A S E American Society of | Echocardiography Heart & Circulation Ultrasound Specialists Guidelines for Chamber Quantification ‘Adapted from: Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise J, Solomon S, Spencer KT, St. John Sutton M, Stewart W. Recommendations for Chamber Quantification. J Am Soc Echocardiogr (Dec. 05). ~— Poster ordering information and full text of ASE guideline documents available at: www.asecho.org Design and illustration by medmovie.com © Copyright 2005 The American Society of Echocardiography www.asecho.org Guidelines for Chamber Quantification Page 1 of 9‘Moe Ve 55, Na 14,2010 ‘el 6, 2010:00-000 Figure 2. Atherosclerotic lesions. Flow dia gram in center column indicates pathways in evolution and progression of human ath- ‘rosciorotic lesions. Roman numorals indi cate histologically characteristic types of lesions defined atthe lft ofthe flow dia- fs Heel fxg gram. The direction of the arrows indicates the sequence in which characteristic mor- Bhologies may change. From Type Ito {Type IV, changes in lesion morphology ‘cur primarily because of inereasing aceu- muiation of lpia. The loop between Types Vand Vi ilustrates how lesions inereage in lal thickness when thrombotic deposits form ‘on thor surfaces, Thrombote deposits may ‘orm repeated over varied time spans in the same location and may be the principal ‘mechanism for gradual occlusion of medi lum-sized arteries, Adapted from Stary etal (10). iss 3. For measurements taken by echocardiography, the intemal lameter should be measured perpendicular to the axis of blood flow. For aortic root measurements the widest diameter, typleally at the midsinus level, should be used. (Level of Evidence: ©) 4. Abnormalities of aortic morphology should be recognized and reported separately even when aortic diameters are within normal limits. (Level of Evidence: C) 5. The finding of aortic dissection, aneurysm, traumatle injury and or aortic rupture should be Immediately communicated to the refering physician. (Level of Evidence: C) Table 2._ Essential Elements of Aortic Imaging Reports 1. The locaton at which the sorta aoa 2. The maximum diameter of any statin, measued from the external all ofthe ota, perpendicular to the axis of flow, and the longt of he ant tha is abnormal 5. For patents wit pesumad or documented genaicsyncromes at rik or ‘antic oat disease measurements of arc vahe, sinuses of Vala, Sotubuiar junction, and ascending ana 4. The presence of intra fing detects consistent wth trombus or aneroma 5. Th presnce of MH, PAU, and akin. 6, tension of aortic abnormally into branch vessels, incuting isocton and aneurysm, and secondary evidence of end-organ in (eg, na ‘bowel nypopertsion, 7. vience of aor npr, including erate and mediastinal ema, pericardial and pleural fi, and conta extravaston frm ‘he aortic lumen 8. When a pri examination is avait, direct image to nage comparison {0 determine i tere has bon any increase in damater. 6. Techniques to minimize episodic and cumulative radiation ‘exposure should be utilized whenever possibie. (20,23) (Level of Evidence: 8) 41. If clinical information is available, it can be useful to relate ‘aortic diameter tothe patient's age and body sie (see Tables 3 and 4). (Level of Evidence: C) Definitive identification or exclusion of thoracic aortic dis cease oF one of its anatomic variants requires dedicated aortic imaging. Selection of the most appropriate imaging study ‘may depend on patient related factors (i.e.. hemodynamic stability, renal function, contrast allergy) and institutional capabilities (.e., rapid availability of individual imaging modalities, state of the technology, and imaging specialist expertise). Consideration should be given to patients with Table 3. Normal Adult Thoracic Aortic Diameters Range of Reported Reported Assessment Toad Aorta Mean (em) SO(n) __ Mato oot mae) 3800372 038 cr Poot male) 3emas1 038 a Ascending (female, mal) 285 NA on Md-escendng lemale) 2451264 031 a Md-descending (mal) 2391298031 a Diaphragmatic ema) 24010244 0.2 a Diaphragmatic (mal) 24319269 027 040 CT, aterigraty IH indicates intramural hematoma; and PAU, penetrating atherosclerotic er Cr indicates computed tomographic maging; CXR, chest ray and WA, at applicable. Reprinted wth permission trom Jost eal. (27, Downloaded from content onlinejace-org by on March 28, 2010{ACC Vl 5, No 4, 2080, ‘et 6, 2030000-000 Table 4. Sex Differences in Aortic Root Dimensions in Adults irate ota 2010 Guidelines on TAD: Executive Summary ‘osc Vales (6m) Indexed Vales (enim) ote Root Men Vale Women “Men pValue ‘onus 26203 <0.001 23202 —*18201 Sinses of Vala 34203 <0.001 30203 17202 ‘Shot uncon 29203 -<0.001 26x03 15202 Prosial acending aorta 30204 -<0.001 15202 TS nda nt sgncant. Adapted fom Roan eta (28) borderline abnormal renal function (serum creatinine greater than L8 to 2.0 mydL)—specitically, the tradeolls between the use of iodinated intravenous contrast for CT and the possibility of contrast-induced nephropathy, and gadolinium agents used with MR and the risk of nephrogenic systemic fibrosis (22). Radiation exposure should be minimized (21,23-26). The risk of radiation-induced malignancy is the greatest in neo- nates, children, and young adults (21). Generally, above the age of 30 to 35 years, the probability of radiation-induced ‘malignancy decreases substantially (20,21). For patients who require repeated imaging to follow an aortic abnormality, MR. may be preferred to CT. MR may require sedation due to longer examination times and tendency for claustrophobia, CT as opposed to echocardiography can best identify thoracic aortic disease, as well as other disease processes that ‘can mimic aortic disease, including pulmonary embolism, pericardial disease, and hiatal hernia. After intervention or ‘open surgery, CT is preferred to detect asymptomatic post- procedural leaks or pseudoaneurysms because ofthe presence ‘of metallic closure devices and clips. CT and MR measure external aortic diameter, whereas ‘echocardiography measures internal aortic diameter. Lumen size may not accurately reflect extemal diameter due to inaluminal clot, wall inflammation, or AoD. A recent refinement in the CT measurement of aortic size examines the vessel size using a centerline of flow, which reduces the error ‘of tangential measurement and allows true short-axis mea- surement of aortic diameter. Essential element of aortic imaging reports are listed in Table 2. 