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Echocardiography relies on the use o ultrasoundhigh-requency sound wavestointerrogate bodily tissues. Ultrasound waves penetrate through and are reected by tissuesbeore returning to the transducer, where they are then converted into images. Modern ultra-

sound equipment uses three principal modalities. Tey include M-mode imaging, B-mode (or

two-dimensional imaging), and Doppler imaging. Tis chapter will introduce the basic physical

principles o ultrasound and tomographic anatomy in cardiac imaging with ultrasound.

Basic Principles of

Echocardiography andTomographic AnatomyBernard E. Bulwer, Jose Rivero, and Scott D. Solomon

Figure 1-1. Ultrasound waves used in medical ultrasound imaging are generated by the piezoelectric

elements housed within the transducer (left panel). In order to generate an ultrasound image, the ultra-

sound pulse must make a round trip between the piezoelectric elements (housed inside the transducer),the scan line, and the region o interest (imaged structure). Te ultrasound waves that are emitted

travel along scan lines and interact with tissue structures. Ultrasound waves or echoes are dierentially

reected rom cardiac structures and returned to transducer where they are then converted to electrical

impulses and subsequently converted to images by system components (eg, signal processor and scan

converters) housed within the ultrasound equipment. wo-dimensional images representing cardiac

cross-sectional anatomy are composed o se

scan lines (see Fig. 1-3).

Te principal method used in order to prod

ultrasound images is reerred to as B-mode or b

ness mode imaging (right panel). Echocardiogr

images are processed and displayed as pixels, orpicture elements, o varied shades o gray (black

white). Each pixel has its own anatomical addre

and echoreectivity and is mapped accordingly

Te major components o a modern ultra

scanner include the ollowing: 1) ransducer. T

transducer is the interace between the patien

and the beamormer. Electrical energy is conv

here into ultrasound and returning ultrasound

(echoes) into electrical energy. 2) Beamorme

beamormer has several components with var

unctions, including the pulser and the amplif

Receiver/signal processor. Returning echoes r

the imaged tissue must be processed and flte

Processor/ scan converter. Te scan converterverts echocardiograph data into echocardiog

images that can be displayed, stored, or urthe

processed. 5) Display monitors. Tese are cath

ray tubes or liquid cr ystal display (LCD) screen

display the image. PRFpulse repetition requ

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\ Atlas of Echocardiography

Figure 1-3. Modern ultrasound equipment

phased array transducers, which electronical

generate and steer the ultrasound beams gen

ated in sequence. Each beam results in the g

tion o a scan line. A defned sequence o sca

lines is swept through the angle o view in or

to generate a composite called the scan sect

scan sector still rame rom a phased array tr

ducer typically consists o 96 to 512 scan line

Ultrasound beams or standard B-mode im

are generated in pulses. Te requency o thepulses is called the pulse repetition requency

tory nature o sound waves is caused by the compression and rareactio

particles. Te properties o ultrasound (as is the case in all waves) includ

requency (): the number o cycles occurring per second; 2) wavelength

the length o the waveone cycle; and 3) velocity (c): propagation spee

velocity. Tese properties are related by the equation c = (top panel)Amplitude represents the height or power o the wave. Te intensi

represents the power in watts divided by the area in square centimeters

Ultrasound waves are subject to attenuationthe decrease in amplitudrelative to the distance traveled as sound waves weaken as they travel

through a medium.

