Normal Echocardiographic
views and normal dimensions
Introduction
▪ Echocardiography (echo) – the use of
ultrasound to examine the heart
▪ safe, powerful, non-invasive and painless
technique
▪ easy to understand as many features are
based upon simple physical and physiological
facts
▪ It is a practical procedure requiring skill and is
very operator dependent – the quality of the
echo study and the information derived from it
are influenced by who carries out the
examination!
Patient position
▪ Supine and flat
▪ Sometimes left decubitus position
▪ Occasionally right decubitus position
Placement of transducer
Standard Echocardiographic
Views
▪ Parasternal
– Long Axis, Short Axis, RV Inflow, Pulmonary Long
axis
▪ Apical
– 4 Chamber, 2 Chamber,
▪ Subcostal
- Long Axis, Short Axis
▪ Suprasternal Notch
- parallel and perpendicular to arch of aorta
Examination through the base of the
heart and root of aorta
▪ Long axis view
- long axis view of
aorta
- aortic valve
- left atrium
- LVOT
Parasternal Long axis
Short axis view
- aorta and its leaflets
- right, left coronary and non coronary cusp
- left atrium
- IAS
- right atrium
- tricuspid valve
- right ventricle
- RVOT
- pulmonary valve
- MPA and its branches
- left atrial appendage
- LMCA
- RCA
Parasternal Short Axis View
Pulmonary Artery
▪ Pulmonary artery
bifurcation
▪ Right main PA
passes posterior to
ascending AO
▪ Left main PA not in
R
L same plane
Short axis at mitral
valve level
Parasternal Short Axis
Mid-Ventricle (Papillary Muscle Level)
Right
Ventr
Septum Left
Ventr
Posteromedial Anterolateral
Papillary Papillary
Muscle Muscle
Parasternal Short Axis
LV Apex
Apical Four Chamber
Standard presentation
Post Septum
Lateral wall
Apical 4 Chamber view
The tricuspid valve more apically placed
Apical 4 Chamber View
Pulmonary Veins
L inf
R sup L sup
Apical Two Chamber
Anterior wall
Inferior wall
Apical 5 Chamber
• Transducer angled anteriorly from 4 chamber
Subcostal Four Chamber
Subcostal Short Axis of LV
Subcostal Short Axis
Level of the AV
Liver
IVC RCC
RA
LA
PA
Subcostal short axis view to
visualize IVC and hepatic veins
Subcostal assessment IVC
▪ Image situs by IVC relation to aorta
▪ IVC connection to RA easily seen
▪ RA pressure estimate
– IVC collapse with sniff
▪ Full - RA pressure = 5 mm Hg
▪ > 50% = 10 mm Hg
▪ < 50% = 15 mm Hg
▪ No collapse - 20 mm Hg or higher
Subcostal
Descending and Abdominal Aorta
Suprasternal notch
▪ View of arch and descending aorta
– Coarctation
– PDA
– Dissection
▪ Doppler in descending aorta
– Coarctation
– Severe AR
Suprasternal View
parallel to arch of aorta
Suprasternal View
Aorta Long Axis
Brachiocephalic vein
Arch
Ascending
Descending AO
RPA
Suprasternal view
Aortic Arch
Suprasternal view – perpendicular to
Aortic Arch Short Axis
Myocardial wall segments
M-mode
▪ Multiple pulses sent out along single
line
▪ High temporal resolution
▪ Standard for measurements of chamber
sizes
▪ X axis - distance from transducer
▪ Y axis - time
M-mode measurements
▪ Must be made from parasternal long axis
and not short axis
▪ Leading edge to leading edge
▪ Avoid including RV trabeculations
M-Mode at level AV and LA
LA AV coaptation in center of aortic root
LA
M-Mode level of MV leaflets
IVS
E
F
Mitral leaflets move
apart in diastole
M-Mode level of LV cavity
M-Mode level at PV
Doppler effect
▪ A sound wave reflected from a moving
object changes its frequency
proportional to the velocity of the object
Doppler Effect
Doppler effect used to calculate
velocity of galaxies as well as velocity of
trains
or red blood cells relative to observer
Pulse wave Doppler
▪ Pulse of ultrasound directed at moving object
(blood)
▪ Frequency shift of returning signal indicates
direction and velocity of object
▪ Pulsed wave Doppler
– Determine velocity in a small area called sample
volume
– Used for color velocity mapping
– Cannot resolve velocities >1m/sec
Color Doppler Imaging
Toward
Away
Color Doppler Imaging
LV Short Axis
VSD
Pulse wave Doppler
Color vs Spectral display
MR velocity aliases since
- Mild to moderate MR