4.1. Chest X-Ray Routine chest x-ray may occasionally detect abnormalities of aortic contour or size that require definitive aortic imaging. Chest x-ray often serves as a part of the evalua tion of patients with potential acute AoD, primarily to identify other causes of patient's symptoms, but also as a screening test to idemiy findings due to a dilated aorta or bleeding. 4.2. Computed Tomographic Imaging CT scanning has several advantages, including near- universal availability; the ability to image the entire aorta, including lumen, wall, and periaortic regions; to identify anatomic variants and branch vessel involvement; to dis- tinguish among types of acute aortic syndromes (i.e, Downloaded from content.onlineja intramural hematoma [IMH], penetrating. atherosclerotic ulcer {PAU}, and acute AoD); and the short time required to complete the imaging process and the 3-dimensional data. Electrocardiogram-gated techniques have made it possible to generate motion-free images of the aortic root, ‘and coronary arteries, similar to coronary CT angiographic imaging. Reports of newer-generation multidetector heli- cal CT scanners show sensitivities of up to 100% and specificities of 98% to 99% (29-32), ‘The sequence for a CT performed in the potential setting of acute AoD generally would include a noncontrast study to detect subtle changes of IMH, followed by a contrast study to delineate the presence and extent of the dissection, flap, identify regions of potential malperfusion, and dem- onstrate contrast leak indicating rupture. Imaging of the vascular tre from the thoracic inlet to the pelvis, including the iliac and femoral arteries, provides sufficient informa- tion to plan surgical or endovascular treatment, if needed. Prompt interpretation and communication of findings to the appropriate treating physicians are essential in the ‘acute setting. (For further information on technique param= eters and anatomic coverage, see the online-only data supplement.) 4.3. Magnetic Resonance Imaging MR has been shown to be very accurate in the diagnosis of, thoracic aortic disease, with sensitivities and specificities that are equivalent to or may exceed those of CT and transesophageal echocardiogram (TEE) (30,35-39). Ad- vantages of MR include the ability to identify anatomic variants of AoD (IMH and PAU), assess branch artery involvement, and diagnose aortic valve pathology and left ventricular dysfunction without exposing the patient to cither radiation or iodinated contrast. Disadvantages in- clude prolonged duration of imaging acquisition during Which the patient is inaccessible to care providers; inabil- ity to use gadolinium contrast in patients with renal insufficiency; contraindication in patients with claustro- phobia, metallic implants or pacemakers, and lack of ‘widespread availability on an emergency basis. 4.4, Echocardiography Echocardiography can detect the presence of aortic enlarge: ‘ment and associated cardiac pathology that suggests the underlying etiology of the aortic disease (¢g., bicuspid aortic ‘org by on March 28, 2010LV Dimensions Measurement of left ventricular end-diastolic diameter (EDD) and end-systolic diameter (ESD) from M-mode, guided by a parasternal short axis image (upper left) to optimize medial- lateral beam orientation. Range WOMEN MEN Reference| Mildly |Moderately| Severely | Reference| Mildly | Moderately| Severely teal Abnormal | Abnormal Abnormal] Range | Abnormal | Abnormal | Abnormal CV dastotic iageter] > 4. IBSA (cmimé) 2:4-3:2 3.3-3.4 3.5-3.7 338 [2234 3.2-3.4 3.5-3.6 oir LV mass = 0.8 x (1.04[(LVIDd + PWTd + SWTd)® — (LVIDd)*}) + 0.6g LV massiBSA(gim*) | 43-95 96-108 109-121 2122 | 49-115 116-131 132-148 2149A S E. American Society of echagaral Ogre pa LV Volumes 2-D measurements for LV volume calculations using the biplane method of discs, in the apical four-chamber (A4C) and apical two-chamber (A2C) views at end diastole (LV EDD) and at end-systole (LV ESD). Lv EDD Lv ESD A4C A2C Ejection fraction = (EDV - ESV)/EDV WOMEN and MEN ie | |e | Sot LV diastolic volume/BSA (mi/m2) 35-75 76-86 87-96 297 LV systolic volume/BSA (mi/m?) 12-30 31-36 37-42 243 Ejection Fraction (%) 255 45-54 30-44 <30 www.asecho.org Guidelines for Chamber Quantification Page 3 of 9. A S E American Society of oe fw Echocardiography LV Mass Two methods for estimating LV mass based on the area- length (AL) formula and the truncated ellipsoid (TE) formula, from short axis (left) and apical four-chamber (right) 2-D echo views. Am _f[A2 A BP ovale tafze-p Am=A,-A, LV Mass (AL) = 1.05 {[ 5/, A, (adit) ] - [5/5 Ay (a+d) J} & # LV Mass (TE) = 1.05 x {(b+t)®[% (att) +4 Ee ]-b?[ 7) ard - — } WOMEN MEN snail Reference| Mildly |Moderately| Severely | Reference| Mildly |Moderately| Severely 2D method Range | Abnormal] Abnormal |e Range |Abnormal| Abnormal | Abnormal] Lv mass/BSA (gim*) | 44-88 | 89-100 |101-112 | 2113 | 50-102 103-116] 117-130) 2131 Where At = 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 annulus plane. Assuming a circular area, the radius (b) is computed and mean wall thickness (t) derived from the short-axis epicardial and cavity areas www.asecho.org Guidelines for Chamber Quantification Page 4 of 9& AS Bseeatece RV Dimensions Right-ventricular diameters measured in the apical 4~-chamber view at level of left ventricular papillary muscles (left). Measurement of the right ventricular outflow tract at the pulmonic valve annulus (RVOT2), and at the main pulmonary artery from the parasternal short-axis view (right). Reference | Mildly | Moderately | Severely Range | Abnormal Abnormal | Abnormal Basal RV diameter (RVD 1) (cm) 20-28 | 29-33 | 34-38 23.9 Mid RV diameter (RVD 2) (cm) 27-33 | 34-37 | 38-41 242 Base-to-Apex length (RVD 3) (em) 71-79 | 80-85 | 86-91 292 ‘Above aortic valve (RVOT 1) (cm) 25-29 | 30-32 | 33-35 236 Above pulmonic valve (RVOT2)(em) | 17-23 | 24-27 28-31 232 Below pulmonic valve (PA 1) (em) 15-21 | 22-25 | 26-29 23.0 www.asecho.org Guidelines for Chamber Quantification Page 5 of 9LA Volumes Area-length method using the apical four-chamber (A4C) and apical two-chamber (A2C) views at ventricular end-systole (maximum LA size). The