ECHOCARDIOGRAPHY

ESSENTIALS
HANDBOOK
Updated 01/26/2023

Helen Rimington, PhD

Table of contents
Overview
Knowing what your machine can do 4
Understanding the essential imaging and Doppler modalities 5

Nuts and bolts

Preparing to scan 6
Optimizing your image 7
Making measurements 8
Recognizing artifacts 9
Controlling infection 10

Parasternal long-axis (PLAX) views

Obtaining an optimal image 11
Mastering the PLAX inflow view 12
Mastering the PLAX outflow view 13

Parasternal short-axis (PSAX) views

Mastering the PSAX aortic valve view 14
Mastering the PSAX mitral valve view 15
Mastering the PSAX papillary muscle view 16

Apical views
Mastering the apical four-chamber view 17
Mastering the apical five-chamber view 18
Mastering the apical three-chamber view 19
Mastering the apical two-chamber view 20

Subcostal views
Mastering the subcostal four-chamber view 21
Mastering the subcostal IVC view 22

Suprasternal view
Mastering the suprasternal view of the aorta 23

The ventricles and pulmonary pressures

Evaluating left ventricular size and hypertrophy 24
Assessing left ventricular global systolic function 27
Assessing left ventricular diastolic function 28
Identifying left ventricular regional wall abnormalities 29
Evaluating right ventricular size and function 31
Measuring pulmonary artery systolic pressure (PASP) 32

The valves
Assessing aortic stenosis 33
Detecting aortic regurgitation 34
Recognizing mitral stenosis 35
Diagnosing mitral regurgitation 36
Spotting tricuspid and pulmonary valve disease 37
Checking replacement valves 38

Other uses of TTA

Detecting pericardial effusions 39
Assessing intracardiac masses 40
Recognizing imitation masses 41
Identifying abnormal vessels 42
Spotting simple shunts 44

Finishing your TTA

Archiving the images 45
Creating an exemplary report 46

Appendix
Reference list 49
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OVERVIEW
Knowing what your machine can do

Full size
PRO CON
• Complex techniques • Heavy
• Wired to archive • Difficult to steer
• Optimal quality • Expensive

Laptop
PRO CON
• Portable • Not usually wired to archive
• Moderate cost • Reduced imaging quality
• Reasonable functionality

Handheld
PRO CON
• Highly portable • Limited functionality
• Cheap • Limited storage
• Imaging can be challenging

Probes

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OVERVIEW
Understanding the essential imaging and Doppler modalities

The behaviour of the ultrasound within the body is described by the formula:

Propagation velocity = wavelength × frequency

Wavelength and frequency are inversely related.

Amplitude
Increasing the frequency will decrease the
wavelength, which is good for resolution. But there is
a trade off: with increased frequency, penetration will
also decrease.
Wavelength

Pulsed wave and color Doppler are similar: they but cannot localize within the ultrasound beam. So
are good for localization but unable to accurately make sure to use the Doppler modality best suited
display high velocities. In contrast, continuous w and swap between them as required.
wave Doppler is good for measuring high velocities

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NUTS AND BOLTS

Preparing to scan

Before you begin your scan, remember to ask yourself the following questions:

• Have you got the right equipment? • Have you explained what you are going to
do in a way your patient understands and
• Have you got the right patient? gained verbal consent?

• Have you entered the patient’s details • Have you made allowances for any
accurately on the machine? cultural/religious/language/disability/
individual patient preferences?
• Have you attached the ECG?

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NUTS AND BOLTS

Optimizing your image

Here are some tips you can use to obtain an optimal image:

• For a large patient, use a lower scanning • Move the focus to line up with any structure you
frequency (and for a small patient, use a higher are especially interested in. You can use a high-
scanning frequency). resolution zoom to help improve the image, too.

• Adjust the sector width and depth so that you • Freeze, then trackball, can help if you want to
display only the structures you are interested in slowly scroll through your images to give yourself
for each clip you record. Always expect to adjust more time to work out what’s happening.
these when you alter the window (e.g., changing
from parasternal to apical views, or from apical • Adjust Doppler velocity scales and sweep speed
to suprasternal). to display two or three waveforms with the
waveform taking up at least two-thirds of the
• Try not to over gain your images, especially if you available y-axis display.
are scanning in a well-lit environment. You can use
TGC to enhance the display of deeper structures. • Archive good quality clips using the ECG to
If you are using a machine that doesn‘t do this trigger them, and cycle select to make sure you
automatically just ramp down the top two or save the best example.
three sliders to reduce the echoes from nearest
the probe. w

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NUTS AND BOLTS

Making measurements

To help you make your measurements, here are some things to keep in mind:

• Use the same conventions as the rest of the aorta was measured leading edge to leading
your department. edge in systole but there is a trend towards
measuring inner to inner and some centers now
• Make sure the normal ranges you use are measure in diastole.
appropriate for your patients, and that you are
using the same measuring conventions used • Don’t over measure Doppler velocities. Trace
when the normal range was devised. around the main body of the waveform, ignoring
artifacts, especially at the tips.
• In general, a leading edge convention is used for
measuring in the parasternal views. However, • Don’t try to perform a Simpson’s ejection
the left ventricular outflow tract (LVOT) is usually fraction if you can’t see the endocardium.
measured inner edge to inner edge. Historically

Inner edge to inner edge convention: Leading edge to leading edge convention:
bottom of interface to top of next interface. top of an echo interface to the top of the interface below.

