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THE PRACTICE OF CLINICAL ECHOCARDIOGRAPHY, FOURTH EDITION ISBN: 978-1-437-72765-4
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The practice of clinical echocardiography / [edited by] Catherine M. Otto.—4th ed.
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Includes bibliographical references and index.
ISBN 978-1-4377-2765-4 (hardcover : alk. paper)
I. Otto, Catherine M.
[DNLM: 1. Echocardiography. 2. Cardiovascular Diseases—ultrasonography. WG 141.5.E2]
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THE PRACTICE
OF CLINICAL
ECHOCARDIOGRAPHY
Fourth Edition

THE PRACTICE
OF CLINICAL
ECHOCARDIOGRAPHY
Fourth Edition
CATHERINE M. OTTO, MD
J. Ward Kennedy-Hamilton Endowed Chair in Cardiology
Professor of Medicine
Director, Cardiology Fellowship Programs
University of Washington School of Medicine
Seattle, Washington
PREFACE
T
he purpose of this book is to provide the definitive advanced less expensive, and easier to use, the clinical applications of this
reference text on the diagnostic utility of echocardiography in imaging modality likely will continue to expand.
clinical practice. Put simply, this book reflects our role as clini- Each chapter in this book provides an advanced level of dis-
cians caring for patients with cardiovascular disease. The clini- cussion, written by an expert in the field, building upon the
cal information in this book will be of value to all cardiovascular basic material in my Textbook of Clinical Echocardiography,
specialists, not just those focused on cardiovascular imaging. Fourth Edition. In contrast to the Textbook, the primary focus
This book also will be of interest to cardiology fellows, cardio- of this book is the role of echocardiography in clinical decision
vascular anesthesiologists, and other health care providers using making and the impact on clinical outcomes. Emphasis is also
echocardiographic approaches in the clinical setting, including placed on the principles of optimal data acquisition, quantita-
radiologists, interventional cardiologists, electrophysiologists, tive approaches to data analysis, potential technical limitations,
emergency medicine physicians, and internists with an active and areas of active research. In addition, the strengths and limi-
interest in cardiovascular disease. Cardiac sonographers, car- tations of alternate diagnostic approaches are reviewed to put
diovascular technologists, physician assistants, nurse practitio- the role of echocardiography into the context of clinical prac-
ners, and nursing professionals who wish to go beyond the tice. Detailed tables, color illustrations, echocardiographic
basics in echocardiographic imaging also will find this book images, Doppler tracings, and figures with key data from pub-
valuable. For the clinical researcher, there are eight chapters lished outcome studies are used to provide clarity and depth.
dedicated to newer advanced echocardiographic modalities, To complement the printed text, multiple choice questions at
and this information is integrated into subsequent chapters expertconsult.com provide an opportunity for readers to test
throughout the book. their knowledge or quickly review the core material. Some high-
Echocardiography is a key component in the evaluation of lights of the fourth edition include new chapters on echocar-
patients with suspected or known cardiovascular disease. As this diographic guidance of structural heart disease interventions
technique has evolved and matured, the role of the echocar- and echocardiographic evaluation of cardiac assist devices.
diographer has shifted from simply providing a description of It is hoped that this book will provide the needed back-
the images to integrating the echocardiographic findings with ground to support and supplement clinical experience and
other clinical data and finally to providing a diagnosis or thera- expertise. Of course, competency in the acquisition and inter-
peutic recommendation. Often, echocardiography supplies all pretation of echocardiographic and Doppler data depends on
the data needed for clinical decision making. When additional appropriate clinical education and training, as detailed in
information is needed, the echocardiographic findings help accreditation requirements for both physicians and technolo-
define other imaging modalities that may be helpful. In effect, gists and as recommended by professional societies, including
echocardiography has become a specialized type of cardiology the American Society of Echocardiography, the American
consultation. College of Cardiology, and the American Heart Association. I
The information now requested by the referring physician strongly support these educational requirements and training
includes not only the qualitative and quantitative interpretation recommendations; readers of this book are urged to review the
of the echocardiographic images and Doppler flow data, but relevant documents.
also a discussion of how this information may affect clinical Advances continue to be made both in the technical aspects
decision making. Specific examples include decisions regarding of image and flow data acquisition and in our understanding of
interventional procedures (e.g., suitability for a transcatheter the clinical implications of specific echocardiographic findings.