length (L) is measured from the back wall to the line across the hinge points of the mitral valve. The shorter (L) from either the A4C or A2C is used in the equation. Biplane method of discs, using the apical four-chamber (A4C) and apical two-chamber (A2C) views at ventricular end-systole (maximum LA size). Left Atrial Volume = 8/3r1 [(A, )(A,)(L)] * * (L) is the shortest of either the A4C or A2C length WOMEN and MEN Reference Mildly | Moderately Severely Range Abnormal Abnormal Abnormal a 2 a | LA volume/BSA (mlim2) 22 +6 29-33 34-39 =40 www.asecho.org Guidelines for Chamber Quantification Page 6 of 9: AS Essences Aortic Root Measurements Measurement of aortic root diameter at the sinuses of Valsava from 2-D parasternal long-axis image. (Top) 95% confidence intervals for aortic root diameter at the sinuses of Valsalva based on body surface area in: children and adolescents (A), adults aged 20 to 39 years (B), and adults aged 40 years or more (C). (Bottom) y = 1.02 + 0.98x y = 0.97 +1.12x SEE =0.18 SEE =0.24 r=0.93 eT e071 p< 0.0005. p< 0.0005 e iS Sinuses of Valsalva (cm) zp py a 6a 8 1 1 1 04 08 12 16 20 16.20 24 1.6 2.0 24 Body Surface Area (m?) ‘Adapted from: Roman MJ, Devereux RB, Kramer-Fox R, O'Loughlin J. Two-dimensional Echocardiographic Aortic Root Dimensions in Normal Children and Adults. Am J Cardiol 1989;64:507-512 (with permission). Guidelines for Chamber Quantification Page 7 of 9a ‘ American Society of K Echocardiography Heart & Circulation Ultrasound Specialists LV Segmentation Segmental analysis of LV walls based on schematic views, in a parasternal short and apical long-axis orientation. Api 1) Four Chamber 2) Two Chamber 3) Long Axis ® picalcap @ Cap o Apical Cap www.asecho.org Guidelines for Chamber Quantification Page 8 of 9ASE American Society Echocardiography Heart & Circulation Ultrasound Specialists Typical distributions of the right coronary artery (RCA), the left anterior descending (LAD), and the circumflex (Cx) coronary arteries. BBeca Ol rcaorcx Cou. Wtadorex Ticx EBrcaortap www.asecho.org Guidelines for Chamber Quantification Page 9 of 9& AS Eargissnsee Heart & Circulation Ultrasound Specialists Guidelines for the Evaluation of Valvular Regurgitation ‘Adapted from: Zoghbi WA, Enrquez-Sarano M, Foster E, Grayburn PA, Kralt CD, Levine RA, Nihoyannopoulos P Sito CM: Quinones MA, Rakowsla H, Siowart WJ. Waggoner A, Welesman Nd recommendations for Evaivation of The Severty of Nate Valvular Regurgitation wih Two-Dimensional and Doppler Echocardiography. Am Soc Echocardhog. 2003 Ju: 16(7)777-802. Recommendations endorsed by the American Colege of Cardology, the American Heart Associaton, and the European Society of Cardology Working Group on Echocardiography Poster ordering information and full text of ASE guideline documents available at: www.asecho.org Design and illustration by medmovie.com © Copyright 2006 The American Society of Echocardiography www.asecho.org Guidelines for the Evaluation of Valvular Regurgitation Page 1 of 9A S E American Society of Epa aralo ebay Aortic Valve Central AR Jet Jet fo SL Wane terres Central and eccentric aortic regurgita- tion (AR) jets. VC = vena contracta; LA = left atnum; LV = left ventricle. Color Doppler CW Doppler Desc Aorta - PW Color Doppler, continuous wave, and pulsed wave (PW) Doppler recording of flow in the descending aorta in mild and severe aortic regurgitation (AR). Arrows: holo- diastolic flow reversal in the descending (desc) aorta. www.asecho.org Guidelines for the Evaluation of Valvular Regurgitation Page 2 of 9hy rasound Specialists erican Society ocardit ‘UOHEIEIIP A JO 5% “SUOISE] 91UOJ4YD 0} AJUO paridde ezIs AT Z Page 3 of 9 INDAN BY L On0s os= o9= ¢ jueweBse|ue A s912016 40 eyes0poyW + eyoe Bulpueosep ul! |es1ene1 MOY ONJOE D1OISEIPOIOH + sui yeaq/|w ‘|OAY | susjouiesed _eaneynuend sonjen ayeipewoyuy z92IS ATIeWON + sw 00s < ewin “Hey eunssolg By0e Bulpuessep Jessenes moy d1}0)SeIP Auee youq4oON + wo sw9 €°0> 90 < e}eNUCD eUeA - eyoeuoo Bue, + LOA7J0 | eu@jU9 ou yng uesesd LOAT 10 %SZz> %S9Z WIPIM Jer eENUED + | —_pili Snipes BoUEb:eAUOD Mo, 6z0-020 | ~ 6£-08 vy-08 1 uonouny A eUuoU e9zis AT |EUON + uoym Aueinomed ‘2: uBIS YW Je\ddoq MO v1 pue A7 pebuelu3 oijoqesed ‘Ausuep yos > (s/W Z'L-< 3) MoyUl ‘moyul (es Jeni yueulWop ereM-3 queuIWop oAeM-y * 1ef uw se1ddog sOupuy/subis suron Aseuowwind ul subis, MoO uein6ue ‘esueq + a1eIPEUE}U] | MOY JUEUILIOP D1O1SKS + eanioddng psn Aueiiided pesmdns 10 JOUER AW I1eY WOUIWOIG sulon Kreuowind Ul Jess9nes 2018KS + 20ue610nu09 eoue6ieAuoo moy oie] + MOY [eWIUIW JOON + v1u! Bulpims ‘ezis Aue woe o> jo yo! Buibuidwit-jem e GM UIpIM eyeUOD eUBA * 40 (W150 %Ov < Bose) Jor uw MW [eqUad e6seL woZ'0 | a19Aes 40j BUOYS OU Ing Ayuaneg jo = UIpIM eyesUOS eUeA_- juaseid pI JF IENUEOTIEWS . | suBls oyJoeds 210005 ‘91240pOW PI. SATeA ‘www.asecho.org Guidelines for the Evaluation of Valvular Regurgitation Page 5 of 9& A S E Asst Tricuspid Valve Color Doppler CW Doppler Hepatic Vein Flow Jet recordings by color Doppler, continuous wave Doppler, and hepatic vein flow by pulsed Doppler in mild and severe tricuspid regurgitation (TR). Systole = S; Diastole = D. www.asecho.org Guidelin uation of Valvular Regurgitationhocardiography American Society of E Heart & Circulation Ultrasound Specialists ASE & FOUIUOA 1UBU = AY “wWnUIe UBL = ve “(eunsseid vei perensie “uoneiugy jeue ‘uypim ByeNUCD EUSA 129 BUDA JOUBJUI = DAI ‘JeKddog vem snonuAUED = MO Ba) Bununig ajorsAs esnes eu! suonipucs JoyIO S S/UD 8z JO ULI ISINDAN WIM YIUS OU|OSeR "S/UID Q9-OG JO WII ISINDAN ery © “UL eINDe :uondesxy z ‘uON ‘AY 40 Wx 40) SUOSBAI JOJO Be 8194) SSQIUN | ‘BOUBUTWIOP 1essenes 210)ShS Bununiq s0\shS ONOISKS Moy ulen onedaH Bunjeed Aye | 3n0jUu0o T Mo- um seinBuenn ‘esueg | eiqesen ‘esueq | ooqesed pue yos | nojuoo pue Aysuep ier [ Toso Oo. 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Ud Q10N98 405 Oy dd einve :vondeoxa z yueWeBielue Ay 10} SUOSEOs TOMO Ose. Page 9 of 9 peseesoul Aneoio, eyeIpowequt peseesou! Anubis o1we3shs 0} posedwo0o Moy d1IOISKS D1UOWING ‘™OUs o'oyseip jo uoneuIey Ayes ‘uonese1990p desis tesueg eiqeue) uoness|s90p sesueg uonese}@98p MOIS. ¢MO- eyes uonessjaoep pue Ayisuep jer e um ‘e6uel Ailensn, eqeipowseyuy moueu © YIM (uyBue; ur ww OL> Aijensn) uy seiddoq | 4ojoo Aq ezis jor payerp zpareiig 410 JeWION pICUON, jeuusuge yeuuougy 40 JeWION JEUON ears ‘@10AeS aje19poWw HW Ayueneg uoey!64nb ‘Guidelines for the Evaluation of Valvular Regurgitation www.asecho.orgA S E American Society of WI EG Echocardiography Heart & Circulation Ultrasound Specialists Echocardiographic Assessment of Valve Stenosis Adapted from: Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, lung B, Otto CM, Pellikka PA, Quifiones M. Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice. Eur J Echocardiogr and J Am Soc Echocardiogr 2009. Poster ordering information and full text of ASE guideline documents available at: www.asecho.org Design and illustration by medmovie.com © Copyright 2009 The American Society of Echocardiography www.asecho.org Echocardiographic Assessment of Valve Stenosis Page 1 of 6fy ASEscsusss Tricuspid Stenosis Findings indicative of hemodynamically significant tricuspid stenosis Specific Findings | ‘Mean pressure gradient >5mm Hg , Taflow time velocity integral | >60cm th 2190 ms . Valve area by continuity equation® | <4 om? Supportive Findings Enlarged right atrium 2 moderate Dilated inferior vena cava *Stroke volume derived from left or right ventricular sutton the pesance of more than mild cusp tog ‘dorived valve area will be underestimated. Noverinetess'avaive 4 cn es 8 significant hemodynamic burden imposed by the combined lesion. ‘Stenotic tricuspid valve The peak velocity, diastolic Oblained ina modified time-velocty integral, mean | 4-chamber view rt ‘and pressure haif- ing diastole. So Grading of Pulmonary Stenosis mild | Moderate | Severo Peak Velocity | < 3 3-4 >4 (ms) Peak gradient | < 36 | 36 to 64 | >64 (mmm Hg) Doming of the pulmonary Aliasing of velocities at__Continuous wave Doppler leaflets in systole noted the level of the pulmonary across the pulmonary valve in valvular stenosis. valve in pulmonary ‘showing increased velocities. stenosis. www.asecho.org Echocardiographic Assessment of Valve Stenosis Page 2 of 6A S E American Society of « “1 Echocardiography Heart & Circulation Ultrasound Specialists Aortic Stenosis nv Fie a Left ventricular outflow tract Left ventricular outflow tract Continuous wave Doppler of diameter measured within velocity as measured from severe aortic stenosis jt. OStot0cmotthe vale the apical approach once Data recording and measurement for AS quantitation Data Recording | Measurement LivoT 2D parastemal tong anie view. | taper edge to hiner lameter|> soge f ‘mio optimize the |+ aidstystote J bicea ete mtortace Parattel and | Ieee + Sismeteris used to calculates circular ee vor [+ Pulsed wave Doppler. Mania elocity LYOTay |¢ Aplea! tong axis orScnamber |" from peak of conte ewe talocly curve Sample volume positioned |+ Wit raced tram juston LV sige ctvaive and__|" modal velocity. tmoved caraully inte the [VOT iTeegutred to obtain trina | ieeteees: |- Velocity Besetine and scale sdjusted to maniacs sce of Soloctty curve = Time axis (swoop speed) 100 meio | Low wal fiter setting Smooth vetociy curt with a troll doled peti anda | Marrow velocity range at peak | fatoely as. jot_ | SH Doppler (dedicated [+ Maximum vloiy [velocity er). ak of dense ; ‘acoustic windows city curve (eg:apical suprastermel,, — |+ Avoid volse and ‘abt parasternal sty fine finer signal. |. Decrease gaits, nerease |+ Viitraced fom wai fiter adjust Baseline |" outer edgo of dense tnd seals to optim sional cave sovel - Be present | Stay scale spectra display |" calculated from wwit/expandied tne act traced velocy |. Velocity range andisesetne | curve Aajusted so velocity signal’ |+ Report window ite but hits the vertical ‘whtre maxims sca jocity obtained. ave Parasternaliong and short |- identity number of vatve | sate vows Ieanets in systte, Y |. Zoom mode. |" mobitity and Commiseural fusion . Saeses valve calcification CSA: cross sectional area, VTi: velocity-time integral. www.asecho.org Echocardiographic Assessment of Valve Stenosis Page 3 of 6A S E American Society of we Echocardiography Heart & Circulation Ultrasound Specialists Aortic Stenosis Measures of AS severity obtained by Doppler-echocardiography Cutoff lunits| Formula! | top Concept Advantages Severe| it [Direct las jet | mis [Direct 4.0 |Velocity \velocity measurement increases as measurement of stenosis er Roe eee predictor of clinical outcome. Pressure Mean gra in |mmisay2 " eet ae (Hg tee LN 40° gradient laveraged from is" or calculated from the velocity 50°* velocity using curve. the Bernoulll, Measures Continuity] cm? |AVA = 1.0 Nor pat (CSA, yor * find in the ‘tepenprescase: ITI. yt, istenotic orifice Ivor! Vay is equal. The ratio of LVOT [Uses more Simplified | cm? |AVA = 4.0 |to-aortic velocity easily lcontinuity is similarto the measured lequation (CSA, yor x ratio of VTis with [velocities Mivor! Vay native aortic valvelinstead of VTIs. ” |stenosis. VTI: velocity-time integral, CSA: cross sectional area, V=velocity, N: number of samples. * AHA/ACC Guidelines; ** ESC Guidelines Classification of AS severity faric | i aserae liteners Aortic let ig) | $2.5mis| 2.6-3.0 3-4 >4 Mean gradient <20(«30"*) | 20-40430-50") | >40* (°50") AVA (cm?) 71.5 1.0-1.5 <1.0 aa >0.85 | 0.60-0.85 | <0.6 Vetocty ratio. >0.50 | 0.25-0.50 | <0.25 * AHAJACC Guidelines; ** ESC Guidelines www.asecho.org Echocardiographic Assessment of Valve Stenosis Page 4 of 6S E American Society of Echocardiography mA 146 sya ‘oanssasd Kuaye Azeuownd 91}0\S4s :gyds ‘uoIpedB :aV ‘Coxe OAJeA [esNL “WAN. “AyD0| UA JYBL AY “wNLAe “uoneyGunBoi 08 :y aeinasea Aseuownd jo vonewnse ou - aunsseid yy Jo uoneWnse renique - SI MUM syuc JSow Ut pat ‘Ra voomyog yuorpesB wnusnxe' ue eunssaid yy Jo uonippe vas | men = d¥€S|64 wus] Aseuowind 2 ‘oy pue ayes weoy Uo Uujeygo 04 Kseo us9g 94) Bursn Ky120}0n ‘wo4y payeinaye9 yuoipes6 ounssoud z=" a1 64 wu }SeIP \7 ‘eouey|dwo9| 2} J84}0 Uo eouapueda| jonodoid Ajasianuy |WISUEN JO BSEaI99p J0 1B) at y aunssaid - jBA 010095 “mopul 29) Skemie jO1 bas eaueriedx ‘onsnoze 100d) Pe soBeyuenpesi Aoeungoe - soBejueapy ydoou09 oyse ued - axe oneal az fq hy ‘ounssaid Aioye| | qwoipes6 ueoy| | powew /einuuos) syun| — yuowounseow $|SOU9}S [es}]W Jo UOREN|eAE 0} SoyoRosddy {(u6u) 90x fyoojen ear ou mam ued Kuea. ‘sxe: yous jeweisered hyde Sopsenouse eousUel ‘Soyo FAN ay jo AhOwUELS o uowelodespo 04 ena) oy eae od eps ods ‘oyez2}209p