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'p;Efilno ro Aporralsod rsAoul IAd aqt .alolsetp tdesc sdsnr $ql {Glorssrp Buung 'a1e,{e rurp;e} *ql Je.{o
Suunp puu pru,udn .ro fl.rolratuc ss.roiil ri&d ary .a1ols;is Sur:rrp ut paif,t,r}s3Jr{n 3q pr}e saoq}a uJrrJlun ecnpord
{:crtrouJ .itaql
'st ielil lsll ary ol x$rtrlelrp elrssddo sqi ur se^our &d gq.L 'urr.p readdu plnclqs sdsnr qloq pur ]3N aql ol ;otrstue
'pJr.rylino ro ,{1.1*r;a1uu s}^out
SAI +ql 'aloisarp Eurrnp :{lnur si*edde f,3g .qI 't3f,M dsne,{rei,o:o}*uorr oqt p$B (Jf,Ui
A'l aql olur pJ*^rilr ro dpot.raisod ss,Aorn pu€ sualstq] SAI dsn* ,&euoros lqatJ aq dllansn sl srqi :r$al^ srrll tuo{ u3a5
aqi 'sllu.lluo} A"l sq} su 'a1o1sds Bul.lng .$saulstrll ur lunhe aq ues BAls^ ]t].rou oqt ga sdsnt slJql aq} Jo o,\rl ..r!ar.r
:o rul*uru{r 3q plnoqs A{d puP sAl Brll Jo s$i}$}iilql eqJ slr{l ruo{ psleica:dde sq ,,{11rnsn uE? Im?IfirTrfE;?ieFTlstrrs
'saollia ilJoJtufi arnpord plnoqs pue en_-_"---- .eiliiiuET_@E'aqt sB ii3ns
A-I aqr -go (11u,rt IBJE]BlojeJUi ]oor
ro) A\d aq] puu SAI er{i go suorsrod plur pue lsseq }qJ. Jl]-r6u arl]
"1o,suort:od
snollu1 'aisisstp ut d1"r+r.:+1sod pue
'e!+-oilis .rcedde plnoqs rnur atolsdr Suurip X1:ol;a1uv aAou leql seurl 1a11e.red urqt
"{;
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'sarqg a4r1-ffulrts .lnel uaas o;p el.rou Er:rpuarse ;erurxo-rd pLrB loo: orl_roe eql
se usls aq osle deru a;+snu: .,{.raylrdud aq} ot sleg€str l€rllul 'szrs i-ll s*seorlep {lrrec
aq? r13"1:lE rj3!q.i'\ spros srlourpusl qqJ" .u'r .fld) alolsulp JGAN ?Lll priu sii+{;trll llu,rl AH JstJatu* aql 's}JeJjror ,{U
Sur.rnp rno3o ;?ql saseqd sfiotJert aq; ol enp stag.Bal att.raa aqt se o6rlsds Suun6 @il
aqlJs:lBrll su eldrurs $s 1ou sr a1c,{t curprrr or{t laAo sto!}ssl :@ElrF7--te-1jJllnlrefijiEp:s-i-w-n
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L,r psl.3ulsarun aq pfi? saoqSe uuoJtun arnpand .urq]:eaddu (gg) a*1u,r pidsntr:1 aqlJo suorjlod dlluuolsemo :sa4-or{oo
plnoqs s]agusl qiCIB'ilAurdlM .ruacids plnoqs 1OAX ?lit Jo dtr^?o eqi .gAl ary puE iie.4! AU
(t^ure).lFEEEi- ror;$luB ar;l .{q papunoq st qi}rrl.* IOA}I aql st lla,$ lseqJ'arll
snl?4 lsJirru -loualuuEii] .^1?r^ stri] uto$ ueas lla^1 o$la ile ol .lol.ralsod dlalerparurul 'gEAr ?ssrlo +ql st slral^ luenbasqns
(4y$ aapa l*$ru eqt Jo stagi€el .lolrolsod pne .louelu? aqf fi8 pue ,11sl.l! 5lq; tu0$ peJeli.l!10?ua sJnl'ruls lsiU aql
.sdsnc lrpoe
aqpgo
'niltA 51q1 tuo{ psltalap eq ,(uu.r }stll sslIlBrruouqE
sJ?p:sq sa+ aqt u:o4 Bursr.re use$ Jo auoz s;nsolo eAle,l aql aql stsrl :arduqr stqt Jo pue srll tE J'a alquj :{C ry.J) 9'a
J0 sJEJins Jslnsulus^ aril oi peqlBnu lsqlla slurllrElu a[]qoui e.rn6rg ur pa,teldstp JJC ;!\3t,1 strll ulo{J pasrlullst.,\ ssliltrruls
pus Jea$tl '*uU *rg u*as dlJuuorsu:ro aq ,tuur a^lE/L ],Uoc aqi saua.rsBddy rlqdEr6otFleioLlo3
fi

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 CHAPTER 2: Tit E Two-DrM ENSrONA L ECHocAR.DIoc L4FHIC txAtv{ illATI

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acra l\{:':i-Jiciil]i,,T;lli li llr.r .',!.l j ir:r.1ti i,rr ii;-rjs.r.i .ri.,,: ri,::ir+r: .r!i --irci.ri iiriirr.i.r

l.i*41' ;.rler;al

P0slirrlr Sir;tarrir
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ru
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::^3::,:::.1n:,31:Xg:.:P:::h.e qhiari.l'l*t*:'k a$:een irom the parasternar rons axis view or the risht ventricuiar iriitow; rhe
schematic illustration ir,sfifl shows the aector orientation and structures s*en. The
rnembrane at the orifice of the lvC. On real-time lrnaging, this network can
C#;;l;;
ti;*, ;pp;;;; d;ffiffi!}*;,[
appear very impresslve due to its chaotic motioft within the
EA. This structure is a *orynar variant and snauH not neionfused with
nathoiogy.
Ch=Chiari netr,vork;Cs=o+tiaof thecorenarysinu*; IVG-i*ferioru*i""u";fri'=rightatrium;
RV=rightvenkicteltu=tricuspidvalve.

lnreging Tips: PLAX of ftVlT lrr,iagi*S Yips: FL.4X of RVGT

il,{insr pr0f,e aeijrJStm€i-its inat m;jy he rBqlr}i",}{j io M!nor proile adjusirx6nt.'s rhat rnay '[:e requir'ed io
:'iChie,JC if ,rs vrey, ;rr,;11:r6 Jc F,rev= 1l:s v.eu, ,n(.ludc.
! ilo,"Jefie.it of tl:e 6:rot:e iaieraliy or slii;hiiy a,ray frr:ri-, * inovemeni oi il:e probe
the sternu,=i]
superiorj).- or ar: intercosiai
space higher
. fitoyenr*nt*i the prai:e ;lferi*r-iy L1r' aft ifitera;s.ial " r'rxlvei"nent of the probe iatei-aiiy i)r avr'ay irom iite
space iovrer anC,/or st€rriuin. ar,ld/or
o slighi clcckwise rntatioli of the prche tj5"
t,r 2il,,! . siigit clockwrse rotatlcn o{ lhE pr-ose iiess tha_r 20-,)

-,-

;ffi;;d;; ;il oil"r*il,i.irr* mstn LSAU) Ferl molina l{*culuar
"*
plnoqs sie$s*l *satli pu€ uaas ,{gunsn }JB slsi}u}1 *^lst
d*euourlnd esrqt aql Jo o^t1 'ee.*-og3e 39 ptnoqs Ydr{ 3r-ll
jo uorunl aqt put JOAX aq1 qtEual qi 3uc1e ralaue!p
tualslsuoe u Burulelurur.u '1ue$d dlapln readde plnoqs Vrlf{
eql 'a1:ite retp:us aqt ltoq8nr:;tit luatsd ,t1apt,u rItr{lte:
piroqs pu€ eH0? aql $1 lBluazrjoLl pue rouelus sall JoAu e'{l
'aAltlr *l$os aq3 oi.lou+dns sl auuld
Bur8su;r slql sg l6Aal s,ql 18 uaas.{1pnsn loil e.ru sdsnc rt}lc?
sriJ '(tI'A '81.1) e?urut *qt.;ic tq$r.r 6ql spJuArol s:raddu
(y41) d.r*ut tucuowlnd Us! sqr altq*r aBrurr 3i{} Jo Uel aql
sprB*lst uses s'l vdu aqi :aaEtill aqt 3o lq8u eql sp-13^1o1
s.reoddu V;IAI sql ultq.rrr *8erlr aqlJo 3llu33 aql ul pesllsnsti
sr euog sql pue d;rorralue uop$ sr JOAX aql ',trata slql trloli
uoll€3rn$8 Yd aql lo xvsd
':t4*as eqtr3o lqBu
eqt ol uoo$ 3tE $arnl3fllls lEJ,lui ro pspls'$3l pue'ro1r+s
aq] Jo S3l aq! ot uaa$ er€ $ernllnrls l?tperu 'ro pepts*q8ry
'lol33$ a$ J0 r*otloq ew 1s uets are saJ$lInJlS :ot.:e1sod
slrqAl rol3as aqlSo dq trp ie ueas e-IE selmsnlls lol;o]lle $t{i
o! polrtuorJo are aBrul Joltas aql o1 sdtqsuoilelu tlruo;Bny
uol+e$rspo rolsos
-laael qcue
uog Pa$alep aq daur lulil sstllletuJoilqt
eq; stcrl :aldeqe stqt Jo p$3.ql ls 5'f alqu::^rslaq
paqussep orE lp^)l xYSd q083 uro.$ posllBnslA sern13uls
'xedu 6-J eq1 pus sslcsnu ,fue;1dud stp 3io |aAal
ar{l 1e A:I aql Jo srxs iloqs }ql qflno:qt sessud auuld .rolcas
aql i{11aralu1 dpq8lls pa18ua prre .4|.Jor"r*J.ur ps}Ip st aqord eqt
t .t-
1.1! ;i /it:il!i:' :i) ;allii:' il:.i;'
1q6--g aqi ;o aatn srxa 6uc1 purswp-ied €*l s&tsqs *rsg s*g 11'6 e*nfu'{
ueq,t 'v'I puB slroB aql p$3 u$ll?, .Irgq vd sqlJs sls^al srxE
poqs aU q8norq ssssed auuld Jolsts ar[] ',{11e1peu ,tpq?t|s
pelEuu pur ,tpou*dns palltl sl aqo:d aqr uaqtr& 'peulEqqo sl
AI^l eqrJ0 lrAel el{l A'I 3{1Jo ,!na!a $!xB Uor{$ E '1;ertr lsaqc
18
Bqt ol ,rqn?pued: d sr eqo.d 3$ ueqlq'{g'Zt'e '8rg) xade
istprs} 3gl Ol 'Uteq 5q1 Jo es8q sq q8no.rq 'sauapr 1u4.6
eqt Jo la^sl oqt uio.g iltoq sql trasuer ptp sdaams 3o ssuas
r qBnorql pa:tnbce pJs s,rrall sser{I 'psgu$apl sa nltfi4s
carprto fueurtrd aqr a1 Eulp-lorss pell?qel laAsl qlne qll?q
uoltrsod XVSd eqr ul lseJolur Jt sle^el $I€Iil S srt araq.t
'dtq tqBp aqt pu" r$plnoqs Sal oq1 Surutof aull fueu6eu1
ue Suoie 1a11u.lcd lsotule sunJ "sloJaJaqt 'oue1d uucs eqJ
'(v'ZI'[ 'Erg) uoursod qsolr.o t eqi l; dlapmpordde s1
pu? sssoJ lelncr,ra;rerdns $;al s.luslled eqt p:erttol palurod
sl tst6d sql 'sluaq iet1,ra1eo1r n66 aqo:d eql Eunalor Kq A'l
?rg Jo ,rrarl sxe Euol agtr oi Jelnrtpuad.pd palcoltp sI Ereaq
punosu.qp aq; 'aeuds l?tso3ralul t{SS ro 'qrnoJ 'prlql 3qt
u1$t^r 'sr teqi iuorlrsod puralsered eqt u] sul"utar oqord aq1
uouEn6ilv puE $qlBlou tu0!u*od €qqH
srlrau[ slxv uot{s lpu$lsEred
uB, seqru"rq Uq prs lqEp or.u! VdW aql ro
',{1puol*re6 'sa4-sllts eq Plilotls l?ss*^ slqlJo [Ieunl oql
""ff;m"l;
"ryBua1 su 3uo1t Jelslu?lp luelst$Ioe e Buulegleru loated
dlep;,n *adde plnoqs pfl" uees ltsii\ st y4trrq puxord aqa
'VdN aqtJo e$uss sql ulqtl/s ell puB elolsBlpJ0 iisuo aql l?
,4pdnrqu asolt $egesl aql 'iVnW) {:*ue djsuoupd umu
arg Jo slp^r aq ol ;a11amd dp*au ar1 pue uodo deus spgual
 '+1r a'},{{rfirll l 'i-1 .,tr,,..
111 i-W{}..i-Lllii:]NSioti,{,i-. il{'l!oc:.tijit-):o{,i11,,:,plilc [:r.\iii]\

irpp.ilr !hin. ir{',Jdircc trnili}rnt ech().s anii be tnr-estricti:d in

tlitir :li:trcr r iiui:aqi:oi:t ilirr i:ardltc c!clr,:_ tiurins systol*.
PSAX of the Aorta and LA
tirr pr: ir-rii:iraii icaJlr;is snap oFcn en{j liL- pi:r;rll*l io Lhe From this view, the aorta appsar$ as a circie in the centre cf
ri:iii,-ritir: Jl iha u*strl r::i rii:is1*lr:- il-r* i*aficls llos,* the inrage; the RVOT c6ur$es aoteriody abcve rhe aorra" tlie
:j!-)i,.ii'al) rtrd"ii.1.:
iia a-!tiialiri. x,ithirr tlr* h.llrA tl:rt.ir.:uitiiit llr* LA Iies direcfly po$terior to the aarla and the MpA is see*
i: st,:,, i ire- t rrrj
i.i : r
t* the rigkt cf the image rvhile the RA appears to the bonsrn
Ile pl.rrrriil ;rllrt unij lf i't iltii:-!1cililrl *riet,rj bi;!t{lif s left of the image {Fig. 2. t4}.
snoul.: irc ,ri ;1 3!111i;i1' sizc nnd their lunrerr_q sh*iriii tic rcirt> As for fhe PSAX ar the FA bifurcation, the RVCT lies
lir'e (lrir il sholt J':ot-rion o1'the prr:.rir.n:.ii leii ;1ulr.r-r*rra:"v
anterior and.horizontal to the ascending aorta and should
iriir-.ii : Lir.jr; it.;i;;i!i! h* :-:et-:! {.}i: li}f i'i::i}i. tli'ii:* iir':ttgt.
r:;.:r't ren:airy.*,ide1y patent throughout the cirdiec eye le. From
fitd i:ntrrrt:ii ili!,1 r;,ir-: i:c i,:,trr +rtilr:!irr I){)\tc:.to:.lti hL-iiia}ai ,
thiq levei, the anterior wall of the RVST arid a pofiiofl of rhe
tirc ecit; rlii
io rhc lr:it r:1'fhc irrr:itc. l-lrr- ilsci-nd;ng eofia is infeiiar RV wall arc seen.
-seeir in rt: -:ho[ i:xrs ai:ri lis iunrcli shoLil<J rn1:car t'ii:rr-iie:
Frorn this vier4 all three e usps of the trileaflet asrtir valve
{.t;g11;,1.lllqili. iirr- r':;'i,:lt: ri!'thr rir:itt ti)ti.l11itj.r ;rr-ti:t.r llii',\i cat: be $€en. The RCC apFears most anterior" the left ca;qnary
!:t,lr lrj \aarl ilr,
ite r,. i'ittt;iiis*rl- tlr* i{L'A Lt:Li*li_o iit.tsr:: [:-ilr.ti
cusp iLCCi is post*ri*r ard to the right af the irnage w&ile
litt' 3i-riira fol-,i :i!. iti]{}tii i I *'riorl, th* NCC is p*sterior and to the l*ft cf the irnage. ln diastale,
'{ when fhe acrti{ val't'e is c]osed, fhe cusps produce ai '..y',
pattcrn. During systale. the [eaffets are $een to sfiap open rv,ith
tlie c*mmissure$ exteEd;ng to rhe ae*ic roat.
lmaging Tips; PSAX cf PA Eiiurcatio* Regions of ihickening in the middie cf the free edge of
each gusp {on the ventricnlar aspect of the valve) nray be
Tc acliii'e rhis vier!,. it ry:a.y be nec*si;ajj- t$ ijicve il-re
*bserved when th* valve is closed. These are the rrodes
F.Obe sa ifiiergs5il* t'1iqil6r. 3 '5t€etlef' il:?j€rjr $csiiisil
of Arantius. These ned'es tend to beconre iarger and more
as .,eii a= i1 nf€ath $ut afco fsciiitete this v!ew.
lmaging cf rhe trA tliiijrcattort rs srrperroi or ,abover tlte prorninent rvit!: advaireing age " $nrali mobite ilu**ur, k"y
aor-tic vaivE ievei. sr: lf ih€ ao!-tic valvg cafi sliil be seen, elss be noted *n tire ventricular surfece cf the valve; rhese
ihe X-Dhe..ee,J:'O b,t r,tte:J rr,1rre Sr-r:!e'iDr lv are Lanrbl's excrescsnce$. Both the nodes of Arantius *nd
tambl's excresc&ngrs ar€ notrn&l struefures that may be seen

t,i

iii-:'-;;+ 1' :::]-hese irnages shr:w the il.obe position rotation cn ihe chest wall (A) ar:d the var.ious views that can be acquireci froirr
"rnd
the parastefnal sncit axis views (Bil il]the ievel cf lhe pulmonary 3.fiery bifur.cation,
l2'i the level oi the acrtic valve ancl ieft aiijufi, l3l lne
levet 6f the mitral valve, i4l the ievei of the papillary rnrrscles, and
{5i ihe ievel of the left ventricular apex, The red arro\.,.J on A and tire retj
ci$t +n E illdice t€ the prcrtle orieniatlon marker.