Ultrasound waves are primarily reected rom the boundaries betwee

tissues o dierent acoustic impedance (bottom panel). Tis type o reec

tion is reerred to as a specular reection. Although part o the ultrasoun

is reected as the echo, a percentage is transmitted (transmission) throug

the reector. Ultrasound waves can interact with tissue in the ollowing w

1) Reraction is a change in the direction o a non perpendicular incident

ultrasound beam without a change in requency. Tis results in the bendi

a portion o the incident ultrasound waves away rom the main beam axi

Scattering is a combination o reection and reraction o incident ultraso

waves within tissues, which diverts them in multiple directions. Interactio

tissues and tissue boundaries produces a pattern o echoes that are chara

teristic o the tissues imaged, which gives them their signature appearance

Hyperechoic structures produce greater amplitude o reections and appwhite. Hypoechoic tissues produce echoes with smaller amplitudes and a

as various shades o gray. Anechoic or echolucent structures appear echo

because they completely absorb all the incident ultrasound waves. 3) Att

ation reers to the loss o amplitude or beam intensity with distance trave

within the imaged tissue due to absorption and scattering. 4) Absorption

transmission o ultrasound waves with complete loss o acoustic energy a

with no reected echoes. A raction o the acoustic energy is lost as heat.

Figure 1-. Ultrasound waves are high-requency sound waves, which

have a general range o over a million cycles per second. In contrast, sound

that is audible to humans all within the 20 to 20,000 Hz range. Te oscilla-

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Basic Principles of Echocardiography

Figure 1-4. Te resolution o ultrasound images (ie, the ability o the ultra-

sound beam to detect and display anatomical details within the structures

imaged) is dependent on many actors, including the characteristics o the

transducer combined with the physical principles o ultrasound. Each ultra-

sound beam emitted has a defned slice thickness (left panel). Te components

o overall resolution include axial, lateral, elevational (slice thickness), temporal,

and contrast resolution. Axial resolution, which is also called depth, longitudi-

nal, linear, or range resolution, reers to the ability to resolve or detail echoes

that are reected rom two contiguous structures oriented along the axis o

the scan line. It is inuenced by transducer requency and wavelength (pulse

length) and is equivalent to one-hal spatial pulse length. Increased transducer

requency results in increased axial resolution, although this is a trade-o o

penetration, which decreases with increasing transducer requency. Lateralresolution reers to the ability to resolve or detail echoes rom two side-by-side

structures oriented perpendicularly to the scan line axis and is inuenced

the beam width and imaging depth. Spatial resolution reers to the ability

resolve detail in an ultrasound image (averaging 1 mm) and is dependent

both axial and lateral resolution. It is heavily inuenced by transducer req

(right panel). Slice thickness (elevational) resolution reers to the ability to

resolve details situated out o plane o the ultrasound beam or scan plan

emporal resolution reers to the ability to precisely capture still rames o

moving structures as they move rom instant to instant accuracy in time

averaging 50 m/sec. Te greater the pulse repetition requency (ie, the mo

pulses emitted rom the transducer per second), the greater the ability o

transducer to accurately capture a still rame o a moving structure. Con

resolution reers to the ability to discern dierential reectivity between d

ent tissues (eg, endocardial border) and the myocardium, and is inuencepre and post processing. (Far-right panel from Otto et al. [1]; with permiss

Figure 1-5. Harmonic imaging is an important development that has

greatly improved ultrasound image quality. Harmonic images rely on the act

that tissues may reverberate at requencies that are multiples o the original

ultrasound beam. Harmonic images are created rom returning echoes that

have requencies twice that o the undamental requency. Second harm

undergo less distortion than frst harmonics and result in increased sign

noise ratio. Image quality and endocardial defnition are considerably be

with harmonic imaging (right panel).

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4\ Atlas of Echocardiography

Figure 1-6. Contrast echocardiography has been an important advance-

ment in echocardiography. It has clinical use in the assessment o both

cardiac structure and unction. Encapsulated microspheres or microbubbles

measuring ~3 to 6 m in diameter can pass through capillaries. Microbubbles

contain a shell or gas comprised o one or a combination o air, lipid, poly-

mer, peruorocarbon, insoluble gas (eg, perutren lipid microsphere (Defn-

ity). Tese improve their echoreectivity. Microbubbles may have resonant

requencies ranging rom 2 to 10 MHz.