eu ‘onem-3 out 40 BdOfs JOU Pion fepcuna S Mu e/T ie uonecuuoveg 94 GuIsn Gail avfen fel Jo UonewnES, vorod prs pouiow eun-yey ainssaxd SISOUSIS [EAH Echocardiographic Assessment of Valve Stenosis Page 5 of 6 www.asecho.orgican Society of rdiography & Circulation Ultrasound Specialists Mitral Stenosis anats mitral stenosis, Data recording and measurement in routine use for mitral stenosis quantitation Data element Recording determine the smallest lorfice by scanning from apex to base positioning of measure- iment plan can be. loriented by 30 echo lowest gain setting to ‘visualize the whole mitral loifice Planimetry "contour of the inner mitral [atrial nbrilation, Mitral flow |-mean gradient from the traced parasternal long-axis view |- apical two-chamber view - continuous-wave Doppler C Splcal windowe ster” |contourofthe dinette mi scfenbie (optimize Intercept |fow ena “pressure halftime from the aGjust gain setting to | descending slope ofthe Earave ‘ouinvaldefined tow |(ma-dastele slope not ine) contour \"iverage measurements ata! ibrilagon | Systolic |- continuous-wave Doppler_|- maximum velocity of wicuepid Blimonary |-mlipleacousie windows|rogurgtant how. Enory itocoptimize intercept angie” |"estimation of right atrial pres- Presture stre according te inferior ven cave ciomoter | Valve |: parasternal short-axis view]- valve thickness (maximum Anatomy land heterogeneity) commissural fusion textonsion and location of iocalized bright zones (fibrous nodules or caleifieation) valve thickness | extension of ealeification “valve pliability Subvalvular apparatus (chordal thickening, fusion, or Shortening) - subvalvular apparatus |ichordal thickening, fusion, oF |shortening) Detail each component and Classification of mitral stenosis severity Mid | Moderate | Severo Specific findings ‘Valve area (cm?) >1.5 41.0-1.5 <1.0 ‘Supportive findings: ‘Mean gradient (mm Hg)" <5 5-10 >10 Pulmonary artery pressure (mm Hg) | <3Q | 30-50 | > 50 “at heart rates between 60 to 80 beats per minute and in sinus rhythm www.asecho.org Echocardiographic Assessment of Valve Stenosis Page 6 of 6Heart & Circulation Ultrasound Specialists A S E American Society of Echocardiography Echocardiographic Evaluation of LV Diastolic Function ‘Adapted trom: Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampt FA, Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography, Eur J Echocardiogr and J Am Soc Echocardiogr 2009 LV and LA Pressures in Normal and Abnormal Diastolic Function Normal EDP = 1R| Rapid Fitting] S10, 20 Pressure (mmHg) 3 8 10 TIME (ms) Poster ordering information and full text of ASE guideline documents available at: www.asecho.org Design and illustration by medmovie.com © Copyright 2009 The American Society of Echocardiography www.asecho.org Echocardiographic Evaluation of LV Diastolic Function Page 1 of 8A S E merican Society of Echocardiography Heart & Circulation Ultrasound Specialists Relation of Mitral Inflow and TD Velocities with LV and LA Pressures HB Rapid Filling = LA Systole Impaired Relaxati Normal Normal LAP High LAP 2s s LV and LA Pressures (mmHg) 0 _fem/s) ao Tissue Doppler Velocitis www.asecho.org Echocardiographic Evaluation of LV Diastolic Function Page 2 of 8(21-0) (g'2-S"0) (V'e-2°0) i 0760 $0751 9:06" ve ieee (6'61-6's) (2:02-S"LL) (9's2-pb) (z'9z-€4) See) ©7Fl9b 6'278°6L S'eF9'0z (shui eisteve7) (sz'L-sv'o) (z'1-s'0) (9'2-9'0) ; Z'0F58°0 eOFL'L $'079'L A 8/9 1eades (9"yL-z'9) (8°91-9°2) (60z-b'0L) | (64-101) 2Fy'oL ezFzzb L7S'St P2z6PL (sjw) @ 1eides sueak og < | sueeXog-Ly | sueeXop-1z | sueak 0z-91 ean eoeeUC %S6) sElg Eels (921-001) (61-201) (€S1-LOL) (2b1-62) an 6lF8eh elseel e1Flzh Piette) (ul) uopenp y eli (ggz-zvL) (612-er1) (v61-8e1) (o8t-vor) (sw) 1a eels 624002 613181 vlF991 6132p) 33\f 22/5 ze"L-9'0) (gz'1-82°0) | (ee'z-e2'0) | (8z'z-86'0) wa ws 8107960 S7'0F82"1 Ov'0FES"| Sv'0F88"L é (vot-e2) (88-09) (e8-Ls) (g9-z¢) = : LFL8 LL #29 60S (su) LHAI = sueakgg< | sueahgg-Ly | sseakoy-1z | sseef 0z-91 aoa ear %56) A SEAIIU] BUN] PUL SAI!D0/aA MOyUT [esyW JO Sanjen [EWON Page 3 of 8 Echocardiographic Evaluation of LV Diastolic Function www.asecho.orgBOD ica: 8 Circulation Uisrasound Specialists Relation of Pulmonary Vein Velocities with LV Filling Pressures Normal High LVEDP + normal LAP (normal or EF reduced) Ar High LAP s (often with reduced EF) Ar Normal Values of Pulmonary Vein Velocities mean + SD 4 (05% contdercetnterva)| 1620 years | 21-40 years | 41-60 years | > 60 years 0.8240.18 | 0.984032 1.2140.2 1.3940.47 sid (0.46-1.18) | (0.34-1.62) | (0.81-1.61) | (0.45-2.33) a Gate) 16210 2138 2343 2529 rom (1-36) (5-37) (17-29) (11-39) ; 66239 96433 112415 113230 Ar duration (ms) (1-144) (30-162) (82-142) (53-173) www.asecho.org Echocardiographic Evaluation of LV Diastolic Function Page 4 of 8A S E American Society of Echocardiography Differentiation of Constrictive Pericarditis from Restrictive Cardiomyopathy Constriction | Restriction Septal Motion Respiratory shift Normal {mira E/A ratio 15 >15 Mitral DT (ms) <160 <160 Mitral inflow respiratory | Usually present inneenit ariation Inspiratory diastolic | Expiratory diastolic Hepatic vein Doppler Nsw reraraal flow reversal |Mitral septal annulus e' >7 emis <7 cmis Mitral lateral annulus e' | Lower than septal e' |Higher than septal e' | Ventricular septal strain} Usually normal Reduced Septal and Lateral TD Velocities in Constrictive Pericarditis ft) and septal (right) TD velocities from a patient wit! constrictive pericarditis. Notice the higher septal eat 14 cm/s in comparison with lateral e! at 8 cm/s. www.asecho.org Echocardiographic Evaluation of LV Diastolic Function Page 5 of 8Heart & Circulation Ultrasound Specialists A S E American Society of Echocardiography Diagnostic Approach Estimation of Filling Pressures in Patients with Depressed EF a E/A <1 and E < 50 cm/s E/A 22, DT <150 ms Ele' (average e') <8 Ele’ (average e') > 15 Ep <1.4 ENp 22.5 SID >1 siD<1 Ar-A<0ms Ar-A2>30ms Valsalva A E/A < 0.5 Valsalva A E/A > 0.5 PAS <30 mmHg PAS >35 mmHg IVRTIT. >2 IVRTITe. <2 www.asecho.org Echocardiographic Evaluation of LV Diastolic Function Page 6 of 8A S E American Society of Echocardiography Heart & Circulation Ultrasound Specialists Di tic A h Estimation of Filling Pressures in Patients with Normal EF Sep. Ele! > 15 or Ele’ <8 (Sep, Lat, or Av.) Lat. Ele’ > 12 or Av. Ele' > 13 LA volume <34mi/m?