Art$riry
+
Sr.tiri <-t+ Ldt
t
F6l*ritt

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'i{li.ti

1r,
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* ,ralden* &ryurias-u*u s ]eil :uian &euorr:tnd 'teddtr *€l = Adn-l

:uio^,{.}euo{uFid rai!1sl U+l = nd'I-i :dsn$ fueuuoe
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Jo u*rluAJes{o dq pautur:alap sq
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s=nB3*q S1 SiUl D$S013 $1

,;*q1u; uadc si Edle,l aul ilaqt* a1*lsxs $ut.tnp apur-u aq sier'r;t

pinc.l$ AVfl B ;s si$oijsBlp sul :i^Vfi) a'\icfi :iiro8 pldsnlg
'piilElai dileiutou art Vd pLrE E#oe *'{l i0
$iosgsri xe=if, aql iFr.il. Si-tililL.lcr e:r-l*.r**celL: "+!3ir;'-€$i"r:t"s'
:lrii ?llff= igjl-i:lJi:r ai;l 0l j+lJSlij* SSEgOi:l leiji anelnE:i i'i-]1
..qi iiiilij +ul :e:iuei*clj*ie ,,41-r:r;'a*eseEs=, 9
s''L"il*i x.vsd
€ttl; l"Lic-li ua85 $e 'v*t/,jil0i1* Gtii OLlf; 8l-lsE Bl-{i Li*s6\}sc
iir-iguo;]ela; SrtuoiBuE ieLl-.:Jou aLli :liairr',-+l;rJi;r-aDilsnES"

sdtl *$sou$elO g
'd11$uozr:oq ssslnoo fiagv xagurRcrrl
'ul?aq p$n0cB.nin a{it elrqnl A1"ror:*1ua $ssr{1ol C'Vl eql lsaqaue;q xaUuInJrI?
aql ot la11UUd lSoEllP ssll iliiq,rd arnl3fills $tq] {la^*8lol slt{;
pur {OvT) Eutpuecsap lorrelus Usl atl} olur Ertptr'tp ueas
$ls+ seoqlle Jo rerms4acq :ood 3o llnsa.l e sB sJns?o qslqiA :q urc X.leru ,(:euoros ul?ltl $el eql'suolsecco uC} Isols.o
-s^t}teJap reedde deru g .{:3eu.lrxo:dd? 1s s.{le^ 3il-ro€ oti} Jo la^al 3q} uo.lj a$FE o}
irr;*yn ..1no-dorp,, Jo :lll'lsal u sl s{ilJ 'n13lA slql ut pl$l]oePl
uoos sq us, Y3"1 aql 'pesllensla ueq&
'33nlq'p!JE &3lA Srqtr u.to.l3 .,{1a'rqua sll tll u?e$ aq 1ou 'deur 5vl
aqJ "iqgll ot Usi uro{ ,{1lq3r1s *81nq o3 ils3s aq '{utu gyi aqi ?q uago uue {V3'il ,'{-raile fueso:os Sal aql 3o urBr:o aq1
'Y"] aql ol 'louatsod
'vu *qr:o lsql u8i{} "raqSrq dpqElls s} vl eql irlqll'tr arnssa;d
aqt a$ns?s8 'aAlsA sujo€ eql lo 33N ol{tr u-'o+ {For'e1sod 'srxu poqs s1t tti 'oeas eq ssl? ueo ?ilog 3l3s'ls{'8 fiutpuarsap
sun: 'eu1€ Usl pus iq8u *ql salcredas q*tq'u '3y1 aq1 artJ 'vU srll 01 lsrlets$d ua+s aq u€3 snuls Alsnoroo plts 3Al
eq1 'ue{:o 'slesEsl arrle,r pidsEcl*l eql esllBnsiA o1
paxaber st
'VU aqlJo tmdsu r*uslsod sqi sltil
a8rul eIIlJo s'lueulisnfpc.rourru ql!,it1 'u:IA lsuol3tppe se
aurld
Sururerp uaes aq os1* u{uur f,AI aqJ nd"IT stlx uur;l "r:qffq, ro
",tpuanba.lg ?$s? eq} 01 t$asol* pur '{lprpou^sruaddu 1a1s
sreadde ndn'I aqt uess uaq*1 :Y'I aql 3o lrodsu lBJelEl aql
allqrt\ a6amr eqt 3o $a{ aql o1 sffedde lAd 3qJ
olur ?ulutt.tp uaas 3q osle ,{ru {n*:f) uran druuorulnd in1* aql }3q113
d11atrd,{;, 'euqd Enr8uut *q1 uorln sp*adap uess sra s}?$eel
la,{1o[ ,Jol puc iAdfi'l) utea &etrou-t1nd ;aridn Uel eqi qlog
r,./*1 qsrqi[ 'ps$rlBnslA ars sl3$B$l Al asjql 3qr Js 0^u
p$slq Jo slsgtr$ aAtlBlil eql J* sgnB3sq u0llEurr0J
"t\ou 'YdN sqllo 34u43 aql $ttlll,tl all puE
snqulortll o1 pesodslperd sr aBupti*ddu 3t1tr "$u';{ilpusfl asaql "sll€1t1 YdiII erp o1 lal1*rud ai1 or
u1 :ueuodrul sl slsourls lulllffi pus uorleilFqg lelrisJo 8fiulas' trdesc da+ 'a1*$rtp Euung
a1+rds ur uado deur slapaal aql 'eros aql 3a rq$u st{t ol
pi'e
a$ ul yy1 s{il Jo uolluuru^rtxa qfiaorcqr y 'a3erul ailt 3o lq$r'r

aqi oi fipra:e1 puu dlror'radn* sp*ex* 1t su paBturt *q "tau ,{llouaiue uaes ale siagi?q an;aa f,.luuor*1nd aaql aq}Jo oAU
',ffio1oqltd qtt,/tr pssnJusi ?oil s;u $ax{il:}s aseql
{VVfi aBepuuddr lslrtn g'}l arp1".:a3ur1 oql'dlluuotsursp si li 'poo8 {11euor;darxa sr a$ad;t uaq*r
'3uo8 3rltr ox "r$lratrsod flaprp*urur pauolllsod sl v'I aql ier43 lue$otl$l 'ftlpnb

:I u3J,dyHf,
i'.lolJ}/F{Ii{vxa SlHdldusCItox\l3sH}3 TvHoi$Na}i${-fifie} aHI
 l: I'iiiir |fl11. 1:.i itli'i
ee{uraiely trased to }rield the mitral valve area tsee Chapter
9). lrlormally, tlte leafiets will appeaL thin and unrestrictd,
opening to thei-r'full excursion dr"rring diastole. The points on
the r*itral annulus where the anterior and posterior leafiets
ffeei ars the commissttres of the valve . The csmniis*ures
are classified coresponding to the papillary museles: th*
,anterolateral conrmissure of the mitral valve appears to the
right of the image while the posreramedial con:missure
appears ro the left.
The RV is seer &s a crescent-shaped cavity ar:terior to the
LV; the regic*s of the RV seen from this view include the
bpsal, antet'ior, lateral and int-eri*r rvalls. Seitisns of the
tricuspid valve and irs suppofiing apparahrs appear ia $e lelt
of the image and postrerior ts ths RV Whet the righl heart is
dilated, the tricuspld valve mav be transected in full so that
all three leaflets are visualised" In ihir instance. the tricuspid
leaffets produce a round*edge, triangular shape in diast*le: the
anterior leaflet app*ars to the left, the septal leaflet *ppears to
the right and the posterior leaffet is seen posteriorly. _,
, PSAJ( of the LV - Papillary Muscle Level
From iiris r.ies,* the LV appears in the nritJdle of the im*ge with
the papillary nruscles pmjecting into the LV cavityi a portion
of the RY appear$ ts ttre tap lefi *f tlre image {Fig. 2. t6).
The LV, which is transected at the level of the papillary
muscles, appsars eir*ular in shape, At this level, the mid
segmonts of the IVS, anterior. lateral and inferior walls can
he visualisq*. During s-Ystole, as the l-V conlract$$ ths IV$
.ji!i!.ir1
Etalri reil
F, , : i iil.. tl-rlt irlage shour:; iiir: riij;:rrai c"tt,liac
str,Jcilr:es s€3t iroill ii-i+ r-lalas'.€,-lai shSit J:(is visnr al th* l+vel
,; ii'ie rnli!;l! ,ralr?: if-:e ililli.ril-) iai"i+i'r\.1ii{: il!i,:si.t:i+5 il-i* :l+aitf
ir.iraili!i;.rf: ;f-lii 5:iLj{;li-irrl:i iri:r{jiI liae iar-i i'lt ii;iii:*; L.iei;,lir.
E:Trvl ,,' ect(}i'tal il:it.,Qi veiv+ iou:ini; t,ir-..i .. vci:ii+fili ri-irit:! v3i:,'*
h:aJl..-I. EV = rraji!i!":)ririiji,ji;:r r;rr,il';i. i"V ='lirr:l::,F:jii 'r.live
D-,
\tf (l-iil\'i[,-\S](]N:i L{ ll{r{ .'\ir't)ii )(ili rti}i ii{ i ". ""
and other walls thicken and the LV eavity conci:rttric*111'
decreases in siee. Duriug diastole, the ventricle relaxes
aud the ventricular cavity expands. Systolic futiction and
regional abnormalities can be determined by obser:'ation of
each ofthese $egments.
The papillary muscles are displayed a$ nsar equal-sized.
rounded structures along the laterzl a*d medial aspects rri
the LV cavity. There are normally two papillary msscles:
the anteroiatsrai {AL) papillary muscie has a single body
rvhieh difurcates into rwo heads and the posteromedial {PMi
papillary muscle usually hat t$,o b*dies aftd trifkrcates
into three ireadr. The position of lhese muscles is va{able;
typically the AL papillary muscle is seen fo the right cf the
image betrueeu 3 and 5 o'clock and the PM papillary rnr"rsple
ia displayecl to the left of the inrage between 7 *nrl 9 o'ct*'ck.
The Rv- is seen as a creseenl-shaped cavity anterioq-and
medial to the LV; the ragions of the RY seen frorn this vierv
include the mid anterior, nrid lateral and mid inferior rvalls. '
{i tmaging Tips; P$AX ri{ l-V
An ci';i:i - or erg-*ha;:ed LV c*\rity ;ii*irai**t ihs: tire " erirr:i+
is tralsected oiiliqr-iei.v afio irot iii ti$ irue shot .}.,4;. i-;r,s
oflen resuits fr<lm the nrobe i:eing positicrec ioc lcl& rn lr+
-[]ier"tfor*,
ri-reai 'wail. i:y noving the i;roi:* a.r, rriq;ai);-:l.
spaee highei an on-axis PS,a.t nan ofterr be eclr*'.ier.'.
F rr.,: . : :, .,,! Tire 1;.t,; irracle sir.:u,rs ihe ,t.rri;1i a,:-iai .ta
slruL-lilti,i5 seen froifi iitn paragler:]al Sl ')'-.t a) iS '. r+r i,,: lire irfi
vefiii'icie {LVi at ihe ier'*! cf the papillar'.! fiiusci€s: il:e r'oilsrrr
*a-i:riT'raiiiC !iiilsta:tie$ ih'J irtjaii..il iia,eni'aiti.rJl :l'lr::i !:,iri-aij':3 suiil
5";ri llxt fJi iLraiir*t tJaiii:iis
a i - ante.Clattrill FaFlii3!'y t'rr,;5,ij€. LV - !ei! r€riai:r'rr-:r;l -a.ii-
[j-lii :]rjij::iarD{'ll,';tfiri l:ltciiiu;,!iilligcl!:r.3V=riilh::r:rri'rLitiar rr ",
 1f,Ebtrilq&
:t .i:1lIrl, \ll '.\i!i1il lir:rl :rr lrl'1 llll!l i rli ir:llr .lillrl i.iliilr.l :l ':rl-1.. :1-: :- i '- 'r- :;- 'i l rilflor r! Eo.fu, nod pcfiild tJo tdsF {f tE"}

dllansn r{rrlliA 'A'l aqtr Jo iulll u{,qt pairtrr-rsoqurl {lst1s!^qo

alolr; sresddr tuntp:s3offfi Ats aql 'arouueqlJfiJ A'] ?p,1o
rcqI uEtF u€+q ot{l }o a$eq aql o} Jesol} pamol dlpuxau st 'ille1+p l!:LlL1ill ;'li lX'31 '}tg 'il3il$ 'liilill;')iiilg irl'iil ii'!1?'ir'::'' i
xede rq6 eq1 'slxe {uoqe; ,Iolllff s pur slxu {Suc1} ;ol*u: e .!ii1)gt Erir 3e;ii.:l:.rjii ]!:trl!;q:)t rr.iiill:1i-i ili"lj lx'}iJ:.' i.^"1; li:a::lli rliiir,
l.!;ll 4!jl ilj i;r!;r; Eiil ia,',:l!r/-. ar,/r ,.uLi;. l1-t':':l'i'-'4";-,= ' ''r1i;r;;-e
sEq ssp AU aq; '711 lqi JsJ su :A,t aql Js errs 3I{} Jl€tl-sua
si},j!"i;l]1,].j;!iElp,!?;iEili,:fr:l#*jg.fli.j.$i;i}i-:iur;i.:i.:q;.'<
lnoqt .{lar: B W1tt oderJs ut .ie1nBuu1'r1 s:esdda AU *tll"
'uutq aql 1t xe{t uxp turro5 xa{e l{\ et}
priB u*3s oJs aql J0 llEie prslslolslw pu€ sAI Jillrsj{Ir
dl
arlt 'aaa1n stql rrtsJd 'i;.,1 xed€ p*radq B qll.rtl {stxa r:*qs}
roi:lt.l $ll urq; .re8u*1 sI ltq1 sixs (Suol) r*put 3 $eq A-J 3q1
lsill qins prosdlll* :p1o;d palmfin:i r: s'e srusdds n"I ll4J
':ruadds plnoqs Blrru til$q pu' .alpulse^ t{toq Js *,iX;-:r-;
5l f, 'Bl'Z "8lJ) srequuqe cBrprEJ inoJ 1".!: Jo uoriesrlunsr^
$^{slle A\ar^ J*{lttttrlc-p pcrde aq} 's}taBBts stuuu aql sY
rtJn}md
sa.fi aiesddv +I{de"*s*lFJssaqaS +

l"{uroN pue p€$llBnslA 6€Jn}3ru}s ufl {+ ri.iog

+
ro$rluv
'{fl
'g l'I
'Srg) -ropas *qtrlo t++l sqt oi mes nX pil€ yU **
aqt sE qcns $aJrutrus papts-lqfir-r slulAr Jslras *ql {o tqBp aqt
o1 u*es aJB Al pus v"I aql se qrns :3"lfil3rLlls p3pls-Usi :Jsic$s
aq} J* i$o3loq aql lE usss ale sllt? ttli 5e q$fl6 s+lfitrsnils
;ouadn$ pus rorla$ aql;io do1 aql it rrsddu salslJl*aA qloq
3o seerde TETFJBJ eql sB qtns selnlsnlls lollaJut 13q1 $s
p:iuluarJo ars a8eu:t "tslles eqtr o1 sdlqsucrirls: tILuo;BUV
uortBtu*Fo a6eurl puE lotratss
's!-Iw ?tf 8urPry*ur
';seq sql o; xadu sql uorJ ilesq 3ql llesueJl ol pslutl;{)
sl $Baq aW trqt os pueq s.1ua11ed $q] spr€,llc,tr ,(1;otradns
pat:alp sr rruoq punosu$ln aqJ '{E ry V 'El'Z 'Sr3) ryto1*.o
g,{laruurrxa:dde o1 p4e1*"i sl NOri cql pue uat8e; u11txu-ptur
eql ur aeecls lrlsslJalut qUS aq; psns;u ro as;ndrnt leurtx?iu
eqt 3o &rurcrA slrrps*ltur ?ril ut .io 1t parr;d sr *qo:d aq;
uollelusHo puE $o;lfsod sq*Jd
nfia! rsqueqS-t Imldv A"I 3t{1 o} lotJ?}uB
:e6uo; nu sr puu aBaurr aqlJo Sal aql otr s*edda 'psstlenstn
'surdns luariud aql {1ll,tt peiduraile aq ptnoqs uotltstnbse 3r 'xsde AX aqJ'^latA sltll tllo{ usas sq plnoqs 'xade 45 aql
*Surur 'uorlrsod stl1rqffiap lere1rrl ? ur luoued fi{l i{tlrlt a;tnbat yo luatuB*s LEIITs EJo uottdacxe *lqtssod ti"F qlt,rA 'serlucn-ljs
ot iln;stp are saBeut luoldu3l ".B1ncrilud tt1 'uorlrsod aurdns asrprso iaqlo ou '1orra1 lcs::oe aql ulo{ pu*erut uaq111
'salillswrouqE iuuor6er puB Eorl3trn*
e ut ifiet]ud 3q] Llll^\ pa:1nbre eq osl? ,{eu sa3eu,t ltrtdt
'dlleuarsr:og '{Eutuuecs papust{-gsl ra; d11uro*d*a} *xela strlt ar;o1s,{s roJ p*ssesffi pue paslltnsl^ aq ue} qle^t iolleJut pue
nSAl aqi
uro# peaq aqtr fururuext ur lerrgouaq ,{1trua.rlxa st 4r\opurr* Jurelul ';or.rs1us Jo s]*slilSes lerrdu J*^el stql tV
'a1o1sds Sulrnp ;auurru stJrilaluor
]no-tri) B set{ tsqi psq V'pseq s.lusrlud aql c^oqe papualxe
urBusl osJ€ plnoqs tnre iJai e{J 'ogd o1 gg dlaleutxo.:dde e ut 'a1u;a1r1qs lou lnq 'qslututtp plnoqs azts ,.ttnsa stql
'tf t'e 'EtS) ,&1aer aa.t;-ot{}e uu q}l/tr alnlcnrls papuilor
3o ol8uv up tE ;prs #ol llttl uo surer:sr 1u*tied aq1
'll€uls e se a8eut ;qtr;o a;Iust aql ut sruadde 61 aq1
6u1uq1pod 1uaged ' uol1l sod ?ardu-urPd,, 31-ll sB 01 PalJsJ3r
.,1

'srlrata petde slurrlruios sr uorysod aqo:d srql '.rearo1 s*ce.ds leisosJeiul

o&rt lo suo Frrrr lllllulrls oqi uro+ {,tuarre) .{11ua1u1 aqc.rd aqt
aqil uro{ p}t3e1ap aq ,{eur treg ssltllusuouqe eqtr slst; ;a}deqo
uorlrsoda"i ctr dressorau usso sl ]l 'mat.t sltl] ululqo ol JapJo
silit-lo pus aql tt 9'e alq?I:moJaq psquisep oJ?,\{?l:\ tlsei sl{f
ul 'r\\3rA srxB ,Jot{$ letrdu aql sB ur$ou{ osls st ,t'iol:\
uro.t3 pesrlen$ln ssJnt}n.r1s "il'Z *1qe1 aas) ,tretA XV'l s
pue *rrlsra r3qureq} o*r1 a '*ratl
{reqweqt-g) {t:qucql-g) |a^s1 ls?ldv - A1 aql lo x!ilsd
Jsqru?q3 3^s I {;aqrurl{3-t) J$qurEI{: JnOJ U ul
"raet.r 'r,o",r"n ,,
pr-rnbre ag utl il€sq eqt go ss$uurt ',uopul,!t ;astde ryl uo.r3
t*;rsnu fuelirded a$aqt Jo ttotlsiuauo puu uolltsod ar{f ilaas
eq .{rru AH aW Jo sslisnlu {.rr1pdud BaJt{l atg ',{;leuotsecc6

>y $ICIIrYNitAlVXS JI HdYE 30IgS V30H33 "l Y NS I SN:rpU{ -O,lil,I 3Hl r SE idVHJ
:
 ,=,,,,,,,,