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NUTS AND BOLTS

Recognizing artifacts

An artifact can make it look like there is something present that isn’t there, or it may hide structures from
being seen. If you suspect an artifact, try one of the following:

• Image from other views.

• Alter the machine settings.
• Observe whether it looks and moves physiologically.

Artifacts are particularly likely when there is material are interpreted incorrectly because the normal
within the scanning zone which is unlike normal assumptions about the behavior of ultrasound in the
cardiac tissues, such as a pacing lead, replacement body do not apply.
valve, air, or calcium. Typically, returning echoes

Prosthetic mitral valve Doppler artifacts

Comb artifacts Prosthetic aortic valve

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NUTS AND BOLTS

Controlling infection

This is an important component of performing an echo and will be informed by your institution’s policies
and practice guidelines. As a general rule, anything that touches the patient should be cleaned carefully
after every scan. Some cleaning agents can damage ultrasound probes, so make sure you use a method the
manufacturer supports and it’s good practice to routinely check the probe for damage before you use it.

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PARASTERNAL LONG-AXIS
(PLAX) VIEWS
Obtaining an optimal image

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder RV

Probe position: 4th intercostal space, left sternal edge

LV AV

Probe orientation: notch towards patient’s right shoulder MV LA

w
Right ventricle (RV)

Aortic valve (AV)

Left ventricle (LV)

Mitral valve (MV) Left atrium (LA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
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PARASTERNAL LONG-AXIS
(PLAX) VIEWS
Mastering the PLAX inflow view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder
RV
Probe position: 4th intercostal space, left sternal edge

Probe orientation: notch towards patient’s right shoulder

RA

w
Right ventricle (RV)

Right atrium (RA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
12
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PARASTERNAL LONG-AXIS
(PLAX) VIEWS
Mastering the PLAX outflow view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder RV

Probe position: 4th intercostal space, left sternal edge LV

PA
Probe orientation: notch towards patient’s right shoulder

Right ventricle (RV)

Left ventricle (LV)

Pulmonary artery (PA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
13
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PARASTERNAL SHORT-AXIS
(PSAX) VIEWS
Mastering the PSAX aortic valve view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder
RVOT
Probe position: 4 intercostal space, left sternal edge
th

RA AV
Probe orientation: notch towards patient’s left shoulder
LA
Tilt probe upwards towards head to show aorta as a circle.

w
Right ventricular outflow tract (RVOT)

Right atrium (RA) Aortic valve (AV)

Left atrium (LA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
14
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PARASTERNAL SHORT-AXIS
(PSAX) VIEWS
Mastering the PSAX mitral valve view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder

Probe position: 4th intercostal space, left sternal edge

RV
LV
Probe orientation: notch towards patient’s left shoulder

Tilt probe downwards towards spine to show left ventricle

as a perfect circle.

Right ventricle (RV)

Left ventricle (LV)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
15
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PARASTERNAL SHORT-AXIS
(PSAX) VIEWS
Mastering the PSAX papillary muscle view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder
RV
Probe position: 4th intercostal space, left sternal edge
LV
Probe orientation: notch towards patient’s left shoulder

Tilt the probe even further towards the spine keeping the
left ventricle as a circle but showing the papillary muscles
instead of the mitral valve.

w
Right ventricle (RV)

Left ventricle (LV)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
16
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APICAL VIEWS
Mastering the apical four-chamber view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder

Probe position: over the apex beat, or V5 of ECG RV LV

Probe orientation: notch towards patient’s left shoulder

RA LA

w
Left ventricle (LV)

Right ventricle (RV)

Right atrium (RA) Left atrium (LA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
17
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APICAL VIEWS
Mastering the apical five-chamber view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder
LVOT
Probe position: over the apex beat, or V5 of ECG LV
RV
Probe orientation: notch towards patient’s left shoulder, tilt
upwards from the four-chamber view
RA LA

AV

w
Left ventricle (LV)

Right ventricle (RV)

Left ventricular outflow tract (LVOT)

Aortic valve (AV)

Right atrium (RA) Left atrium (LA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
18
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APICAL VIEWS
Mastering the apical three-chamber view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder

Probe position: over the apex beat, or V5 of ECG LV

RV
Probe orientation:
orientation:notch
rotate counterclockwise from the four MV
towards patient’s right shoulder, tilt
chamber view
upwards from four-chamber view
LA Ao