Encapsulation enables gas to stay within blood vessels, and to not be lost to

diusion. Microbubbles create increased echogenicity during interaction with

ultrasound waves. Left panel, At the low-pressure (rareaction) regions o

incident ultrasound wave, microbubbles expand (may expand 2- to 10-o

the crest o the ultrasound wavesthe regions o peak pressuresthe m

bubbles are compressed. Tis creates bubble oscillations, which produce n

echoes. Tese echoes contain harmonic requencies o the incident ultras

that improve their echoreectivity, and hence image analysis. Te dieren

acoustic impedance o microspheres is lower than that o blood, which le

increased linear backscattering and reectivity at the microsphere-blood

ace. Te microspheres produce echoes in response. Right panels above

below, Contrast harmonic imaging with generation o microbubble harm

this figure could be

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need space(covered in

contrast chapter)

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Causes o Ultrasound ArtiactsFaculty equipment

Instrument malunction

Intererence rom other equipment (eg, electrocautery during surgery);malunctioning transducer

Improper instrument settings

Too much time gain compensation (gain)

No harmonic imaging (undamental requency only)

Suboptimal imaging technique: inadequate transducer requency,

sector width, depth, dynamic range, and power outputImproper technique or patient characteristics

Sonographer inexperience

Suboptimal imaging due to patient movement, breathing, obesity,COPD, post-chest surgery

Suboptimal imaging technique: inadequate transducer requency,sector width, depth, dynamic range, and power output

Acoustic or sonographic artiacts

Attenuation artiacts: shadowing and enhancement

Propagation artiacts: Poor spatial resolution, section/slice thickness,speckling, reverberation, comet-tail or ring down, mirror image,range ambiguity, and slide lobe artiacts

Figure 1-7. All imaging modalities are subject to artiacts, which can h

adverse eects on the interpretation o studies. Artiacts are alse image

can be caused by aulty equipment, improper technique, or by acoustic

phenomenon or intererence. Understanding artiacts and their mecha-

nisms is important is important in echocardiography because they comm

occur. Teir recognition is crucial to proper interpretation because they

cause unnecessary alarm and unwarranted clinical studies. COPDchro

obstructive pulmonary disease.

Figure 1-8. Reverberation artiacts are caused by internal reverberations,

or back-and-orth echoes within the imaged tissue itsel, which result in

equipment miscalculation o the return trip time o the emitted pulses.

Reverberation artiacts occur at greater depths than the true image, but at

distances that are multiples o the true image. Let panel, Te ultrasound

is both reected rom and transmitted through a structure (ie, an area ocalcifcation) beore reecting o a second structure. Te reected echo is

re-reected in the direction o the original beam returning to the deeper

structure and is then reected back to the transducer. An artiact is gen

erated at a distance that is a multiple o the original reecting structur

Right panel, Te image resulting rom the inow conduit o an LV ass

device positioned in the LV apex. With reverberation artiacts, the arti

are equally spaced, located parallel to the sound beam axis, and are see

depths deeper than the true reector. Acoustic shadowing or dropoutacts appear as hypoechoic or anechoic regions below structures with

attenuation (eg, calcifed structures).

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Figure 1-10. Upper left , Side lobes degrade lateral resolution. Artiactsappear side by side at the same depth. Grating lobe artiacts ollow a

similar principle in their maniestation, but they arise rom the structural

arrangement o multiple transducer elements within the transducer.

Upper right, his side-lobe artiact, arising rom the pericardium in this

parasternal long-axis view, gives the impression o a linear echodensity in

the let atrium (LA). Lower left, he hyperechoic linear echodensity seen

in this let atrial appendage (LAA) on transesophageal echocardiography

does not share the same echorelectivity pattern as thrombus or the tinate muscles, which would appear isoechoic with the LAA wall. Ne

does it exhibit the characteristics o the wararin ridge that appear a

linear shadowing within the LAA lumen, which moves synchronously

the old o tissue separating the LAA rom the let upper pulmonary

It is actually a side lobe artiact that is mapped into the LAA lumen.

right, Color low Doppler angiogram shows no evidence o a physi

presence within the LAA lumen.

