DEPARTMENT NAME

TRANSTHORACIC ECHOCARDIOGRAPHY (TTE)

Angela Gooden RN, MSN, CPNP-PC/AC

Director, Advanced Practice

Cardiology Nurse Practitioner

Instructor, Baylor College of Medicine

DEPARTMENT NAME

• Describe basic principles

• Review limitations

• Describe the various methods

• Identify common views

• Review reasons to obtain an echo

• Identify normal findings

OBJECTIVES

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Basic principlesUtility

INTRO TO ECHO

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BASIC ECHO PRINCIPLES

• Non-invasive imaging • A transducer placed on the

chest emits sound waves that are used to create images

• No known adverse effects at clinical imaging frequencies

• Sound wave reflection determines image brightness

Sound wave reflection• High (white) = Air, bone, tissue

• Low (black) = body fluids, e.g. blood

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UTILITY OF ECHO IMAGING• Quantitative and qualitative

evaluation of cardiac anatomy, hemodynamics, and function• Chamber size• Systolic, diastolic function• Valve motion, function• Masses, fluid collections• Hemodynamics

• Data is influenced by height, sex, age, ethnicity, body habitus, and athleticism

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ScreenWindowsPlanesProtocol

IMAGING ORIENTATION

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SCREEN ORIENTATION

Transducer

L: Medial/right structures

R: Lateral/left structures

D: Distant anatomy

L R

D

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IMAGING WINDOWS• Suprasternal

• Parasternal

• Apical

• Subcostal

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IMAGING PLANES• Long axis

• Short axis

• Apical

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• Parasternal, long axis• Parasternal, short axis• Apical• Situs View• Subcostal, long axis• Subcostal, short axis• Suprasternal (arch views)• Ductal view• Pulmonary veins (crab view)

BASIC IMAGING PROTOCOL

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2DM-ModeDoppler

ECHO TECHNIQUES

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ECHO TECHNIQUE, 2D

Two-dimensional (2-D)• Cross-sectional• Snapshot, provides real-time

imaging in quick succession

Usefulness• Assessment of cardiac

structure

• Assessment of chamber & vessel size and volume

• Quantitative assessment of LV function and ejection fraction

DEPARTMENT NAME

DEPARTMENT NAME

ECHO TECHNIQUE, M-MODE

Motion mode (M-mode)• Ultrasound signal transmission

along one line• Graphs represent depth and

strength of ultrasound signal• High sensitivity to recording rapidly

moving structures, e.g. valve leaflets• Useful in providing dimension

measurements, e.g. shortening fraction

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Continuous wave (CW)• Doppler continuously sends and receives

signals across moving blood flow

• Detects high velocity flows: Blue, Away-Red, Toward-Turbulence, Green

• Measures severity of stenosis, regurgitation in valves, shunts, conduits, etc.

ECHO TECHNIQUE, DOPPLER

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ECHO TECHNIQUE, DOPPLERPulsed wave (PW)• Intermittent signal

• Allows spatial localization

• Limited by velocity of flow

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ECHO TECHNIQUE, DOPPLER

Color Flow

• Integrated with 2D image

• Displays blood flow timing, velocity, direction, and turbulence

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Acquired images and demonstrated structures

IMAGING PROTOCOLS

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PARASTERNAL LONG AXIS VIEW• Transducer at 3-4th intercostal

space

• Structures: LA, MV, LV, LVOT, AV, IVS, RV, Ascending aorta

• Tilt and rotate the transducer to see RVOT, PV, PA

LA

LV

RV

LA

RV

LV AV

MV

Asc Ao

IVS

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PARASTERNAL SHORT AXIS VIEW (PSAX)• 90° rotation from long axis

view, tilted superiorly

• 1 dimensional assessment

• Structures: AV, LA, RA, TV, RVOT, PV, IAS

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PSAX TRANSITION• 90° rotation from long axis

view, tilted superiorly

• Great vessel level—Focus on aortic valve

• Mitral valve level, anterior and posterior leaflets

• Left ventricle, papillary muscles, apex

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PARASTERNAL SHORT AXIS TRANSITION

1: Great vessel level 2: Mitral valve level 3: Papillary muscle level

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APICAL VIEW

Four chamber• Transducer at the cardiac apex

• Structures: LA, MV, LV, RV, TV, RA, interatrial septum, interventricular septum

LARA

LV

RV

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APICAL VIEW

Five chamber• Transducer tilted anteriorly

towards the chest wall from the four chamber view

• Aortic valve and ascending aorta come into view

LVRV

LARA

AV

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SUBCOSTAL VIEW• Transducer placed under the

xiphoid process

• Long axis: IVC, RA, IAS, hepatic veins

IVC RA

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SUBCOSTAL VIEW, LONG AXIS

LV

LA

Liver

RA

• 4-chamber view

• Structures: RA, RV, LA, LV, IAS

RV

DEPARTMENT NAME

SUBCOSTAL VIEW, SHORT AXIS• Structures: RV, PA, LV

RV

PALV

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SUPRASTERNAL VIEW• Transducer placed above the

suprasternal notch, ‘arch view’

• Ascending/descending aorta, arch, take-off of the great vessels, and right PA short axis

RPA

Asc Ao

Dsc Ao

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PULMONARY VEINS• View from the suprasternal

notch, pulmonary veins and LA

• ‘Crab view’RPA

LA

Ao

1

23

4

SVC

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IndicationsLimitationsFindings

ORDERING AN ECHO

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INDICATIONS TO REQUEST AN ECHO

• Evaluate valve/ventricular function

• Evaluate for structural abnormalities

• Estimate intracardiac/vascular pressures

• Rule out cardiac source of embolism, e.g. stroke or TIA

• Evaluate for LVH with hypertension

• Evaluate pericardial effusions• Assess for intracardiac

vegetation, masses, or thrombi

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LIMITATIONS OF ECHO IMAGING

• Poor acoustic windows: Obesity, chest wall deformities, chronic lung disease

• Excessive movement—sedation may be required

• Masses

• Apical lesions

• Aortic dissections

• Pericardial disease

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VELOCITY DATA• The simplified Bernoulli

equation translates velocity data to pressure gradients

• Velocities toward the transducer are above the line, those away are below

• Flow color: laminar vs. turbulent

Valve Peak (m/s) Range (m/s)AV/Ao 1.3 0.9-1.7

LV 0.9 0.7-1.1MV 0.9 0.6-1.3TV 0.5 0.3-0.7

PV/PA 0.75 0.5-1.0

ΔP = 4V2

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BERNOULLI EXAMPLE• ∆P = 4V2 = 4 x (5) 2 = 100 mmHg

• Interpret with caution when there are multiple levels of obstruction or small/long vessels

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NORMAL FINDINGS• Mild mitral, tricuspid

regurgitation

• Chiari network• Embryological remnant of the

sinus venosus R valve

• Web-like, mobile structure in the RA

• Eustachian valve• Endocardial ridge or fold at the

RA/IVC junction

• Crista terminalis• Embryological remnant of RA

fusion

• Anterior muscular ridge passing from the SVC to IVC

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COMMENTS/QUESTIONS?