|_ LA volume 2 34 mim? Ar-A<0Oms Ar—A230ms Valsalva A E/A < 0.5 Valsalva A E/A > 0.5 PAS <30 mmHg PAS >35 mmHg WRTITE 1 22 IWRTIT, 1 <2 www.asecho.org Echocardiographic Evaluation of LV Diastolic Function Page 7 of 8_ Septal e'28 Diagnostic Approach Grading Diastolic Dysfunction Septal e' <8 Septal e' >8 Lateral e210 | Lateral e' 210 Lateral e' < 10 < 34 mi/m2| LA2 34 mi/m2 LA 2 34 mi/m2 www.asecho.org Normal Normal function, function | athlete's heart, DT > 200 ms Av. Ele' <8 _ ArA4mis Mean gradient v <20 mmHg 20-35 mmHg >35 mmHg Doppler velocity index 20.30 0.29- 0.25 <0.25 Effective orifice area > 1.2 om 1.2-0.8 cm < 0.8 cm Triangular, Early ‘Triangular to Contour of the jet vel ul trical contour ‘ontour of the jet velocity [7ey'au iaeeoae Rounded, symmetrical contot Acceleration time <80 ms 80 -100 ms > 100 ms = incondtons of normal or naar normal stoke volume (60-70 mi Obstructed Pulsed Doppler vo i coed Mean G = CW Doppler Prosthetic AV 22mmHg cr) rey es Per eT www.asecho.org Evaluation of Prosthetic Valves Page 5 of 9A S E American Society of ‘wo\ Echocardiography Prosthetic Mitral Valves Normal Obstructed | roe I ore Mean G = 4 mmHg Tee ear) PU rxty een Doppler Parameters of Prosthetic Mitral Valve Function 7 Suggests | Normal* Soa Significant | Stenosis* | Peak velocity » <1.9m/s 19-25m/s 22.5m/s | Mean gradienty <5mmHg 6-10mmHg >10mmHg | VTlpewv/VTI Lvo ¥ See 2225) >25 EOA 22.0cm? 1-2cm? <1 cm? Pressure half-time <130ms 130-200ms >200ms * Best specificity for normality or abnormality is seen if the majority of the parameters listed are normal or abnormal, respectively. ¥ Slightly higher cut-offs are seen in some bioprosthetic valves; these parameters are also abnormal in the presence of significant prosthetic mitral regurgitation. www.asecho.org Evaluation of Prosthetic Valves Page 6 of 9A S E American Society of ‘oe Echocardiography Prosthetic Mitral Valves Flow masking in mechanical valves from the transthoracic approach can hinder assessment of prosthetic mitral regurgitation www.asecho.org Transthoracic Transesophageal Findings Suggestive of Significant Prosthetic Mitral Regurgitation by TTE in Mechanical Valves with Normal Pressure Half-time + Peak mitral velocity 21.9m/s © VTleaav! VTlivo 2 2.5 + Mean gradient 2 SmmHg + LV stroke volume derived by 2D or 3D is > 30 % higher than systemic stroke volume by Doppler + Systolic flow convergence seen in the LV towards the prosthesis + Tricuspid regurgitation jet velocity > 3 m/s Evaluation of Prosthetic Valves Page 7 of 9American Society of chocardiography Prosthetic Tricuspid Valves Normal Obstructed Findings Suspecting Prosthetic Tricuspid Stenosis Prosthetic Valve Consider Valve Stenosis" Peak velocity © >1.7 mis Mean gradient 26 mmHg Pressure half-time 2 230 ms + Because of respiratory variation, average at least 5 cycles ® May be increased also with concomitant valvular regurgitation www.asecho.org Evaluation of Prosthetic Valves Page 8 of 9ASEtsssavess Prosthetic Pulmonic Valves Findings Suspecting Prosthetic Pulmonic Stenosis Cusp or leaflet thickening or immobility Narrowing of forward color map Peak velocity through the prosthesis > 3 m/s, or > 2 m/s through a homograft Increase in peak velocity on serial studies Impaired RV function or elevated RV systolic pressure Normal Obstructed www.asecho.org Evaluation of Prosthetic Valves Page 9 of 9A S E American Society of Echocardiography Heart & Circulation Ultrasound Specialists Prosthetic Aortic Valves Parameters for Evaluation of the Severity of Prosthetic Aortic Valve Regurgitation Parameters Valve structure and motion Mechanical or Bioprosthetic Structural parameters LV size Doppler Parameters (Qualitative or Semi- Quantitative) Jet width in central jets LVO diameter) — Color* Jet density - CW Jet deceleration rate (PHT, ms) - CWs LVO flow compared to pulmonary flow — PW Diastolic flow reversal in the descending aorta — PW Doppler Parameters (Quantitative) Regurgitant Volume Regurgitant Fraction Mild Moderate Usually normal = Abnormal » Normale Normal or mildly dilatedo Narrow, Intermediate, (s 25%) (26% - 64%) Incomplete or faint — Slow Variable (> 500) (200-500) Slightly ; eee Intermediate Absent or brief early diastolic ‘Intermediate < 30 mi/beat 30 — 59 mi/beat < 30% 30-50% Severe Abnormal » Dilated o Large, (2 65%) Dense Steep (<200) Greatly increased Prominent, holodiastolic 2 60 mi/beat 250% W Abnormal mechanical valves: eg. Immobile occluder (valvular regurgitation), dehiscence or rocking (paravalvular regurgitation); Abnormal biological valves: eg. Leaflet thickening or prolapse (valvular), dehiscence or rocking (paravalvular regurgitation) * Parameter applicable to central jets and is less accurate in eccentric jets; Nyquist limit of 50-60 cm/s § Influenced by LV compliance Applies to chronic, late post operative AR in the absence of other etiologies: CW continuous wave Doppler; LV = left ventricle; LVO = left ventricular outflow tract; PHT = pressure half-time; PW= pulsed wave Doppler. Page 1 of 6A S E American Society of LAD ES Echocardiography Heart & Circulation Ultrasound Specialists Prosthetic Aortic Valves Normal Doppler Echocardiographic Values for Selected Prosthetic Aortic Valves Peak gradient Mean gradient Effective orifice a a (mmHg) (mmig) area (cm*) f noris“"zs0s % oaeaztasas 1303 ae 2 18.7283 105245 17204 Bieatet 4 15.1256 75231 20206 = toad btaea H seaeng masse 1t803 Bo aing isriss—t3to3 Beet B BG ites | (2s88 ae 2 joores—iss03 0 asezy meres opsoe Bite Wsse2 803 Carpentier Eowarde B 0 marrs—istsez isos Sarare B oo ual) eres fotos Sie pine hoi Gitss «Sits 2 cosz0—zesus a teres i3toe = B saostsoseses tate as % — morss.oasze esos Metts msartatee * forse x Greet t4z03 Mearone Fresetye Bima thas | gens see 3 Sarat zases 2 tesa 2ses BH werms —tatssehasoz B eres setas tase ee cy A7A87.0 95443 15205 ‘Single titing disc a 189297 8756 19202 x fgeso tates BB omerno | Beles Stee — 3 usin fzier tases eee 2 ossaa—iasor 3 mates basez B sess orsa i ts02 Boo Malws aiits —tas03 rose 3 Sistoo farter =a Bb Saies taiee mores eases i ertzo those tee04 RO Ree ae ue ceding «= s“(‘“‘ RR cee aan — B irises erazastos nT 1eies Sealy wakas 0 gorwo sees tesot M0 Brrosfsaisatatos Bo neitstsasse isso Stiudeedeslsantard 3S agsr3 