-1{l {- i..l A]1'f LlR I : T l-i Ll'T lV*- f}l tult,li S I Oi.; A I _ F.{ i J{X.'.,\ lt Di {lC RnPII i {' i:.Y\ A! I t
\;.f i- i{ ) "\

appears relativsly sfiooth-w{lied hy eonrparison" }e
reoderet$r ba*d can usually be seen arising fi*rn the apiaal
third af th* IVS exte*ding across the Ry cavify to the RV
iateral {free) rvall.
- Bcth AV valves, along with their suhvalyular apparalus,
cart ba identified and asse$sed in this vierv. D*ring diastole,
'these leaflets operr wiihout restriction with their leafiet tips
p*intirg into their respective ventricles. During systole, the
AV valves coapl and lie ia a plane almost pcrpendicular to
the AV riug. Th* mitral leaflets can be seen *riginati,ng frorn
the l*& atri*r,entricular ring. The smaller pnrvl is sem arising
1
as$es$ment fbr defects ir: th* IAS shculd nol be carried
out using this view alone. The IVS is more muscular and
therefbre thicker than the IAS as the pressures within tlre
LV in particular, are rnuch higher than tlre pressures within
the atria. Ar a result, "drop-cut" arteftct is nct usually a
prabiem in the i*terrogatior: of the lYS.
Pulmo*ary venous drainage into the LA ca* alss be
appreciatrcl frorn this vie*,. The pulin*nary venous orifices
are, typfually locared at the posterolateral
{left pulmanary
veins) and posteromediel {right pulrnanary veins) aspects

frsrn the lateral border of the AV ring" The larger amvl
arises from thc medial aspecr of the AV ring ad.lacenr to rhe
iVS. Cordatr aftachm*nrs tiorn the mitral leaffets to ihe AL
papillary rnuscle may be appreeiated. The tricuspid leaflets
can Lre identi$ed originaring from the righi .4v ring with
the ptvl or atr I arising from the faterai border and ,t!re sepkt
tricuspid valve leaflet {*&l) *rising flrer:.r the medial rnargia.
Lea$ets of bothAV r,alves should appear thin ard mobile.
Imparta*tly, the stvi arises t'rom the AV ring slightly inferior
to the amvl. The portion of.seiturn located between the
septal tricuspid iea{Iet atrd the xnterior rnitral leaflets is
refered to as the AY $cpfum.
The IAS and iVS ca* be cle*r{y delineared in th*ir entirety
flem this view and when *t*axis, the plane ol tire septa
slrculd be vertical ro or parallel rvith the uftrasound heam.
As for the PSAX, *'drnp-cut'" artefa{t is commonly seen in
the region af the fossa ovalis. Due te this potenti*l pr*Lrlem,
cf the L.A eaviry'. Frcrn the apieal 4-chamber view, both the
right upper ar:d right iower pulmoi:ary veius may bi'seen
drairiing into the n:edial asper-:t of the L,{; however, the right
|ower pulm*nary vein {RLPV} is rypicalty sesn from ihe
standard 4-chamber tierv while rhe right upper pnlmonarv
vein {RUPV} is us*allv seen rvir}r more enterior titting. ?he
left *pper and iefl [*wer putmorary veins may also be seen
draining into the laleral aspecr of tke LA wir\ the LUPV
beinSi locat*d superior to the Lt.F\,,.
The descending thors{:ic aona app{:ars as a eircular, echo-
f'ree structure.along thb lateral margir of the Ln. ethe
circular shape of il,is'vessel *,ill differe*tiate it fromgthe
pulmonary veins" which are u$ually elcrtgsred and of a
smaller calibre.
Occa*ionalln the LAA may be $eelt &$ a fi*ger-like
prcje*lion at the tateral anrl inferior b*rder of the LA. Tirie
appendag* shonld be echo-&ee"
The apical 4-chamber view is also usefui fi.:r c*nfirming the

A.
w E?

j L*- .***.
qf
***d
-e,

"'t--#"'-"

LA
[r/i
l.L.irv
.. DA:
HLPV

F ,his figure shiws tha api,:a; 4-.ihar*ber viev; with respeci ta the prcbe position anci !-oialion crn the chest wail
iA}, the
imaging p!a*e throuqi] the hearl iBJ, an echccerdiffg.aphic irnase acqu;rsi-'i frcrn this rriew (C), and the $ector *riantation
and $truc:Lires
seen {}}. The red arrow on A and the res
'Jol *n ts indicate the proh}e o;'ienti*ticn marker. See text foi- fgrther deiaiis-
amvl = anierior fiit*l valve leailet; alvi = ante*oi tricus;:id valve leaflet; $A = Clescending a.lfia; LA lefl airiun:; LLpV left lower puli-nonary
= =
veinl i-V = jeft ventricie: F.JB = *todEratDr ba*rl; pmvl - p*sterior nriiral valve lea{lett EA right atrium; fiLpV righi lower pulmonary
= = veir,;
PiJ = righl venl!';fi*; stvi = s€ptal iri+uspici tratve leaflel.

k
 ,{6} equa
l*itr*rr +i.11 }$ }$ll**i r{:!rs}r'ra aq} pue {t} anlea F{dsn*!.4 aq}
ia labesl Fld+$ silt,irJ r{gr;ue4.*u pue'iS} L$fl}d8s rElrs$}ueAr*}ul
l+il.,, stll puB {fl} ujn#6s renxu}ilF4o1,*€ agl '{i} *:n$es leplera}$r
runuld eq1 ,{q filp*,ilaA paturq q xmD cslFJBs EUi 'rruB ceiprse
iilj.l l(} {}iilial Bi..il Lli i..ll}?i.l.ifi.l i}lll$Ll$ XOCIE /\-l SUi q
-i0!:,rli],i a$ ulrol l€ill selnlsnils su] sale4Bntl! Lugil4q eu uo $tlBilrsq?$
;l\ei^ joclu13i.ili*f i}rsldts plPp|jtls *u} stll sllwn xil$ cslpJBe eq; ic ,$sl^ ry4detfu1p;eroqsa psrrrsoe
uro.r; r{,it?rpaul a3?i *{io.rd ai"il *Ljii6u8 ,{i; palini-:*e -ti . e s1 do1 oul uo a6eul1 oql '$eau sql Ia .ariuac,, sui ul poierol
:r!1*eil pgsnssl-&t* ssois ro xru3 eElpJB3 srrl slqs&6!q atnEg s1q1 6l? aJnEH{
p+.llriLr*: *q
o$lE Csr-i.j {aredt ie;**rl+}l,rl aqi L}rq;1.\t uou} -;iciii*'l qij
e i0 as*s 6|ii u0 aqcrrJ e Lll lo ]LlaLUelurdl .rii'i>i':o-r-11i;.
arll f}r.rritt; Ltt g3i}i1}e.! &Q :-iu} o
:di-r*r..ri)l,,:? ,{11qfir1l *i:ii:.!,:l
,{1:oue;sr-rd ,;o} tla}lt} sl +q,:.rd aql uaij}.l $Jl'l}x\c t
;*6&!se *v sttl .!$ !+s Bur$drl3
eilldn-q uauro J$ .lsrj*+y: tuB,leC
aili Suruouie*dal ,{q ilu? js,l,{(ll Ea}Bds l3}*rJi.l*}tJl
B.iF.l ro i:i.it': *qoli:i aili f,utnr:ui dq p*l3t1raj il*}lt) lil *
,S.fi]trl UA nP XA4u ,1-1 tEl,irriri,!
aUtr le u{1;}}eriu{}i li"ii' I}u!3 x+d8 ,4, I :iSilii e '*Siilriiliif'\
pelesultls uErjl jsulEj paprinor irl Llar;rluopl sl * rtrt ltfilf
:Al aql +$ sirlL!€${}q€aJ$*
aqili* +Ll} firrllSue '{,q il*lilir.l-t
'd11srpau.r a-i*Llr lrei
aci uE3 elql$$l p+l[ir"it: sr aqo:d {il{i 'sA' i}lii
',(i;e-r+ir:i
r-i|i paJBdur0s preMllisu arou siBaddl] $vl sui ll .
d1}ela1e1 Qrolrr it€} eqold sqi Liultfiue Aq {:et}llro.t
*rl r.r€3 srq-L ,4lter$:+u.r *fri ii*ltltrP Sl eqrJid aLil 's^i
-!1 Utrlrn F€"r'e{:ulLqr irirts,^/,+lirl alc}u.r sjEti}t1i'E '!Yi aq} il $

:ieiiu+^ .teoridp plx{ll1s t.V1 Flitl i;,11 eu} ir::1r"1+''it'l$rp: eq1

ftrttih Jaquia'el*-g 1e*1dy isdt5 Strl$clul '

'et\;E^ prliE!"i.:)!.]i': :3i']}l.rl1lilr.:

^)
iilf.it: * ,16 :i.i-ini.lrF ii]$i-i = 'd* :ai]rjirjaA +*l = i-i irr:r:t}t; ga1 = p,1
'niie]?iJ j.-:t.iurli J.'r.t
l{ts] ;)*$ 'i j+ia: -t;ijiall:,lj1s
iii.t{; uoiiejLie!.i(] .}fii:l€s sLll saiEJisn!it }tieire!4:l:r {"t]*1tili; ou}
:Sirrlyi ,aualscti !..irr/a .,\ern J+qlr-itsLjl:-i: te*rCe aqi ii.i*.r! utas si:
iSSi si-,1;-. Iue*oiol aiii si,l.*i;s a$eur C<;: ai.{i r-:;1 ,,; ": 4
'slagBal JorJ4sod pus Fldos eql aJs s?ss flF?$n slcui?al
prdsil}rrl $&u aqt ',ltera pas*cc3-AH tql $oJS '{6 regdeq3
pcs) lxropur^{ lffitdq aW u.ro+ p*uua}3d s}uauJpjns?sir.! AU
sfiouc.it JOJ pasll$n st ,$eln slql'sriqtr PUE IIs*1 i?Jelcl AU sqfJo
3u$aut su{i {if'g 'Btg} p*xnb*B eq
ps,rsJd{.ur saprAs.Id altsrA
il€3 ]1tlel^ pasnJoJ-AH us t{llBrpail) areS aqo:d sqt EurlguB {8
"(OZ'; 'Etf) VJ 31i1 ol rolr?l$od e^oo€
Av srli rir 6rnl3rJ3s eryl-lauuatr 3 se slsadds snurs dj8$oroc
-rnrialrS
srll 'p?sll8nsr^ ueqi& '\rT ?ql olul aurulelp p5$lls$sl^ sq
{eru snurs ,{leuo.rol aq1 {pou*1sod p*ill} sr aqo:d sr{t uar{rq1
uxt t.t8!U 'pasllrlspr ,{;lsz* osJe arB selsiJllls
icuoiul 0q1 's3^lE^ Av uol pue lqBrr aql Bui{Jnuapt fllaeuar ,{q
,eroJarei{l '61 rrSoloqd;oru aql ol $pesl s{e,r*;e
&$l oql
pu? AU sr8oloqdrour aql ot speol sds,tile Al eq] a?urs
sellrrtua^ gel pu€ }t{EF eqll0 Eollcis$uapr 3i{1 roJ Irsl,upuEt
$ll*rolBu? tuBUodu$ 18 aprAoJd fl?ss3l s,ii$ €s3tlt ro3 slutod
uoluasur eql 'J?ln3u:ed u; ^yrur 3+1 Js lulod u*Iilssul eql
qt1,,*. pamduo, l^!s 3q1 J0 usrilsstu rolJaJur a^lorn egl ,{q
pssuetc€reqr 5r xruJ rrrprBt l?rzuou aqJ'{61'f 'Brg} rrrqdas
Ay eql (S) pur SVI aril go uotpod rop*Jul Jo rrnnJud eqt
it) 'Snt l$lur orlt (g) 'prue arir {Z} ';a6 aq1 {1} :sa:qrnns
srurolBn€ ang ,tq p"lruoJ sr xru3 slqJ xru? t3lpr83 aw se o1
psrrsJar sr lisrqrA ,reaq 3ql urqlF{! {rollBlnSgloc stlt-ssoJ3
B ruoj saAIE,l prdsncul pnB l€Ilrru sql J$ slsfi?sl 3^R3€dsel
eql ilj? sldas lBlml4ue^ pil" Puts uoo,tusq liorysurf sqJ.
"wsdrqsuo[ulal }luol?us
'sslsrrlu?/1 or.il Pus Et$e sql uasd\]eq

LI rr{Jl l\:!ill.til.'.'",.l ')llldt}11)L}ifi}l\i.ii"}H lC'l\i|!{.'tiii\itl'x.tril-{1,,1i\.1- li-i"L ,r t11i.1 ,1 l'11 .1

Ullcl-

1ti {' i,,4 PT l-. f{ 1 : l'l-l E -l-\\,' {}- il l t'"

1 F. ir; S I {-tr",- A i tr{'l iOC '\f{ i}l t,}{i f--\irl Ii t, I r )". \', I 1'..,

Structures Vi*ualised and Hormal

Siffgn0$tic ?ips Echoc*rdiographic Appe*rances
!n additiori to the $tructures idenaified in ihe apical
Ctier*cierist;c teai*res which l-relp cii{'ferertiate the 4-chamber vie\&', the LVOI praximal
ascending ao$a and
rnorchciocic itV frr:r:r ihe morphologic LV rnclude the aortic valve leaflets ars also visualised (Fig. 2.22i. The
rnoiJ€lai*r i..iiruj. the coarser irah*culaiio:rs r:f th* RV
LVOT is bouaded medially hy the IVS and lateratty by the
eridocardiunr and tile more inferior insenioft point of the
septn! iricxspiC vaive l*afiet istvll comparsd wiih the anrr.i. Tlre LYOT should appear widely patent througlrout
irilerl-r$l: {}f ihe anierior r*ilral vaiv* ieaflei (atrlvi!. thg cardiac eycle" Two of the tlrree asrtic !:alve cusps are
see$. The cusps vizualised vary,, but typically. it is the LCC
and RCC that are seen.
The LCA rnqy $offetimes be idenlified arising tiom the"asrla
lo ths ilght of tlre image as it passes along the left,4.V groove.
In scme individuals it is possibk to ti:lt the probe ett€n
m&rf anteriorly from the apical S-chamber vier.v t* inrage
the RVOT {Fig, ?.23). This view is particularly Lrsefiri in
instance$ rthere the RYOT arrd puirrronery valve cannot be
seeryfrom the parasternal viervs-

-iite
ailiC;lt 5-Cl3fiLtei.',.,e,0, S a t-i:$:t.t1€, ..i
.,rsi.,ltiis;:irti: ri iril i 1:a'l ;u i -i. ^ i-: r : ,arai_,
-<il!:. :i-* 3,,i r:,i il',r1 r,,p,ri ;1 =1;.l:ii:ii:-j: ':lj:;":.'li': n a : -:
: arrrr;,; :::1rj inil i,; i::14": :,, "ri: irl.i a rr::: ;ii:

tr:, ,,,,,. l.:. : Ti"i* i** ii:rag€ i:: iij* sisiiij.tr.-1 rjrjr,..l.i -l-!: .: .-:r
;lerr' v:hij€ ihe cottcr* ilr:3'3e r* ;hc Fir i+!-ii:iii-: -, I r -
c.rSrriiei ',:ie,.r'. $Lsei'i,e ili'i lire il\.."itil:-q+c i.i*:- l;rl-:-s:,i
illaqi.r! *{ illa ili/;;ii€ial v;allt a!:-:ri l{,:le lh:{ it'ra -ii :-.+:,r f*riir;
in iiie Cei'ii+ Lri ti-!i] s+{-rnr. iiris vieir; r:: ai-::ail:.,r.: l:r. ::- :rii; l: i -:
pr*ija taire ilre.j:allv il-i:iir t!-1+ -i.i:ir': jaiaj r*:',;ar: ':-:ri--:iti+ . -.,

S.pi*al 5-Cha*:b*r Visr.v

-i
ir* lr1',ir:r:! :.-cii;:r'riirri ;'i.',r" ,q r i:+tiili,:utior'! r,l' ilt.' *1,-ii:r:i
{-rl:l:i:L--ci'r ier",. iirrrclitt"e. iltt llriihc ir.i}iiiii,'!i tliii ai}i.1ii,.rii
ir t!l* sarlc :i:; ii:u ai:ii:;ii .!-ti:+n;hci' r i"-rt Titr: rli-,ir::i!
-r-r:h,ilrhci ri{t\ i: ;,itqri;r'ei} ili i:lnt*Iro{' Liiti;rc (.)l- ii:c pfttlit
ultiii ii-id i,i i-i']- i:*ri n!'(i:\li:"iir! lirii:niling :l$fi;i i:irrr r isr.illilril
l-l,r t-.ir;:.lr::iri iir!ri:?iti'il* a!arriLl ililtl lir* 1".\'{}l ii{}nstitiitf ill.-l
"i!liil" c::irnlher",

ts, :: : .. tr Ti,.e t*lj;iT.age$hawgAii;lpic;l ii-;:1,a:i:.,i_ra:..,i.:. .;:::

:lttlafi] sait€rititiia lllilritIaiL's ilo s*cLci{jlrarilatiLrit .tira :-:r.r':t.tijia:
f lic tcl*r' iili*rii;'.tilrit it;r tlt* l1.,ii:l! 5-cl-tt;:rhr:r' r ie .,i ts ilt,"" $e€!i Tl)ii: vie'# i6 obtarirloli i::y tiiiinq ihe prc,ls ar:eirar, rrcru iitr-i
sililtc ir-! rhr: api;*i J-;li*iiil-"'er'." ii:\\'iiii:.. Llli, l-lr'- [-.\ii]'I'ri ai:real .:i-chi,.iiibei vievu' Ses ter:i {or lua(n*a deiaiis.
sr-*ri :,rl ihi: ,;'di:t]a' i:i1'fh* iui.rgc ir ith t.!re lrroxit:rai ascftliiitl! Ac = i.lsc+lrding;rcl't.ai. LA = iefl atriilir: i,V -, ieii,",:r:irrcle:
Ir* r1:r ail ;:,:iili irt-,1 i,o r a; t ittt i-.\,' (i'i-. FA =, riqhl atriufn, EUPV . ri-Cj;i Lrpp+r ili;irICt-.-.r I ,,:i I
"uptl iiv .. riqirt veriri.ii

Er'
 isiloc Sutpu+ese lerutx*;d
xli;rrs aq? )JF4 plrt JIH filil
lor:1s^1
t.o,&X eq! Ats rofitstuE aql pllI*tl! '$al^ $iq; iri$'I.I
u3e$ s3$lr3n"ils aqtr '6rsJar+qr '{c ;p } '}r'r '31.1} 11 a{{l ;o
x*de art:i eg s€ ll3*r sa AT aql Jo XY'1d ,gl Js;i paqffissp
3soq3 llB spnlrul /ilalA xv'IdY 3qt ul pesll€n$^ sBrnlf,ruIs
sasusleaddY qqds'lsotpjesoq1I
Ieulroll pu€ pssllEftslA 3arnl3nIl$
'affuuu eqt3a lqgF eql si s'Ieadde eJio* €q} pua'sfferut
aql Jo $q uroltroq aqt lu *eadd* Y-I aql 'a3sull stp Jo Sal
dol aW $ s;eeddr aql '?ruaH'{0 'pf'I '$rg) a8eut aqt
Al
a8eml aql
'Eu0ll3ssslp 5liroE30 lUSLrtSSOssB sLltr ul lrussn Jo g*{ st{} o} uoas ;.rs s*Jn1rruis .tcpalmd a1tq,u
;o lrpp sqt sl uaes aJE s?trltr)R.tl; rolJsiuv:a?erur aq13o lqftr
,{pr1ns:ped st 'struet}sd Alilss rr1 6lqBA$iq}E 1ou r$nor61t
oloilsq +qt FFJe&I!; ussg ale ss;nls{Ll1s:ouadns altqa* aBeutt
'ir1sr^ slrlJ 'aa{-oq}t pur ais{r 3tlpJco 31i} trnoq6noJql
'igf"Z 'StU) ol.li Jo Xirl dot nql spru/trol .readde sorllls!'!.rls lolJaJut lsqt os
,iuaxed dlapq,.rr eq plnoqs losseA s!i11Jo usulel ;q3.
psletrilerlo ars aBsrut totrr*s sql o1 sdlqsuotlula;t cttucluuy
usrlsloJ asi.n{ro11{1ur puu uoJtalnfiur lttpau 1q8tls q1t*t
sll olus 1no pauedo uoltEtuoHo a6uul puE rotses
A1.lo1.l*lsod *qo.rd aqi 8u111p ,tq stxu ffuo1
og $sle us; aqL'Y"1 *q; o1 .rouatrsod
El.Ios Srttpu*rs*p
piiBJs sqt ot slx€ lJotls sl! uI ssas 5l aFoB il3eloql {ierepl .ro,(1;e1p*ul aq*:d aqSo peLl}€Aour ro
"stl,oqt '^\erA raqrrruqc-Z lrctde stxe-uo u? tuoJd 7pw u*qe1*3tffi Flp*{r $} l$r31€l lL{AlIs ffi qans }iirnh'* eq
Eurpuaosap
"eo+-otll* aq finoqs pua ,{1:ouaiur slurod }y1 sq} :V'l
{ew s}uaff}snfp* rou;1n1 {S ry V't['f '3lg] uoplsod Isole.o
oglJo lsploq ,lqBlr, eql 3u uotsue$a_*4t1-.ra3ug erce s;eadde
ql eql d1e1*urrxo.:ddr t* qsloE lsurstsEjdns s.luailud eql
pre^&ot potqod sl F{Od aq1 'snql :/rral^ roquleqc-7 pctd* aql
vy'l aq.} 'usps u6rll1r1 '*r.E-oqra r?edde plnoqs {lirur YI aql
'SuP AV eW ol .rqnerpuadr*d rub4 asrru4rot?lilly ?06 eqo:d *rp *utgttor r(q uoqrrad_;ucrde
aqt lxs+ p*;tnbae *t .ttat,r {XVfaV} s1re 3uo1 $crdu aqa
sunld e ur aI! par trdeor slegxal l€&til: +ql '*;op,{s $uung
'n-l aql orul Bullltlod sdrl logeal eql qlr,*l uoillrrisel ustlelua$o p$E uollso$ *qord
tnaqllll uada pproqs slegsel lulllru sql'aJotrsutp f;u1:ng ,,rq 6lxu $uo1 le3ldv
'slrqoul puu u,t{t :esdde plnoqs $l}ge*J 3&lBA 1Erltrl ot{J
?aq*oq:* Jsadda plnoqs d1r*,*o 7g eq; 'spuedxe
gq;ng ir3irustu saF r{Jeuou|fld = Ad :dla$* irpuouqnd
,t11aue 41 eql pue saxEsJ A'1 aql 'a1o1s*tp ulgril = ygy{ :qou$*A l+ai = A-t 'sl!Pl?p ral*tn, Jti ixal ee$ 'dtAEA
ai;lila*1lo3 s ut a?!s ilt sassaJslp dtltm 61 6ql pue u313lq1 i6qureiJl-* leqde arg uo-4 ,tpcpalue a.mr'u $u$!l {q peugiqo s!
slls/i\ l\T aql 'str?u.Buo, ffi 3ql su 'e1o;s,{s 3uun6 'xl3;s el? nAsr^ sqi 'us6s $alnl3ruF puE usllEluele .$}3e* aql Esls4snll!
olle[rarlss ruo]]oq aq] :slopulrl l$srde ar4 r-iror1uees ss &oAH] reerl
Al atil Jo slls,4A rolJaJur ?rul aq] puB JollaluB onJl aLiI A{3lA liAcljlno relnrutruaa lq0p €r.11 srrtot{s aSsLUl dol aql Ea'e o;n6g<1
srql m dlruupodul 't$Z'l "Brj) a;lou ?lsrlot{l Sutpue*sap aql
pu€ w.I 3ql '$*Beel 3,4i8,{ lB.Blu Llloq 'vl A'l eqt spnl}ul
uaas ,tlauqnol alg l*ql $;JlBeffls *?tpJeo sql that^, slql ut
sas$Br*addY s$dEifi qpjesoq*3
|etujoN puE pasllens!* *elnliluls
'(EZ'Z'Et$ eEvtur aqtjo UBI eql oluaas ore sornlcnrls
:or"relsod algqx a8utul eq13o 1q$r.r eql $lu$ss ole salnpnrs
J$ualuf ieBtmt €ql Jc luoltroq *91 i3 Eaes sJB ssJnlsnJls
;or:Bdns alrqa a3emt aqi gio dot aqi 1u readdc ssrruJruls
sqedn$
rorrs]ul 'aJoJsJ3qI /\\ar^ NVIdY elfi sE auEs otll AllEtluesss
+
sr fiern Jlqffisqs-I leordt aqi JoJ uoltru1ualJo Jolsas Bi1l Uai {-+-} }qD!U