Left ventricle (LV)

Right ventricle (RV)

Mitral valve (MV)

Aorta (Ao)

Left atrium (LA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
19
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APICAL VIEWS
Mastering the apical two-chamber view

Patient position: lying on left side, left arm raised, raise the
back of the bed or use pillows under the left shoulder
LV
Probe position: over the apex beat, or V5 of ECG
MV
Probe orientation: rotated about 60 degrees counterclockwise
from the four-chamber view LA

Left ventricle (LV)

Mitral valve (MV)

Left atrium (LA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
20
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SUBCOSTAL VIEWS
Mastering the subcostal four-chamber view

Patient position: lying supine

Probe position: below sternum, almost flat to skin RV

TV
RA LV
Probe orientation: notch towards patient’s left shoulder
MV
LA

Right ventricle (RV)

Tricuspid valve (TV)

Right atrium (RA)

Left ventricle (LV)

Mitral valve (MV)

Left atrium (LA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
21
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SUBCOSTAL VIEWS
Mastering the subcostal IVC view

Patient position: lying supine

Probe position: below sternum, almost flat to skin

IVC
Probe orientation: rotated slightly counterclockwise RV
from the subcostal four-chamber view RA

LA

Inferior vena cava (IVC)

Right ventricle (RV)

Right atrium (RA)

Left atrium (LA)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
22
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SUPRASTERNAL VIEW
Mastering the suprasternal view of the aorta

Patient position: lying supine with neck extended Innominate

Left common carotid
Probe position: in suprasternal notch
Left subclavian
Probe orientation: notch towards patient’s left shoulder
RPA

Desc.
Ao

Innominate

w
Left common carotid

Left subclavian
Right pulmonary artery (RPA)

Descending aorta (Desc. Ao)

References and further reading:

1. European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography (2nd Edition). Lancellotti P,
Zamorano JL, Habib G, and Badano L (Eds). Oxford, UK: Oxford University Press.
2. Anderson, B. 2006. Echocardiography: The Normal Examination and Echocardiographic Measurements
(2nd Edition). Hoboken, NJ: Wiley-Blackwell.
3. Wharton G, Steeds R, Allen J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: a guideline protocol from the British Society of Echocardiography.
http://www.echorespract.com/content/2/1/G9.full.pdf
23
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THE VENTRICLES AND

PULMONARY PRESSURES
Evaluating left ventricular size and hypertrophy

National echo societies and echo guideline documents recommend slightly different normal ranges
and severity criteria for left ventricular (LV) size. Ideally you should use the same values as the other
echocardiographers in your institution to ensure uniformity of practice. If you do not have this guidance
available, these tables may help:

Left ventricular diastolic cavity diameter

Mildly Moderately Severely

Normal dilated dilated dilated

Women
LV diastolic diameter (cm) 3.9–5.3 5.4–5.7 5.8–6.1 ≥6.2

Men
LV diastolic diameter (cm) 4.2–5.9 w6.0–6.3 6.4–6.8 ≥6.9

Measure using a leading edge convention at the tip of the mitral valve leaflets in the parasternal long-axis view.

If you have a very small or large patient, you

may need to correct for body size using body
surface area.

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Left ventricular diastolic cavity volume

Mildly Moderately Severely

Normal dilated dilated dilated

Women
LV diastolic volume (mL) 56–104 105–117 118–130 ≥131

Men
LV diastolic volume (mL) 67–155 156–178 179–200 ≥201

Measure using Simpson’s biplane (or 3D).

If you have a very small or large patient, you

may need to correct for body size using body
surface area.

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Left ventricular wall thickness (septum and posterior wall)

Mildly Moderately Severely

Normal Borderline thickened thickened thickened

Women
LV wall thickness (mm) 6–9 10 11–12 13–15 ≥16

Men
LV wall thickness (mm) 6–10 11 12–13 14–16 ≥17

w
1 IVS = interventricular septum
2 PW = posterior wall

Bear in mind that sport or fitness training

can cause mildly increased wall thicknesses.

References and further reading:

1. Lang RM, Bierig M, Devereux RB, et al. 2006. Recommendations for chamber quantification. Eur J
Echocardiogr. 7:79–108.
2. Lang RM, Badano LP, Mor-Avi V, et al. 2015. Recommendations for cardiac chamber quantification by
echocardiography in adults: An update from the American Society of Echocardiography and the European
Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 28:1–39.
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THE VENTRICLES AND

PULMONARY PRESSURES
Assessing left ventricular global systolic function

Not all echo labs use ejection fraction (EF), and the severity criteria vary in different guideline documents. It’s
best to use the same values as your colleagues and audit that you are all reporting EF similarly.