aortic valve implantation), medical or surgical therapy (e.g., This book represents our knowledge base at one point in time;
treatment of endocarditis, surgery for aortic dissection), optimal readers will wish to consult the current literature for the most
timing of intervention in patients with chronic cardiac diseases up-to-date information. Although an extensive list of carefully
(e.g., valvular regurgitation, mitral stenosis), prognostic impli- selected references is provided with each chapter, the echocar-
cations (e.g., heart disease in pregnancy, heart failure patients), diographic literature is so robust that it is impractical to include
and the possible need for and frequency of periodic diagnostic all relevant references; the reader can conduct an online medical
evaluation (e.g., congenital heart disease, the postoperative literature search if an all-inclusive listing is desired.
patient). In addition, echocardiography is critical in choosing Additional resources for the reader interested in achieving
the optimal therapy for each patient (e.g., selection of patients mastery in echocardiography include Echocardiography Review
for intracardiac defibrillator implantation) and has become Guide, Second Edition, which I wrote with Becky Schwaegler and
essential for monitoring percutaneous interventions and the Rosario Freeman, and which provides a quick summary and
effects of medical or surgical therapy. self-evaluation questions for my Textbook of Clinical Echocar-
The clinical practice of echocardiography no longer is diography, Fourth Edition. These books are now complemented
restricted to the full diagnostic examination performed in an by the new Otto Practical Echocardiography series, all pub-
imaging laboratory. Instead, echocardiography has become so lished by Elsevier and available in electronic format and online
integrated into cardiovascular care that specialized instruments at expertconsult.com. The Practical Echocardiography series
are now used in the intensive care unit, emergency department, includes Intraoperative Echocardiography, edited by Don Oxorn;
interventional laboratory, and operating room, as well as during Echocardiography in Heart Failure, edited by Susan Wiegers and
electrophysiology procedures. As instruments become smaller, Martin St. John Sutton; Echocardiography in Congenital Heart
ix
x PREFACE
Disease, edited by Mark Lewin and Karen Stout; and Advanced be aware of our own limitations, scope of practice, and clinical
Echocardiographic Approaches, which I edited with Linda Gillam. practice needs. The concentrated educational content and
All four of these books also offer online clinical cases and video cumulative clinical experience contained in the Otto series of
clips to enhance the learning experience. textbooks and online cases not only provides a solid foundation
Little time investment is needed to acquire basic skills in upon which to learn the practice of echocardiography, but can
echocardiographic image acquisition and interpretation; the also accelerate the learning curve for those who wish to chal-
challenge lies in transitioning these skill sets from “basic” to lenge themselves to become a master of echocardiography.
“expert.” As echocardiography becomes fully integrated into the
practice of medicine in every clinical setting, each of us should Catherine M. Otto
CONTRIBUTORS
Jamil A. Aboulhosn, MD Michael A. Chen, MD, PhD
Co-Director, Ahmanson/UCLA Adult Congenital Heart Disease Assistant Professor of Medicine
Center Division of Cardiology
Assistant Professor of Medicine and Pediatrics Harborview Medical Center
David Geffen School of Medicine at UCLA University of Washington School of Medicine
Los Angeles, California Seattle, Washington
Director, Children’s Heart Center Nevada Adult Congenital Program
Las Vegas, Nevada John S. Child, MD
Streisand/American Heart Association Professor of Medicine and
Gerard P. Aurigemma, MD Cardiology
Professor of Medicine and Radiology Director, Ahmanson/UCLA Adult Congenital Heart Disease Center
University of Massachusetts Medical School Director, Ronald Reagan UCLA Medical Center Adult Non-Invasive
Director, Noninvasive Cardiology Cardiology Laboratory
UMass Memorial Medical Center David Geffen School of Medicine at UCLA
Worcester, Massachusetts Los Angeles, California
Heidi M. Connolly, MD
Thomas Bartel, MD
Professor of Medicine
Assistant Professor of Medicine
Division of Cardiovascular Diseases
