Basic Echocardiography

Wendy Blount, DVM

 Echo Technique - Anatomy

Tricuspid valve Mitral valve

• Septal leaflet • Leaflets are less
• Parietal leaflet distinct
• Posterior & Anterior
Pulmonic Valve
• Right cusp Aortic Valve
• Left cusp • Right cusp
• Intermediate cusp • Left cusp
• Septal cusp
Echo Technique - Anatomy

RV
• Conus arteriosus - RVOT
• 3 papillary muscles

LV
• 2 papillary muscles (usually)
Echocardiography

Equipment
• Transducer - microconvex or cardiac
(sector scanner)
– small footprint
– Fan-shaped beam or sector
• Higher frequency for small animals
• Lower frequency for large animals
• Machines range from 2.5-10 MHz
• 5-7 MHz will work fine for most
dogs and cats for echo
 Echocardiography

Equipment
• Double window with simultaneous
B and M modes
• Can do measurements on B-mode
or M-mode
• Need a cursor which can measure
mm, or cm marks on the images
• Ability to capture images is
important
• CINe loop is helpful (3-7 sec)
 Echocardiography

Preparation
• Thin coated animals – alcohol, part the
hairs, gel
• Thick coated – shave the window – at the
sternum, just behind the right elbow
• Sedation only if needed
– Acepromazine – 0.025 mg/lb (max 1 mg)
– Buprenex – 0.01-0.02 mg/kg
• Or butorphanol 0.1 mg/lb
– Mix together and give IV (handout)
– Trazadone (cat study) – lower BP
 Echocardiography

Indications • Cyanosis
• Murmur, CHF • Effusions – pleural,
• Gallop Rhythm pericardial, abdominal
• Arrhythmia • Cardiomegaly
– Tachycardia • Pulmonary edema
– Bradycardia • Heartworm Disease
– Pulse deficits
• Thoracic Mass
• Muffled heart or lung
• Splenic Mass
Sounds
• Thromboembolism
• Syncope
 Echocardiography

Positioning for 8 standard views

• Right lateral recumbency (>90%)
• Cardiac table is nice but not always
necessary
• Sonographer needs a stool or chair
• Placement of probe:
– Feel the apical beat, and put your probe there
(probe marker cranial)
– Imagine the longitudinal axis of the heart,
probe at 90o (short axis views)
– Adjust 1 intercostal space Cr or Cd PRN
– Rarely move the probe head – just fan and
rotate
 Echocardiography

Positioning for 8 standard views

• Right lateral recumbency (90%)
• Cardiac table is nice but not necessary
• Sonographer needs a stool or chair
• Placement of probe:
– Feel the apical beat, and put your probe
there (probe marker cranial)
– Imagine the longitudinal axis of the heart,
probe at 90o (short axis views)
– Adjust 1 intercostal space Cr or Cd PRN
– Rarely move the probe head – just fan and
rotate
 Echocardiography

Equipment

microconvex probe microconvex probe cardiac probe

rib shadow artifact lung shadow artifact
abdominal settings
1. Short Axis – Left Ventricle

• Fan from base to apex, until you are just below

the chordae, and the LV papillary muscles
appear (“Mushroom” view)
• Rotate until PM are the same size
• If you are getting a rib or lung shadow, try one
intercostal space cranial or caudal
• Rock cranial or caudal to center the heart on
the screen
1. Short Axis – Left Ventricle

Abbreviations – Structures
• P – pericardium
• RV – right ventricle
• IVS – intraventricular septum
• LV – left ventricle
• PPM – posterior papillary muscle
• APM – anterior papillary muscle*
1. Short Axis – Left Ventricle

dog

Abbreviations – Structures –
• P – pericardium
• RV – right ventricle
• IVS – intraventricular septum
• LV – left ventricle
• PPM – posterior papillary muscle
• APM – anterior papillary muscle
1. Short Axis – Left Ventricle

cat

Abbreviations – Structures –
• P – pericardium
• RV – right ventricle
• IVS – intraventricular septum
• LV – left ventricle
• PPM – posterior papillary muscle
• APM – anterior papillary muscle
1. Short Axis – Left Ventricle
1. Short Axis – Left Ventricle