uo$BluCIlrsl aEeurl pue Jolses t

'srlrsl^ xY'Idv pus reqrilEqs-p 1uc1dr aql u33Jttlaq

ersq/rleuos sar; aueld Hur3eErr slqt 'aroSaraql '^tel^ xvJdY
eqt rxs:3 ast*qaolt ogy {lelemrxcrdde eqold aq} Er!€1or
dq pertnbte st r$etA JsquIEqs-Z lerrdr eq1 '&arlr XY'IdY
'3qt se sulEs aql 5I uoltrlsod aqo:d etl '3ro}3ret{i '.4{talA
Xv'ldv "rlt Jo uolt€aglpo&r E sl A{3rA J?quuq3-Z 1e*lde aql
pue
uollsluelio sqorduc!*fsod
,$aa raqtrler{3-a |so$v
n1 oqr;o xade
an:l aql pss s&Bts drr$oroe sql'EuoB rrt€Joql ffmpuarsap
?ql "&lA€t 4"1 6tfi 'lle^l AT {iura1r1o;e3ur} "roualsod 6q} 'SAI
roualuB J,OA'I erl} 'lnurd puE IAilrB ?Lll 'Y-I Jg} 'a^lB^
"1{i a

-i i- \ilil-i'i\i1&i \rl ..iiii.1\'iii-:)ili{i}j\,,-lrliil.f iY'li{liljl'r:lixl{l-i}1"1.r1 ii.: i; ?j :, 1.(:'Y:i )

 {ll }AP'|LR l: 'Ill L- 'f !VO-l}lN,l ilNSlONAL flC}l{]atA
tillt{.lC R \ t,ii tr

B.

\
$

ancirctarian on rh* chesi walr(A). iheimrsrils

XI:ffiA$X".,':f.ff;::f-:ili#I^y::::n-::':f:^,,::o.,1?:;ftron
[T:.f ,xffi *:f::: i?] *..?ji::'ff':fl*?:",r:::::,,:.:r::*;:+{fi;;j#1J"',}},:x;il;N;$l$;fJili-fii
*:,iy *:fj*ff
amvl = anterior rnitral *.:^,?:_:ot-c,n
E,,icrir:aie,
valve ieaflet.Ao = asiiendins".;l;;
aort;i
;;;;C.,,',.i,0..'s"Ii#J il;lruffi ;
#;d*'Lf: ffi;;#ffi:';ffi"]'po*urio,
ilce = non-Soronary cu$p; rec = right coronary cuspi ffi f =
= right ventricle.
rnitrar vatue reafler;

I art!:ia r

C,iaraaili

) fi;riri ;.:i:'fhe iop ,lnage shov,,.S an apiaal Z_cira*"rber,:iewt ihe
botLoin schenlfltic illustrates the seclor crietiiation and
structur-es
seen. This vier,v is ohtaioed by rotating spproximately 4S.1clo<;krarise
from the apisal ,ong axis uisun. Sse text fnr turther dltails.
ainvi ; anlerior nriirai valve leaflet; DA descending
=, th€racic aorto;
rA = leit airrum; LV: ieit veilfrlfi*; priri = pasterir-,r miirsl vaiie ieaiiel.
FFri;.:ir, .,j,2* The top intage shcws a rnccliiied apical 2_e ilarnber
'iiew and ihe tang a.xis of the descending aofi* ('DA)j the boltorn
schemetic iliustrates th€ $ectcr 6rieniatlcn anO sli,uCtUreS
Seen.
arnvl- a..tterior rnitrai \ralve ieailet; LA = left atrium; LAA _ igil s11;s1
appendace: LV = leit ventricle; pmvl posterior milrai vaive
= leailet.

L,*-
 til a'i i.4 P'ii::lt r, -l-l-
L I t\'{J-i i} t" I frNSi iir:
i
",\ I i:{. !i(,'i'.\:t;)iijl,,i.ii,iii{. i .. i\:r.. .

l
EI

*Figure z'tf rhis fig*rre shaws the *ub*oet*! 4'chember view with rsspecl
to the probe pcsitian and rotation an lhe sher
imaging plane ihrough the fteart.(s), aft eehoca'diogrrpr,uc inr*g*
seen {D}' The red arrow on A and the red dot on B iioicate
*"quiG n6* ir1io* view ic), and ihe sector o*sntation e
tne frreue ori*ntatto., malte;'si!iltio,i.,it"h#;l5*
elrrivl 5 anierior iT?ilral vafve
ieatfl; = anlerisr tricuspid vaive leailet; rns = nGrat*al sepfum; LA = left atriurr! LV
$i
pmvi = posterior rnikal valve leaflet; HA * rigni =
atrium; RV = righi ve*ricie; stvl * ssptat tric.Jspid valve leaflet.

'- ,,.:
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 -5:i CH.{PTER z: T?lE TWO-DIMENSIONAL ECHocARprocRApf.IIC ExAMlxAr
SubSAX of the LV
Fram the Sub$AX various levels
sf rhe LV ,#
displayed; these iaclude the LV apex, tfte LV at the level of
the papitlary muscfes and the LV at the level of the mihal
valve. The LV *pex can fue identifled by angling &e probe
to the patient's left s* that the scan plale ip directed toward
the patient's left shaulder. Frsm this view, the LV appears as
a small rounded EtrucnJre witfu a sruall echo-free cavitSr"
The LY at the lev€l cf the papillary muscles is acquired by
sweeping the probe &orrl tke LV apex towards the patie*tis
midline. At this let'el, the anterolateral papiltary rnuscle is
Feen at about 6 o'clock while the posteromedial papillary
muscle is seen at aboui I I o'clock {fig. 2.3?).
The LV at ths level of the mifral valve is acquired by
sweeping the probe from the papillary muscte level rowards
ilte pati*nt's midline- Tha ruitral valve leaffets are vi$alised
in the eentre of the LV cavity wlth ihe an:vl appearing to
the top and right of the iuage white &e pmvi apjiears ta the
bqftom ard left of the image (Fig. 2.33).
:
Sub*AX of the BVOT dnd AV
This visw is obtained by sweeping rhe probe from the
patieat's rridline coward rhe right mid-elaviculas line.
This view is sirnilar to the pSAX view at the level of the aark
and I-A; Irence, all $tfirsktre$ visualised from thi* view ran
also be appreciated fram the SubSAX vi*w ar this level (Fig.
?.34). From the $ubSAX vierv, the RVCIT, pulmo**ry valve
lsaftets and MPA appear ts rhe rig&t of the image. The RVOT
) i:;3r;,: -lhe
:..::? tcp ifiage shr:ws th* lett ventricle (L\4 at the
ievel oi the papiliaty muscles as seen fronr a subcosiai short axis
i,ie,.!.,: the boitom schemat!c illus.tratas the sector one*tation and
slfuriures seeil.
3-i = ariis...]iaterai papiiiary muscle; p-rn * pcsieromeorai
paoiliary muscie; FIV = righl ve*irrcje.
,r,'d,
and h4FA should remain widely patenr rlroughout rle cariiia;
cycle. The puk*onary valve ieafiets should appsar thin and
b"
mobile, oper:ing duricg systole and closing with diastele.
Oecasi*nally, the bifurcatiou of the puknanary aftery inro
right and feft branehes can be seen. Thc teft branch is seen
to the riglrt of the image and the right branch is seen to the
left of the image.
The TV is alsa imaged aad appears anterior to the RyOT
near tlre ce?rtre of the irnage. From this view, all three
ficuslid leaflets can sornsrimes be visualised. Moving
cldck*,,rise from 12 c"elock, they are the anterior teaflet.
septal leaflet and posterior leaflet. :;
Th* short axis of the aortic rost as well as the aortic valve
cusss appsar id'the centre of the image. ;
Portions af both left and right atria are seea to tlre left of
the image; dre afria ar* wparared by the L4$, whick appears
perpendicular to irhe ultrasound bearn.
S*hSAX cf the Sicavall/tew
This,view is abtai&ed by sweeping the probe fronr the
patie*t's rnidiine tsward the patient's right side ro tist the
scari plene is directed-rilward the
right mid-el*vicular re,sion.
From the bicaval view, both the ]*C and $VC ean befl*""n
draining iilts rhe RA (Fig. ?.35). The SVC is seen draining
into the supericr aspect of {he RA while the tVC drain*
ints the inlbrior aspect of the EA, The IAS liss betweea rhr
IVC and SVC: the R 4^ is anrericr tu rhe IAS while rhe LA is
posterior to the t.4S-
> i:t;i.r,',r :,:.:;::The tap irnage shows the mitral valve as see* irorr;
a subco$tal short axis vieur; the bottom schematic ilustrates the
sector orieniation alld Slructur€s s€en.
err'1\rl = anterlor mitral valve leaflet; pmyi
= posterior miirai value
ieaflet; fiV,= right ventric{e.
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 -q6 {-li{1t}fL:it l 'i Ilt T1\t} Dil'lEhlS{ONAL l:( }{iJ{',\ttt.}lixii{,:\i}l'ii{. l:\' \.r,ii'r \.1 :r ,'

Pattent Frsitioning
'For
suptarterna\ \wtag\ng, r\e patls$. ts tsup\$e. Til\E \is\r rs
oft*n facilitated by removal *f the pillow from behind the
patient's head or neck hyperextexsion over a pillow which is
placed behiud tlre patient's shoulders.

Suprasternal Long Axis View

Probe Fosition and Orientation
t'he prob,e is placed ir the suprasternat noteh with the POM
pci{rting roward fhe patient's letl supraclavieular fossa to
appraximatelv the I o'clock position {Fig" 2.39, A & B). The
prabe is tilted steepiy inferiorly and *ngled anteriorly so that
I: This iffaoe silc\us the ionq aris lif ti-:at ila(li]linal
.1r:'1n P.liUi r Ai)l the probe is almost parallel to ihe neck" $light rotatioas may
be reqr"rired t$ \,ieqr the long axis of the aortic arch.

$sctor and lmags Orientation

A.r'latomic relationships to the sectsr image are orjeffeted so
that supericr Etrucfures such as the head and neck vessels
appea,r af the top of qhe image while inferior structHes are
seen ,at the bottarn sf the image; anffi!:ior stfllctures such as
the ascending astt& are $ee* to rhe left of the imagd rvhile
p*srerior structrires such as the descending acrta are seen tc
the right of tl.re image {Fic. ?.39. S}.

\iil,ilr... i 1.,, 1 ;.;,1't....1, l i. t,.".r ;Li.: iir:iri;r,,cii iti l:i!tl'..

- i t .-t .; '. - iir. rir,i ,-,i- tlrtr r-liliiricl iist: tlt;
>Fig*te 9,38 Thi$ imege shows the iong axis sf the abdominai abnormalities that ma-!. tle dete*ed flsm this view. Tbe
aarta (Abdo Ao) and the origins of the cetiac trunk {6T} and asce*ding a*rta. er,$i{: arch a*d descending thorecic asrta
superior mesenteric a*ery {SMAi.
are besi er:al6*t*O tts* this view and produce a "candy-
qa&€" of, "q$ffiti$il mark" appearance. The ssesndiflg aor-tA
is oiten rirri *dr}l seen from this view in adults; hor.vrver,
nhen see* the *seending aerta should appear rvidely paterl
lrnaging Tips: $utrcostal \llews
maintaining a consist€nt calibre along its le*giir. Likewise,
F*r the **b*r*tel 4-*han:b+r siew; the aani* arcir and descending ao$a should alss appeer
g i, tir* RV arri 1y14;.ep!i1 .,ttinlrlLis :r.* .i:;_-s*ii siJ. liie widelS. pet*nt. The deseending aorta shoutd be see* to taper
l.'-.tle iS Lrsuailv iii;eg too pcsier ioril/ slightlS' as ir extends inferiorly. The lumen of this vessel
e r: iiie i-VCT is in vier,v. ihe probe is tilteci tno ai:{or',,_;r should be eeho't-ier. A charaeteristic systolic pulsation of
lf irnaE*s 6r+ diff icult t* ecq*ire frcrn th* subxiphoid this vessei is alsr norrnally app*rent.
pssition, try: Tlie rrigins cf the three head and neck vcesels may be seen
E iT:C.'ri:t ire ,:;Cli* icvrtrdE ine psiieiri't tiiji".'. i _:.e ; arising from the aortic arch. From a*teri*r to posterior,
-r"';r, rTlJrCjr.; +ld iileri anCle iili9 pl,.:i:.+ i;lr:+r l"lair these vessels are the braclriaeephallc {innomiaate) anery,
:i:, ;a :la':i-i+ :-14iiL'lI'* :i:it left ccmmon carotid artery anC left silbclavian artery" lt is
4 'r,;:.::ili,.:li:!- i:.t* i:Iiljttiil lii,: :: itt:t,- . :-::-: i.l,;i,:,i: j
important to note that lTrost coilmofily all three r,.essels do
not arise from the sanre imaging plane s* usually only 2
iV{i ser**'s abdenri:ifil a+rta: vessels are seen at any one time.
e A*i:;t Cl:,i-qiS rr- r:.,r.j.e .;-*..:..t a, =_ . - :. :'.: r]ililr4 The left brachiocephatic (inrcminate) vein cafi $ften be
i:i;);l:1.-.,; {-rii ii :1. ,'3;ii'(-ar ,'..i-, !i'-r1,1 +
--: .-:,_: _; seen superior fo ths sortic arcir as it courses hoiizontally
" ii,:'e a,-:i_ir':::j: i'ii:t;.i:i:;1,:- :: :tr j -:, ai;::J t$wards the $VC. Recognition of this vessel is irnportant
i( ". .'. .r :? 19: i,,':" 'cI: : : ,

* lvii ci;'l D-o ifii$i/;€ci:a.::l(:..i-- '.-s -. t" .-J+. ,:.-'. : iiA
as it carr solnetime$ be ecnfused with a* ao*ic di$secri$n
{Fig. 2.a0}" Dernonetrating that lhis vessel drairis into the
SVC rvitl confinr its idsnrity.
The RPA, irr i* shert axis, is $een posterior ro rhe ascendlng
aorta asd infefiar to the a*rtic arch,
Occasicnally. the LA can be identified inf-erior ro the RPA"
?he aortie valve a*d IVOT may aiso txcasitrrally he seerr
directiy inferi*r to ihe eo*endiog aorta.

re
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sl &aHe u€!&glgqn$ *sl oq$ ,*cl^ sll.ll lro4 uses aJE si66ss^ l.au pug peeq aarql aqtr,o o'14] 6luo ler.ll +ruasq0 '{d uees so,ln}3nlls puB
uoli4ilslro rolss eql pue '{3) }d\a! slq} urol} p64nhee e$euX r1qda6o1p;esoqra ue '{g} yeatl ee q$no;ql ar.rcld Sutfiet.lll aqt '{V} ;1e;tt }sqr
aql uo uorlelo: pue uagsad gqu*d erii ol loadto.l tlHlr uoJB ell;oe sUl Jo isgii slxe 6uq 1eurcpe;d*s 6u: si'rlelis a;nBg s1t1tr
=

()v csac
?4- , vd.H t v-l

d {ffik {)v 3sv

l8ue1$i

v:f!-l ++rqltfl4i
*L'e
t,)rr1!ad
vs

m
I

'€l

LE \l{.i}l\ \lt.!\'\li .liil,:!\''till(}li-ll:l 'i.X}i'i.},,i '!i'lriilrl:llri i(J"iil\.1 :lil"i. r;"iJ.-i i-ri'Yii )

T

ili (lH:\P]-LI?.I TllF l'Wt)-DlhiEi\StONAL ECHOC,{RDtOCRApt-ti{.- EX.AI\1llr,A]'ION

Struetures Vi*ualised artd Horrnal
Echocardiog raphic Appearances
While this vietv is nct routinely *urployed in the standard
2D examinat:ion of the adult patient" it may he very useful
in identifying pulmonary venous drainage int* the LA, in
detennining the sidedness of the aortie ar*h, ard to vielv
the pulrnoaary artery branch*s in patients rrhc have had a
LeCornpte rfianseuvre (pcrfarmed during an arterial sn itch
operatio*)"
.r Drainage cf all four pillmonary vein* into the LA is els*
referred to as the oocrabo' view (Fig. 2.a2). From this vie*,
tbe aartic *rch is trarsected in its shwt axis and the RPA
is seen in its long axis, coursing frorn right to left aersss
the image display and inferisr to the arch. The right
pulmonary t-rins appear to the lefl of the irnage with the
right upper vein superior to the right lower vein while the
left pulmoqary veins *ppear to the right af the image with
the lgft upper veir superior i,o the left lcwer veir.

B.

ffi
p.