Grading left ventricle systolic function using ejection fraction (EF)

Mildly Moderately Severely

Normal Borderline abnormal abnormal abnormal

>50 50–54 41–49 31–40 <30

Measure using Simpson’s biplane (or 3D).

w

References and further reading:

1. Lang RM, Badano LP, Mor-Avi V, et al. 2015. Recommendations for cardiac chamber quantification by
echocardiography in adults: An update from the American Society of Echocardiography and the European
Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 28:1–39.
2. Poppe KK, Doughty RN, Gardin JM, et al. 2015. Ethnic-specific normative reference values for
echocardiographic LA and LV size, LV mass, and systolic function. JACC Cardiovascular Imaging. 8:656–665.
3. Dalen H, Thorstensen A, Vatten LJ. 2010. Reference values and distribution of conventional echocardiographic
Doppler measures and longitudinal tissue Doppler velocities in a population free from cardiovascular disease.
Circ Cardiovasc Imaging. 3:614–22.
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THE VENTRICLES AND

PULMONARY PRESSURES
Assessing left ventricular diastolic function

Assess left ventricle diastolic function using tissue Doppler and pulsed wave Doppler at the mitral valve.

Deceleration time

Normal filling pattern w Tissue Doppler to measure E/E’

If you measure E, A, E deceleration, and lateral E/E’ you can use this composite table as a rough guide to see
if it helps identify the filling pattern:

LV diastole E/A E deceleration time (ms) Lateral E/E’

Normal 0.8–1.5 150–200 ≤10

150–280 if >65 years

Slow <0.8 >200 ≤10

>280 if >65 years

Pseudonormal 0.8–1.5 150–200 >10

150–280 if >65 years

Restrictive >2 <150 >10

References and further reading:

Rimington H and Chambers JB. 2016. Echocardiography: A practical guide for reporting and interpretation. Boca
Raton, FL: CRC Press, Taylor & Francis Group.
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THE VENTRICLES AND

PULMONARY PRESSURES
Identifying left ventricular regional wall abnormalities

Use these diagrams to guide you when you assess regional wall abnormalities. The walls can be described
as ‘normal’, ‘hypokinetic’, ‘akinetic’, ‘dyskinetic’, ‘aneurysmal’, or ‘hyperkinetic’. The 16- and 17-segment
models have different terms for some of the walls so make sure you use the same model as your colleagues.

16-segment model

Mid Basal

Anteroseptal Anteroseptal

Septal Anterior

Inferior Lateral

Posterior w Posterior

PLAX view SAX view

Anteroseptal

Apical
Posterior
Anterior
Inferior
Lateral
Septal

Mid

Basal

Four-chamber view Two-chamber view Three-chamber view

Territories of the coronary arteries:

Left anterior descending distribution

Right coronary artery distribution

Circumflex distribution

Left anterior descending/circumflex overlap

Left anterior descending/right coronary artery overlap

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17-segment model

Mid Basal

Anteroseptal Anteroseptal

Inferoseptal Anterior

Inferior Anterolateral

Inferolateral Inferolateral

PLAX view SAX view

Apex Apex Apex

Anterolateral

Anteroseptal
Inferolateral
Inferoseptal

Apical

Anterior
Inferior

Mid

Basal

Four-chamber view Two-chamber view Three-chamber view

Territories of the coronary arteries:

Left anterior descending distribution

Right coronary artery distribution

Circumflex distribution

Left anterior descending/circumflex overlap

Left anterior descending/right coronary artery overlap

The 16- and 17-segment models are reproduced from Segar DS et al. 1992. J Am Coll Cardiol. 19:1197–1202.

References and further reading:

Segar DS, Brown SE, Sawada SG, et al. 1992. Dobutamine stress echocardiography: Correlation with coronary
lesion severity as determined by quantitative angiography. J Am Coll Cardiol. 19:1197–1202.
30
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THE VENTRICLES AND

PULMONARY PRESSURES
Evaluating right ventricular size and function

Upper limit of normal diameters for the right ventricular (RV) cavity

Basal (RV1) 4.2 cm

Mid (RV2) 3.5 cm

Length (RV3) 8.6 cm

These are used for women and men.

TAPSE <16 mm and tissue Doppler S wave <10 cm/s suggest abnormal right ventricular longitudinal
systolic function.

3
2
1

1 Basal (RV1)
2 Mid (RV2)
3 Length (RV3)

References and further reading:

Rudski LG, Lai WW, Afilalo J, et al. 2010. Guidelines for the echocardiographic assessment of the right heart
in adults: A report from the American Society of Echocardiography endorsed by the European Association of
Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of
Echocardiography. J Am Soc Echocardiogr. 23:685–713.
31
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THE VENTRICLES AND

PULMONARY PRESSURES
Measuring pulmonary artery systolic pressure (PASP)

To estimate the pulmonary artery systolic pressure perform the following:

• Measure the peak velocity of the tricuspid • Add them together, as long as there is no
regurgitation and note the peak pressure pulmonary stenosis or right ventricular
difference. outflow obstruction.

• Assess the IVC and use this table to estimate

the right atrial pressure, either as a range or a
mean value depending on the preference of
your echo lab.