oss. toes cote Bo areaa basse toe BS osiss | tartrdakes Ho meus wrete —i3t08 B “earns usar tatos % areezeaset—tatos ‘St Jude Medics! a 10.1258 50229 20203 ‘Stentiess 2 TIs44 41424 24206 ‘www.asecho.org Page 2 of 6A S E American Society of Echocardiography Heart & Circulation Ultrasound Specialists Prosthetic Mitral Valves Echo/Doppler Criteria for Severity of Prosthetic MV Regurgitation Using Findings from TTE and TEE Mild Moderate Severe Structural parameters LV size Normal* Normal or dilated Usually dilated** Prosthetic valve o Usually normal Abnormal y Abnormal y Doppler Parameters Large central jet ‘Small, central jet (usually > 8 cm?or > (usually < 4om? 40% of LA area) or Color flow jet area ve (SUAIY = Ac’ arianje 40% Of LA area) o area) impinging jet swirling in LA Flow convergence $ No or minimal _ Intermediate Large Jet density -CW o aoe Dense Dense e ; Early peaking -— Jet contour -CW Parabolic Usually parabolic FV peal systolic Systolic flow Pulmonary venous flow gst. Systolic bluntings Systolic fo Quantitative Parameters VC width (cm) © <03 0.3-0.59 206 R Vol (mi/beat) <30 30-59 260 RE (%) <30 30-49 2 50 EROA (cm?) < 0.20 0.20-0.49 20.50 ‘© Parameter may be best evaluated or obtained with TEE, particularly in mechanical valves. “LV size applied only to chronic lesions. “In the absence of other etiologies of LV enlargement and acute MR. Y Abnormal mechanical valves: e.g. Immobile occluder (valvular regurgitation), dehiscence or rocking (paravalvular regurgitation); abnormal biological valves: e.g. Leaflet thickening or prolapse (valvular), dehiscence or rocking (paravalvular regurgitation) W At a Nyquist limit of 50-60 ems. < Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and > 0.9 cm for central jets, respectively, with a baseline shift at a Nyquist of 40 cm/s; cut-offs for eccentric jets may be higher. 5 Uniess other reasons for systolic blunting (e.g. atrial fibrilation, elevated left atrial pressure) + Pulmonary venous systolic low reversal is specific but not sensitive for severe MR. © These quantitative parameters are less well validated than in native MR. ‘CW = continuous wave; EROA = effective regurgitant orfice area: LA = left atrium; LV = left ventricle; MV= mitral valve; MR = mitral regurgitation; R Vol = regurgitant volume; RF = regurgitant fraction; VC = vena contracta tn cert te cams nan nt nant annaenettamrnnnmnrment www.asecho.org Evaluation of Prosthetic Valves Page 3 of 6A S E American Society of Echocardiography Heart & Circulation Ultrasound Speci sts Prosthetic Mitral Valves: Normal Doppler eae Values for Selected Prosthetic Mitral Valves Valve ‘ae Mean gradient Peak velocity Pressure _Effective orifice (mmHg) (mis) half-time (ms) area (cm?) 2 50 19 2 587223 18203 Bjork-Shiley monostrut 27 453222 17204 Tilting disc 29 4.26216 1640.3 31 49216 17403 2 19401 12627 25 36206 13201 9338 29208 conereencs 27 3464103 161203 8920 292075 cau 20 3392097 152203 98217 23204 31 3322087 1612029 © 92228 2esiis 33 48225 45202 93412 27 60220 17403 98328 Carpentior- Edwards 29 47220 1763027 92214 Stonted bioprosthesis 31 44220 1542015 92219 33 60230 93212 27 36 16 100 29 5252236 167031102 15 pericardial as # 40se089 159201 want 27 50220 13208 Hancock |ornot specified 29 2.48 +079 115220 15202 Stented bioprosthesis ci 4.86 + 1.69 95217 1.6202 33 387220 90212 19202 27 14 78 Medtronic-Hall 2 isrso1 oa a ee u 1.45 £0.12 7217 29 354081 1620.22 Medtronic Intact Porcine 31 422144 162026 ‘tented bioprosthesis 3 40213 142024 35 322177 13205 2 80 25 6052181 172024 1022 16 Omnicarbon 27 499205 1632035 © 105433 Titing se 29 4932216 1864027 120240 31 4ter14 132023 194891 3 40220 2 40 15 160 10 25 25210 1348112 7544 1352017 pha aac 2 502182 1614029 «© 7521044672017 29 415218 © 1574029 ©5210 «17520.24 31 4462222 1894033 74213 «(2.032032 6 100 14 28 702275 4.94087 Starr: Edwards 30 6.99225 1.7203 125 25 1.65 20.4 omar 32 5.0825 17203 110225 1.98204 4 50 26 ‘www.asecho.org Page 4 of 6A S E American Society of ks Echocardiography Heart & Circulation Ultrasound Specialists Prosthetic Tricuspid Valves Echocardiographic and Doppler Parameters Used in Grading Severity o' Prosthetic Tricuspid Valve Regurgitation Parameters Mild Moderate Severe Usually normal Abnormal or Valve structure valve pea dehiscence Jet area by color Doppler— ss central jets only (cm2) 2 cat elo VC width (cm) Not defined oe but >07 Jet density and contour by Incompleteor Dense, variable Dense with early CW Doppler faint, parabolic contour peaking Doppler systolic hepatic flow ae = Blunted Beer RAIRVIIVC Normal* Dilated Markedly dilated * If no other reason for dilatation © For a valvular TR jet, extrapolated from native TR; unknown cut-offs for paravalvular TR. RA = right atrium; RV = right ventricle; IVC = inferior vena cava; VC = vena contracta www.asecho.org Evaluation of Prosthetic Valves Page 5 of 6A S E American Society of Echocardiography Heart & Circulation Ultrasound Specialists Evaluation of Severity of Prosthetic Pulmonic Valve Regurgitation Parameters Mild Moderate Severe Abnormal or AErOniGL or Valve structure Usually normal valve ‘ SBRigconGS valve dehiscence RV Size Normal* Normal or dilated Dilated* Usually large, Thin with 2 intermediate; Jet With a wide _ narrow origin; origin; Jet width Jet size by color Doppler Jet width <25% Width 26%- 50% no’ o Cte of pulmonic ee pulmonic annulus annulus; may be brief in duration Jet density by CW Doppler ene. ‘or Dense Dense Steep Jet deceleration rate by CW Slow Variable deceleration$, Doppler deceleration deceleration early termination of diastolic flow Pulmonic systolic flow Slightly Intermediate Greatly compared to systemic flow increased increased by PW Doppler + Diastolic flow reversal in the None Preesat Preesnt pulmonary artery * Unless other cause of RV dilatation exists, including residual post-surgical dilatation “Ata Nyquist limit of 50-60 cmis; parameter applies to central jets and not eccentric jets § Steep deceleration is not specific for severe PR. 4 Cut-off values for regurgitant volume and fraction are not well validated, # Unless there are other reasons for RV enlargement. Acute PR is an exception. RV volume overload is usually accompanied with typical paradoxical septal motion. www.asecho.org Evaluation of Prosthetic Valves Page 6 of 6A S E American Society of