F Fili;ra 2.'! 1 Thes* imafies stt+w ;he proile porition a$ci rot*tian cn ti1.j n*prasi*rRai n{:tch iA) sncl ihe ifile€iig piane thrnuph lhe heart (S}, a*
echocntdiographic intage acquirer:! lrom this view {C), and the sector orientetion an{i structur€s seen
{D}. Tne rerj arrow on A and the red dot on
8 ir;dicate the prob& crientaiion marker See lexi for fudher {:jeiai,s. AA * aodic arch: gpA right pulrnonary eriery; SVC SLlperior v efia cava,
= =

.ffi
T
ffi
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'
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'euos aql
Ltlr).iJ i.l-:ilr i;,l.ii'ii.lii.ili .!;1illa i 1t-;. . ii i l ::t'"t: iur-'i r:.ii i.;; i,.-
ol rolrslul $lxE }oljc sll ul ueas 0$lE q {vduJ de}de ,{.reuor.ulnd
}USU aql 1oV a$d euop 6urpu6osE 1cr-urxord oq+ sA4orls '/rropuM
;.r!l,iitiil t?j.i{)[ ;:ltii-.ti]."i!ilt i].til3\!,,lii r:rLi! 'lj::1!, isir-1.'i ;:r.i: ,.r1
1eu..re1se.red tL{61: aq} iro"q pa;inb*e 'sBeuJI srql tt'A arfi5g{ !i:)itrli.lt:i{)iiiilri i,;.liillt: :r.lr,i,,i i}tj} tjii t\ i.:i.lii .1!.ir!riii.,,. :.tr-ij i!:,
t- . .': i

eql 01 uass
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3r{t trB UAss :ll
c{ct aql tu u:

'fiiit,t:,.iLlir1lli iit .,'1,-'\'". I ;rr1;lri' ., .)!tr.!,ir-i :rlJl (

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'lrBsri 3{lJ0 sixu IJOrls Jo stxs 8uo1 r3o asor.p
,dlJrnsn e-ls paurulqo aq ueo ]eql soueld a8erur aqg 'l:raq
*ql 3io autld SurBetur alquslufora.r B urelqo ol pelBlndlueru
eq plnoqs aqo;d oql :slqeueA sr uortslor :qord aq1
Issqc aq] oi J?lnlrpusdJed aq plnoqs aqo;d aq1-aur1 rgndecs
ti.il -([ \.t': \\ -1]-Uti:.] a,ii1 i],r:tf;ir.! :.! !/5,1i-]{i rLj i llilii ij(}i,", :tj ,.
ii.filltii,rslr 1i:i.rtir,lri1 .ri1l i : .i ',-1,,,,. i,.r! {,,l'Ji riririci lrirll
lLlil}(l illiI :illl t\ l:.,111.1 .riii rij .- i' il.riirt:r',,,.ir.iilr' ii.ll:]i.rir :ir i:ir;
liil 'll] la,ll .:L1.l .r;;lLt:t ir 1 i i.j .l!r f i j. ,t i,.i i irlrtll).,,, i) ,, -
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PlSll Jl:l,il Lii:iil.i.:tll;'lri.)irtl,-l! jllia{!:r.!i"r}iil.r,l:ri tililir j.r.rriil'j ,

-prtu 8q1 ur IfEq g,Iuarlrd etll iro peeuld sr aqord aq1

lil:1! )-lC S:iUitli ".:ll1.i il:i ir,1,' .' -:i - r,r .,;'. ;11;:l;; 1,111 1,
'{St'Z '8lg) uo*lsod Supirs u ul luer}ed aqr .,,-rt;eil lltl:,;r:,":-t;::ji.ti li-iili; .ir' f)t,ti.t.iii ;:iti !il l.1ir,rCi!j !i{ . '1.,;ri I

qtrr1lr psrrr€iel0 3q osl? ,{uu: ,uopur,r,t slill rrro+ EurBerur :puar1

.r13q1 J€^0 pspuslx$ nrJ? lq8tj s.}u?tlEd 3q1 qlt*l uorll$od
stltrqnaep leretel tqfr: ds+rs s ur pace;d sr luerled aq; 'pm{ Jro{} r?,ro
P}puatxa luJB rqEp !.}ueu€d aqt {p!,n
uolllsod aqord puB tua$Bd uOrllsod siltqneap ;"Je}a1 lq8u daals e ur pruld sr 1ua$ed aq1
uoilfsod $rolled
'Bur6sujr tlqlqu] snllqsq dpoq lurrpd oq:l pue srlssll
pae sue8;o 5ur,{1rano Jaq}o p{rr s8unl sr;l arsqnn s.!Loput^r 'VU eql o}ur e8uurrrP 351
.;lrteJoqlsuerl preprsls s{il ssq}
$uar{ arl} 3o saFeu:r .r*paq l;fAS ar$ pu" BVI eq, sBsur! 01 Frs* sq oslr {tur ,uopulx
aplao:d duru ,lropularr ElrF -InBJ uJ 'slroe ?rsulcr{} 8ulpu*rs*p stllf 'p$lsFp a.Is B1roa ffutpuacse pilB IooJ cl;roe eqtr Eaq^r
puu trrrcr{ ;q} Jo s}?Blul dt;1mb q8rq deldsrp rrur dlpicedse lepau Surpua$E prra troer 3:ilos aqt Jo uollsnle^e
^{opui.r\
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1runa1d 'uslclryJa prn*1d iJ$l +firrl E Jo e?uesard aqr u1
flropulnl |eulalsE ed Iq6!U
llsi/t l$srl3 Joualsod
i ir 11 illii,: .iil{ :"ii:',i !,i -rili l}ritl !'.arari.il
'ix?ag punosr4ln sql ol .rqnupuedrad i11,l.l,ir-llili(.i tLli::i .liil . Iiii rili iir!riirlil,iili!:, .'ti.1l:.ii|1ii5i.ir'-
psluello sf SVI aql 'mslA slrlt ruo.rJ 'igt'f 'Elg) uees aq :r'i:l i.!l !:i.il:tL'j (i;-1 .-irr :ii::; It.ii : :.,.,.iriit:i i. ji_il1]:lil.1i:l
,{uut aenec Bu?A JorJsJut puir .rot"rsdnc oq} pilE 'gy1 e{}
,srge a{t '}qE!r s.tuaued aq1 spru,lo1 eqa:d aql Surl8ue .{g

(:: l':i:ijr:i"iil!l.,.rl iiji,i\?irift!1"lii!i:, {i;i'r i'i'r.:ir;..r..-li!1i:.ii.,11 -r ;ii

 ciiAPTER 2: Tlfr rllro-DIMEHSIohTAL ECHocARDiCIcRApHtc EXAMIr{ArIol.l

Sector orientation
The secror orientation is such that $gr*rlure* ,""n'S ,n*
top of the sector are posterior lvi:ile stnrcture$ 3eo* mt the
bsttom of ihe seetor are anteriru. Structures $sen tc the
ng:ht and left of the irnage will depend on the imaging ptane
obtained and on the protre rotation; remer*ber th*t rhe FOM
wil| be displayed to rhe right of the image elisplay so if
this is pointed towards the patient,s head then the superior
l'
struciures will be seen to the right of the sesr*r and inferier
structures *.ill be seen to fhe Ieft of th* seet$r.
\
iirr iir:i )r:'1.i!:i'1.ria r-*i{iilr'rrt!-*{i hl rl:c r.r!rritsr:rri'iri i-rear: lli-riri
.. iti,, i: iitt pt"rstr:r'ii.rr
titi.s ch*sl rvilii. ll*lwr*il th; Frist,..ilor fu.-
ehcst ri.rll :ritl thc heai-r is rhe lc!.r pl*ur;:l elTirsion. Tht:
1:lcut':ti ai't 11s!on shol;ld appr:irr rrr"]sr.l-!.cchri-il,cc.: hLr,.i.cr.cr_
r-lhcgcn c itrl iapsr-tl lurig nra1, h,;:(n SfL:il rr,i Lh in l lr is,snlrc
r

ii- rg I I L illllcr struc tLll-r.s unar(Ll ..r ril ,lui_rcr,tl lri the
tiiilb!-.,ftcir'r]tiirri.'ltplcali), thC drtsCcnd;ng lhr.iraCic iiol.la in
#
its sir':ri 'i\i] ir'L)'lg ilrrs carl {-:*
-"ccn iintr-!ia}r't* rrrc,rcir*ii
lililslcrr arri post;r-rr,r lo the hf,lrti. Thc {e ll r,cn,rrir:lc rs r:lsc
Lrsir.ril'.. srtrr

F*gure 3.4d These photos sholA, the patieftt and probe Fo$ition
for posterior imaging through a left pleural effusion. d**
t**t
fqr detai{s.

)Figure ?-4? This ir$age was acqui*d t or!.i pe$teriar irnagiilg

thrr*ugh ihe petierit's back using the Ieft pleural efft.rsion es an
aeoustic window.
DA = descendi*g aar-la; LV left uentricle; Fl Eff = pleural
ts:f ,,.:,::,:: :i Ti"rjs image. fisr)ilii+ci ffcm th€ |$ht tar.jsrer-ei sfusion: RV * right v€ntricl6.
xti;Cr't;.:hir'r',t tlie ini+filiris; sepiLlrl ilA:ii. ti*,ii:rh+ :t:iurji (EA:,
ir,.ll aifiuFr iLAi, the ilie ri;-ri vena eavii {;Valj, ih*: supeircr v+r,ra
l.r,;.i i-{Vi]t ilnij il-te 1.:cilspiti v;rjvE itv}.
 { "'p;:rtulluog}

{; },,\s-i 1u:1sts.i*ii rs.li

!l t{li1\ p ltirossrr rluitu:x;t}} isi}u!i $sii$}sllp d *, cprrrs i.i !:l.iri-!t r -.)

,,ilttltlt ! itr,-r
{alrsoddo u,\1ogs lqlssio {fio1sJ1e} {} lrlri)v-ir;_iii I\
suslsel uuai{ lrtrue€uo3 ur8u33 ur Eses su dSmuq*arsrp :!r I
it tii.?S-{}1..r{ ) !

{r$!r*;aHat {
r-t(ii ir?f ilr Jl ?3 ql
1.- fi r: r u:rr1 c I

{}niijn+ Js!p;ci}
p.irlirp*-rj* s,-c$uatS _irln,{iE^i r.ral!s-tr!3rp tolllt+l l,;}}fti}.a_i
.lsdul*:tl
(;:sde1o.rd
*| Ir.,ltslllp -, 1 .{u r u1rlp rI Iots:(-r } s,,r ;l; r prdsn:rrq ;.1^itl]\ .1! ].ii!lj

$rgfu€}$ ru;rurpnu:dnr
srxsdj$s$c 8AI?slqA Js snul$
d+g uoprasqp q
rjsFstBIIp t
sffi $,{msu€ }rIJoE S${pu*?ss
"ftprs ssaesqe l0sr cl}roY

j1l +!.i] i$ xY-],j "!rj; ir:{}.li pai3@i+* serlilPlrijfluqy .

t 'r.) iii.tl l\rtrit'.i\-'l,ii! ,)itldVllliill{l}i\,',}(iH,.r::l li,,Nili:;!.*ii^Ji{l"i-ir\l I :1it-i .i ?Jrl.i qi1 l1 .r

 cH,A PT ER 2: Tl{E TWo-orMENsIoNAL ECHCCA RDlocRA pt{]c EXAMINATTON

Table 2"2 Abnormalities fletected from the FLAX of tha LV

{ccntin*ed}

Descending Aorta . p di{fer*nri*tiug lrft pleuret effueion

lifi *l"orn
(DA) f
| pericardiat effusion (FE)
f . dilatation

f
. disrection flaps

I nterr,entlir-'Lr ill' *irnr: r'rlzi I nrot iou i l.,l] ts Ii. ptrcentake r rh y th nl.
irrlst {rp{t.r
Seplurn t I\IS hr'8rt -.{utg.ry, r$irrrnc or pre lsurc- ot.erlOat.led
1
f{\,i
) asvtnmerric septal h1.;rertrophr, {ASH}
h::pi-rkir:i:sis or 1|.:inesis (essrrciitteri ri irl"i ll{D pr:\ll}
irtcreasccl thii:kne ss or h1'pe rrr-oplrr
redricrd svst,ri ic thickerrirrs
tiririning (arsociattrl rvith &,11 i

Left Atrium (LA) l. cor triatriatum

l" dilut tion
l. tumours (e.g. l myxoma)
I' thrombus

l-cft \eirtriult-. F tXilatation

{ [..\r i irilrut* i, rl' r'tasseir ii.r n1rt n
i Lr

svsl*lic clvsiuns_.t irln

I ltrrri':',;hr:s

{$riniinued... I

k
 1+ljE;:i igilrt.i; rerr.jifllji: ru r-.jcii.li! lLji.ii-i1i.irj,:r!i{-tiiri::: il,]:;r* :l_t.jt};lgjrI iStfi.rg:1,}i:*, !id : ::
EU8A JoIArinS Usl * SIS] l4oofi qsuElq slpunq u*, - r;liltl-l:il:;i:iisirl ijf:jtj -jJl-iri!-fr.i:irj: ni-.1 'liiirrJii{jiuirrii.riE:: *,iii:rnjltqi, f1,1c,:ji-:,j*j! - rj.ll,,1 ..
uurftlos lrlsF crltr lri iiii,- 1'" fiijtjjLlt* rjlj3fl ajl.i] r.li *",+i*.j tri_UJlif,j; i:;jl!JiiraLili{)!.!c!"{;ailjei:ia:til_-.1 :j}ltl l-r! 1;{+i pl9ff r.:_

!s"?ulrr{.1} il!?^i,\}J F;isBarJ{!r {ir.t;r,ij

!.J()!t3iin-i 3r isls{5 l}+.ile{lEfi I 1.1!r.i.L :\i iiit;li.r
ri$tlrusl!p { _t1'ritl:]i,1 !it.j.1 lii a D

ftru qll"e p*lslsosse) 5quu1q1 q

Furrsliilql r!lst-s{$ p"}nper
,dqdoued{q Js ssau:lrlg} pesmJfiirl
ifir'; 'lo flgI rill*r slsauD{r;o slsauqad{g
patreraossu)
u:silneurcpnssd ia rurd.:nsuu ;1t:.\:\ .,1' ] .i{1i.1ai!i '.1

5u<lti113-rfr;1"'
ilt)!I:]]l1IJi1t3 $t] Inuile _:{r .i61111'rr,
LJOrles!,Ij lu] ?e *uru*r;lr q;
{ui.}0H
{lt r 11\ p+}el,li}$sl:r } i.\iitll -l* l{fl t?*tu .1i}t.i+l it r :t;o;s;(:;
i!*p_l$,"!f, p+-rntd rr.i

{i*dini"r
.)r? p"ir?il p.3rl pi_lJ "ro s ! sclu.]1s .le n,r; l,r) lil llqarx Fillln ps"{
r
I r

asclr;a;d 4
$tlF*3t lll1l}
utrlu;clur:ll rf, Lj ra!,J o i,in I ! *, i'riD1, ilt.:i1ir

r.rl:
rir :r'; .

I
r.i.il !i)
l;trfiB Jo llttVsl Eo$oru Jogtalru a1yo1s{r { 01 anp ir1?.tL il;)llii1{)
Js'snoue-rqiljolil'r?lnrsnuj) uorl)rulsqo lf,trll Aloglttt) * .rili113r.ilitf,1 li,a i

"rrrlrrn:r.1 *:;.r'.1

{p*nqluoa} ,\-l sq1 rq X\fid a$ ruo{ palcs}oq stst}llaurtoaqy A? e61el

a

j
!'i NO I TYNIHYXA 3IH d yH S*i fl uY30H3a lyN0t SNSrir0 -onill" 3HJ :
u H3j"dyHf,

\--
 (i4 {'il,\PIi:fi. l. I'l li:l-\!i)-iliiLJL,NSi(i}:r.'\i-L{'li(}i-'ARili0{rR..1.Plll('l:X.!.'illhj.\'iid_rr',

I ri:r,: ' l: r:r Ai'::r*rrmalitiqs Detect*d tr*ni the FL,{X *f t}-re ftVlT

irri*riur \tir;i nr i gr:itr:ry thrc:m hi.ls

lurndlurs te .g" tF extencicn ilf ren*l trll e*rcin*rn;ri
lcava{rvc}

Right Atriunr . iiilatation

(RAJ " inlracardiac nrassesitumorrrs
. thromhu.s {*,g. } migraton' thromi:us li*nr t\,'Ci

Rigl* Ye*tricle d ilaration

(RV] ircreased &Y watl thi*kness or > I{\' hvperfroph5
{!{.}r}
intramvify maa*e#tumaurs
syrtolic dysfunctiaa
thrornbus

Tricuspiil Virl.,,e . {ixed. thickr:ned^ senri-op;'n ieallets {carcinoid

('lvi sy ndroine t
" pr*lapse
. reiiucecl ruobility {valvr-rlar ret"iuce,J c;ll'diac
rlutpul i
" nrplured cr>riis
. sy.it()li. {.h)rniiie (stcrtl}sii)
. F vegetatin*s

The Bold text ic the Detectable Abnorrnalities ccl*mn refers"to the echs exernole shouJn in ihe richi column

t
 uujrl;$} ]uilrj +ui Lri u..!".clls Jjdlitex; cr,j3+ 3qi o; sraia,t u,,Lrnl$3 selillt?il.uouqv alqE}selo* e'{li u! }rel plcg 3--

*! $ou elsp ulia-*.,, :m?:;fKH :

EollElsllp " {y:trq; i.r.:t.r1
Bur,raor,leuysrsouatrs {rg$e fueuouqnd qouarq - i:*rrouiiu.l ulr1',,

rucrielrSo,l
ifi ttttitop rllo;s.il ;) stsolt;is
asdrl':;d
i auro;p*ds
F r oir r rr:.i r?;l i ic I,1 L!
ri i ulri<:- l ttt is' 1!
a u3 -1r] i t"! I' p.l a u 1J

ttls*1ds.{6: 4 -1.,".
| lt,\ d.illrii;iir I ir,-;

Eurarrorrru lr;ftqlpurgl:I {rcnul

$s3ux?lql 118ft1 fs.g pGstff$sl l3erl, &toilf,no
ns$?lsltpJ,oj\N, { rqlspiue,r 3q31x

loAH aqi l0 xv'td 6ql u*ri palcalao safl!]Eurreuqv ?'6

,:/ iri.ij ilifiil\\,,1{jj.l!l{<jl:i}J,-X,jiLl ll\;,-=1i.llt^,-rl:l

'i
\:\fji:;i\,1,1 i,tlil a},'.4.i -lli.i :f }Jri.j_{i 'i ri.}
 (r6 {. ii..1 irli.l.: . l'i j!: i-*'{i-ili\ilr\ji!{l\i.\.i }i lil}i'i;r jjtr'){;h'\Ji rlt i:.'-,,.ti'iiii',iiir\

. .', Ai:ncrn:afities ilsteet*d fffi,-?] th* F$A.X Vi*,"v*

iru!n:rj:ilri1 Aiier)' r.i l irrlirirtrr ai,\,1 i,).4. ltx o.l i ;t i.ri i-.r ;rrrr i ii":s. Fl\'{ }l- l;.
liii'uicit{iir* itif rlt,.itii':l ir(it iii
1:r-*rirnai !tdi1r!ris ili'ii::il riiiri ir:it lririrriL;irlrr'r :irtr:r.r
branth*s
thi-orui:us
h filil}o$!'s

!..*r+ 1, L.,ir A()ftii,: \ ail!t:

,1lrir-rr-;r (i-"Ai . :rl-rr'!{}}'iiliil tr!in}bel'{)Itutr\ i} h!r-rrspirtr. i.irtrr":trs[itd.
.r, , r,i.,,. .,,, ,r,.-t r

. stcurisrs'' r,:alcilicatitrn
" vegcr;1ti{]ns

Aor'1ic ioot:
. itilrtic t!;ssrr-ti{}lr il;rps
.,ii lrt,tt i(rI oJ-.inLI.j,i). t'Lll\t
, 5 i rru.r tti \ aisalr. a :ritcl,!r\ ...t jtr r-i!pl ri rr

( orcnarv arteries;
0 aneur_v-srfls at origirl of'l'l( AiLCA (iisli{}(iated \". iti}
I(au,asaki's <liseas* )

. afl(lmalou$ origin oi i{{ A'L(' A

. *Jrlrratinn ot'R('.{ L ('.\ ,rri,:,i,r

IAS:
. abu*iiral nloaion (b,irlges ti)\!'aid l-A ri i:cir ii,'1,
pressurll increaseil)
. aneurj"srn of IAs
. > ASD (trerva:e $l"'drop-$lrl" rr(cilcr)

LA & ttrA:
. dilatarion
. i rrt racald iac ilirornLrus,'tLrlr.rolrr-{

I)\'

. sterlosis. prol*pse. dl,'splasia

" \'cg.-trlii{)lls

Itv{^)-I:
" dilaiatio*
. lr-:.lc,r:ril rvrll tlilckrtr.,.
. i n tu*clihii lar rr,{rr0\r'in!r

I\.
. cldlloils. L prrllatirt. \ cui'.31rrrr1)
, {rrcri. th itkrrrtti. serr i- i}p*rl ir:;,rJlef s ( i,rarr: i rrr,rrd
$r.1'riiri!ni{- i

t**rrtin*ed... )

,..I{|
 sellllBu#ouqe u*llolu llBill Ftjcls€i = viAtARu :rL*pe fu€u3ros tqfi! = v3u :slBoll€ls lE,$ul = sl l
:L;gpB trr*'roios Uel = V3f :6qledo{uiorp;es enusnr}sqs srqdS$adnq * H3OH :e^le^ ol}oe p;dsnqq = AVg :pal+p teldss l€$18 urnuiud = OSV -l
uumpr iq6u aql ut ulnoqs aldu:wxa oq*e +L{l ol $r€i€i uurnloo salllleurougv aiqsia+}sq stl} tJi }xa} p1o€ aql

\,.14i,.\\ri .
r;rde,1r:, iriltr.iJ;, I'l$ "
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;nH

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{ tf .lflX ii1 I A\ palEI lt}-rrsrl ui'rqtscdlutlt .
( a,\ B.\ Aili rli slr.l rps.r*d
I I

rJlt11 p}]Et"-a(lssr 11,i r1frurs.t .r3[iilinu lertuoalqu .