Normal Intermediate High

0–5 mmHg 5–10 mmHg 10–20 mmHg
or mean or mean or mean
3 mmHg w 8 mmHg 15 mmHg

IVC diameter (cm) ≤ 2.1 ≤ 2.1 > 2.1 > 2.1

Collapse with sniff > 50% < 50% > 50% < 50%

References and further reading:

Rudski LG, Lai WW, Afilalo J, et al. 2010. Guidelines for the echocardiographic assessment of the right heart
in adults: A report from the American Society of Echocardiography endorsed by the European Association of
Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of
Echocardiography. J Am Soc Echocardiogr. 23:685–713.
32
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THE VALVES
Assessing aortic stenosis

Assessing severity of aortic stenosis:

Mild Moderate Severe

Aortic valve (AV) Vmax (m/s) 2.6–2.9 3.0–4.0 > 4.0

Peak gradient (mmHg) < 40 40–65 > 65

Mean gradient (mmHg) < 20 20–40 > 40

EOA (cm2) > 1.5 1.0–1.5 < 1.0

EOA is the effective orifice area of the aortic valve. w

1 2 3 EOA = (CSA) × (LVOT VTI/AV VTI)

1 LVOT VTI
2d
3 AV VTI

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THE VALVES
Detecting aortic regurgitation

Assessing severity of aortic regurgitation:

Mild Moderate Severe

Color/LVOT height (%) < 25 25–64 > 65

Width (mm) <3 3–6 >6

Reversal descending aorta None Not holodiastolic Holodiastolic

PHT (ms) > 500 200–500 < 200

Continuous wave intensity Faint Intermediate Dense as forward flow

w

PHT is the pressure half time of the continuous wave Doppler signal lined up with the regurgitant jet; LVOT = left
ventricular outflow tract.

Continuous wave Doppler Color M-mode of flow reversal

34
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THE VALVES
Recognizing mitral stenosis

Assessing severity of mitral stenosis:

Mild Moderate Severe

Planimetered area (cm2) > 1.5 1.0–1.5 < 1.0

PHT (ms) < 150 150–220 > 220

Mean gradient (mmHg) <5 5–10 > 10

PHT is the pressure half time of the continuous wave Doppler signal lined up with forward flow through the mitral valve.

Mean gradient Rheumatic mitral stenosis

35
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THE VALVES
Diagnosing mitral regurgitation

Assessing severity of mitral regurgitation:

Mild Moderate Severe

Neck width (mm) <3 > 3 and < 7 7 or more

Flow recruitment in left ventricle None Some Lots

Continuous wave (CW) signal Incomplete, faint Moderate, complete Dense, holosystolic

Assessing severity Mitral regurgitation

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THE VALVES
Spotting tricuspid and pulmonary valve disease

Tricuspid regurgitation
Assessing severity of tricuspid regurgitation:

Mild Moderate Severe

Neck width (mm) None <7 ≥7

Continuous wave (CW) signal Incomplete, faint Low or moderate Dense may be
intensity triangular

Hepatic vein flow Normal Systolic blunting Systolic reversal

Tricuspid stenosis w

Suspect tricuspid stenosis if there is a narrow forward color jet and mean forward gradient >2 mmHg.

Pulmonary regurgitation
The pulmonary regurgitation is severe if regurgitant jet PHT is <100 ms and the color jet fills more than 50%
of the right ventricular outflow tract (RVOT).

Pulmonary stenosis
Rough guide to grading pulmonary stenosis:

Mild Moderate Severe

Peak velocity (m/s) < 3.0 3.0–4.0 > 4.0

37
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THE VALVES
Checking replacement valves

Valve function will depend on the position, size, type, and implantation technique.

• As a general rule, assess a replacement valve • Mechanical valves are especially difficult to
using the same methods as you would the scan because they cause artifactual echoes, so
equivalent native valve disease, but also check a TEE may be helpful, especially for mechanical
for paraprosthetic regurgitation, which will be mitral valves.
outside the valve.
• Biological replacements usually deteriorate
• Almost all replacement valves are more slowly, but occasionally a cusp tear can cause
obstructive than a native valve. sudden severe regurgitation.

• Mild regurgitation through a replacement valve • A change from baseline measurements is the
is usually normal. most useful guide.

• Look for cusp thickening and reduced mobility—

but these can be difficult to see.

w
If you don’t have a baseline study to demonstrate deterioration in function:

Mitral valve replacements Tricuspid valve replacements

Suspect replacement valve obstruction in the mitral Suspect replacement valve obstruction in the
position if the pressure half time >200 ms with a tricuspid position if the velocity through the valve
peak velocity ≥2.5 m/s, there is a narrow forward jet >1.6 m/s, mean gradient >6 mmHg, pressure
on color Doppler, and increased pulmonary artery halftime >230 ms, there is a narrow forward jet on
systolic pressure. color Doppler, and you note a dilated IVC.

