ECHOCARDIOGRAPHY REVIEW GUIDE This page intentionally left blank second edition ECHOCARDIOGRAPHY REVIEW GUIDE Companion to the Textbook of Clinical Echocardiography CATHERINE M. OTTO, MD J. Ward Kennedy-Hamilton Endowed Professor of Cardiology Director, Training Program in Cardiovascular Disease University of Washington School of Medicine; Associate Director, Echocardiography Laboratory Co-Director, Adult Congenital Heart Disease Clinic University of Washington Medical Center Seattle, Washington REBECCA GIBBONS SCHWAEGLER, BS, RDCS Cardiac Sonographer University of Washington Medical Center Seattle, Washington ROSARIO V. FREEMAN, MD Associate Professor of Medicine University of Washington School of Medicine; Director, Echocardiography Laboratory Medical Director, Coronary Care Unit University of Washington Medical Center Seattle, Washington 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 ECHOCARDIOGRAPHY REVIEW GUIDE: ISBN: 978-1-4377-2021-1 COMPANION TO THE TEXTBOOK OF CLINICAL ECHOCARDIOGRAPHY, SECOND EDITION Copyright © 2011, 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4377-2021-1 Acquisitions Editor: Natasha Andjelkovic Developmental Editor: Brad McIlwain Publishing Services Manager: Anne Altepeter Project Manager: Louise King Designer: Louis Forgione Working together to grow libraries in developing countries Printed in the United States of America www.elsevier.com | www.bookaid.org | www.sabre.org Last digit is the print number: 9 8 7 6 5 4 3 2 1 INTRODUCTION ECHOCARDIOGRAPHY REVIEW GUIDE, diastolic function, ischemic cardiac disease, cardio- SECOND EDITION myopathies, valve stenosis and regurgitation, pros- thetic valves, endocarditis, cardiac masses, aortic A companion workbook for the fourth disease, adult congenital heart disease, and intraop- erative transesophageal echocardiography. edition of the Textbook of Clinical A step-by-step approach to patient examination Echocardiography is detailed. Information is conveyed in bullet points, This Echocardiography Review Guide complements the with each set of major principles followed by a list Textbook of Clinical Echocardiography, fourth edition, pro- of key points. Potential pitfalls are identified, and viding a review of basic principles, additional details approaches to avoiding errors are provided. Data of data acquisition and interpretation, and a step-by- measurements and calculations are explained with step approach to patient examination for each diag- specific examples. Numerous illustrations with nosis. In addition, self-assessment questions allow the detailed figure legends demonstrate each major reader to be more actively involved in the learning point and guide the reader through the teaching process. All the self-assessment questions in the second points. At the end of each chapter, the short Echo edition are new and supplement the questions avail- Review Guide from the Textbook of Clinical Echo able in the first edition. cardiography is included for quick reference. Self- This book will be of interest to practicing cardiolo- assessment questions help the reader consolidate the gists and sonographers as a quick update on echocar- information and identify areas where further study diography and will be of value to cardiology fellows is needed. Along with the correct answer to each and cardiac sonographer students who are mastering question, there is a brief discussion of how that the material for the first time. Cardiac anesthesiolo- answer was determined and why the other potential gists will find helpful information about details of the answers are not correct. examination and a chapter dedicated to intraopera- This review guide is intended as an adjunct to tive transesophageal echocardiography. In addition, formal training programs in echocardiography; a primary care physicians using handheld echocardiog- book does not replace hands-on training or practical raphy can use this book to get started and to improve experience. The three of us fully endorse current stan- their echocardiography skills. Multiple-choice ques- dards for education and training of physicians and tions provide a review and self-assessment for those sonographers in clinical cardiac ultrasound as pro- preparing for echocardiography examinations and vided by the American Society of Echocardiography, may be useful in echocardiography laboratories for American Heart Association, American College of continuous quality