Figure 1-9. Left panel, Comet tail or ring down artiacts (arrows)

on the parasternal long-axis view (PLAX). hese app ear as hyperechoic,

comet tailed, and linear in appearance and are located parallel to the

ultrasound beam axis. hey arise rom merger o closely spaced reverbera-

tions (middle panel). Mirror image artiacts are commonly seen whe

imaging the thoracic aorta on transesophageal echocardiography (

his is a long-axis view o the descending thoracic aorta long-axis vi

(right panel). Etransthoracic echocardiography.

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Figure 1-11. Left panel, he Doppler principle as applied to normal

blood low dynamics within the thoracic aorta. he Doppler requency

shit, sometimes reerred to as Doppler requency, is a shit in the re-quency o the returning echoes compared with the requency o emitted

ultrasound waves. he Doppler requency is itsel a wave with its own

requency. Echoes relected rom blood lowing away rom the transducer

are at lower requencies compared with those emitted rom the transduc-

er ( left panel, blue column). Echoes relected rom blood lowing towards

the transducer are at higher requencies compared with those emitted

rom the transducer (left panel, red column). Echoes relected rom blood

lowing perpendicular to the transducer show no changes in requency

compared with those emitted rom the transducer ( left panel, white

column). Right panel, Doppler assessment o blood low hemodynam

Normal laminar low exhibits a range o requencies that are detectabspectral Doppler, which is so named or its ability to exhibit the spect

o requencies. Note the narrow range or band o requencies in the (

panel, blue and red columns) and their relationship to the baseline, w

creates a window between the Doppler display and the baseline. Ri

panel, deep red column, During turbulent low, there is a wider ran

blood low velocities seen on the spectral Doppler display (spectral b

ening) with a illed-in window. Right panel, blue column, Flow aw

rom transducer. Right panel, red column, Flow towards transducer

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Figure 1-14. Te Doppler equation is used to convert Doppler requency

shits into blood ow velocities. However, the accuracy o the Doppler

requency shit is directly inuenced by the beam-vessel alignment or the

Doppler angle. Te smaller the Doppler angle (), the more accurate themeasurement. Although the actual angle can be used in the equation to

correct Doppler beams that are not exactly parallel to the interrogated

(most ultrasound equipment has the capability to do this), the urther

angle is rom 0 degrees, the less accurate the measurement will be. Cs

soundblood

; Vvelocity; FRrequency o the received or returning echo

Frequency o the transmitted ultrasound pulses

Figure 1-15. In order to construct an ultrasound image (eg, a scan sec-

tor), the ultrasound pulse must make a round trip between the transducer

and the target. In pulsed Doppler studies, the transducer must listen or

the Doppler signal ollowing transmission. A new ultrasound pulse cannot

be transmitted beore the previous pulse has returned. he pulse rep

tion requency (PRF) is the number o pulses transmitted each secon

he urther the imaging depth, the slower the PRF must be to allow

the round trip. Ddepth.

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Figure 1-16. In pulsed-wave Doppler (upper left panel) the ultrasound signal

is emitted repeatedly rom the transducer and the return signal is listened

or by the transducer. Sending out Doppler in pulses allows the equipment

to interrogate velocities at particular depths by gating, or only listening at a

certain time ater the pulse is emitted. By ocusing on a particular scan line, a

region o interest (sample volume) can be defned by both the depth using

time gating and the lateral location. Because pulsed Doppler is sent out and

received in pulses, the Doppler velocities are essentially being sampled at

the pulse repetition requency and are thereore subject to sampling issues,

which can limit the velocity o the blood ow that can be interrogated.All

spectral Doppler signals (upper right panel) show time on the X-a xis a

velocity on the Y-axis. When the pulsed-wave Doppler signal appears

low (Doppler window), it is indicative o laminar low where the ma

o red blood cells are traveling within a narrow range o velocities.