Aortic valve replacements Pulmonary valve replacements

Suspect replacement valve obstruction in the aortic Suspect replacement valve obstruction in the
position if the velocity through the valve > 4m/s, pulmonary position if the velocity through the valve
mean gradient >35 mmHg, and there is a narrow is >2 m/s for homografts and > 3m/s for other types,
forward jet on color Doppler. there is a narrow forward jet on color Doppler, and
you note an impaired right ventricle.

References and further reading:

1. Nishimura RA, Otto CM, Bonow RO, et al. 2014. AHA/ACC guideline for the management of patients with
valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force
on Practice Guidelines. J Am Coll Cardiol. 63:2438–88.
2. Vahanian A, Alfieri O, Andreotti F, et al. 2012. Guidelines on the management of valvular heart disease (version
2012). Eur Heart J. 33:2451–96.
38
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OTHER USES OF TTE

Detecting pericardial effusions

• Is it pericardial or pleural fluid? • Signs of tamponade?

Check position relative to the descending Right ventricular free wall diastolic collapse,
aorta: if the fluid is anterior it’s pericardial. dilated IVC with reduced reactivity, mitral
Doppler velocities fall by > 25% on inspiration.
• Size?
Measure at end diastole: small <1 cm, • Can it be drained percutaneously?
moderate 1–2 cm, large > 2cm. Check subcostally whether there is enough
w fluid at proposed drainage site for safe
• Distribution? pericardiocentesis (ideally 2 cm, but at
Global or loculated (in compartments)? least 1 cm).

39
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OTHER USES OF TTE

Assessing intracardiac masses

Check:
• Site, attachment, size, shape, echo density, mobility, and any invasion of the myocardium.
• Then integrate the echo findings with the patient’s clinical status.

Think of thrombus if there is slow moving blood (e.g., poor left

ventricular function or a dilated left atrium).

A vegetation resulting from infective endocarditis is likely to be

situated on a valve and cause destruction. This may be seen
echocardiographically as increasing regurgitation.

The most common benign intracardiac tumor is a myxoma,

which is usually in one of the atria (left more commonly) and
attached to the atrial septum. It may, or may not, have a stalk.

Primary malignant cardiac tumors are very rare.

Myxoma Lambl’s excrescence

40
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OTHER USES OF TTE

Recognizing imitation masses

• A Chiari net is a normal finding in the right atrium. • The right ventricle is normally trabeculated with
a moderator band towards the apex.
• A eustachian valve may be seen at the mouth
of the IVC. It can be thin or thick and fixed • Generalized thickening of cardiac structures can
or mobile. occur with age.

Moderator band Thickened mitral valve annulus and atrial septum

41
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OTHER USES OF TTE

Identifying abnormal vessels

The aorta

4 1
1 2 3
2

1 Annulus 1 Arch
2 Sinus of valsalva 2 Descending aorta
3 Sinotubular junction w
4 Ascending aorta

Aortic diameters are related to body habitus, gender, As a really rough guide, if you measure a diameter
and age, so use the normal ranges recommended by of around 4 cm in the root, ascending aorta, or arch,
your department, making the corrections they advise there is likely to be some degree of dilation so make a
(e.g., body surface area or height). There are phone thorough assessment of the aorta at all levels and refer
apps and websites that can calculate the expected to normal ranges. If it’s >5.5 cm, intervention may be
normal range for your patient based on their height, indicated, but if the patient has Marfan syndrome or
weight, and age. a similar connective tissue disorder be more cautious
because a diameter of 5.0 cm or even 4.5 cm may
trigger an intervention to pre-empt a dissection.

42
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Aortic dissections can be classified using this terminology:

Type A Type B

Proximal Distal

On echo assess the dissection flap, the site of the check for pericardial fluid. For type A/proximal
entry tear, any hematoma, and involvement of dissections make sure that the aortic valve is
other vessels. Measure the aortic diameters and functioning normally.

IVC w

The IVC is normally <2 cm in diameter and collapses cannot be made. The abdominal aorta is sometimes
fully with a sniff. Its size and reactivity can be used mistaken for the IVC but its motion is very different—it
to evaluate filling status and right heart pressures. pulses with each cardiac cycle, unlike the IVC which
However, if a patient is ventilated these assumptions reduces in diameter with inspiration.

43
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OTHER USES OF TTE

Spotting simple shunts

Atrial septal defect (ASD)

Check:
PA AO
• Position
• Direction and size of shunt
PDA
• Right ventricular size and function
• Pulmonary artery systolic pressure RV LV
• Other congenital abnormalities VSD

ASD
Congenital ventricular septal defect (VSD)
RA LA
Check:
• Position
• Direction and size of shunt
• Left ventricular size and function Shunts
• Pulmonary artery systolic pressure
• Other congenital abnormalities
w

Ventricular septal rupture Patent ductus arteriosus (PDA)

This can occur following myocardial infarction. If you find a PDA check the shunt size and direction,
Assess as for a congenital lesion but interpret the left ventricle, the pulmonary artery, and
your findings carefully, the patient may be, or pulmonary artery systolic pressures, and see if you
become, hemodynamically unstable, and an can image the PDA in both the suprasternal and
urgent intervention may be required. parasternal views.

