Echo with KOSMOS

An introduction to performing Echo with the KOSMOS

device
Objectives

1. Brief review of transthoracic echocardiology views

2. Echocardiographic Imaging Challenges
3. 2D, M-Mode & Doppler Measurements per view
What should we measure?

4. Echocardio report
5. Be able to do a demo with no fear!

2
Overview Echo Basic Views

3
Basic Views

• Parasternal long axis (PLAX) and short axis (PSAX)

○ to assess heart wall motion and thickness, chamber sizes and valves

• Apical 4, 2, 3, 5 chamber
○ To assess: Valves, stenosis, regurgitation and chamber sizes

• Subcostal long axis

○ LV function assessment, pericardial effusion

4
 How to get a good
view?

• Place patient in Left Lateral Decubitus (LLD)

position
• Helps to get the heart closer to the front of the
chest
• Improves image quality

5
Echocardiographic Imaging Challenges

Journal of American Heart Association:

- “According to statistics by the World Health Organization ≈20% of adults in Europe and ≈40%
in the USA are obese”

- “Obese patients present unique challenges for optimal echocardiographic imaging and
interpretation”.

https://www.ahajournals.org/doi/10.1161/JAHA.119.014609

Other challenges:

- Patient with poor echogenicity

- Lung hyperinflation

- Operator with poor skills

6
 • The probe is positioned within the 3rd to 5th

Parasternal Long Axis intercostal space and close to the sternum.

(PLAX) • Probe orientation marker is positioned toward

patient right shoulder (at 10:00 to 11:00 )
PLAX: Identify Diastole / Systole

DIASTOLE
• Aortic valve close
• Mitral valve open
• LV diameter larger than in
systole AV

SYSTOLE
• Aortic valve open
• Mitral valve closed
• LV smaller than in diastole
Parasternal Short Axis (PSAX)

• From PLAX view, rotate the probe orientation

marker toward patient left shoulder (2:00 position).
• May need to use different intercostal spaces.

9
Parasternal Short Axis (PSAX)

- By tilting the probe, we can get

different ultrasound planes from
this window.

- We are able to visualise:

- Aortic and Pulmonary Valves
- Mitral Valve
- Papillary Muscles

10
Parasternal Short Axis
(PSAX)

• Tilt probe to visualize :

○ AV, TV, PV,
○ MV
○ Papillary muscles

RVOT = Right Ventricle Output

MPA = Main Pulmonary Artery

11
 Apical Views
Probe is scanning from the Apex
• A4C = transducer orientation marker at 3:00
• A2C = transducer at 12:00
• A3C = transducer at 10:00
• A5C = from A4C angle toward Left shoulder
• May need to move up an intercostal space

12
 Apical 4 Chamber

• Transducer orientation marker at 3:00

• Patient may need to blow breath out and
hold
• Structures displayed:
• Left heart: LV, MV, LA

• Right heart: RV, TV, RA,

• Interventricular septum (IVS)

• Interatrial septum (IAS)

13
Apical 2 Chamber

• From A4C rotate transducer to

approx. 12:00

• Shows: LA, MV, LV

14
Apical 3 Chamber

● From A4C rotate the transducer to

approx 10:00

● Shows LA, MV, LV, LVOT, AV

LVOT = Left Ventricle Output Track
 Apical 5 Chamber

- Used to assess AV and cardiac output

- From A4C, tilt the probe head upward to
create the A5C
RV
- The ascending aorta is now seen in addition LV

to the two ventricles and two atria LVOT

AV MV
*LVOT = Left Ventricular Output Track
LA

16
Subcostal View
• Patient in supine position
• Transducer positioned et sub-xiphoid
process and orientation marker toward
3:00
• Displays: Liver, Right & Left Heart
chambers
Subcostal View to assess IVC

RAds
d
Are you still there?

19
2D measurements

20
2D Measurements in PLAX

Diameters to measure in systole & diastole

● Interventricular Septum
● Left Ventricle
● Posterior Wall
- To assess Ejection Fraction (EF)
*EF = how well LV is efficiently pumping blood to the body ;
Normal EF>50%

21
2D Measurements in PLAX

● Diameter of Left Ventricle Output Track

(LVOTd)
● Part of the procedure to measure Cardiac
Output (CO) & Aortic Valve Area (AVA)
● Possible to zoom the image to better
position the caliper

22
2D measurements

PLAX : Aorta
• Annulus
• Sinus
• ST Junction (Sinotubular)
• Ascending AO

23
 EF by Simpson's method (2D)

● Requires both view (A4C, A2C)

● Tracing the LV contour in systole and diastole
● In most ultrasound machines, the user has to do
this manually

*EF = how well LV is efficiently pumping EF>50%

 Automatic EF with Kosmos AI-Trio

● Kosmos AI-Trio:
○ Provides automatic Ejection Fraction
and Stroke Volume
○ Draws automatically the contour of
the LV in dist & syst
Edit LV tracing

• Tap any of the thumbnails in the result screen

• Tapping and dragging any dot in the outline
• New values are displayed in the top left and
compare the AI calculated
• Save or discard these new values

26
 Why sometimes we can't get an
accurate EF?

Some reasons that prevent to have a correct visualization of the LV:

● Obese/large patients limits access and echogenicity.
● Lung hyperinflation - there isn’t a great deal we can do about this. it’s usual that lateral and inferior
walls can be covered in patients with long-standing Asthma or obstructive airway disease (OAD),
that means clinicians are not able to get an EF or SV.
● Poor operator skills can also be a factor that prevents the acquisition of a good image for the FE.
 Right Heart
2D measurements

• RV basal
• RV mid
• RV length

28
Right Heart assessment

M-Mode measurements
• Helps to measure TAPSE (Tricuspid annular
plane systolic excursion)