:t.td

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ifi'j \r l

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u0ri8|$lfp r
:AX

uop3unlsdpsfio?3ds r
YW.4AH ,
("rl"nart:W{S* ro 3il1u3f,u0,) sstu{}lr.ll ll8nrr p3$BaJiur r
AU Jo pEolrsao oruRloveJnsslrd {
!ir.i5.i.r!"isi:ir .!l iii i''ri) :riirils 1 | ri{}!i.i{}lili) {
"J{)

st 0ilEls8arr +
uoB"J$rrlp31.slrore$ { r
a*duloid
'
uorte?dss, isglssiJ0 arfilre] r i;:r,rir"{ i _\ i{ I :r',it-',
{al3 r . i{'.i li\ { '. i
;Atr{I ;]1,-ii.i]it,:, \ i.l i- j

{penuguoc} sr$€l1 Xlrsd aql uo4 ptrc.Bs{ $spllslurorry g'U qqel

a

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 '.",.'--;.'.i: '.' ''
fr:.{ {. H.\irl ! ji - -f : ,

Table 2.6 Abnonnalities Eetecx€d lrom the Apical

Yiews

I ;\pi';;il "i-rita:t:ber . abrarmcl r*lati+a*hips of eanliac €r{x (€'g' mal-

alipr*er* of {VS and lAS; Ebstein's anon}aly, aorti{
ovexidecf lV$
. abnsflBalities of*itr/ valves & subvalvuiar apparatus
, {stenosis, prsiap$s, fl*il leaflets, ruptured cords,
r annularealeifieati*n, vegetations)
F aneur-vsnn of IAS
dilatatisn sf e&*rche$
irtracardiac meesesltllrom hus
RWMA
s;;stc I ic d,';s i uriri ir-'ri LVI ttV
\,'Sii t*g ccirgenital.;lcst \{I}
ai:rt i c va I vc abno rnr a i t t i e -c ( i-{ ic n e}s i s, cli i} i i"l c at i o n,
Apical -!-chamber
prrilapse, vegetaiitrns l
L\,'{}'l *l}rliluclion (e.g. }IUi'1'1" ts s*th*trtii:
nrenrttrRnqi)
vst)

r\pical LAX dilahtion of LAa*#orLV

RHTMA
LVOT *bstruction {e'g. r HOCM, subaortic
men&rane)
abnprmalitie{ r:f mitral & aortic valves (stenosis.
ealcifi catioa, prol*p*e, vegetations)

;\ pirai I -r:ir;l *rLrer :rl"rntirmal ities ol mitrni vtl ve isteni.isi r' cllcr licatir:n'
prtti apse. v e gctationri i
dilatation of descenriing lorlir
dilatetiotl cl l,A andior L-\i
} RWR,T,d

refe;s to i.he echo exainple snc""i r' i^'

The Boid text iri the Detectahle Abiilormaiii;es rolLjInn ',' . r,'rcardial rrriarctiort.
r

lni A = lnlerto: :l-:-.' .-' SAM = sYsi'Blic

AV = acrtic valve; HCC|"4 = hy'r*rtrophic otlstrllclivi) carc]ictryopathy;
, sUb.iortrc *erllbralt; VSD =',er:r '-' :-
:,: -....1
anterior n'loticn oi anl*rioI e,'lit!-al lea{let; Suf-:Ao Mem =

b
 Llt!-irliif iliEri ai-il il Lr/\ralr.js tslclirr.i'l +il3:3 3r]i .lJ t;+ls, i-i1.1,r!"rli.l:, s.ilri,ltlra;iiuqy;iq[-]ljiJii;ttj i,l{i ur }1ar illog : -

ti ES5SJ J El fi 31,18!.;llrc{ns S} I
uro& uals) ;)A,$ UE tualdrsr?d 3'a) -ssryleuuouqs :)n S
' snl$qHra drru*ur1nd q
siunqs prr$rn*,t:tuourlaci-i;Hse urHF03
aHuur*.,r1-r sno!ii!.r\ dreuturgild snslr$ouu XVS luiilaisrlllrl\

ft:g +renes qli,& ueas) rlloeJo &lllreslnd pssesr3ur

d
,' vdxJG uot}etsilp
" ?uouJo t ollrlEllp ?

$.1s8 aql Jo uortrstsJeo3

$o-rllessJp cllJoE < ;y"l pulo1serdng
1iiii.]ti.i:\
!ilii1.ti' i

sr$erA l€ulelsE;clng eqtr incrl pslt*16fi $arillei.uroilqY . , r.

Isalap tetrdas jelns,rlue^ = ilSn :Lro$nljs prprBcF*d = fd :]3elBp lBld€s |€pte = CSV
uuinpe ii,lsir si.il ul uilrolja eidurBxp ailJa aqi ol slfilar uu.rn|o3 sallllEuirouqv s!qe]5ala0 aul ui lxat Blo€ aql

urllJnj}sqol,SAu
(ocope$8a*'usdalo.rd'uoqeogir*18,
'stsouels) ssqJlcrluouqe pAl?^ o!$os pue dlauoragnd
usururgsfp cr 1o6,ts AN/A]
norsuslxa Jnstunl/*flqulelqf f,AI {
SAI Jo uortarursqo/uoilBl8lrp
sute* cuedeq Jo fio*€t*llp
{ulsdrr*re Bdag
"rtrigessl$'uoBelslrpi $Brl:lEIrij0lr{lg Etr88 lt}rtr$Otcu li YE I ill\1.].-:il1: {,

trS,\
(gtr) uag*nga 1*lprraped 4
{suor1qa3*n 'asdqord
'rroussgi$183'srsoual.s) E3rill8triiouqB 3/\lB^ nv
uorlrunJsdp *r lo6ds AU7,\I
Syl J0,{qdor1-rad,tq snopuoqif l
($Jnalilru/rnqHoJql) sess6rr] 3stpJ?ru$ul
sse${31$ llB,\i AN prs€aj3ul
$equeqo rprpref, Jo u6rrerelrp JeqttrEii]-t
fiSV irlsci]qss
.r.t il l.lllt |\
1|tlt:lrt rr.rl{l \ .}l{lr:!.};)1,!{i .1r:tli.rtl-i

s,qalA ;e16*3qfi$ *qi !Lrsr$ pB+3$16fi talS.itsrujouqv 1 :,r",

69 f.i{,.}!11,'i\lL\\,'.'{:l .ii1i.i '!i}iliijlc)li',)i-l'-{.}.j -;v\i jl\:i:.li!l{l-{1.'r!.j. ,jtil : tr j"l.,;\ }j ,

 70
Aortic Valva Leaflets
With the onset of vsntricular ejection, the aortic leaflet+xnap
open with the right csronary cusp rnonring anteriorly and the
nstr-corunary cusp r*oving posteriorly. Bo& leaflets remain
separated througheut the election peri*d and lie parallel tei
the anterior and pcsterior aortic walls. Fine systclic fluttering
of the aartic ieaflets may be seen irl the normal individuai.
With the onset of diastcle, the leafleis close abruptly and
coapt in the centrs of the aortic root producing a single
li*e*r echo" Thraughout rlte renraiader of diastal* the leaflets
remain closed together f*ilowing the posterior matian *f the
aortic root. This rliastolic ard systolic matioo of the :iorgic
lesflets forms a characteristic 'box-shape' within the aortic
root; impartantly this 'box'is not always seen sn every traee,
From the Q n'ave of the eleetrocardiograni {ECC} to the
rCG
t
F (4
i-
E S'
tr ',6 CF
0i) r&
p,fig,i'
o"oE
(d0
L(J
>ia
EE
Figure 4.1 The top imege rhows the imaging plane, cursor
po$ition, structurs transected and the M-mode trace for the
ao*a, eortie v6lve and l+ft atrii.m (LA) as acqr.;ired fram the
parasternal long axis view. The schemaiie drawiflg illustrates
the structur&$ trafisected ag weil as their motion $Jith re$pect
to the various phas*s of the sardiac cycle. The isovolumic
relaxation time {lVFlT} i$ the pericd from aoriic valve closure
ts fi*tral valve cpqning; -this period as well as the a*set of the
rapid filling phase and dia$tasi* is difiicuh ts determine frem this
M-mode trace alone. Atriat coitractien follows ihe P wave of the
electrocardiograrfi {ECG). $ee tex* tor other detaits.
ilrr
Ao = aort6; MCT = isovolumlc conlraction timei Ly left - a letter frorn fhe alphabet and these points refiect various
venyicle; nec a fiofi'osrol.rary cu6p; rec s right coron*ry cu$p;
RVOT = right ventricular autflow r&ct.
t*
h
{'lt,lPTI:l{.i TliF \,i-\i{-lDLl l:\.\:\,llir.Al'l(]lj (r]: I 11 t-. ttr]r,a,iiT
onset of ventricular ejeetion {opening of the aortie "box"J is
a period known as the pre-ejectior period ar the isovolumic
contracrion time.
Lett Atrium
The LA Iies direetly posterior to the aorta. Alrhough the
anterior LA wall and the posterior wall of the aorlic rooi are
anatomically separale struciures, their elqse prax.imity and
spatial resqlution Iimitarions of the ultrasound machine result
in tlrt pr*duction a single echo. Therefor-e, the anterior LA
wall Ibllows the same phasic r:otion as rhel of the posterior
aortic wall throughouf the cardia* cycle. The posterior LA
rvall displays minimal motion and so rem*ins relatively *,flat"
dtring the cardiac cycle. The speeifrc phases of LA emptyir:g
may be appreeiated by close ebservstica of tbe anteri*r LA
wall/posterior aartic root nlotioil.
The M-nrcde examination of rhe mitrai valve q,'itlr respeet to
theocursor position* strucalres inten-ogated and the normal
motion of these sh"$chrres is displayed itr Figur.e 4.}i Table
4.3 al the elid of this chapter lists ihe abnonnalities tl.l6t ts16y
be derected from this h4-mode examination.
tmaging Plane and Po$itiofl of M*mcde Curuor
The mitral valve can be exaniined &cnr the PLAX viei.v of the
LV and fra*l the FSAX vierv at the lev*l ef the rnitral valve.
Frqff these viervs. the curscr is directed through the tips of
the mitral valve leaffets.
Structr.*res transected by the M*mode Gur*or
From anterior to pcsterior, the ultrasor.u.ld beam passar
through the anterior ehest rvall. the anterior rr,.all nf the RV,
the RVCT. the interventricular septum gVS)_ the anterior and
po$terior lsaflets of the mitral valve, and the posrerirr wali
ofth€ Lv.
Normal lrfotion of the !fritral llalve during
the Cardiac Gycla
As previously merrtioned, n:otien of the mitral valve
thrcugh*ut rhe cardiac cycle is not a* sinrple as that ofrhe aortic
valve ir*cail Fig. 3.7 in Chaptcr ?). During diastole, tire mitr*l
leafl*ts i*pemte widely with rhe anterior leaffrt approaching
the IVS and the pasterior leaffet movi*g toward the posteriar
r+,all of the L\{ When the patient is in nor*ral sinusrhythm, the
anterior mitlal valve leaffet {amvl} produces an "M-shaped',
c*nfiguration while rhe posterior mitrql vaive leaflet {prnvl)"
which rn*r,es in tlre epposite direction ta the cntcricr leaflet.
ma;.' he seefl to fsrm + "W-shaped" pattern. During systol€,
thc trvo mitrai ieaffets close postrr;orly wilhin the LV eavity
prcdilci*g multipie linear echces thai nrove slightly anteriorly
througftout the systolic period. The longer amvl has a grsater
diastolic exsursion than that of the shorier pmvl; hence, the
ftmvl features rnore premioerrtly an the M-rnode trace.
Each characteristic point which forms the'.M-shaped" p*ttem
afthe amvl throughcut the cardiae cycle has kreen designated
events wilhin the cardiar eycie (Table 4.t). The pmvl ffin
also be iabelled in * similsr m&nnrr with the addition ol ar.r
 ,qtspg qrruJ slr i{q pagpuagsr.oqpaut ;aprlilJed lueltir\
-lrrprrede roplsod eqJ-umprsrgad eq pue:tl aqtJo IlB.s .-_.-....
{1e.rare1o.la3ur) rorrasod l"seq er{l :&taec ,\T a$ 'Sn1 lsseq
aql 1OAU 3ti] AU aqlJo llEm lolr3luE aql 'llB,t\ lsaqJ JouJlue
sqi sl;asuejl ra:eaq Punosellln sql 'lotr;lsod sl iouclue uioJj rnl i r .;iq=l p.lE l:{;r irs '} .;:- '- -t -: -.'a ,-a' :'-,- - ,' :
JosJnS opour-uu aql dq pal+s$usJl so,lnpnrls :pli:11ui a:railJ rii:F rala:illa i)? 3r n-i ,:;,-aY - .a.' a a'--- --
.:.i. -.I: ,; -:.i-..)-:.-.
:.) ,.., i..iJ . f rr J1:,j#F d',.
-.;
+t;i I'il iialllriiiiss +q !8,-r +.ri?r, l-1riro.: 3-i..i: ?O i:rLjli:(O ar jar :
ru04 uess trs}q ils s4rsrupuBl }lruolgu? lstl}o
'^,rsl..{ Srq} puE
ii!,i.iil
lLl] 1C 3riir:;,'ii,-: ;j,.i; ail :1. a,tg- Eri.i-l i-i i: : '-:aia a
*rxr Su*1 AT eql se ,+ael^ Xv'id ery sr n'1 stllJo uolte$or"raxut Li.i-1jl;l,3ir. ri li.li -:r ii:'11;i irtirl r]+i;tr:iJii:fl;l tr!LLiliai.*r?i -:r l .;,,. -
sporu-N e{fi loJ n&}r,r pslruJard aq1 'flage*l sAle;\ lu{lru ii) i.]r-i:r"t.l,ic Lr/.!ii;,: iif,lliLL ll 1;!r;1ri:, i:r!jl 5i \-a.,it)lr.r ; ;11r jl'.'i.-
;-1,:ijjf il$irii:i iLli !i ij dli) i-r![rll i.:aii=r;E]+j ill,1l;rli"r-,:g' iii-:': j . ... :
uado *ql3o sdrl aq1 ot lsrs:p tsnl6 *utJo $ix€ 5ua1 aql ot ': l
U-ri.l lr:{]til.:i."3;:;i:lilj? iliil lr-: :ii3i'i, -!. ei.i; ;il; Srj* +lli l[ ;.li].-::.,-. ,
.rulnrrpuadr*d peuor3rscd sr -losrn; aqJ 'sallsniil ;fuu;;ldrd :;; ,{; -,,r. ''r.. .:i i.1r -1,.i, I j, i":r- .i j:.t,,'r., , . . .:. :

aqi Jo I5A*l 3q1 le ,rrr^ xYsd ro A-l eql Jo {.isiA xY'ld aq:;* tsseu:i ;iiai-i-ri! ;rll al iJ-:liir, L;j.!i ..r-,1 j . ' . f,,i !:? ra'.
stll rus{ Fass3$se }q tt83 ,{-] aQ} 3C ilOr1u8C.l;tlul spour;nl -{iil ij+14+gi-irli :,ijilj:.riri;:.: +:.ji -r+iir,:i ,11 i:r.,'-l'," -i,li.,l'l:.j.;i. ra:
' ii*iR s,{? 5ul, 1;ural$t.l*d it-i: iuu;; ilr.l-rnh:)i','l!i:r $Jrlil,. :.* i
Joiln3 fipotrl-pll lc uoqlsod puE au€ld 6u$eur; c,{} Jii 3:-}f;-,J ,10*L-i1-t1j :r-tr!1 ili!:: iiSi:}+*rjejl S*.ial:inriri rirr:rli-'l
.ic€jnl 'ai,:g:d i-rr;iit'i::; a:ilii !'.'j, jij:i rriii.'rt:: iJ*; :rr1-1
'p$3at?p sq ,{e ur leqt setltlsuuouqB eql sisrl .ra$ar;r sltil So
puo 3q] 1€t'f ';lqu1 g'p e.ln8rg ut pa{aldstp sl s€"int}ruIs asaql
Jo rroitour luu"lcu aql pue palu8ox*1ui s*Jru]nJls 'uorlrs*d
.rosrno aq:l ol tcaeisa: qll,rr A-l aqt Jil uorleurr$Ei-? aponr-i4tr $r{l

l,

:l,.ii! i!; ii-:iir 'ri.ili,;,i Lr1 .iQi.n.i i.illIIr;t:irtit,Lrr

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t.r.rirss;r.rcl 3u r r1 -11 l,;ii.r.i.rlru
lulod J lvri I

1 1

3.iql i.rprli rr.'>rl,!1 liiils(ir ,rqir.:ns* r: llriiirJ ir11

:r1ois.is .txln)iJI!.r"?,! l{i Ia!uo a,tli
lrj lJt.tl?.]i ,rDr.i.]]"1!il rLlt.ic ili:r1$ttc1 ilr-i] *t s,r.!il.1"r iLilr.)d fi
\ |.',lt"lL" 1i;f il'r;rrt.'.1
ir{1,} Ll 1,.,.:rJ,)\l t.tlll)ri' ,ll ,n,trllit'\l \a\r'\t \{ir
:.ri:$;.:.ir,i k'-l iLIl i"r,-)iii0.!lr-i();: li]:-ili] riir *.
iiilt 3i'll i riili i u r.r 1u Eu r.rlt:i 1{) I s.i 11'}f, {.}
:1