44
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FINISHING YOUR TTE

Archiving the images

Well-archived study:
• Good quality images and waveforms
• Representative
• Effectivels labelled
• Edited
• Safely stored
• Easily retrieved

w
Server Cloud CD/DVD Video tapes

45
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FINISHING YOUR TTE

Creating an exemplary report

Demographics and identifiers

• Patient name and other identifiers (e.g., hospital number, date of birth, address)
• Referrer’s name, reason for echo
• Date of study, where performed, archive location
• Age, gender, heart rate, rhythm, height weight, body surface area, blood pressure
• Name and professional affiliation of who performed, reported, verified the study

Measurements
• 2D, M-mode, Doppler
• Include indices used to assess severity.

Observations
• Based on the systematic study performed, describe each structure imaged.
• Mention structures not seen.
• Include severity assessments. w
• Include minor abnormalities and normal variants.

Summary or conclusion
• Integrate and summarise the measurements and observations. Answer the clinical question.
• Must be understood by non-echocardiographer.
• Flag abnormalities, exclude minor or normal findings, compare with previous studies if relevant.

References and further reading:

1. Gardin JM, Adams DB, Douglas PS, et al. 2002. Recommendations for a standardized report for adult
transthoracic echocardiography: A report from the American Society of Echocardiography‘s Nomenclature and
Standards Committee and Task Force for a Standardized Echocardiography Report. J Am Soc Echocardiogr.
15:275–90.
2. Evangelista A, Flachskampf F, Lancellotti P, et al. 2008. European Association of Echocardiography
recommendations for standardization of performance, digital storage and reporting of echocardiographic
studies. Eur J Echocardiogr. 9:438–48.
46
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Become an expert by learning the most important clinical skills at www.medmastery.com.

Janet Patient Hospital number 123456

47 Main
Janet Road XX99
Patient Procedure date 06/11/07
Hospital number 123456
47 Main Road XX99 Procedure date 06/11/07
Ward: Devonshire Date of birth 23/07/30
Referring consultant: Dr James Smith
Ward: Devonshire Age
Date77
of birth 23/07/30
Care of the Elderly Team
Referring consultant: Dr James Smith Female
Age 77
Care of the Elderly Team Female
Reason for request: recent myocardial infarction with heart failure, in AF
Reason for request: recent myocardial infarction with heart failure, in AF
Performed by Anna Greenaway BSE accredited sonographer
Reported
PerformedbybyAnna
AnnaGreenaway
GreenawayBSE
BSEaccredited
accreditedsonographer
sonographer
Reviewed by Anna
Reported by Dr Sam Jones, Consultant
Greenaway Cardiologist
BSE accredited sonographer
Reviewed by Dr Sam Jones, Consultant Cardiologist
Recorded: on ward Image quality: fair
Machine:
Recorded:mob3
on ward Archive: main server
Image quality: fair
Machine: mob3 Archive: main server
Studied in AF 85 bpm , BP 100/68 mmHg
Studied in AF 85 bpm , BP 100/68 mmHg

Imaging
Aortic
Imagingroot 3.4 cm Ventricular septum 1.0 cm
Left atrium 5.5 cm
Aortic root 3.4 cm Left ventricular
Ventricular posterior
septum 1.0 cm wall 0.7 cm
Left ventricular diastolic diameter 5.7 cm
Left atrium 5.5 cm RV1 3.7 cm
Left ventricular posterior wall 0.7 cm
Left ventricular
Left ventricular diastolic
systolic diameter
diameter4.6
5.7cm
cm RV TAPSE
RV1 3.7 cm17 mm
Left ventricular systolic diameter 4.6 cm RV TAPSE 17 mm
Doppler
LVOT vti 12 cm
Doppler AV Vmax 1.0 m/s PV Vmax 0.9 m/s
MV E 0.6
LVOT m/s
vti 12 cm MVVmax
AV A 0.9 m/s
1.0 m/s w MVVmax
PV Edec 170 ms
0.9 m/s
MV EE/A
0.60.7
m/s MV A 0.9 m/s MV Edec 170 ms
LV Lateral
MV E/A 0.7S 7 cm/s LV Lateral E/E’ 5
LV Lateral S 7 cm/s LV Lateral E/E’ 5