• Correlates closely with RV ejection fraction

measured by radionuclide angiography, the
“gold standard” modality for the assessment of
RV function

29
IVC assessment

M-Mode measurements
• IVC min & max
• and Right Atrial Pressure (RAP)

30
Still with me?
Let's make one more effort…

31
 ● Pulsed Wave Doppler (PW)
Doppler in Echo ● Continuous Wave Doppler (CW)
● Color Doppler
MEASUREMENTS ● Tissue Doppler Imaging (TDI)

32
What is the purpose of the spectral
Doppler?

Provides functional information on intracardiac hemodynamics

● Helps to assess Systolic & diastolic function
● Provides real-time Blood flow velocities, volumes and pressures
● Allows to determine the severity of valvular lesions
● Helps to locate and assess the severity of intracardiac shunts

33
Pulsed Wave Doppler (PW)
MEASUREMENTS

34
Pulsed Wave Doppler

• PW is displayed as line with a Sample

Volume (SV)
SV
• Allows to measure the blood flow velocities
at one specific region (ROI)

• Spectral tracing is displayed on a SV

velocity/time graph

• NO angle correction needed

 PW - Mitral Valve
● Measure MV inflow in A4C view
○ E & A peak velocities

○ E = Early diastolic filling

○ A = Atrial kick
SV
If E & A are reversed then indication of diastolic dysfunction
E
● E/A Ratio
A

Normal E peak vel 0.6 – 1.3 m/s

Normal A peak vel 0.2-0.7 m/s
PW - Mitral Valve

● MV VTI (manually tracing) SV

PW - Aortic Valve

A5C View
• PW at LVOT
• Trace LVOT VTI

LVOT VTI trace can be done :

• Auto
• Manual

38
PW - Aortic Valve

Cardiac Output assessment: LVOT diam

● PLAX view
○ Measure diam of LVOT D

(normal 2.1 – 3.4 cm)

SV
● A5C View
○ PW at LVOT

○ Trace LVOT VTI

● Heart Rate can be measure en PW

● Normal CO
○ Average Men: 5.6 L/min,

○ Average Women: 4.9L/min. LVOT VTI

Continuous Wave Doppler (CW)
MEASUREMENTS

40
Continuous Wave Doppler

● Captures the blood flow along the

cursor line
○ No sample volume
○ No aliasing factor

● Used to assess high velocity flows

○ Stenosis & Regurgitations
○ Aortic, Mitral & Tricuspid valves
CW in Mitral Regurgitation

● Mitral Regurgitation
○ Needs a A4C view
○ MR jet going away from the
transducer
○ Spectral Doppler displayed under
the baseline

● Measurements
○ AV VTI MR jet
 CW in Mitral Stenosis

● Mitral Stenosis
○ Needs A4C view
○ MS jet goes towards the transducer
○ Spectral Doppler appears above the baseline

● Measurements
○ Mitral Valve Area (MVA) can be assessed by
Pressure Half Time (PHT) method
○ PHT: draw a slope from the peak of the A wave
○ MVA = 220/PHT

PHT Normal = 30 – 60 msec; MVA= 7 - 3 cm2

PHT Severe = >> 220 msec; MVA= 1 cm2
CW in Aortic Regurgitation

● Aortic Regurgitation
○ AKA = Aortic insufficiency
○ AR jet goes towards the transducer
○ Spectral Doppler appears above the
baseline

● Measurements
○ Typically just peak velocity
○ Can do PHT
CW in Aortic Stenosis

● Aortic Stenosis (AS)

○ Needs an A5C
○ AS jet goes away the transducer
○ Spectral Doppler appears under the
baseline

● Requires AV VTI measurement

AS jet

45
CW in Aortic Stenosis (AS)

● Allows measurement of Aortic Valve

Area (AVA cm²) using the Continuity
Equation.
● Procedure to assess AVA
○ LVOT diam (2D PLAX view)
○ LVOT VTI (with PW)
○ AV VTI (with CW)
Normal AVA= > 2.0 cm²; Severe AS = < 0.70 cm²

46
CW – Tricuspid Regurgitation (TR)

● Tricuspid Regurgitation
○ Almost everyone has it
○ Can be indicator of Right Heart overload
(>vel & mmHg)
○ Pulmonary Hypertension (PHTN)

● Measurements
○ Measure TR peak velocity
○ Helps to obtain pressure gradient (PG)
○ Right Atrial Pressure (RAP) must be
added (normally RAP = 10)

47
Doppler – Range of normal values

*L. Hatle and B. Angelsen, Doppler Ultrasound in Cardiology, p. 72 (Philadelphia: Lea & Febiger, 1982).
Almost there…

49
Tissue Doppler Imaging (TDI)
MEASUREMENTS

50
 Tissue Doppler Imaging
(TDI)
• Provides information on the diastolic function

• TDI is based in PW

• Measure velocity of myocardial tissue motion

S’ septal
• SV is placed in the Ventricular myocardium SV
immediately adjacent to the mitral annulus
(septal & lateral)

• Includes two diastolic (E′ and A′) peaks and one E’ septal
A’ septal
systolic (S′) peaks
Color Doppler Imaging

52
Color Doppler

● Clinical Applications
✔ Screening valves for regurgitation
and stenosis

✔ Imaging systolic and diastolic flow

✔ Detecting presence of intracardiac

shunts
A4C with TR
Color Doppler

A4C with residual MR A4C view with color on the TV showing severe TR

Flow toward transducer = RED

Flow away from transducer = BLUE
 • PDF format
Images can be saved
Report •
in DICOM or JPEG
format

All measurements and

calculations are included

55
Hands-on
Thank you.

57