transthoracic echocardiography (tte)
TRANSCRIPT
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DEPARTMENT NAME
TRANSTHORACIC ECHOCARDIOGRAPHY (TTE)
Angela Gooden RN, MSN, CPNP-PC/AC
Director, Advanced Practice
Cardiology Nurse Practitioner
Instructor, Baylor College of Medicine
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DEPARTMENT NAME
• Describe basic principles
• Review limitations
• Describe the various methods
• Identify common views
• Review reasons to obtain an echo
• Identify normal findings
OBJECTIVES
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DEPARTMENT NAME
Basic principlesUtility
INTRO TO ECHO
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DEPARTMENT NAME
BASIC ECHO PRINCIPLES
• Non-invasive imaging • A transducer placed on the
chest emits sound waves that are used to create images
• No known adverse effects at clinical imaging frequencies
• Sound wave reflection determines image brightness
Sound wave reflection• High (white) = Air, bone, tissue
• Low (black) = body fluids, e.g. blood
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DEPARTMENT NAME
UTILITY OF ECHO IMAGING• Quantitative and qualitative
evaluation of cardiac anatomy, hemodynamics, and function• Chamber size• Systolic, diastolic function• Valve motion, function• Masses, fluid collections• Hemodynamics
• Data is influenced by height, sex, age, ethnicity, body habitus, and athleticism
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DEPARTMENT NAME
ScreenWindowsPlanesProtocol
IMAGING ORIENTATION
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DEPARTMENT NAME
SCREEN ORIENTATION
Transducer
L: Medial/right structures
R: Lateral/left structures
D: Distant anatomy
L R
D
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DEPARTMENT NAME
IMAGING WINDOWS• Suprasternal
• Parasternal
• Apical
• Subcostal
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DEPARTMENT NAME
IMAGING PLANES• Long axis
• Short axis
• Apical
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DEPARTMENT NAME
• Parasternal, long axis• Parasternal, short axis• Apical• Situs View• Subcostal, long axis• Subcostal, short axis• Suprasternal (arch views)• Ductal view• Pulmonary veins (crab view)
BASIC IMAGING PROTOCOL
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DEPARTMENT NAME
2DM-ModeDoppler
ECHO TECHNIQUES
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DEPARTMENT NAME
ECHO TECHNIQUE, 2D
Two-dimensional (2-D)• Cross-sectional• Snapshot, provides real-time
imaging in quick succession
Usefulness• Assessment of cardiac
structure
• Assessment of chamber & vessel size and volume
• Quantitative assessment of LV function and ejection fraction
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DEPARTMENT NAME
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DEPARTMENT NAME
ECHO TECHNIQUE, M-MODE
Motion mode (M-mode)• Ultrasound signal transmission
along one line• Graphs represent depth and
strength of ultrasound signal• High sensitivity to recording rapidly
moving structures, e.g. valve leaflets• Useful in providing dimension
measurements, e.g. shortening fraction
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DEPARTMENT NAME
Continuous wave (CW)• Doppler continuously sends and receives
signals across moving blood flow
• Detects high velocity flows: Blue, Away-Red, Toward-Turbulence, Green
• Measures severity of stenosis, regurgitation in valves, shunts, conduits, etc.