Left ventricle Right atrium Pulmonary valve

Mildly dilated with extensive
Left ventricle Moderately
Right atriumdilated. Thin mobilevalve
Pulmonary cusps and forward
anterolateral
Mildly dilatedakinesis and
with extensive Moderately dilated. Doppler velocities.
Thin mobile cusps and forward
apical dyskinesis.
anterolateral Anteroseptal
akinesis and IVC Doppler velocities.
hyokinesis. The inferior
apical dyskinesis. wall
Anteroseptal 2.0
IVC cm with ~50% reactivity. Tricuspid valve
is
hyokinesis. The inferior wallnot
hyperkinetic. Simpson’s 2.0 cm with ~50% reactivity. Normal
Tricuspid structure
valve and function,
performed due to
is hyperkinetic. inadequate
Simpson’s not Aortic arch trivial regurgitation
Normal structure and noted but
function,
endocardial
performed due definition. Visually
to inadequate Not seen.
Aortic arch waveform too faint to
trivial regurgitation measure
noted but
estimated
endocardial ejection fraction
definition. 30–
Visually Not seen. peak velocity.
waveform too faint to measure
35%. Septum appears intact.
estimated ejection fraction 30– Aortic valve peak velocity.
35%. Septum appears intact. Normal appearance. Three
Aortic valve Study comment
Right ventricle cusps
Normalnoted. Good mobility.
appearance. Three Small pericardial
Study comment effusion
Normal diameter with normal
Right ventricle Trivial regurgitation.
cusps noted. Good mobility. noted,pericardial
Small 0.9 cm circumferentially.
effusion
free wall motion. with normal
Normal diameter Trivial regurgitation. No echo signs of
noted, 0.9 cm circumferentially.
free wall motion. Mitral valve haemodynamic
No echo signs ofcompromise.
Left atrium Thin
Mitralmobile
valve leaflets, mild haemodynamic compromise.
Moderately
Left atrium dilated. regurgitation.
Thin mobile leaflets, mild
Moderately dilated. regurgitation.

Mildly dilated left ventricle with regional wall abnormalities and moderate systolic impairment. Visually
estimated
Mildly ejection
dilated fractionwith
left ventricle 30–35%.
regional wall abnormalities and moderate systolic impairment. Visually
Moderately dilated atria.
estimated ejection fraction 30–35%.
Small pericardial
Moderately dilatedeffusion.
atria.
Small pericardial effusion.

47
APPENDIX

www.medmastery.com
 Updated 01/26/2023

Reference list
Anderson, B. 2016. Echocardiography: The Normal Examination and Echocardiographic Measurements. 3rd
edition. Australia: Echotext. (Anderson 2016, 11–23, 49)

Dalen, H, Thorstensen, A, Vatten, LJ et al. 2010. Reference values and distribution of conventional
echocardiographic Doppler measures and longitudinal tissue Doppler velocities in a population free from
cardiovascular disease. Circ Cardiovasc Imaging. 3: 614–622. PMID: 20581050

Echocardiographic Normal Ranges Meta-Analysis of the Left Heart Collaboration. 2015. Ethnic-specific
normative reference values for echocardiographic LA and LV size, LV mass, and systolic function. JACC
Cardiovascular Imaging. 8: 656–665. PMID: 25981507

European Society of Cardiology. 2017. The EACVI Textbook of Echocardiography, edited by P, Lancellotti, JL,
Zamorano, G, Habib, and L, Badano. 2nd edition. Oxford: Oxford University Press.

Lang, RM, Badano, LP, Mor-Avi, V, et al. 2015. Recommendations for cardiac chamber quantification by
echocardiography in adults: An update from the American Society of Echocardiography and the European
Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 28: 1–39. PMID: 25559473

Lang, RM, Bierig, M, Devereux, RB, et al. 2006. Recommendations for chamber quantification. Eur J
Echocardiogr. 7: 79–108. PMID: 16458610

Nishimura, RA, Otto, CM, Bonow, RO, et al. 2014. AHA/ACC guideline for the management of patients with
valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force
on Practice Guidelines. J Am Coll Cardiol. 63: 2438–2488. PMID: 24603192

Rimington, H and Chambers, JB. 2016. Echocardiography: A practical guide for reporting and interpretation.
Boca Raton, FL: CRC Press, Taylor & Francis Group.

Rudski, LG, Lai, WW, Afilalo, J, et al. 2010. Guidelines for the echocardiographic assessment of the right heart
in adults: A report from the American Society of Echocardiography endorsed by the European Association of
Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of
Echocardiography. J Am Soc Echocardiogr. 23: 685–713. PMID: 20620859

Segar, DS, Brown, SE, Sawada, SG, et al. 1992. Dobutamine stress echocardiography: Correlation with coronary
lesion severity as determined by quantitative angiography. J Am Coll Cardiol. 19: 1197–1202. PMID: 1564220

Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC);
European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Vahanian, A,
Alfieri, O, et al. 2012. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 33:
2451–2496. PMID: 22922415

Wharton, G, Steeds, R, Allen, J, et al. 2015. A minimum dataset for a standard adult transthoracic
echocardiogram: A guideline protocol from the British Society of Echocardiography. Echo Res Pract. 2: G9–G24.
PMID: 26693316

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