Normal/Abnormal Features
Assess volume status
• normal – round with adequate fill in diastole
• Volume contracted – oval or small round, walls
look artifactually thickened & contraction intense
Check for pericardial effusion
1. Short Axis – Left Ventricle

• Cord slightly toward the head

1. Short Axis – Left Ventricle Technique
1. Short Axis – Left Ventricle

Measurements (RV, RVID)

• IVSTd - IntraVentricular Septum Diastole
• LVIDd - LV Inner Diameter Diastole
• LVPWd – LV Posterior Wall Diastole
• IVSTs - IntraVentricular Septum Systole
• LVIDs - LV Inner Diameter Systole
• LVPWs – LV Posterior Wall Systole
1. Short Axis – Left Ventricle

Measurements (RV, RVID)

• IVSTd = IVSd = VSd
• LVIDd = LVd = LVLd
• LVPWd = LVFWd = LVWd
• IVSTs = IVSs = VSs
• LVIDs = LVs = LVLs
• LVPWs = LVFWs = LVWs
1. Short Axis – Left Ventricle

Measurements - Calculated
• FS – fractional shortening
(LVIDd – LVIDs)
LVIDd
– Assumes perpendicular to myocardium
– Assumes contractility is uniform in the LV
– Extremes in preload and afterload can affect FS, as
well as myocardial function
1. Short Axis – Left Ventricle

Measurements - Calculated
• FS – fractional shortening
• AKA shortening fraction (SF)
– >30% in the dog
– >40% in the cat
– >45% if MR is compensated
1. Short Axis – Left Ventricle

Measurements - Tips
• Make sure you don’t include PM in the LVPW
measurement
1. Short Axis – Left Ventricle

Measurements - Tips
• Don’t include PM in the LVPW measurement
– If you do, your LVPW will be artifactually thicker
– Clue – check for this if LVPW is much thicker than IVS
• Make sure you are not too far apical
– If you are, your LVID will be artifactually small
– And LVPW will be artifactually thick
– Measure at top of PM as they transition to chordae
1. Short Axis – Left Ventricle

Measurements - Tips
• Measure 3-5 times
– Take the average
– Throw out any outliers
• Several sets of normals published
– 1-2mm outside normal may not always be
significant
2. Short Axis – Apex

Structures
• Pericardium
• May or may not see RV
• LV apical lumen – no papillary muscles
No measurements here
2. Short Axis – Apex

Structures
• Pericardium
• May or may not see RV
• LV apical lumen – no papillary muscles
No measurements here
3. Short Axis – Chordae Tendinae

Structures – ”Windshield Wiper” View

• Pericardium
• RV
• LV
• CH - Chordae Tendinae (posterior & anterior)*
No measurements here
3. Short Axis – Chordae Tendinae

large dog

Structures
• Pericardium
• RV
• LV
• CH - Chordae Tendinae (posterior & anterior)
No measurements here
3. Short Axis – Chordae Tendinae

small dog

Structures
• Pericardium
• RV
• LV
• CH - Chordae Tendinae (posterior & anterior)
No measurements here
3. Short Axis – Chordae Tendinae

Structures -
• Pericardium
• RV
• LV
• CH - Chordae Tendinae (posterior & anterior)
No measurements here
3. Short Axis – Chordae Tendinae

cat

Structures -
• Pericardium
• RV
• LV
• CH - Chordae Tendinae (posterior & anterior)
No measurements here
4. Short Axis – Mitral Valve

Structures – “Fish Mouth” View

• Pericardium
• RV
• RV Papillary Muscles
• LVOT
• MV - Mitral Valve (Posterior & Anterior)*
4. Short Axis – Mitral Valve