With continuous wave (CW) Doppler (lower left panel) the Doppler si

emitted continuously (similar to a continuous tone) and continuously list

or. For this reason, CW Doppler can be used to identiy peak velocities, b

cannot localize velocities to particular depths. Note the flled in appearan

o the CW spectral Doppler display in the ( lower right panel). Tis reects

wide spectrum o velocities detected within the much larger sample volu

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Figure 1-18. Left panel, Apical ive-chamber view in a patient with

dynamic LV outlow tract (LVO) obstruction showing accelerated low

on color low Doppler ( inset). Pulsed wave (PW) Doppler showed aliased

velocities with baseline set just above 2 m/s. Right panel, Nyquist limit

and aliasing; baseline adjustment. he same patient as in the (left pa

with baseline set at 6.0 m /s and switch to continuous wave Doppler

mode, the entire spectral display and peak velocities are now unamb

ously displayed.

Figure 1-19. Te law o conservation o mass states that the ow in one

part o the heart has to be equivalent to the ow in another part; ie, ow

rate in = ow rate out ( left panel). Doppler ultrasonography harnesses this

principle in order to calculate valve area (eg, in aortic stenosis). Blood ow

velocities increase at sites where blood vessel diameter narrows. Te dier-

ential ow velocities are detected by Doppler and used to calculate the valve

areas. Te continuity equation suggests that the area at a particular location

multiplied by either the velocity o ow or the time integral o owveloc-

ity time integral (VI) represents the area under the curve o the Doppler

ow proflewill be similar in two locations assuming no shunt is prese

For example, in order to calculate the valve area in a patient with suspec

aortic stenosis (right panel), the cross sectional area (CSA) at the level o

LV outow tract is calculated (in actuality, the diameter is measured and

area is calculated), and multiplied with the velocity or VI obtained at t

same location using pulsed wave (PW) Doppler. Tis product should eq

the product o the velocity or VI across the valve itsel, which is estima

using continuous wave (CW) Doppler to fnd the highest velocity and t

aortic valve area (AVA), which is then calculated. LVOLV outow tra

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Figure 1-0. Te Bernoulli principle serves as the basis o calculating pressure gradients (driving pres-

sure) across a narrowed orifce. Te Bernoulli principle broadly states that as the velocity o a moving uidincreases, the pressure within the uid decreases. It assumes the conservation o energy, though in reality

Figure 1-1. One o the advances in cardiac ultrasound has been the development o color low

Doppler (CFD) imaging. It has dramatically improved the assessment o cardiovascular hemodynam-

ics, and complements the cross-sectional and spectral Doppler examination. CFD is a pulse wave

(PW)based modality that, unlike PW, uses multiple gates ( ie , multiple sample volumes) simultane-

ously instead o a single gate and provides spatial display o real-time color-coded velocities super-

imposed upon real-time two-dimensional (2D) imaging. CFD thus provides inormation on low

velocity and direction. CFD imaging is subject to the same physical principles as PW Doppler and is

some energy is lost through heat, turbulent r

and vortex ormation. Doppler-derived veloci

are inserted into the modifed or simplifed ve

o the Bernoulli equation in order to calculate

sure gradients across cardiac chambers and va

As a blood vessel or orifce narrows or becom

stenosed, the velocity o blood downstream

the stenosis must increase. Blood proximal to

stenosis (location 1) will thereore accelerate a

ows downstream rom the stenosis (location(law o conservation o energy).

