Formal echocardiography

Diagnostic Pearls

• Normal directional flow in CW and PW in apical, parasternal short:
  • Below the line for pulmonic and aortic valves (systole)
  • Above the line in tricuspid and mitral valves (diastole)

Parasternal long

• Assess for mitral valve prolapse, systolic anterior motion
• Differentiate pleural effusion from pericardial effusion
  • Pericardial effusion is anterior to descending aorta
  • Pleural effusion posterior to descending aorta

Pericardial effusion vs. pleural effusion

• EPSS, E-Point Septal Separation in PSL view
  • M-mode distance in mm between anterior leaflet of MV and septum in diastole
  • E-point is shortest distance
  • LVEF = 75.5 - 2.5 x EPSS in mm
    • EPSS and MRI LVEF correlated ~0.80 in study that generated equation
    • Excluded MV prostheses, asymmetrical septal hypertrophy, significant aortic regurgitation
  • Values as calculated by above study
    • < 5 mm, normal
    • > 7 mm, EF < 50%
    • > 18 mm, EF < 30%
  • Falsely elevated EPSS in:
    • Mitral stenosis, rheumatic heart disease
    • Mitral calcification
    • Aortic regurgitation
    • LV dilation

Apical

• Best obtained in left lateral decubitus with L arm above head to open up ribs
• EF estimation
  • LVEF by Simpson, LV volume change
  • LVEF by Teichholz method, using M-mode (estimation of LV volume by diameter measured just beyond mitral tips in diastole)
  • EF visual assessment:
    • >65% = hyperdynamic
    • 55-65% = normal
    • 45-54% = mildly depressed
    • 30-44% = moderately depressed
    • <30% = severely depressed

E/A Ratio

• Measure of diastolic dysfunction
• PW Doppler across MV in apical view bisecting across MV tips during opening, diastole
• Tissue doppler at MV annulus (base) at either septum or lateral position to measure tissue velocity

PW across Mitral Valve Opening and Tissue Doppler of Mitral Valve Annulus

• The following rules will apply to most patients(Video)

1. Rule 1: Normal diastolic function if echo normal, age<45 yrs, E>A
2. Rule 2: Impaired relaxation if A>E, with E/A<1
3. Rule 3: Pseudonormal if echo abnormal (LVH), age>65, E>A, E/A>1
4. Rule 4: Restrictive filling if E/A>2

See Also

• Aortic stenosis for CW Doppler measurements

External Links

• Critical USG - Echocardiographic evaluation of left ventricular systolic function