Large Dog

Structures – “Fish Mouth” View

• Pericardium
• RV
• RV Papillary Muscles
• LVOT
• MV - Mitral Valve (Posterior & Anterior)
4. Short Axis – Mitral Valve

Small Dog
Need to zoom in

Structures – “Fish Mouth” View

• Pericardium
• RV
• RV Papillary Muscles
• LVOT
• MV - Mitral Valve (Posterior & Anterior)
4. Short Axis – Mitral Valve

Med Dog with MVD

Need to Zoom Out a little

Structures – “Fish Mouth” View

• Pericardium
• RV
• RV Papillary Muscles
• LVOT
• MV - Mitral Valve (Posterior & Anterior)
4. Short Axis – Mitral Valve
Cat

Structures – “Fish Mouth” View

• Pericardium
• RV
• RV Papillary Muscles
• LVOT
• MV - Mitral Valve (Posterior & Anterior)
4. Short Axis – Mitral Valve

• Cord close to perpendicular to the skin

4. Short Axis – Mitral Valve

Measurement
• EPSS – E-Point to Septal Separation
– If increased above normal, can denote
enlarged LV, volume overload and often
poor systolic function
– Less than 6 mm in large dogs
– Less than 3-5 mm in small dogs and cats
4. Short Axis – Mitral Valve

Measurement
• EPSS – E-Point to Septal Separation
– If increased above normal, can denote
enlarged LV, volume overload and often
poor systolic function
– Less than 6 mm in large dogs
– Less than 3-5 mm in small dogs and cats
4. Short Axis – Mitral Valve

Measurement
• EPSS – E-Point to Septal Separation
– If increased above normal, can denote
enlarged LV, volume overload and often
poor systolic function
– Less than 6 mm in large dogs
– Less than 3-5 mm in small dogs and cats
4. Short Axis – Mitral Valve
Normal

MVD
RV

LV AMV

PMV
5. Short Axis – Aortic Valve

Structures – “Mercedes Sign” View

• RVOT – Right Ventricular Outflow Tract
• TV – Tricuspid Valve
• PV – Pulmonic Valve
• Ao – Aortic Valve
• LA – Left Atrium*
5. Short Axis – Aortic Valve

Normal Dog

Ao
Structures – “Mercedes Sign” View
LA
• RVOT – Right Ventricular Outflow Tract
• TV – Tricuspid Valve
• PV – Pulmonic Valve
• Ao – Aortic Valve
• LA – Left Atrium
5. Short Axis – Aortic Valve

Dog LA
Enlargement

Ao

Structures – “Mercedes Sign” View

LA
• RVOT – Right Ventricular Outflow Tract
• TV – Tricuspid Valve
• PV – Pulmonic Valve
• Ao – Aortic Valve
• LA – Left Atrium
5. Short Axis – Aortic Valve

Cat
obliqued

Structures – “Mercedes Sign” View

• RVOT – Right Ventricular Outflow Tract
• TV – Tricuspid Valve
• PV – Pulmonic Valve
• Ao – Aortic Valve
• LA – Left Atrium
5. Short Axis – Aortic Valve

•
5. Short Axis – Aortic Valve

• Cord toward the sternum

• Point beam to the left shoulder
• Some call it the “5 Chamber Short View”
5. Short Axis – Aortic Valve

•
5. Short Axis – Aortic Valve

Measurements
• Aos – at largest dimension (systole)
• LAd – at largest dimension (diastole)
• LA:Ao –
– 0.8 to 1.3 in dogs
– 0.8 to 1.4 in cats
5. Short Axis – Aortic Valve
Normal

Enlarged LA

Ao

LA
5. Short Axis – Aortic Valve
Normal

Enlarged LA

Ao

LA
6. Short Axis – Pulmonary Artery

Structures
• RA – Right Atrium
• Ao – Aorta (ascending)
• MPA – Main Pulmonary Artery
– LPA – left pulmonary artery
– RPA – right pulmonary artery
• CaVC – Caudal Vena Cava*
6. Short Axis – Pulmonary Artery