Ir:qi .Srrrurr{o-r.i. t}lllr}l .1r tLrrod rrl} strrlli}.I ]il1{}(l Y

arli:1s.1-':1 dta;s u rit f,urtlnsa: prdrr I tj.
sl fi*ir r
! i r,t,!l pLr ur{ii;(1{i
fr ir r.:. tri Lr-r *r V'l'il I
*+*
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fiuttt$ Sl .r0rpuB fiur,(rdurc I
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Vl .{("} }pl.r iilt.lo .r*tp}rpui ur.r sl ldols srqt
t

irlJi{r,li -roil. 1il8 :!l} JQ

u.l]eui fiurso1:r 3rloliirlp It;rirur . ril slLrrs":;de.r ":t1+;s g-3
srrldu.i.r \,'l .1il1 s? sllr-l ;r.inssr;cl yl .ili
sil pt.!t lillLl Al crll sr'r sau.l "1.ri-lss.r.lci 1'1 atp sir
s;su;.r3ep \l iluir vl ll.lt Lr.r.S \\lF,-i "1iii.r.-l-i+llri)
t.t i tssl.rr"l xil I !.! $rl.r s-r n.tiLr t ior to*r .ror J?]sDd
I Lt i Lrcl I 1 i Ll.j i:- ti l,\! (r I i $ l .i
1
: I il t p.r t Ll t tt I

liU[,rl -11.1] lL) l"ir,]l.llsoti .t(ll tlll...uil ir.tlti, i1l-11 lulod I

1:1 .-ltil ur p"inssr-rei +qt.\\ol;ri \l;ril
,t"1 ltii ur -r:rtssr.ici )rll u.1rl,\\ s.ri1:r,io p.l111,1

lr,,tiiu Jill.lo ii-rruldri puu ;iur11i1 prciu"; ,i"1;*;

;lolrPill -ir; Jstrl(i
iur1lq itrclr::',lg.rLl.r rqi ol orlp l.Uuni Itil'ui
:L;l ..irl lirrlrcl ;:'Lrrr"trcl* icru;\ui-rr rrll iitrJgr"r ]ulod g
'u()r3cBJ]lro,
:l{}j'iitI ll .,!i iJ!{i1.} ;}Ll l
jil sl.'il+[i]t i,\i[,i ir].itiLlr ]rij i{,r t;i}iirs(jii i:1";L:LLt $rlod fr lsu;E fiurxo11o3 uo'l]3ut]p rous]sod unu$x€n! eqt c]3ss3,
tulod JFr o$ allqr$ Eur1lg lrlolsrtp prdrl {1rea qlr,t 6utrrncao
uur ltlr;.rr,r1; \lul{t(l r. Iessal JorJalsod aql Jo uoll]$gap rorratsod ulnurrxBursql
$liJrod )allBal ler?r$ lsH"ltJv i. :- i;ii'rt'-: '-
ficeil:s.l lillod eql l^ud aql uo '?idlu?xa JoC {.) aqdo.tlsode
"E

LL -LUVAH gHI {O NOI.LYNIIAIYXA A(OW-iAl eHl,:}SgJrdYI{3

t{
 78
CH.{PTER4: THE M.MCDEEXAMINAflON oF THE HEART

Normal Motion of these $tructures duri,lp posteriorly while the posterior wall m*ves anteriorly.
the Cardiac Gycle Nomrally. the posrerior LV wall peaks sligtrrly after the peak
At the onset *f the early, rapid filling pha_se of diastale, there of lVS. This is due to the eqlductioil putt *uy through the
is an abrupt antericr msve$lent oi tt e tVS" As the early LY sueh that the IVS is the firsr regian ef the ventricle
to be
filling phase continues, the fVS continues to mor.e steadilv depolarised a*d, hence, this is the first region
ofihe vettriele
anteriorly while the posterior u,all *rove* steadily posteriorly. to confrast; depolarisation and csnfraction ofthe
other wails
This gradual anrerior and posterior motion af ihe IVS of the LV then quickly fall+w" Thrretu-r*" fhe mation
and af LV
posterior wall cantinues into diastasis. Following wafs refr**ts chalrges in ventricular dimensions
atrial {expaasion
contraction, the IVS and lhe posterior wall (to a le$$er and*contrActiorr) over the cardiac cycle.
exfent)
mave abruptly anterierly and posteriorly, respectively" 4V ttre anteEior RV wali maves *ateriorly during
fgr'tle
iJiastole and posteriorly during systole.
Follerving the onser of sysrote, the basal IVi rnoves rapidly

The M-mode examinatio* of the pulmo*ary vatve

with
respect ts ths cursor p*sitian, stfirctures
intenugated aad the
riormal motion oF these strucfi.res is displayed
il
figure +.+.
Fuirnoiiary valve kl-rr:od$ is rarely performed
beeause it is
r8reiy usefirl in fhe warld ofreal_time 2I imagiag;
included her* fur ihe sake of completene** oity.'
ir-h* ;;

lmaging Flang and position af m-mpde

Cursor
iJsualty tw* sf *re thrce puhncnary valve
leaflets can be
visualised from the FLAX and/or pSAX views
of rtre RVOT
but only one leaflet can be ffansected by the
lr4-rnode cursor
at any one time. From the FSAX view, the
cursor is usually
directed thrrugh the rightrvard cilsp rather lhan
; through
the leftivard cusp' as the rightrvard cusp is
less likely to Ie
overshadowed by lung rissue.

Structures tra*sected by thc M-mode eurssr

The only $tructure
of interesi that is tr.ansected by the
ultraseund beam is the pulmonary valve Ieaflet
itseif.

Harmal Motion of the pulmanary Valve

during the Cardiae Sycle
During systole" the pulmorary valve snaps opens
and is *een to
*rove postericrly lvhile in djastole the leafiets rnove
t, anteriorly
tc their clased position in the rniddle olthe pr.rtmonary
a,,tery.
PH fi E As for the nriira! valve, the prineipal p*ints which ior*
th,
.EE p*ttern of pulmonary valve rnction thruughout
?{E 'iH E
P the cardiac
a6
P"u Eh
cyele have been designared letrers *fthe al{haber
{,lahle 4.2}.
>
By
s'I
4
The M-mode examination of the tricuspid valve with
ilr3r:r'* 4..:i Tils Ioj] imag€ i-hows ihe iflaginq plaflB respect
cuisor to the cursor p*siflcn, structureE i*fen"cgated
p*siticn, strl,clures transected and lhe tvl-mJcle *nd the fis.rmal
trace of ilre leit
ventricle ill0 as *cgliired irom the oarasterrai nrotisR af these stftrct$res is displaye<i !n Figure
io*g axrx view. 4.j. As
The schemalic *r*wi,1.{ lilijst.at*$ !h6 st.,J*tl{res i,.Jrrse*te<j
*s for puim*nary valve M-made, tilcusp;d valvJ- lvf-ruode is
v'reij ;s their ilrcti,5* wilh riiapect t,] the
vatisu$ phases *i the seldom performed. It has been included here for
e+rdiac eye!*, i.lols tflat the e*d,*r. lhe eftily {}it;,iq perioei the sake of
and tlie completeness onty.
one,."i oi d;astdsls cannot be ideniii;ed {ron:
:rre ivi_r:ri:,Je irsr.e
+t ths L\i ffisile. Ths iso':otumic contractici! tim* itrlCi)
is the
Frorn the PLAX of the RV inflow tract, the cursor is
periocl frorr ihe closure of ihe mitral vaive positioned to trenssct the tip of eithir tlre a*terior
or end,diastole to clr postenor
the openiftg cf the aortic v*lvel enC_diastole is identif ie.l tricuspid leaflet. The only structure of interest transected
as the
o.i$et oi the QflS complex of the B{ec{.ocardiogram by
{ECG) ,"vhile the ultrasound beanr is the tricuspid valve teaffet
cpening sf ihe a$rlic valve can b* estimalfir: Ly tir* rrrciron
r:l itself,
th€ intervi-.r]triitula. sepiLi.il 1i'/S) and posieflciloiat! The rnotian *f the tricuspid valve leaffets throughout
ipt/t') as wilh tlie
yerltriculai e,eclion the IVS and pfl eardiac cyele is sirnilar te the motion cl rhe mirrel
movs in,,,,rsrds towatcis ,1he valvp
L.V caviiy. See text fLY fr,,rthef detaijs.
Ieafl*ts. Therefare- the rnofi$n paftern can be labelled
fiVOT = ril;ht !sniriclr,ai- {,r.jlflow tri}{,.l. in the
sa.ma ma$ner and wi,h the srme t*tters as the raitrel
leaffets.

E{**,t
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I

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slurod la!,eel d;euou1*; '; :, i::t:i.:.i.
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',. , Abnormalities detecled trom the $4-mode Exarnination

.1ll'tic i . ec*entrie closure of aurtit vrllr,*t rss*e ialr:tl

, Rr:li, I tli : lri{h u [lA\"
,,\i::rr;r,- i L,:i. I " riii:ti:rtii;ri
';1'lhl ii*til,; r{r'ill *ilii,rJ. {.,i
.:ig11;;;1 i,.iii.g , - li:iiric*ii rtaliitii: !'{}s1 !!'!,i\l!ait. ;i5-{{iLiJ!f{,! rr itir Irrri
i .;;r l'1ri:. i.'{- i :.til'res
'
' MilrCal-.e{i ;l*rii* l(i(}( ttiii{it,;'t: Li$soCi:tir-(i '!r,ili:
, i;il.:r-r:,,i:ed 1....\ i!ilinq {t {- ntif:;ri lr*irlgiririrri:;1
'' i';:tttia,;:,.i rii.)l'Ire d!i!p iep;.irilti+i"!: a]'\!rrii;r.tarl '.\'iii1
: ..\S. ir:..r { (} -qrrries
. - ltrirl-s',stolir: tir,',5Lir',: oitJri aol'iic r*lr*.
:l;:,i:,: iarrei il 1,,i: I \. {.1 i" Li$lii tii.'i ir:--rt
iu.li;Ll Vilivr' ; , di$st*lrc l-lriitsr rsri(iur;ri*d *'irh Al-{
.[ .rr flct.c '. '"8-n,:tch'" : :rsst-rciaterl q ir.h incirllsril LVEtli)
,. rcclu*trl I,F sla:re: *ssi:rciateri ',qitir \'!.!. r*<!u<:*d
: L!t cor:ipli*nc*.
, . errlly .i,J1trrr. asslii*tecl r,, it!t acriic srvdrc ,i\R
: & iirst ci*giec h*rrr blocli
, . s'r,rrolic artbricr inof icn of amr !: :rss*tittetl
, with HOCII
. lt.tinnrrrciiinu" ol' rrtiti.:l !r;ri]ets. i:i\{}r'i,rtt'(l
i ,.virh il't\JP
I Left Ventriclel . dilatarion
Itr-vi, nigi', l. reduced sysrolic function
I , jrri-'r'eascC u tll rl'ricktress: asstirilt*C ',r.itll
, l:-r pci'{r'ii1-.h,t,
i " r.lccrelscel toIi thickni:ss: IltYorrarajiai sfnr'rnr.t
: tollor\ rllc h'l I
l'"ffT"" l. atrnorrnal scptal rrr{ion: clue tu l.Bt}t}.
i ischaentia r,ri' i*ihrction. pnceii'rakrr rhr ll:rrr.
: post *pen ireari sr.rrge rr'" l1\,' r,*lunrc or pre .-isr!".
I cverload
i. rliastclic ljutler r:1'!Vrt: associnreci rr,irh A ti
I
. liclr*ard ra I ei'iiriiarr
1P*itnrrnary i' iricrear*d ii wa\e: ass*ciated r.vith pulnroni:r-r'
, \''alr e i $tenosis
i. de*:r"eas*d a \1.a!e: associared u,ith 5xrlnicr;iri
j hi,p*rtrnsi*l
i" *tid s5'str:lic nctching bet*'een the c-d sl*pe:
i characteristic of pulrn*rary hy'pertension

The BeH text in the Detectable,qbnocnalities coiumn refer$ to ihe *cho ei{ample shown in the dght csiurnn.
A$Ivi = anterior mitral valve leaftei; AFI s ssltic r'egurgitd,iorr; A,S = s*rtic Btenasis; ASH = asymrn€triq ssptal hypertrcphg *AV = 5iq$p;3 r*41.
valve; C0 = cardiac output HOCM = hypertrophic obstructive cadiomyopathy; IVS = interuenkiculaf septum; LBBB = lell bundio branch block;
LVEDF = le* veniricillar end-diastslic pressure; LVOT = teit ventricular outflow tract Ml =myocardial infarction; MS = mitral stenosis;
MVP = rnitral valve prolapse; RV = right ventricle
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61.j I ixot.rn'rrrs-Iv3 cNy sr,Nal^r:Ixrlsygr,lr JlHdvusotouv3oH;il TvNolsuglr,ilo-CI*rJ ;6 NrJdyHJ

I
 I :{i CHAFTE& 9: TWO-DIM ENS1ONA L ECHOCARD IOCRAPHIC MSASUSEMENTS AND CALC ULA

Estrix:ail*rr sf HV volurne* is rirffic*ii via ?ti echocardr,::E:aph.v., becalise: ij) iirere is no simpie glaomilirc :r,a!tr .-=-
apploxirlates the carnplex shag:* of ihe fiV and q2) *rer"+ is ;ro on* iina,.r.inq piane ;hai visuaiises tir* RV :rr ji. -.: ,:..
I'i-r+r*f*ril. ilstimair$ir r:f tre RV r,,$irl*:* vi* ?ilj *ci-r*L:arrJi*6raph17 is ncr f**sjbte in ti:e r*uiiii* exar-ninati+r'1.

Figure I'84 These images acguired.frcrn tl:* stlQcastal 4-chamber view demonstrate maasurernent of the right rrentric*iar
fHV) fr* ,.dr
idgrlt). The ffl fre+ wall thickne$$ is miaured at the peak of the R
lhicknesB. To impror-'e rneasuremeni ascuracy, he irnage is ecomed
y:i:-:jl!! ryfpertdiqll{ :s tl9 RV \+dl. Calirers
!-CG:39trailing are placa{ at the level e{ the ante$or tricuvpid vatve kaffer {arvr} tip irom rhe
leading edge-to-the edge 6f ths HV wail. *A . riEht atrium. rj

Figure S,*[ Frern a RV-6ccusad dsw, the BV are*s are traced at end-diast*le feft] and end-syetole {rigpfrg. Tha RV endoesrdial barder
is trEead at the blae k'white interfrace between the cornpacted myscardiur* 6fid ths verrtdeut*r cavity, exciuding the trabesulatians, tlE
tri6us$d valve funn*l and papillary muecles. Froffi th€se ffiea$,r€mentq the RV fractionel aree ehang* (fAe) c-6n be eatimat6{,, lnthis
exernple, the FAe i* c*hulated asl

= ff19.1
__
- 1G.9) + 19.-t] x-t00
43%

*ieuspid annulu$, excludirig the trabeeulations, thd tricuspid diastole and the RV erea a( e{d-syslole (Fig. 9.?5) and il
valve frnaei aad the papiltary mtrssles. RV ar*as difibr between derived as:
men Bnd women and measurements arc also influenced by body
size. Thercfore, t&ese measurem€nts should be indexed for the
Equntion 9.20
BSA by simply dividing the RV area by rhe BSA. FXC= ffRVAED*RVAES)+RVAED] x jgg
RV areas are $*t tyFieaily perfonned in the routine
echocardiographic examiaation; these e.teasuraffie,r?ts are
w;here FAC : fractioual area change (%) .

r:sually performed tvheu a$ additional fllrasulement for RV

: riCht ventricular area at erd-diastole (cm:!
RVAE$
systolic function is indicated (see below).
: right ventriuular aree at etd-systole {cm3}
RVAE$

The primary limitation of this method in the assessmeot ol

EV fuetolie Funotion
Cl*h,at RV systolic funetion can be fissessed
calmlation afthe RY &actiosal area change if,4ci" The FAC
is the percentage of change in the RY cavity *rea between
end*diactcle rnd *rtd-systole. This msas*rcment is sinrilar iit
principle to the LV e&lsrrlatians of the FS and EF. The FAC
ir c*trcillntsd fi:rm 2I] m€asurefxgnts fff tbe RY ere& &t €nd*
RV systolic furcti*n is that i[ relies on good quatity imaga
by rhe aad *ndacadial border definition. ln particular; the 'drop
out' sf the RV trareral wall ie a sornfinsn pmblem when tlx
RV dilares; heavy trabeculatiols also mak* ideatification ol
th€ true endocerdi*I border diffisult. In additi*n, rlre
fAC is
derived fi*rrt only 6ne imaging plane and does n*t take into
aceount rhe RVOT.
 -)
If

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lit.
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i

TJ
:f,v-- ;ibo'oe shoi-rld 1ir:lil sirriil*r \aliics. As tht'crisir:il ir.s::
palirits plqvide ilistinct illiatiinricill iarrdtriarl<s. nt.-ilsrriL'..-r;
t),t- ol'the anrrLrlus r ia this te cirniquc is nrorc re pLr;iiuciblc
ll'ht ntrlral LV[]T dianieters for-rlcn:rnii *olr-rc.rr ar; I :.-
+
aiorrg r,, ii.li oihrl norrr'al ii{rrtia nlcasltl-etlents in 'l-:iblc .i .l
;t1
' ----
4
x L;-
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= *.fSi x I)' fule+suien-ieirls i-ai' ti:c tt'v'l] I' at irir',.- r. -
"ild.iiir.lst{}}c
tic-ccnbed prelroLrslr {sre \'leasur*rrents ol- the R\'1 \\ r :
Left Ventricular Sutflow Tract est i r11a1i ns rlie R\'O'T strtikc r,oiu me. the RVO1- { r:r pti I irii . -, -

The LVOT lor aiinic a*tillusi is ri:easurerl lirrm the Pt,AX
rl rriid-svsti:lc oi ni*riur*l aorijc valle opcnirrg. Ceiipe rs ar*
;:inreii lirr.n {l.re irrn*r cdge r:ftirc cusp*l l:Tstriion r-.1'lir.: riglit
cc:'f)!r;il'ii rLrsl: i;.:to tirc ivS to ilie ;11nci cdq* r-)l'ir,'hci'' lile
nLlr-r-ca)i*!'isrji iLrsp 'r'r':i-,-'1-(' tlri: a;rt*:'i*r iriitiai i*afi*t i l;ir:.
nnrulus ) is nrra-qur-ed at nrid-s,vstr.rle or at nlarinral []r;lr:..,,; ,
,,'al!e ol:enir,g. illensu|enrltrts c.an usrrilllv bq pci'lorfire d ir
tlre i:tS,\X lieu r,ith lhe crlipr'rs placcrci iisinl ii-rc itrnrti cJ---
ti)-ir'lncr edqe rnr-'thoiJ..1rist ltloxirr:ll li lhe piriirioiiru'.. r,
if:r3. t).-l-l;.

i:ig*r* t.:l Th€$e images d+ffionsirat* moasilrs.t*enl oi the iefl ventricuiar oiitilow tract iLVOT) frcm lhe parast€rnal iong axis (Pl-AX)
vie'r,,. To imr:r*ve fleasliremeili aciluracy, ine imag* is zocmed (jight1. ltFeasr:refirsills are pe|fornrerl perpendicular to the iong axis of
tn* a4$a via the il}r:s|' edg*-i*-i.!nea +*!e techiltqile ai *riri-sl,stole . 'fhe LVCT cair be i'neas*r$d :1i the cuspai i;rscitisn p*ints (y--ijot,
dasl*d tine) or 5 n;r* int.J the LVCT {whlte dsshsd lire)" At th€ eu$pal level, the ant€i;cr caiiper i$ pssitr*ned ai the Juneti{rn oa the ailter-icr'
i|i-c1i:i corcnaryi acrtic cusp and :he inlerueiriric:jlfir $eptLm iiVS) v-(hjle ti.:e poli*rioi- ealiper is poriiianed at thB iur[tion o{ the posterior
q*o*-c*rcrraryl aarfi;t tus.S afid ih€ anterior ftliiral vfllv€ i*affet {ffr*vi}.