University Clinic of Internal Medicine
Mayo Clinic
Medical University Innsbruck
Rochester, Minnesota
Innsbruck, Austria
Lori Croft, MD
Ann F. Bolger, MD
Associate Professor of Medicine
William Watt Kerr Professor of Clinical Medicine
Zena and Michael Weiner Cardiovascular Institute
University of California, San Francisco
Mount Sinai School of Medicine
Director of Echocardiography
New York, New York
San Francisco General Hospital and Trauma Center
San Francisco, California
Milind Y. Desai, MD
Associate Professor of Medicine
Johan G. Bosch, PhD
Lerner College of Medicine of Case Western Reserve University
Associate Professor
Cleveland Clinic
Thoraxcenter Biomedical Engineering
Cleveland, Ohio
Erasmus Medical Center
Rotterdam, The Netherlands Marco R. Di Tullio, MD
Professor of Medicine
Charles J. Bruce, MD
Associate Director, Adult Cardiovascular Ultrasound Laboratories
Consultant in Cardiovascular Diseases Columbia University Medical Center
Professor of Medicine New York, New York
Division of Cardiovascular Diseases
Mayo Clinic Jean G. Dumesnil, MD
Rochester, Minnesota Professor and Cardiologist
Quebec Heart and Lung Institute
Ian G. Burwash, MD Laval University
Associate Professor of Medicine Quebec City, Quebec, Canada
University of Ottawa
Director of Echocardiography Thor Edvardsen, MD, PhD
University of Ottawa Heart Institute Professor and Co-Director
Ottawa, Ontario, Canada Department of Cardiology
Oslo University Hospital
John D. Carroll, MD Oslo, Norway
Professor of Medicine
University of Colorado, Denver Raimund Erbel, MD
Director, Interventional Cardiology Professor of Medicine
Medical Director, Cardiac and Vascular Center West German Heart Center Essen
University of Colorado Hospital University Duisburg-Essen
Denver, Colorado Duisburg-Essen, Germany
Kwan-Leung Chan, MD Arturo Evangelista, MD
Professor of Medicine Head of Cardiac Imaging Department
University of Ottawa Hospital Vall d’Hebron
Attending Staff Barcelona, Spain
University of Ottawa Heart Institute
Ottawa, Ontario, Canada
v
vi CONTRIBUTORS
Kirsten E. Fleishmann, MD Michelle Gurvitz, MD, MS
Professor of Clinical Medicine Assistant Professor of Pediatrics
University of California San Francisco School of Medicine Harvard Medical School
San Francisco, California Pediatric Cardiologist
Brigham and Women’s Hospital
Paul Robert Forfia, MD Children’s Hospital Boston
Assistant Professor of Medicine Boston, Massachusetts
Department of Medicine, Heart Failure/Transplant Cardiology
Director, Pulmonary Hypertension Program Judy Hung, MD
Hospital of the University of Pennsylvania Associate Professor of Medicine
Philadelphia, Pennsylvania Harvard Medical School
Associate Director, Echocardiography
Elyse Foster, MD Division of Cardiology
Director, Echocardiography Laboratory Massachusetts General Hospital
Professor of Clinical Medicine Boston, Massachusetts
Araxe Vilensky Endowed Chair in Medicine
Department of Medicine, Cardiology Bernard Iung, MD
University of California, San Francisco Professor of Cardiology
San Francisco, California Bichat Hospital, AP-HP
Paris, France
Rosario V. Freeman, MD
Associate Professor of Medicine Mary Etta E. King, MD
Medical Director, Echocardiography Director of Pediatric Echocardiography
Associate Director, Cardiology Fellowship Program Cardiac Ultrasound Laboratory
University of Washington Massachusetts General Hospital
Seattle, Washington Associate Professor of Pediatrics
Harvard Medical School
William H. Gaasch, MD Boston, Massachusetts
Professor of Medicine
Department of Cardiovascular Medicine James N. Kirkpatrick, MD
University of Massachusetts Medical School Assistant Professor of Medicine
Worcester, Massachusetts Division of Cardiovascular Medicine
Senior Consultant in Cardiology Associate Fellow, Center for Bioethics
Department of Cardiovascular Medicine University of Pennsylvania
Lahey Clinic Philadelphia, Pennsylvania
Burlington, Massachusetts
Allan L. Klein, MD
Ivor L. Gerber, MD Director, Cardiovascular Imaging Research
Consultant Cardiologist Director, Pericardial Disease Center
Director of Adult Echocardiography Professor of Medicine, Cleveland Clinic
Green Lane Cardiovascular Unit Lerner College of Medicine of Case Western Reserve University
Auckland City Hospital Cleveland, Ohio
Auckland, New Zealand
Theodore J. Kolias, MD
Martin E. Goldman, MD Associate Professor
Dr. Arthur and Hilda Master Professor of Medicine (Cardiology) University of Michigan
Zena and Michael Weiner Cardiovascular Institute Ann Arbor, Michigan