Te modifed Bernoulli equation requires

knowing velocities both proximal and distal

stenosis. In the majority o cases in physiolog

conditions, we can ignore the proximal veloc

Tis is not true, however, when velocities pro

to the stenosis are elevated. For example, i w

were to use the Bernoulli equation in order t

assess the gradient across a stenotic aortic va

physiologic velocities proximal to the valve w

be relatively low compared with the velocitie

tal to the valve. However, i that same patien

outow tract obstruction due to hypertroph

cardiomyopathy or a sub aortic membrane, t

proximal velocities would have to be consideLVOLV outow tract.

thus subject to aliasing when velocities are

enough that the Doppler shit is greater tha

hal the pulse repetition requency.

Left panel, Schema o apical our-chamb

(A4C) view showing CFD sector scan superim

posed upon real-time two-dimensional gray

image. Te active color scan sector employs

ple gates (trains or ensemble) that are color-

velocities. Right panel, A4C view showing c

Doppler superimposed on B-mode two-dim

sional imaging. Flow direction during early syreveals blue ow along the LV outow tract.

ow indicating ow momentum rom let at

into LV is also visualized.

CFD provides an intuitive assessment o c

diovascular hemodynamics because it permi

angiographic view o the ow, and is there

more intuitive than spectral Doppler. It allow

rapid qualitative assessment o abnormal o

patterns. It is an important guide to PW and

continuous wave Doppler position and align

LAlet atrium; RVright atrium.

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Figure 1-3. Te mosaic color pattern shown in this image reects hi

velocity turbulent ow (arrow) in a patient with severe mitral regurgita

Note the mosaic pattern o bright hues indicative o aliasing due to tur

lence and high-velocity ow.

Comparison o Doppler ModesContinuous wave Doppler Pulsed wave Doppler Color fow Doppler

Sample volume Large (with spectral broadening) Small (with spectral window due tonarrow range o velocities); samplevolume adjustable (best 25 mm)

Large with multigating; adjustable actcolor window in color scan sector

Detection o peak/maximal velocities

Detects highest velocities along scanline; peak velocity measurements

Peak velocity measurements, but aliasingoccurs at high velocities

Mean velocity measurements; aliasingoccurs as it is a PW-based modality

Aliasing No aliasing Aliasing (Nyquist limit) A PW Doppler-based technique; alias

Sensitivity Best sensitivity Good sensitivity Good sensitivity(jet size very sensitive to gain setting

Depth resolution/range ambiquity

Range ambiguity Range resolution; detects location o fow Range resolution;real time 2D anatomy o fow

Spectrum analyzed Wide (spectral broadening) Narrow; spectral broadening seen withturbulent fow and large sample volumes

Wide color-encoded Doppler shits oconventional *BART scale and color

hues, saturation, and luminance*Blue away, red towards.

Figure 1-4. Comparison: continuous wave, pulsed wave, and color ow Doppler.

Figure 1-. Images obtained by color ow Doppler (CFD) rames must

be interpreted with reerence to the velocity scales displayed on the image.

Tese reerence maps or scales provide inormation on average ow velocities

based on three characteristics o color: 1) hue, 2) luminance, and 3) satura-

tion. wo major modes o display are velocity mode and variance mode.Left panel, Conventional velocity mode: ow towards transducer is

coded (by convention) in shades o red. Flow away rom transducer is color-

coded in shades o blue (BAR: blue away, red towards). Black color on the

sale indicates no ow. Lighter shades o BAR indicate aster ow.

Right panel, Variance mode maps provide inormation in addition to

velocity and direction. Tey can help distinguish laminar rom turbulent ow.

In laminar ow, the average velocities are not much dierent rom the peak

velocities. Tey are close together (ie, they exhibit minimal variance). When

blood ow is turbulent, there are much greater dierences between the

average and peak velocities, namely greater variance. Deeper shades indicate

slower laminar ow, while lighter shades may represent aster, turbulent ow.

