Discover the ESC Textbook of Cardiovascular Imaging 2nd edition
standardized data acquisition in transthoracic echocardiography 13 Fig. 1.13 The standardized parasternal short-axis view through the pulmonary valve and the pulmonary trunk at systole (a) and diastole (b). The corresponding colour-coded views are displayed in (c) and (d). In (e) the pulsed wave Doppler spectrum of the right ventricular outflow tract is shown. Additional comments in the text. the functional division of the left ventricle into the complete inflow chamber during diastole at fully opened mitral valve and the movement of the anterior mitral leaflet close to the anterior septal wall, as well as into the complete outflow chamber during systole by complete closure of the mitral valve. Monoplane planimetry of the left ventricle is performed using the apical long-axis view for estimation of global left-ventricular function by determination of the ejection fraction. The apical long-axis view is also used for visual analysis of regional wall motion in the posterior and anteroseptal regions, as well as for morphological evaluation of the mid scallops of the mitral valve (A2-/ P2-scallop). The 2D-view is followed by the colour-coded apical long-axis view ( Fig. 1.14c–d) to assess mitral and aortic valve function qualitatively. Because the long-axis view shows best the blood flow direction into and out of the left ventricle, determinations of proximal jet width or vena contracta, as well as proximal isovelocity surface areas in the presence of turbulent flow at the mitral and aortic valve can usually be well performed in this sectional plane—especially for central mitral and aortic lesions. According to guidelines, jet morphology and jet size of mitral and aortic regurgitation is not recommended anymore for assessing the severity of mitral and aortic regurgitation. The derivations of the pulsed wave Doppler spectra of the inflow and outflow tract of the left ventricle should be performed in the apical long-axis view due to the clear positioning of the sample volumes ( Fig. 1.14e–f). The sample volume of the pulsed wave Doppler spectrum at the mitral valve for characterizing left ventricular inflow should be positioned in the region of the transition of the mitral leaflets to the chord strands (about 10–15 mm towards the ventricle from the mitral valve plane) in the centre of the flow direction into the left ventricle. High-quality pulsed wave Doppler spectra are depicted by bright contours at the maximum velocities. The sample volume of the pulsed wave Doppler spectrum at the left ventricular outflow tract has to be positioned in front of the aortic valve (about 5–10 mm towards the left ventricle from the aortic valve plane). The pulsed wave Doppler spectrum of the left ventricular inflow is necessary for characterization of diastolic function by the E/A ratio, as well as for calculation of E/E′; the pulsed wave Doppler spectrum of the left ventricular outflow tract is mandatory for calculation of cardiac output or shunt volumes in case of communication defects, as well as for calculation of aortic stenotic valve area according to the continuity equation.
14 chapter 1 conventional echocardiography—basic principles Fig. 1.14 Standardized grey-scale apical long-axis view during systole (a) and diastole (b), as well as the corresponding colour-coded images during systole (c) and diastole (d). The pulsed wave Doppler spectrum of the left ventricular inflow through the mitral valve (e) and of the left ventricular outflow tract (f) is displayed in the middle of the illustration. Additional comments in the text. In the presence of turbulences at the mitral and aortic valves, the standard documentation should be completed by continuous wave Doppler spectra over the mitral and the aortic valves. The continuous wave Doppler spectrum over the mitral valve is necessary for determination of the velocity time integral in the presence of mitral valve stenosis for determination of mean and maximum pressure gradients, the determination of the stenotic and regurgitant velocities, as well as for calculation of the parameter dp/dt for estimation of global left ventricular function. The continuous wave Doppler spectrum over the aortic valve is necessary for estimating aortic stenosis severity by determining the mean and maximum pressure gradients and for calculation of aortic stenotic valve area according to the continuity equation. For semiquantification of aortic regurgitation, the pressure halftime method is used at the deceleration border of the regurgitant velocities. By an approximately 60° clockwise rotation of the transducer, starting from the standardized apical long-axis view, the correct apical 2-chamber view is obtained ( Fig. 1.15a–b). The sectional plane of the apical 2-chamber view is characterized by the left ventricular cavity tip, the inferior left ventricular wall at the left side of the cavity, the anterior left ventricular wall at the right side of the cavity, the centre of the mitral valve in its commissural plane, the cross-sectional coronary sinus in the region of the inferior mitral ring, the left atrium and the left atrial auricle cranial to the mitral ring and the opening of the upper left pulmonary vein cranial to the left atrial auricle. Near the anterior region the P1-scallop of the mitral valve is depicted, near the inferior region the P3-scallop. In the centre of the mitral valve the A2-scallop is normally seen. The apical 2-chamber view is used for visual assessment of global and regional left ventricular function in the inferior and anterior regions of the left ventricular wall and for the morphological evaluation of the mitral valve. The colour-coded 2-chamber view is suitable for characterization of the defect localization in mitral valve regurgitation (Fig. 1.15c–d). After modifying the hand position of the transducer to enable a further approximately 60° clockwise rotation of the transducer, this isolated rotation will be performed from the correctly set apical 2-chamber view to get the standardized apical 4-chamber view ( Fig. 1.16a–b). The correct apical 4-chamber view is characterized by the left ventricular cavity tip, the inferoseptal left ventricular wall at the left side of the cavity, the lateral left ventricular wall at the right side of the cavity, the centre of the mitral valve (A2- scallop, P2-scallop near to the P1-scallop), the inter-ventricular