Mount Sinai School of Medicine
New York, New York Thomas Konorza, MD
Consultant
Jasmine Grewal, MD West German Heart Center Essen
Clinical Assistant Professor University Duisburg-Essen
University of British Columbia Duisburg-Essen, Germany
Attending Cardiologist
St. Paul’s Hospital Christopher E. Kurtz, MD
Vancouver, British Columbia, Canada Associate Director, Cardiovascular Disease Fellowship
Assistant Professor of Medicine
Brian P. Griffin, MD Division of Cardiology
The John and Rosemary Brown Endowed Chair in Cardiovascular University of Wisconsin
Medicine Madison, Wisconsin
Director, Cardiovascular Medicine Fellowship Program
Cleveland Clinic Mark Lewin, MD
Cleveland, Ohio Professor and Chief of Pediatric Cardiology
University of Washington School of Medicine
Christiane Gruner, MD Lab Director, Heart Center and Echocardiography
Fellow in Hypertrophic Cardiomyopathy Research Seattle Children’s Hospital
Division of Cardiology Seattle, Washington
Toronto General Hospital
Toronto, Ontario, Canada
CONTRIBUTORS vii
Akiko Maehara, MD Michael H. Picard, MD
Director, Intravascular Imaging and Physiology Core Laboratories Professor of Medicine
Cardiovascular Research Foundation; Harvard Medical School
Assistant Professor Director, Clinical Echocardiography
Columbia University Medical Center Massachusetts General Hospital
New York, New York Boston, Massachusetts
Warren J. Manning, MD Juan Carlos Plana, MD
Section Chief, Noninvasive Cardiac Imaging and Testing Co-Director, Cardio-Oncology Center
Beth Israel Deaconess Medical Center Cleveland Clinic
Professor of Medicine and Radiology Cleveland, Ohio
Harvard Medical School Adjunct Associate Professor
Boston, Massachusetts The University of Texas MD Anderson Cancer Center
Houston, Texas
Thomas H. Marwick, MD, PhD
Head, Cardiovascular Imaging Theodore Plappert, CVT
Heart and Vascular Institute, Cleveland Clinic Manager, Quantitative Imaging Core Laboratory
Cleveland, Ohio University of Pennsylvania Medical Center
Philadelphia, Pennsylvania
Gary S. Mintz, MD
Chief Medical Officer Thomas R. Porter, MD
Cardiovascular Research Foundation Professor of Medicine
New York, New York Courtesy Professor of Radiology and Pediatric Cardiology
Director of Echocardiography Laboratories
Robert R. Moss, MB, BS Theodore F. Hubbard Distinguished Chair of Cardiology
Clinical Assistant Professor University of Nebraska Medical Center
University of British Columbia Omaha, Nebraska
Attending Cardiologist
St. Paul’s Hospital Harry Rakowski, MD
Vancouver, British Columbia, Canada Professor of Medicine
University of Toronto
Silvana Müller, MD Douglas Wigle Chair in Hypertrophic Cardiomyopathy
Consultant Director, Hypertrophic Cardiomyopathy Clinic
University Clinic of Internal Medicine University Health Network
Medical University Innsbruck Toronto, Ontario, Canada
Innsbruck, Austria President, National Board of Echocardiography
Raleigh, North Carolina
Bradley I. Munt, MD
Cardiologist Carlos A. Roldan, MD
St. Paul’s Hospital and Providence Health Care Professor of Medicine
Vancouver, British Columbia, Canada University of New Mexico School of Medicine
Director, Echocardiography Laboratory
Tasneem Z. Naqvi, MD New Mexico Veterans Affairs Health Care System
Professor of Medicine and Clinical Scholar Albuquerque, New Mexico
Director, Echocardiography and Noninvasive Diagnostic Services
Keck School of Medicine Raphael Rosenhek, MD
University of Southern California, Los Angeles Associate Professor of Medicine
Los Angeles, California Director, Clinic for Valvular Heart Disease
Department of Cardiology
Aaron K. Olson, MD Medical University of Vienna
Assistant Professor of Pediatrics Vienna, Austria
University of Washington
Seattle Children’s Hospital Ernesto E. Salcedo, MD
Seattle, Washington Professor of Medicine
University of Colorado, Denver
Donald C. Oxorn, MD Director of Echocardiography
Professor of Anesthesiology University of Colorado Hospital
Adjunct Professor, Medicine (Cardiology) Denver, Colorado
University of Washington
Seattle, Washington Zainab Samad, MD
Assistant Professor of Medicine
Philippe Pibarot, DVM, PhD Duke University Medical Center
Professor of Medicine Durham, North Carolina
Laval University
Canada Research Chair in Valvular Heart Disease Otto A. Smiseth, MD, PhD
Quebec Heart and Lung Institute Professor and Division Head
Quebec, Quebec, Canada Cardiovascular and Pulmonary Diseases
Oslo University Hospital
Oslo, Norway