Echocardiography Heart & Circulation Ultrasound Specialists Guidelines for Stress Echocardiography /Agapted trom. Plikka PA, Nagueh SF. Ehendy AA, Kuehl CA, Sawada SG ‘American Society of Echocardiography Recommendations for Performance, Interpretation, and Application of Stress Echocardiography. J Am Soc Echocardiogr 2007 Sept; 20(9):1021-1041 Poster ordering information and full text of ASE guideline documents available at: www.asecho.org Design and illustration by medmovie.com — © Copyright 2008 The American Society of Echocardiography ‘www.asecho.org Guidelines for Stress Echocardiography Page 1 of 9A S Ex American Society of Echocardiography Exercise Stress Testing Apical two-chamber view of a single rest image is compared with three post exercise images. With exercise, there was an increase in end systolic volume with akinesis of the apex in this patient with severe left anterior descending stenosis. - Vasodilator Stress Echocardiography Vasodilator stress echocardiography with myocardial perfusion imaging. Perfusion and wall motion were Dobutamine Stress ormal at baseline. With stress, there was severe rf fe of i hypoperfusion (contrast defect) of the apex with Echocardiography accompanying akinesis of this region Parasternal long axis views show mild global hypokinesis, at rest, augmentation of contractility with low dose dobu- tamine (viability), hypokinesis of the distal anteroseptum at pre-peak, and near global hypokinesis at peak. The patient had multivessel coronary artery disease. www.asecho.org Guidelines for Stress Echocardiography Page 2 of 9A S E American Society of wo Echocardiography Heart & Circulation www.asecho.org exercise. This may occur with a hypertensive response. Guidelines for Stress Echocardiography Apical images before (left) and after (ight) treadmill here were no regional wall motion abnor- malities, but the end systolic volume did not decrease. Page 3 of 9A S Ex ican Society of j Ie Echocardiography Exercise Echocardiography Protocol ‘Symptom limited Workload * 4 1) 46 me (min) ee ae ek kk RK ECG ree tla eae ee * Increase treadmill speed and grade or I bicycle resistance 4% Longer echo exam 4% Echo imaging completed in 1 min after exercise, then repeated Images obtained at rest and immediately post exercise. Reasons for Stopping Test + Maximum exercise until fatigue or symptoms * Significant arrhythmia + Hypotension, severe hypertension www.asecho.org Guidelines for Stress Echocardiography Page 4 of 9A S E American Society of Echocardiography Dobutamine Echocardiography Protocol Atropine .5 mg repeat .25 min * 40 30 Doputamine dose (meg/kg/min} Oo 6) 12) a5 Time (min) +—+—_+—_ +++ BP Ra ECG % Atropine may be administered at an earlier stage Images obtained at rest and at each stage of stress. Reasons for Stopping Test + Peak dose + Target heart rate .85 (220-age) + Moderate or extensive wall motion abnormalities * Significant arrhythmia + Hypotension, severe hypertension + Intolerable symptoms ‘www.asecho.org Guidelines for Stress Echocardiography Page 5 of 9 ce en eSA S E American Society of Echocardiography Stress Echocardiography Report Wall Motion: Rest Score index 1.06 (normal 1.00) ApicalCap Apex Mid-vent Base 00 ©@ Wall Motion: Stress (Worsening wall motion abnormality) 2009 ©@© Legend and score values Normal ‘Mil Hypokinesis 1 Akinesis [1 Dyskinesis DO Aneurysm [1 Not seen Scarred Summary + Exercise echo mildly positive for ischemia + Good exercise capacity (8 minutes Bruce protocol, 102% functional aerobic capacity) + Rest images: Normal left ventricular size, ejection fraction of 56%, inferior wall hypokinesis + Exercise images: Decrease in end systolic size; inferior wall worsened www.asecho.org Guidelines for Stress Echocardiography Page 6 of 9A S E American Society of we Echocardiography Heart & Circulation Ultrasound Specialists Response of Infarcted and Viable Myocardium to Dobutamine Coronary Artery Myocardial Thickening Occluded Rest Low Dose High Dose Infarction Occluded to open \ " ass aay Sustained improvement (Stunned) Severe narrowing ea ee Biphasic response (Hibernating) eer www.asecho.org Guidelines for Stress Echocardiography Page 7 of 9Heart & Circulation Ultrasound Specialists A S E American Society of Echocardiography 43 asio1exe uy eseesep Jo eBueyo ‘Ou “YM o1WeYos| « ayes yeay uo paseq 40 eulwieingop ere 0z 40 sjowepudip 6/Bu 96°0 YIM eIWaYps| « ployseuyy O1WHEYyOS! 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BSIDIOX9 YEAd 48@1 0) pazedwoo uonoury ul eseesour asiouexe yead e19Ko1g oudng aseasip jew 7 Jo Jassenninus ul 43 ul eseaioag ‘AS3 Ul esee.ou} 43 ul esee.0uy AS3 Ul aseaneg 3894 0) payeduioo ‘uoKouny ul eseesep 98100X8-1S0d, 1891 0} pezedwuoo uonouny ut aseeioul ‘9819/9X9-1S0q twupeaay asuodsey 21Wayos} ‘esuodsay [eULON asuodsey o}uWa4>s) asuodsey [euiON Powe ssenS leqoip jeuolBoy 4SIY JO S10}9IPe1g AydesBoipses0yoy sse.jS | Page 9 of 9 Guidelines for Stress Echocardiography www.asecho.orgHeart & Circulation Ultrasound Specialists A S E American Society of Echocardiography Guidelines for Performing Multiplane Transesophageal Echocardiography ‘Adapted from: Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears Rogar P. Nathew JP. Quifones MA, Cahalan MK and Savino JS, ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination. J Am Soc Echocardiogr 1999 Oct; 12(10): 884-900. Poster ordering information and full text of ASE guideline documents available at: www.asecho.org Design and illustration by medmovie.com — © Copyright 2008 The American Society of Echocardiography ‘www.asecho.org Guidelines for Performing Page 1 of 4 Multiplane Transesophageal Echocardiography1 TG Two Chanter B2TG Baul ShotAce 81 TEMG Shon Ave www.asecho.org Guidelines for Performing Page 2 of 4 Multiplane Transesophageal EchocardiographyA S E American Society of Ech iography Heart & Circulation Ultrasound Specialists ‘A. Mid Esophageal (ME) www.asecho.org Guidelines for Performing Page 3 of 4 Multiplane Transesophageal EchocardiographyA S E American Society of Echocardiography Heart & Circulation Ultrasound Specialists Segmental Model of the Left Ventricle ‘Short axs diagrams ofthe LV and MV iustrating now they are transected by the mid esophageal views. www.asecho.org Guidelines for Performing Page 4 of 4 Multiplane Transesophageal Echocardiography