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Te Normal Echocardiographic Examination and omographic Anatom

Figure 1-5. ransthoracic two-dimensional echocar

raphy: imaging planes, transducer positions, and standviews. A2Capical two-chamber view; A3Capical th

chamber view; A4Capical our-chamber view; A5C

cal fve-chamber view; PLAXparasternal long-axis vie

PSAXparasternal short-axis view; PSAX-AVparaste

short-axis view-aortic valve level; PSAX-MVparastern

short-axis view-mitral valve level; PSAX-PMparastern

short-axis view papillary muscle level; SC-4Csubcosta

view (our-chamber).

Would be better for the figure to occupy the majority of the page and the text below it - i.

e., stretch figure down and out - with caption below

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CFigure 1-7. (Continued)

Figure 1-8. Echocardiographic parasternal

inow scan plane and corresponding anatom

IVCinerior vena cava; LLPVlet lower pul

monary vein; LUPVlet upper pulmonary ve

RAright atrium; RAAright atrial appenda

RVORV outow tract; SVCsuperior ven

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Figure 1-30. Echocardiographic short-axis s

planes and corresponding anatomy.

Figure 1-9. wo-dimensional long-axis view showing structures visua

on the RV inow view. RAright atrium.

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Figure 1-31. wo-dimensional parasternal short-view showing the

structures visualized at the level o the aortic valve. RAright atrium;

RVORV outow tract.

Figure 1-3. Views o the high parasternal

short-axis scan plane at the level o the pul-

monary arteries and corresponding anatom

Aoaorta; DAdescending thoracic aort

PApulmonary artery.

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Figure 1-34. Anatomical structures correspo

to the parasternal short-axis (PSAX) scan plan

the level mitral valve (MV) and papillary musc

Figure 1-33. wo-dimensional echocardiographic rame showing the s

tures visualized on high parasternal short-axis view at the level o the ma

pulmonary artery (PA) and biurcation into the right and let pulmonar

arteries. Aoaorta; RAright atrium; RVORV outow tract.

are really

sting space heree figure above

34) could be

de bigger - theis minimal

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Figure 1-36. Echocardiographic our-chamb

scan planes and corresponding anatomy. RA

atrium; SVCsuperior vena cavity.

Figure 1-35. wo-dimensional short-axis rames showing structures visual-

ized on the parasternal short-axis (PSAX) views at the mitral valve level (left

panel), mid ventricular or papillary muscle level (right panel), and apic

level (right panel).

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\ Atlas of Echocardiography

Figure 1-39. wo-dimensional rame showing structures

alized on the suprasternal notch view.

Figure 1-38. Echocardiographic suprastern

notch scan plane and corresponding anatom

LAlet atrium; PApulmonary artery; R A

right atrium; SVCsuperior vena cavity.

Figure 1-37. wo-dimensional our-chamber rames showing the structures

visualized on the apical our-chamber (A4C) ( left panel), apical fve-chamber

(A5C), (middle panel), and subcostal our-chamber views (right panel).

LAlet atrium; RAright atrium.

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Figure 1-40. Panoramic schema o coronary

artery territories and LV segments using nom

ture recommended by the American Heart A

ation Writing Group on Myocardial Segment

and Registration or Cardiac Imaging [2]. IVC

rior vena cavity; LAlet atrium; laalet atr

appendage; LADlet anterior descending aPApulmonary artery; LAOlet anterior o

LCxlet circumex; RAOright anterior ob

RCA/PDAright coronary/posterior descend

SVCsuperior vena cavity.

1. Otto C, ed: Principles o echocardiography imaging acquisition and Doppler

analysis. In extbook of Clinical Echocardiography, edn 3. Philadelphia:

WB Saunders; 2004.

2. Cerqueira MD, Weissman NJ, Dilsizian V, et al.: Standardized myocardial segmen

and nomenclature or tomographic imaging o the heart: a statement or health

proessionals rom the Cardiac Imaging Committee o the Council on Clinical C

ogy o the American Heart Association. Circulation 2002, 105:539542.

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