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ESC Textbook of Cardiovascular Imaging - sample

Discover the ESC Textbook of Cardiovascular Imaging 2nd edition

standardized data

standardized data acquisition in transthoracic echocardiography 19 Fig. 1.20 Illustration for analysis of mitral valve regurgitation affecting the commissures. In the middle of the illustration the standardized 4-chamber view is displayed during diastole and during systole (red surrounding) and its sectional plane is displayed in a parasternal short-axis view (red arrow). For analysis of the posteromedial commissure the transducer has to be tilted to the dorsal region of the left ventricle showing a longitudinal section through the coronary sinus. The illustration shows the corresponding colour-coded images during systole (a) and diastole (b), as well as the grey scale images during systole (c) and diastole (d). For analysis of the anterolateral commissure the transducer has to be tilted to the ventral region of the left ventricle showing the left ventricular outflow tract. The illustration shows the corresponding colour-coded images during systole (e) and diastole (f), as well as the grey scale images during systole (g) and diastole (h). Additional comments in the text. orientation of the notch in the same direction as in the apical 4-chamber view during inspiration of the patient ( Fig. 1.21a–b). The subcostal 4-chamber view shows the same cardiac structures as the apical 4-chamber view. A counter-clockwise rotation shows the subcostal short-axis views. The perpendicular view to the inter-atrial septum in the subcostal short-axis view of the aortic valve is suitable for the detection of inter-atrial communication defects by colour-coded Doppler imaging ( Fig. 1.21c–f). Subcostal short-axis views of the mitral valve and the left ventricle at mid-papillary level can replace the parasternal short-axis views for analysis of the heart if the parasternal window is not sufficient ( Fig. 1.22a–h). The right ventricular inflow and outflow tract, as well as the pulmonary trunk and the pulmonary bifurcation can be well visualized by the subcostal approach. Due to the excellent Doppler angle, Doppler spectra through the pulmonary valve can be achieved in this view ( Fig. 1.23a–e). By counter-clockwise rotation from the subcostal 4-chamber view the longitudinal section of the inferior caval vein should be documented for estimation of the preload of the right ventricle ( Fig. 1.24a–b). In the presence of normal right atrial pressure, the central venous pressure is normal, which can be documented by pulsatile wall movement and a complete breath-dependent inspiratory collapse of the inferior caval vein. The right atrial pressure is increased in patients with cardiac stasis on the right side, documented by partial collapse or a complete loss of collapse of the inferior caval vein during deep inspiration. For the analysis of the aortic arch the suprasternal long-axis view of the aortic arch has to be documented by grey scale 2D cineloop, as well as by colour-coded Doppler ( Fig. 1.25a–b). The transducer should be positioned with the axis directed to the

20 chapter 1 conventional echocardiography—basic principles Fig. 1.21 Standardized grey-scale apical 4-chamber view during systole (a) and diastole (b). Standardized subcostal short-axis view at the aortic valve level during systole (c) and diastole (d), as well as the corresponding colour-coded images during systole (e) and diastole (f). Additional comments in the text. centre of the left ventricle and with the notch oriented to the left shoulder. The correct view should individually be adjusted to the topography of the aortic arch. The suprasternal documentation of the aortic arch is necessary for detection of aortic pathologies— especially for the transthoracic detection of aortic dissection. Thus, it is mandatory to perform suprasternal scanning of the aortic arch in patients with aortic valve diseases and assumed aortic pathologies, as well as in the emergency scenario. Principles of transoesophageal echocardiography—practical aspects A transthoracic echocardiography should be generally performed prior to a transoesophageal echocardiography, if it is possible. The main reason for the transthoracic pre-examination in adult patients is the fact that multiple cineloops and Doppler spectra can be achieved and documented in a high and often better image quality in the transthoracic than in the transoesophageal approach. This mainly concerns the short-axis views of the left ventricle and the mitral valve, which often will be visualized by oblique views in the transgastric documentation and the Doppler spectra of the left heart, which will not show optimal Doppler angulations in the transoesophageal echocardiography. This is very important for all calculations using Doppler parameters. If these parameters are falsified by incorrect Doppler angulations, calculation of pressure gradients, stroke volumes, shunt volumes and stenotic areas using the Bernoulli or continuity equation will be wrong. Therefore it is obvious that a sufficient transthoracic echocardiography prior to the transoesophageal investigation can significantly shorten the procedure time of transoesophageal echocardiography. For transoesophageal echocardiography some prerequisites have to be fulfilled. The preparation of the patient for the procedure includes an ECG, blood pressure and oxygen saturation monitoring, a venous line for sedation, contrast administration, drug administration in the event of complications, the availability of emergency and resuscitation equipment, as well as a suction

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