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
 This will give you the LV ED volume DO NOT UNFREEZE THE IMAGE
 Scroll to end-systole and trace the LV cavity and store image
 Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
 This will give you the LV ES volume

2 Chamber *Biplane Simpson’s Method:
 Acquire an apical 4 chamber image and freeze
LV, MV, LA  Scroll to end-diastole and trace the LV cavity and store image

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Adult Echocardiography Protocol
 Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
 This will give you the LV ED volume DO NOT UNFREEZE THE IMAGE
 Scroll to end-systole and trace the LV cavity and store image
 Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
 This will give you the LV ES volume

2 Chamber Acquire cine loop of 2D image of the left atrium & left ventricle

2 Chamber Acquire cine loop of color Doppler across the mitral valve

2 Chamber Acquire cine loop of 2D image decreasing depth to demonstrate the left ventricle
& 1/3 of the left atrium
3 Chamber Acquire cine loop of 2D image of the left atrium, left ventricle, & aortic valve

3 Chamber Acquire cine loop of color Doppler across the mitral valve & aortic valve

3 Chamber Acquire cine loop of 2D image decreasing depth to demonstrate the left ventricle
& 1/3 of the left atrium
4 Chamber Acquire cine loop of 2D image of 4 chamber demonstrating the left ventricle on
the LEFT side of the SCREEN & the right ventricle on the RIGHT side of the
SCREEN (Mayo Clinic)

Subcostal Window Long Axis Scan Plane

Structure Image Stored

4 Chamber Acquire cine loop 2D image of 4 chambers

4 Chamber Acquire cine loop color Doppler across the Interatrial septum (IAS)

4 Chamber Acquire cine loop color Doppler across the interventicular septum

4 Chamber Acquire cine loop color Doppler across the mitral valve & tricuspid valve

IVC Acquire cine loop 2D image of inferior vena cava for collapse (change EKG to 5
beats)
Aorta Acquire cine loop 2D image of the aorta

Aorta Acquire cine loop color Doppler of the aorta

Subcostal Window Short Axis Scan Plane

Structure Image Stored

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Adult Echocardiography Protocol
IVC Acquire cine loop color Doppler across inferior vena cava & hepatic vein (change
EKG to 2 beats)

Suprasternal Notch Window Long Axis Scan Plane

Structure Image Stored

Aortic arch Acquire cine loop 2D image of the aortic arch and descending aorta
and
Descending
aorta

Aortic arch Acquire cine loop color Doppler flow of the descending aorta
and
Descending
aorta

Aortic arch Acquire continuous wave Doppler through the descending aorta
and
Descending
aorta

Tips

 Pharmaceutical Contrast

o May be utilized upon receiving a written order from the physician.

o Pharmaceutical contrast is indicated for use in patients with 2 or more suboptimal
wall segments of the left ventricular endocardial borders.

o Pharmaceutical contrast is contraindicated for patients with known or suspected:

 Right-to-left and bi-directional cardiac shunts

 Cardiovascular or pulmonary compromise

 Hypersensitivity to perflutren (lipid micro gas), blood products or albumin
(egg white allergy)

 Aortic Stenosis Additional Views

o Interrogate the aortic outflow with non-imaging pedoff probe from the suprasternal
notch window.
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Adult Echocardiography Protocol
o Reposition the patient to right lateral decubitus (RLD) position and interrogate the
aortic outflow with non-imaging pedoff probe from the right Parasternal window.

o Acquire multiple spectral Doppler waveforms from both windows and measure to
determine the highest velocity documented.

 Technically difficult exams

o Document normal cardiac windows with limited views

o Utilize modified views to acquire diagnostic images for physician interpretation

Biplane Simpson’s Method of Discs: Uses the summation of the areas from the diameters of 20
cylinders or discs of equal height is used to calculate the end- diastolic volume, end-systolic
volume, stroke volume, cardiac output, cardiac index, and ejection fraction.

Labs:

 Troponin: an elevated troponin may indicate a myocardial infarction

 BNP (Brain natriuretic peptide: an elevated BNP is an indication of the myocardial
tissue being stretched as in the case of CHF

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