velocity> 1 m/sec
Biventricular dysfunction
Apical thrombus and ICD
Color vs Spectral Display of
Color Doppler
Color Spectral
▪ Samples large area • Velocity at a single spot
– Direction of jet • Hemodynamic
– Extent of jet assessment
– Detects additional jets -
• Temporal resolution
multiple regurgitant jets
superior
▪ Limited temporal
• Timing and velocity are
resolution
accurately detected
Nyquist limit
▪ Pulse wave Doppler cannot resolve
velocities above the Nyquist limit
▪ Does not apply to continuous wave Doppler
▪ Nyquist Limit = 1/2 Pulse Repetition
Frequency (varies with depth)
Nyquist Limit
0.65 m/sec
MR signal aliases
2 Jets of MR by color Doppler
Separation not possible with spectral
display
Color baseline lowered to measure PISA radius
Doppler Applied to imaging
▪ Continuous wave Doppler
– 2 transducers -
▪ Sending US continuously
▪ Listening for returning US continuously
– Determines velocity along a line
– Can resolve any velocity
– Useful for finding maximum velocity
Spectral Doppler Imaging
Toward
Transducer
Time
Away from
Transducer
Velocity cm/sec
Pulse vs Continuous
wave Doppler
PULSE CONTINUOUS
▪ Determines velocity at a ▪ Cannot resolve location of
point by placement of the velocity along line
sample volume ▪ Can resolve any
▪ Limited ability to resolve physiologic velocity
high velocity ▪ Can only be displayed as
▪ Can be displayed as color spectral envelope
flow or as spectral
envelope
Doppler assessment of valves
▪ Optimal 2 D images obtained with
ultrasound beam perpendicular to
structures
▪ Optimal Doppler with ultrasound beam
parallel to flow
▪ Apical views allow alignment with most
cardiac flows
Display of Doppler information
▪ Color Doppler - pulse wave modality
cannot resolve high velocities
– Use of turbulence map demonstrates
velocity, direction and turbulence
▪ Pulse wave spectral display
▪ Continuous wave spectral display
– Resolves high velocities
– Range ambiguity
Pulse wave Doppler
Mitral Inflow
▪ Sample volume at
leaflet tips
▪ E wave higher
E velocity than A wave
A
▪ No significant
respiratory variation
in velocities
Pulse wave Doppler
Tricuspid Inflow
▪ Sample volume at
leaflet tips
▪ E wave higher
velocity than A wave
▪ Respiratory variation
less than 30%
Pulse Wave Doppler
LVOT velocity
▪ Sample volume in
LVOT just proximal
to AV
▪ Apical 5 chamber or
apical long axis view
Pulse Wave Doppler
in Pulmonary Artery
Normal maximal velocity 0.8 m/sec in adults
Continuous Wave Doppler
Aortic Valve
▪ From apical 5
chamber or apical
long axis
▪ Normal peak
velocity < 1.2 m/sec
▪ This patient had
mild AS
Pulse wave of abdominal aorta -
subcostal view
Pulsed Wave Doppler
Descending Thoracic Aorta
Pulse wave Doppler
Right Upper Pulmonary Vein
Normal systolic predominance
S
D
A
Normal Peak velocities
Mitral valve 0.6-1.3 m/sec
Tricuspid valve 0.3-0.7 m/sec
Pulmonary valve 0.5-1.0 m/sec
Aortic valve 0.9-1.7 m/sec
Normal LV volumes
LV volume in diastole 95.5 ml + 20
LV volume in systole 38.6 ml + 10
Ejection Fraction 60% + 6
Normal Aortic & Pulmonary artery
flow Doppler
Aorta PA
Peak velocity 72-120 cm/sec 44-78 cm/sec
Ejection time 265-325 msec 280-380 msec
Acceleration 83-118 msec 130-185 msec
time
Filling Dynamics
LV RV
Peak E 72 cm/sec +14 51 cm/sec +7
Peak A 40 cm/sec +10 27 cm/sec +8
E/A 1.9 + 0.6 2.0 + 0.5
DT 179 msec + 20 188 msec + 22
IVRT 76 msec + 11 76 msec + 11
VEINS PV -Peak S – 48, D- SVC -Peak S – 41,
50, AR-19 cm/sec D-22, AR-13 cm/sec
The complete study
▪ All views and measurements should be
performed in all patients
▪ Additional views, including off-axis views
required depending on pathology
2-D echo ▪Anatomy
▪ventricular and valvular movement
▪positioning for M-mode and Doppler
echo
M-mode echo ▪measurement of dimensions
▪timing cardiac events
Pulsed wave ▪normal valve flow patterns
Doppler ▪LV diastolic function
▪stroke volume and cardiac output
Continuous wave ▪severity of valvular stenosis
Doppler ▪severity of valvular regurgitation
▪velocity of flow in shunt
Colour flow ▪ assessment of regurgitation
mapping and shunts