improvement processes. Cardiology, and Society of Cardiovascular Anesthe- The chapters are arranged in the same order as siologists. We support training in accredited programs the Textbook of Clinical Echocardiography, and we recom- with formal certification of sonographers and evalua- mend that these two books be used in parallel. As in tion of physician competency. The material in this the textbook, there are introductory chapters on book reflects the clinical practice of echocardiography basic principles of image acquisition, transthoracic at one point in time. Cardiac imaging is a rapidly and transesophageal echocardiography, other echo- changing field, and we encourage our readers to stay cardiographic modalities, and clinical indications. up to date by reading journals and other online Each of the subsequent chapters focuses on a specific sources, and by attending national meetings and con- clinical diagnosis, including ventricular systolic and tinuing medical education courses. v ACKNOWLEDGMENTS It is never possible to fully acknowledge all those provided comments and input on the text and ques- who help make a book possible; however, we would tions. Our appreciation extends to Natasha Andjel- like to thank some of those who helped us along kovic and Louise King at Elsevier and the production the way. First, the cardiac sonographers at the team who supported this project and helped us make University of Washington deserve our special appre- it a reality. ciation for the excellence of their imaging skills Finally, we all want to sincerely thank our families: and the time they dedicated to acquiring additional not only our husbands for their unwavering and con- images for us and discussing the finer points of tinual encouragement, but even the younger mem- data acquisition: Pamela Clark, RDCS; Sarah bers—Vea, Remy, Brendan, Sarah, Claire, Jack, and Curtis, RDCS; Caryn D’Jang, RDCS; Michelle Anna—for their support and patience in the book- Fujioka, RDCS; Jennifer Gregov, RDCS; Yelena writing process. This book would not have been Kovalenko, RDCS; Carol Kraft, RDCS; Chris possible without their helping us find the time to McKenzie, RDCS; Amy Owens, RDCS; Joannalyn complete it. Sangco, RDCS; and Todd Zwink, RDCS. Theresa Shugart and Joan Raney in the Cardiology Division Rosario V. Freeman, MD also helped greatly in several aspects of book prepara- Catherine M. Otto, MD tion. Special thanks are due to the many readers who Rebecca Gibbons Schwaegler, BS, RDCS vi CONTENTS 1 Principles of Echocardiographic Image Acquisition and Doppler Analysis 1 2 The Transthoracic Echocardiogram 20 3 The Transesophageal Echocardiogram 44 4 Advanced Echocardiographic Modalities 65 5 Clinical Indications for Echocardiography 81 6 Left and Right Ventricular Systolic Function 95 7 Ventricular Diastolic Filling and Function 120 8 Ischemic Cardiac Disease 140 9 Cardiomyopathies, Hypertensive and Pulmonary Heart Disease 167 10 Pericardial Disease 195 11 Valvular Stenosis 215 12 Valve Regurgitation 239 13 Prosthetic Valves 269 14 Endocarditis 299 15 Cardiac Masses and Potential Cardiac Source of Embolus 322 16 Echocardiographic Evaluation of the Great Vessels 342 17 The Adult with Congenital Heart Disease 366 18 Intraoperative Transesophageal Echocardiography 396 Index 419 vii GLOSSARY 2D = two-dimensional echo = echocardiography 3D = three-dimensional ED = end-diastole A-long = apical long-axis EDD = end-diastolic dimension A-mode = amplitude mode (amplitude versus depth) EDV = end-diastolic volume A = late diastolic ventricular filling velocity with atrial EF = ejection fraction contraction endo = endocardium A′ = diastolic tissue Doppler velocity with atrial epi = epicardium contraction EPSS = E-point septal separation A2C = apical two-chamber EROA = effective regurgitant orifice area A4C = apical four-chamber ES = end-systole AcT = acceleration time ESD = end-systolic dimension AF = atrial fibrillation ESV = end-systolic volume AMVL = anterior mitral valve leaflet ETT = exercise treadmill test ant = anterior Δf = frequency shift Ao = aortic or aorta f = frequency AR = aortic regurgitation FL = false lumen AS = aortic stenosis F = near field frequency n ASD = atrial septal defect F = resonance frequency o ATVL = anterior tricuspid valve leaflet F = scattered frequency s AV = atrioventricular FSV = forward stroke volume AVA = aortic valve area F = transmitted frequency t AVR = aortic valve