ECHO TECHNIQUE, DOPPLER
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DEPARTMENT NAME
ECHO TECHNIQUE, DOPPLERPulsed wave (PW)• Intermittent signal
• Allows spatial localization
• Limited by velocity of flow
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DEPARTMENT NAME
ECHO TECHNIQUE, DOPPLER
Color Flow
• Integrated with 2D image
• Displays blood flow timing, velocity, direction, and turbulence
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DEPARTMENT NAME
Acquired images and demonstrated structures
IMAGING PROTOCOLS
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DEPARTMENT NAME
PARASTERNAL LONG AXIS VIEW• Transducer at 3-4th intercostal
space
• Structures: LA, MV, LV, LVOT, AV, IVS, RV, Ascending aorta
• Tilt and rotate the transducer to see RVOT, PV, PA
LA
LV
RV
LA
RV
LV AV
MV
Asc Ao
IVS
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DEPARTMENT NAME
PARASTERNAL SHORT AXIS VIEW (PSAX)• 90° rotation from long axis
view, tilted superiorly
• 1 dimensional assessment
• Structures: AV, LA, RA, TV, RVOT, PV, IAS
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DEPARTMENT NAME
PSAX TRANSITION• 90° rotation from long axis
view, tilted superiorly
• Great vessel level—Focus on aortic valve
• Mitral valve level, anterior and posterior leaflets
• Left ventricle, papillary muscles, apex
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DEPARTMENT NAME
PARASTERNAL SHORT AXIS TRANSITION
1: Great vessel level 2: Mitral valve level 3: Papillary muscle level
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DEPARTMENT NAME
APICAL VIEW
Four chamber• Transducer at the cardiac apex
• Structures: LA, MV, LV, RV, TV, RA, interatrial septum, interventricular septum
LARA
LV
RV
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DEPARTMENT NAME
APICAL VIEW
Five chamber• Transducer tilted anteriorly
towards the chest wall from the four chamber view
• Aortic valve and ascending aorta come into view
LVRV
LARA
AV
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DEPARTMENT NAME
SUBCOSTAL VIEW• Transducer placed under the
xiphoid process
• Long axis: IVC, RA, IAS, hepatic veins
IVC RA
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DEPARTMENT NAME
SUBCOSTAL VIEW, LONG AXIS
LV
LA
Liver
RA
• 4-chamber view
• Structures: RA, RV, LA, LV, IAS
RV
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DEPARTMENT NAME
SUBCOSTAL VIEW, SHORT AXIS• Structures: RV, PA, LV
RV
PALV
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DEPARTMENT NAME
SUPRASTERNAL VIEW• Transducer placed above the
suprasternal notch, ‘arch view’
• Ascending/descending aorta, arch, take-off of the great vessels, and right PA short axis
RPA
Asc Ao
Dsc Ao
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DEPARTMENT NAME
PULMONARY VEINS• View from the suprasternal
notch, pulmonary veins and LA
• ‘Crab view’RPA
LA
Ao
1
23
4
SVC
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DEPARTMENT NAME
IndicationsLimitationsFindings
ORDERING AN ECHO
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DEPARTMENT NAME
INDICATIONS TO REQUEST AN ECHO
• Evaluate valve/ventricular function
• Evaluate for structural abnormalities
• Estimate intracardiac/vascular pressures
• Rule out cardiac source of embolism, e.g. stroke or TIA
• Evaluate for LVH with hypertension
• Evaluate pericardial effusions• Assess for intracardiac
vegetation, masses, or thrombi
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DEPARTMENT NAME
LIMITATIONS OF ECHO IMAGING
• Poor acoustic windows: Obesity, chest wall deformities, chronic lung disease
• Excessive movement—sedation may be required
• Masses
• Apical lesions
• Aortic dissections
• Pericardial disease
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DEPARTMENT NAME
VELOCITY DATA• The simplified Bernoulli
equation translates velocity data to pressure gradients
• Velocities toward the transducer are above the line, those away are below
• Flow color: laminar vs. turbulent
Valve Peak (m/s) Range (m/s)AV/Ao 1.3 0.9-1.7
LV 0.9 0.7-1.1MV 0.9 0.6-1.3TV 0.5 0.3-0.7
PV/PA 0.75 0.5-1.0
ΔP = 4V2
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DEPARTMENT NAME
BERNOULLI EXAMPLE• ∆P = 4V2 = 4 x (5) 2 = 100 mmHg
• Interpret with caution when there are multiple levels of obstruction or small/long vessels
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DEPARTMENT NAME
NORMAL FINDINGS• Mild mitral, tricuspid
regurgitation
• Chiari network• Embryological remnant of the
sinus venosus R valve
• Web-like, mobile structure in the RA
• Eustachian valve• Endocardial ridge or fold at the
RA/IVC junction
• Crista terminalis• Embryological remnant of RA
fusion
• Anterior muscular ridge passing from the SVC to IVC
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DEPARTMENT NAME
COMMENTS/QUESTIONS?