standardized data acquisition in transthoracic echocardiography 11 Fig. 1.11 The standardized parasternal short-axis view at the mitral valve level. Additional comments in the text. then clockwise: anterior—60°; lateral—120°; posterior—180°; inferior—240°; inferoseptal—300°), the left ventricular cavity, the anterolateral transversal mid-papillary muscle between 60° and 90° at the inner wall of the left ventricle and the posteromedial transversal mid-papillary muscle between 210° and 240° at the inner wall of the left ventricle. The parasternal short-axis view at the mitral valve level ( Fig. 1.11a–d) shows the free wall of the right ventricular outflow tract, the cavity of the right ventricular outflow tract, all basal segments of the left ventricular wall and the left ventricular cavity, near the transducer in the left ventricular cavity the anterior mitral leaflet, which is anatomically one leaflet but can be described by three portions (the A1-scallop near the anterolateral left ventricular wall, the A2-scallop in the centre of the anterior mitral leaflet, the A3-scallops near the posteromedial left ventricular wall) and far from the transducer in the left ventricular cavity the posterior mitral leaflet, which is divided anatomically into three scallops (the P1-scallop near the anterolateral left ventricular wall, the P2-scallop in the centre of the posterior mitral leaflet, the P3-scallops near the posteromedial left ventricular wall). The parasternal short-axis view at the aortic valve level ( Fig. 1.12a–d) is characterized by the following cardiac structures. The basal free wall of the right ventricular outflow tract is near the transducer. The right ventricular cavity is bounded on the left side of the sector by the tricuspid valve and on the right side by the pulmonary valve. The aortic valve is in the centre of the sector behind the right ventricle. During diastole the right coronary cusp is ventrally located, the left coronary cusp is between 60° and 180°, and the non-coronary cusp is between 180° and 300°. Close to the commissure between the right and the left coronary cusp at the aortic valve annulus, the dorsal cusp of the longitudinally intersected pulmonary valve is located. Close to the commissure between the right and the non-coronary cusp at the aortic valve annulus, the septal leaflet of the tricuspid valve is located. At the far side of the aortic valve, the left atrium is shown. Close to the aortic valve annulus, near to the non-coronary cusp, the perpendicular intersected inter-atrial septum is located. Between the aortic valve and the left atrium, the fibrotic aorticomitral junction is located. Between the inter-atrial septum and the tricuspid valve is the right atrium. It has to be mentioned that all parasternal short-axis views display the cardiac structures mirror-inverted. The colour-coded short-axis views through the mitral and aortic valve are additionally suitable for qualitative analysis of the location of mitral valve regurgitation and semiquantification of aortic valve regurgitation by analysing the regurgitant orifice during diastole.
12 chapter 1 conventional echocardiography—basic principles Fig. 1.12 The standardized parasternal short-axis view at the aortic valve level. Additional comments in the text. From the parasternal approach, colour-coded and pulsed spectral Doppler imaging of the right ventricular outflow tract or the pulmonary valve should be generally added to a standard documentation in order to calculate the cardiac output of the right heart and to estimate the pulmonary pressure by acceleration time and the morphology of the flow profile, retrospectively ( Fig. 1.13a–e). If pulmonary regurgitation is present, and right heart or pulmonary diseases are suspected, a continuous wave Doppler spectrum through the pulmonary valve should be documented to estimate end-diastolic and mean pulmonary pressure by the end-diastolic and maximal velocities of the regurgitant flow. The locating of the transducer directly at the cardiac apex is essential for the documentation of the correct apical sectional planes. This is possible by guiding the transducer to the correct apical position by sliding in caudolateral direction on the skin of the patient from the correct transducer position of a standardized parasternal long-axis view to the correct transducer position of a standardized apical long-axis view ( Fig. 1.14). The apical longaxis view is characterized by the same cardiac structures as the parasternal long-axis view ( Fig. 1.14). The standardized apical long-axis view is additionally characterized by the tip of the cardiac apex, which is directly below the transducer surface and the centre of the mitral valve in the centreline of the scanning sector. The centred display of the left ventricle is essential for the correct documentation of the apical 2- and 4-chamber view by rotation of the transducer without tilting and flipping at the correct apical transducer position. If the centreline of the left ventricle is not centred in the sector of the apical long-axis view, rotation of the transducer obviously will produce foreshortening views of other sectional planes of the left ventricle. Oblique apical views in normal hearts and failing standardization can be checked by the configuration of the apical shape of the left ventricular cavity. In normal hearts with a normal electrocardiogram, the apex of the left cavity shows a peaked, ‘gothic’ configuration (early ‘gothic’ in the 4-chamber view, mid ‘gothic’ in the long-axis view and late ‘gothic’ in the 2-chamber view). In normal hearts a ‘romanic’ configuration is obtained due to foreshortening views. Due to guiding to the apical transducer position by sliding down from the parasternal long-axis view to the apical long-axis view, the apical transthoracic echocardiographic examination should start with the two-dimensional imaging of the left ventricle in the apical long-axis view ( Fig. 1.14a–b). The apical longaxis view of the left ventricle is normally perpendicular to the commissure of the mitral valve. Thus, the long-axis view shows