'ti*rrt. 'Tn impro';e !"naasirerr€ni accuiacy. thc i;"faq€ is zce,rned {rigft). i.,.1*ss!rerents aie perfermer:: perpencJicrial to the icnq axiE oi t:1c

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 I;8 {. l li\ PTL.lt 9: 'I\L 0-tll!lL.NSlON A l- UCUiICA tt tltOLiltAPll I(' \'11:lAS l. iR L.\'{ 85.1tr S AN IJ [',,\ LCI]L;\ I
ffi,
h

5i-1*.r* *.*$ ihese image$ demon$trate fiea$uieflent of the tri*uspi* annulus {fopi aild the mitr*! annulu$ ihqrtsfi) frsm an apica!
4-chanrhie; vierry. fu
imFrove measurer}]Brt accuracy, the i*tage is eccmed over eacn annulus- h,{oasureffients are per{one*d ln eany-
rjiastole i2-3 franies after.th€ e*ri of the T !ryave). Calip*rs ate piaceti ai the inseriioil of the ieafiets irlto the verrtrtcular mysccrdiilffi, lrsing
lhe i{:!'!er erJge-ti-;rarer edEe technlque.

of peripheral ataachr*ent of the aortic eusps $s the aortir rrdl.

The greatve*sels thatcan beflileasured by2Dechocardiography
inciude the asrta (at v$rious leve[s), the pulmonary *rtery and
its branehes, &e i$&riar vena cava (IVC), and the hepatic
veins. N*rmal measurernent values are listed in Tables 9.9-
.frr
9.12" Partition values the severity cf abnormality for these
itl
rne&$ursments are not available"
Aortic Dimensions
The aorta can be measured at multiple levels. These ittelude
the LVOT di*meter {or aortic annulus} as described abcve as
well as: {}} the trene-sinus aortic diameter, (2} the sin*lubular
junctian {gT}, {3} the proximal (or upper) ascending aorta,
{4} the aortic arch and, (5) the descending aorta.
Tran*-sinue *ortie Biarn*ter, $TJ and *sc**ding Aorta
The trans-sinus aortic diametcr {also referred to as the aortic
root) is measured at the maximum aortic diameter at the sinuses
of Yalsalva. The sinotubular jurctien iSTJ) is the axatomic
.junction ktween the sinuses of Valsalva and the tuLrular" pc*ian
of the uppcr ascending aorta; this junction denotes the point
The ascending *erta extends ftoru the ST"l and tenairat€c a!
the origin rf tJre hrachiocephatic artery. Measurer&eats ar€
prfonned perpendicular io the long axis *f the ao*a in tfic
acte*or*pcsterior pla*e {rom a high FLAX view; the trans-
sinus aortic disrnetcr can als$ be measured in tfte antenor-
posterir:r plane ftorrl the PSAX view et the level of aorta. All
measursmeBts are pertonned at the onsst of fhe QRS eomplex
of the ECC {a surrsgate for end-diastole}" T?re recommended
measurerne$t technique is leading edge-to-leading edge method
(Fig. 9.37, rniddlei te:]. Ho*,ever, to allsw direct comparison
of the measurements with those performed by other imaging
te*hnotrogis$ such as magnetic resonance imaging {MRI} and
crmputed tonmgraphy {CT}, some ifi$titutions pre&r the inner
edge"to-in*er cdge technique {Fig. 9.3?, right). Imporaatly.
diarnei*rs via the leading edge+o-le*ding edge tand to be
several ntm larger than those diameters performed via the irner
edfe+a-inner edge technique {see Table* 9"} and 9.1 t}.
The aseending aorta can also be measured from the right sternal
edge, *speeially when th€ *orta is dilated (Fig. 9.38). When
perfomi*g this ffeasursment, the distence between &e ao*ic
arm$lus asd the rneasurenlent site should alss bs rcported to

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!luirIIo:nril-i.)!\ 'i0t'6 n'!^:l ) r.\it \ ;qtre dLrol 1ru..l:.;s*.rcir.ls:r";t r-iio-;1 'arolsraql 'a$r $*r*ue,rpl7 i..iitn #$ee;rui e;jo? fiurpuecs:
pA"lnSf+lLl 3,lll SilCiltil;11.1!p rii"lf,it j:-irtg-,ii.r.r',.p J)ilt'tl.1.ill:rti.jarit ii,.L
pLiB il3 )alauretp 3!UoE sill;ts-sr..i?.ti *ql"'.iFlnstlJrd u! 3a?
puE azi$ ,{,poq ,{q pasuarl{ui $-$lE {}l* {}i.il? iJsr,r}sin
piilJ Ual-]"j lJ*O'lAtai.i JSlliil Sitj*$Jg.lIs?aijj }tU*C f u9ii,,

'{Ot'O '6tai eiloe eqiJo srxs Bual

3r{x o} Jflrcrpuadrad SuFnsesu iou sr susrsuetlIrp }rilcB 51il pue
lelaul"lp JoAl 3lil .tOJ ro.u; lsr{ilsrnsrsur u0rilu.rs3 lsou eql
'lEuiJoEqu sE psgrrssBls 3rs sss +
z
&ffi/r xfld +ul uloil $6liJ.ii1uoll
furpeerxa quauerns*epJ'a8u puu ezrs r{poq ,{q paruangul oslu lseq s! luau*sr1e siul puE Bl]oE 3t"11 lo slxB fiuo1 eqi c:
rB jnsl$)usdiad palujaljsd eQ lsnilr sliJ€ualnseau.l SluoE
aJ? pu? u3tB061 pu* uatll uas*rteq legtp slueureJnssgh{ .
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selq€I ul prlstl er? sluaiurjrrsueil quos aql JoJ s3nls,\ lsrujoN snuts-suE.ii aq1 fluiu.ucpad "io1 r*arn pat,retra:d aq1
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}uauernsBoru siili pi.tts
snlnuua clUoc 3Ll1 l"lilanniaq a3u?lslp ail] :iei $nlnililB 51uos aql .uc;i Lu$ g-g,41a}e*rxorrJde ps.rnseau; sr rpoe
Buipua3se sqt lg1li *1g€sqc
(;q6pi poula*i o6oe "leuur-o1-a6po .rauut eql cr^ .ro
{erpp,ru) poqisiu espa hurpeet-a;,a6pa Surpeal arl} etr\ ,ppse aql }s qre Suol 6qi ai
'lElrrslpu€dJecj 'xalduios SUo sql lo ia$uo alil ie paurJoi;od ere siijsuielnseopl '{g) epor 6urpuasse aq; pue ,{7) l;ollruni.reprqnioure eqi'(gi
Jalalrrerp snuls- BUsJl lPLUrxEr'jJ eql10 slualua]nsPalu s+le]lsuou]ap 'nnotil slx? 6uo1 ,*6eur srql
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1 iir;

icrrq a>:is jl;l*ii doi/ed *iies).

FiELre ra..g* lhese imeges ajerr.;fistrate the rieasuremeni of the aor^tic arch (l) ar-rd cJescenciing aorta {2) ftom the su,lrasterna, lonq axis
view. Measurema,-lts are pedormed lfirm ihe onsel ol Lhe QRS ccmplex of tlre ECG. The aorlic arch is Ilreasurecl via lhe |eading edge-to-
leaCing edge nrethcd iust pr*xinral to itre origin cf the brachiccephaiic artery {B,Ai. The des*ending aorta is measured !'ia the inner ecjge-
ic inr-.er e,jqe niethcd jLrEt .lrstal io the criqrn al tlre left suhclai;iai: ai-l*r; {L-iiA} and ai the assurn*d levei of the ligamentum arieriosirm.
Asc Ac = ascerrriing ;:errla; HFA = t-ilht pui;ronary a*+ty
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'fS-Et L:{A}*e:qel gi0tr :rforp"recou.*E 3oS ilry ra "ffiuBtrosail ,llsu$*l/$ rElrl*s?AqplES rs, {ta!i*S BU"
Ar.idet6ouoj p*lndrlo3 rqnsserropte3 1o iplcog aq1 trq pesiapua ;6u!6eiul ;eJnlse^opre3,o ilenepossv upadoinl at;} FUe ,Qdei$cpreeoqrl lo
,{ra;rog ueru*urv aq} rua4 :sllnpE u! EiroB $reroq} eq} ro sesabqp 1o ourseurr &rtsB,oriltl*E 'F le 'S EIBgqV 'V e$fl*Suel3 'VS tJF}splo$ :ocJtrog
lEu#ou Jo iruri.rsddn * N-ii'l :paqlauj a$p* fiu1pw;-e1-a$p* 6upeq = 3l-3': :Pnjslul *3uspliuo3 = 13
':uI g'e *rolsq VSB zu., l.'0 red r"uru g'0l3e;lqns.lo /rr 0'A snoqe vSE ,u,l 1'9.rcd **-l s'0 ppv:tl+it Jo*
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.i::i:r:.:
i'. i : N*rmal lndexed Flelerence Limits {or Aortic
Mea*urereents {lE'lE Method}
lnferiorllb*e S*va and Hep*tlc l$*in
?he IVC and hepatie veirs can be measured frcrn th* srrbeod
.\Ir.!\r j 1!r*ri:rrl i lltii
Iong axis of the IVC {$'ig. 9.42)" The IVC diameter is r*eesut€d
Sinrrs nf \jai.qa l1:3 {
gv-:1,.111: ; perpendicular to the long axis of the IVC just pro:cimal to tb
<3S tr-55 * $.15 I.5l i. 0. I I junctiac of IYC with trepatic veins or about I -2 cm proximat o
30*39 1.65 * 0.16 1.5? .l 0. l3 the lYC.RAjilncrioil. The hepatic vein diameter is m€asurd
40 *49 1.68 * 0"14 t.66a0 t5 perpendi*ular tr thr long axis qf the vein abaut t-2 era frorn
50-59 1.79 * 0.16 1.58 * 0.17 its mkance &ts the IVC. Measurerrents are perfonaed whea

I
60-69 1,75 f 0.17 L78 'L 0.16 thesg vessblo are at their bugest climensions which is usually
>7* 1.82 & 0.I9 L8l * t.l7 rat aid-expindi*n; calipers are placed using the inner edge-to-
Aii $q*q.lt t "66 * 0.18 inner edge method.
TIre IVC size can also be measured at its minimal dirnensim
Sinolr"rbular "l unct ion {cnr,, mr }
(usually at end-inspirarion). The IVC size and its collapsibility
<10 i * 0.14
.l5 l.f I ,:, {} 13
* 0.15 .l.l ., il.1 3 with rcspiration can be used ts Estimate ihe RA pressurE
30, 311 t .43 !
{see Chapter I I}.
10*49 1.46 * {} 12 I..1I ',, {) 1i
50 5! t .57 * fi.11 i.4i,r,f)15
{il} - i:Q 1.4?{0"16 l.ii rt) t6 T:*ble *,19 Nomul Heference Values for Pulcflonary Artery, llE
.:' ?() t.47 + 0 16 and Hepatic Vein
Afi i .3r) ,,. {'i.lg
.\srcnJiri.{ur'-r (crl rr: :

- F*lmona4: artety
<30 l"5t * CI.t6 i.+: ,; ir ri,
{PSAX) {crn}:
30-39 1.54 + S.t8 I.45 + 0. t4 - MP.A 1.8* 0.3 0g l9
4* -49 I "64 + 0.14 I * *.15
.55 - R.PA 1.2* 0.2 ii1 l. j-
50*59 t"80 * *.14 1-62 * fl.15 . LPA t.t r0.2 {i.i I..i
6S-69 1_76*0.17 1.73 * S.l7
>70 1.82 * 0.33 1"75 :l 0.14
IYC (arn) 1.6 * S.3 r:*tl
1.57 * S.t8 tic vein icrl) 0.8 * 0"2 {i5- !r
j ,j
IVC = inleriar uena cava; LAP = left puimonary adery: MPA = main pulmo.ar.
.,\oii ir: .\ rclr {cm inr
afiery; PSAX ? parasternai shorl axis vie'"v; EFA = right pulrnonary ader,
.r: J0 !(.i7;, |i. I{} : t.nt*0.t.; Source; Tr"iulzi, M, Gillam, LD, Cientile. F, Newell, .lE, Weyman, AE. Nort
3{l j.a l16:(i. 16 !.{i8,r0tl Aduit C[css-Seclional Echocardiogrephic Vaiues: Linear Dimensrons a::
.inamb*r Ar:_-as. Frl;oea,.efi*g;r_.pL"y. j gi14 *r:l:1 i4). 4C:J+2S_
.+li - 4(i t.i:<r.fill j i.l-1 .,0.ii
i.;l?'i il.ii j i.ll,, lt.i?
$(l - 6i, I25,r,0. 14 : l.l{}+(1. II
> 7L) l.l7+0. l: , 1.?2 1,013
4 !r l.i9+:il15 : I,li.i(j14
Va{ues e::pressed es i*dexed fl:*an vaiues * Sfi
iE-lE = i*ner edge-to-inner edge method
$suree: Mirea 0, Maffessanii f. {iripari t Tarnh*rini C, Mutalcri M. Fusini
L. Clatflia C. !:i*r*nii,r; C. pie$efi i[, Pe*i !*.;:- $fr*cls 6i e$iilJ an.j i]cd] s!z.e
en **:xi;Iai a.a'd aseenCirg ac,r:a a*d ac*ic arch: il*ei edge-tr-inne; +clge
r*d*r*nce values !il a iarge adillt popillation tly tw*-{iimsr}sionai trafi}lil{lracic
scro{aid:ografrhy, i .4m S*c Eci6c*rcrogr ?$ 1 3,qpr;t6(4): 4 1 S-2 i.

$i6*:"r, "1.ri* These subcosta! images demonstrate the measlrrernent of the in{erior vena cavB ilVC} and hepatic vein (11\4, Measurements
are pct''+rmeci via the inner edge-tc-irurer edg* rnethod. The lalaxi,-ilurr iVC diainsler is meagured perpendicular to its long axis ar1c, jliEt
prr:ximal i* l.lV-lVC junction i-J). Th* maximunr HV rjis.meter is neasur€d perpenclicuiar to its long axis abcut 1-2 cm prcxiftal ta HV-iVC
iiini:tiryn i?!. fiA ., i'iqht iri.ailin.
I lr! t'ftA1'1'\rii !i: lllll]i)i-llit-11,\1-,L1OilYNi!'\4i{- i .:ii,.t-\.i.'-'-i r

IVClSVC Pu!. veins IVCISVC Fr"ll. veins

, I
, ,
{ I
!
..-i*", iI
I

JL
(,i}
'(/ll
d)aJ
+
I I II a

Fru I *Lv ^ B'Y .t eA

,L.rt LV I
I
* I
I *
I
t
t
* T
vsD I
t r ,
t
a
I
I
I i t
I t
affi
Y Y ffi ffi
Y
&
ffi ffi ffi LVOT
ffi
A A ,
t I ES, Asc Acl
****/ a
-*-.,
i;iir:ii]r+ -l l.T This schemal'c illustrates the vctlijmetric flsw Fig:.:r* 1i.* This s*hematic illtrs{rates the volurnetno flow
tnrough the systernic and pulmonary venous circulations as through the systemic and pulmonary venous circulations rn a
seen with an atrial sepial defect {ASD}. Volurnetric {low or siroke vefitricular eeptal de{ect fl/$D). Vohmetric ilow or sircko volurne
velurne is elepicted as oylinc.lers (r#cail that slroke vclume rs is deplciec as cylinders (recall that stroke volume is derived
ieriverj frcm the CSA and the VTI measured in *mi. Observe from the C$A anci the VTI msaslrred in cfil. Observe that theie
thai ih*re is s*urrting irorn ihe left atrium (l-.{} t<i the riEht at!'ium is shunting trorn ihe iett ventricle (LV) to the right ventricle (R\4
(RA] vta the ASD. This ieads io a greaier vqiume of blood flow via the V$D. This results ;n a greater volume of blood flow to
to the pulrnsnary circulation comparexi with that to tlre systernic the pulrnonary eirculation compared riith that to 1he systemic
circulatlon {Op } OS}. Also otrserr'e thai the strci(e v{i,ume circulaiitn iAP > QSi.
through the tricuspid valve {tv}, rigi'll ventric*iar outflow tracl: Aisr) ob$erve that the siroke volurne throuph rtght uentrieuiar
(fiV*lj, and n]ain pLlmoftarl] artery (MPA) is the same; vthile outflow traci {EVOT), main puimonary arfery {MPAI and the
the strol<e voi*rne through the firitral villve {n.;v}, left v*ntricular mitr*l vaive {mv} iE thE sarfie while the stroke voiufte throuoh lhc
*uttlcw traci {LVOT}, and the ascendirig eorta (As{:Ao) is ths lelt veritricuiar $utflow rract {LVOl-i, the asceftding aorta {AscAo}
sarrre. The.'efsre. QP can be caiculated ai the tricuspid annuius, and the tricuspid valve (tv) is the same. Therefcre, Qp can be
frVCT, or the MPA; whiie QS can be calcuiated at ihe rnitral ealculated at the RVOT, MPA or the mitral annulus; while OS can
annillus, LVOT, or the asceflding aorta. Dile to the increased be calculated using the LVOT, ascending aorta or the tr,cuspid
*olurr:e of tlic*d shLlnted to the IIA and right v+ntrieie {F4, th+ annu[is. Due 1* the inereasad volume of blood relurninq tc ihe
iirrht rcafi t*nds t0 be dilated. leli h*ar"t from ti."e Iirngs, tlre left heait lends to tre diiateo.

iVfi$VC Ful. vs!ns

{
I
f
I

,!1-,
iii !t
-'i r lt'
T

iti .a F!;-:,-tr+ 'i-i,* Thrs schematic illu$lrates lhe veiurnet.ic fiow thr+uSh
i!f\ I
ihs E'fstsrn;c and priimor:sry venous sircilialio.)* in a palent *uctus
a
I
rLV I arterlosr.rs (PDA)" VolurTreiric flr:w or stroke valume is depicted as
* I I
I
I cy-iinders {recall lhai volumetric fiow is derived frcm the CSA and th€ VTl
T
! I n:easure,ci in cnr). Ob-s+r.:e that there is shuniing froff tha detcenciing
I
+ Y aeffa {Aoi to the pulfienfirY a$err/ uia the F1pA. This re$ilit$ i!^r a g{eafer
ffi
I
r;r:irim* o{ blc*i] ilc,,v to ths pill${}tlary citcil,atiin eo*lpar*d \rriih lhat
i. ..

i_-:
LVOT
w tr, the syslemic crrculat!..x {fip } OS).
Aisfl $hseive that the :itfcke voiumtr ihrough right Ventricular cutflow
tract (fiVCT). main pulmonary a$ery (MPAi anci ti-!c) iricuspicl veltre (iv)
& ,$ th* safie sJhile ihe -qtrck€ v'.ilufii€ throllgh the lefl ver';tricuiar eattlow
Asc A,:: tract {LV*I, ihe asce::ding aorta {AseA+} ans the ftitrai vaiv* im',1 i* titc
sams- Thereiore, QH lvoiuir,e r*turning itonlihe iungs) can be caicuiated
at the LVOT; ascending aoiia (proxrn']al to the pDA) or thE mltrai annuiils;
while the QE {voir:me returning from the body} csn be calcuial€a at ihe
HVO-,. MpA {pr*::inrel to ttre P}Ai ar the tr:cr*piel annult.;$. *i:e to the
inciEa5ed volume of blerid reltirninq l$ ihc left neart k*ffi the t,,ngsl tne
ieji trearl iefli1,'- i* tre ciilated