PDA

• Lift the cord

• Point the beam toward the head
• This can be a difficult view in the barrel
chested dog
• If present, may see PDA here, entering
the far field into the MPA from the
descending aorta
6. Short Axis – Pulmonary Artery
Dog

PDA

• Lift the cord

• Point the beam toward the head
• This can be a difficult view in the barrel
chested dog
• If present, may see PDA here, entering
the far field into the MPA from the
descending aorta
6. Short Axis – Pulmonary Artery

Cat

PDA

• Lift the cord

• Point the beam toward the head
• This can be a difficult view in the barrel
chested dog
• If present, may see PDA here, entering
the far field into the MPA from the
descending aorta
5. Short Axis – Pulmonary Artery

•
5. Short Axis – Pulmonary Artery

•
7. Long Axis – 4 Chamber

Technique
• Get short axis “mushroom” view
• Rotate 90 degrees counterclockwise
• “Thumb to the Bum”
• Pick up the cord and point the beam to
the TL junction of the spine
7. Long Axis – 4 Chamber

Structures
• RV – Right Ventricle
• RA – Right Atrium – difficult to view completely
• TV – Tricuspid Valve
• LV – Left Ventricle
• LA – Left Atrium
• MV – Mitral Valve, PM – papillary muscle*
7. Long Axis – 4 Chamber

RV

LV

Structures
• RV – Right Ventricle
• RA – Right Atrium – difficult to view completely
• TV – Tricuspid Valve
• LV –Normal LV:RV > 3:1
Left Ventricle
• LA – Left Atrium
• MV – Mitral Valve, PM – papillary muscle
7. Long Axis – 4 Chamber

RV

LV
Structures
• RV – Right Ventricle
• RA – Right Atrium – difficult to view completely
• TV – Tricuspid Valve
• LV – Left Ventricle
• LA – Left Atrium
• MV – Mitral Valve, PM – papillary muscle
7. Long Axis – 4 Chamber

RA

Structures LA
• RV – Right Ventricle
• RA –Normal
Right LA:RA
Atrium – difficult to view completely
= 1:1

• TV – Tricuspid Valve
• LV – Left Ventricle
• LA – Left Atrium
• MV – Mitral Valve, PM – papillary muscle
7. Long Axis – 4 Chamber

IVS

1
LV
2
3
4
Structures 5

• RV – Right Ventricle
• RA – Right Atrium – difficult to view completely
• TV – Tricuspid Valve
• LV –
Normal Left =Ventricle
LV:IVS 4-6:1

• LA – Left Atrium
• MV – Mitral Valve, PM – papillary muscle
7. Long Axis – 4 Chamber
7. Long Axis – 4 Chamber

Normal Features
• LVID:RVID > 2-3:1
• RVFW < LVFW 1:2-3
• RA:LA = approximately 1:1
• LVID:IVS = 4-6:1
• FS >30% in the dog, >40% in the cat
7. Long Axis – 4 Chamber

• Beam axis with long axis of the heart

• 45o to long axis of the dog
• If right handed – thumb on the notch
7. Long Axis – 4 Chamber Technique
8. Long Axis – LVOT

Structures – “In Flow Out Flow View”

• RV, TV, RA
• LV, PM, MV
• Very edge of the LA
• LVOT – AoV (LC, SC), ascending Ao
• RPA – Right Pulmonary Artery*
8. Long Axis – LVOT

Structures
• RV, TV, RA
• LV, PM, MV
• Very edge of the LA
• LVOT – AoV (LC, SC), ascending Ao
• RPA – Right Pulmonary Artery
8. Long Axis – LVOT

Structures
• RV, TV, RA
• LV, PM, MV
• Very edge of the LA
• LVOT – AoV (LC, SC), ascending Ao
• RPA – Right Pulmonary Artery
7. Long Axis – LVOT
8. Long Axis – LVOT