replacement HCM = hypertrophic cardiomyopathy BAV = bicuspid aortic valve HPRF = high pulse repetition frequency BP = blood pressure HR = heart rate BSA = body surface area HV = hepatic vein c = propagation velocity of sound in tissue Hz = Hertz (cycles per second) CAD = coronary artery disease I = intensity of ultrasound exposure cath = cardiac catheterization IAS = interatrial septum cm/s = centimeters per second inf = inferior cm = centimeters IV = intravenous CMR = cardiac magnetic resonance imaging IVC = inferior vena cava CO = cardiac output IVCT = isovolumic contraction time cos = cosine IVRT = isovolumic relaxation time CS = coronary sinus kHz = kilohertz CSA = cross-sectional area L = length CT = computed tomography LA = left atrium CW = continuous wave LAA = left atrial appendage Cx = circumflex coronary artery LAD = left anterior descending coronary artery D = diameter LAE = left atrial enlargement DA = descending aorta lat = lateral dB = decibels LCC = left coronary cusp dP/dt = rate of change in pressure over time LMCA = left main coronary artery dT/dt = rate of increase in temperature LPA = left pulmonary artery dyne · s · cm–5 = units of resistance LSPV = left superior pulmonary vein E = early diastolic peak velocity L-TGA = congenitally corrected transposition of the E′ = early diastolic tissue Doppler velocity great arteries ECG = electrocardiogram LV = left ventricle viii Glossary ix LV-EDP = left ventricular end-diastolic pressure Re = Reynolds number LVH = left ventricular hypertrophy RF = regurgitant fraction LVID = left ventricular internal dimension RJ = regurgitant jet LVOT = left ventricular outflow tract R = radius of microbubble o M-mode = motion display (depth versus time) ROA = regurgitant orifice area MAC = mitral annular calcification RPA = right pulmonary artery MI = myocardial infarction RSPV = right superior pulmonary vein MR = mitral regurgitation RSV = regurgitant stroke volume MS = mitral stenosis RV = right ventricle or regurgitant volume, depend- MVA = mitral valve area ing on context MVL = mitral valve leaflet RVE = right ventricular enlargement MVR = mitral valve replacement RVH = right ventricular hypertrophy n = number of subjects RVOT = right ventricular outflow tract NBTE = nonbacterial thrombotic endocarditis s = second NCC = noncoronary cusp SAM = systolic anterior motion ΔP = pressure gradient SC = subcostal P = pressure SEE = standard error of the estimate PA = pulmonary artery SPPA = spatial peak pulse average PAP = pulmonary artery pressure SPTA = spatial peak temporal average PDA = patent ductus arteriosus or posterior descend- SSN = suprasternal notch ing artery (depends on context) ST = septal thickness PE = pericardial effusion STJ = sinotubular junction PEP = preejection period STVL = septal tricuspid valve leaflet PET = positron-emission tomography SV = stroke volume or sample volume (depends on PISA = proximal isovelocity surface area context) PLAX = parasternal long-axis SVC = superior vena cava PM = papillary muscle T l/2 = pressure half-time PMVL = posterior mitral valve leaflet TD = thermodilution post = posterior (or inferior-lateral) ventricular wall TEE = transesophageal echocardiography PR = pulmonic regurgitation TGA = transposition of the great arteries PRF = pulse repetition frequency TGC = time gain compensation PRFR = peak rapid filling rate Th = wall thickness PS = pulmonic stenosis TL = true lumen PSAX = parasternal short-axis TN = true negatives PCI = percutaneous coronary intervention TOF = tetralogy of Fallot PV = pulmonary vein TP = true positives PVC = premature ventricular contraction TPV = time to peak velocity PVR = pulmonary vascular resistance TR = tricuspid regurgitation PWT = posterior wall thickness TS = tricuspid stenosis Q = volume flow rate TSV = total stroke volume Q = pulmonic volume flow rate TTE = transthoracic echocardiography p Q = systemic volume flow rate TV = tricuspid valve s r = correlation coefficient v = velocity R = ventricular radius V = volume or velocity (depends on context) R = regurgitant instantaneous flow rate VAS = ventriculo-atrial septum FR RA = right atrium Veg = vegetation RAE = right atrial enlargement V = maximum velocity max RAO = right anterior oblique VSD = ventricular septal defect RAP = right atrial pressure VTI = velocity-time integral RCA = right coronary artery WPW = Wolff-Parkinson-White syndrome RCC = right coronary cusp Z = acoustic impedance