• Lift the cord

• Point the beam to the left shoulder
• Rotate probe 10-15o counterclockwise
(“Thumb to Bum”)
• Some call it the “5 Chamber Long View”
7. Long Axis – LVOT Technique
7. Long Axis – LVOT Optimization
Dog RV Measurement Values

• RVWd – less than LVWd

• RVIDd – 1/3 or less of LVIDd
 Echocardiography

Emergency Cardiac Evaluation – GlobalFAST®

1. VetBLUE® (Veterinary Bedside Lung Ultrasound Exam)-
sternal recumbency or standing
– Dry lungs in all 8 spots – No LHF
– Wet lungs (esp Ph) – possible LHF, possible severe PHT
– Dry lung, wet lung, nodules, wedges – heartworm disease

2. TFAST® echo views - sternal or right lateral recumbency

– LV short axis (mushroom, batman) – estimate volume and
contractility
– Long axis 4 chamber – PHT or PS
• RV:LV – normal <1:3, PHT >1:1 – 1:2
– LA:Ao – LA enlargement, possible LHF
 Echocardiography

Emergency Cardiac Evaluation – GlobalFAST®

3. AFAST® - R lat recumbency
• DH View
– normal caval bounce - rules out RHF and confirms
normovolemia
– Flat cava - hypovolemia, possible forward LHF
– Fat cava - possible RHF, pericardial effusion (PCE)
– Pericardial effusion, GB edema, fat cava – RHF, pericardial
tamponade
• SR, CC and HR views
– look for & score fluid (AFS)
– collect fluid at HR
– look for spleen mass if hemorrhagic ascites or PCE
 Interrogating the RA
Left Parasternal Long Axis

• Change from right to left lateral recumbency

• Feel for the apical beat, and place probe there
• This is often more caudal and farther from the
sternum compared to the other side
• Align beam axis with the long axis of the heart,
45o to the long axis
 Interrogating the RA
Left Parasternal Long Axis

• Change from right to left lateral recumbency

• Feel for the apical beat, and place probe there
• This is often more caudal and farther from the
sternum compared to the other side
• Align beam axis with the long axis of the heart,
45o to the long axis
 Cat Echo Normal Values

• IVSTd – 3-6 mm • FS - >40%

• LVIDd – 10-21 mm • EPSS - 0-3 mm
• LVPWd – 3-6 mm • EF - >70%
• IVSTs - 4-9 • LA:Ao – 0.8-1.4
• LVIDs – 4-11 mm • RVIDd - 3-7 mm
• LVPWs – 4-10 mm • RVWd - <3 mm
• Aos – 6-12 mm
• LAd – 7-15 mm (form)
Ferret Echo Normal Values (Mean)

• LVIDD – 11.0 mm
• LVIDS - 6.4 mm
• LVPW - 3.3 mm
• FS - 42%
• EPSS - 0
Cat Echoes for Dummies
 Summary

PowerPoint - .pptx, .pdf 1 & 6 slides per page

In Clinic Forms:
• Echocardiogram (back) - .docx, .pdf
• Oncura Echo Protocol
• Cardiac Evaluation Form (exam front, echo
back)
Scientific Articles:
• Trazadone for Echocardiogram in the Cat
 Summary

Vet Handouts
• Chart – cardiac safe sedation and normal echo values for
dogs (1-120 pounds)
• Oncura Echocardiography Manual

Hidden Slides
• Anatomy of the heart valves
• Indications for Echocardiogram
• Emergency Cardiac US Exams – TFAST® & VetBLUE®
 Acknowledgements

Kittleson, Mark, DACVIM - Cardiology

• Small Animal Cardiovascular Medicine,
Veterinary Information Network. Chapter
6 – Echocardiography
Boon, June – Colorado State U
• Academy of Veterinary Imaging Echo Intro

Huber B, Huber J, Merrell S, Poteet B

• Oncura Partner’s Echocardiography Manual