ECHOCARDIOGRAPHY

NOTE
ASE GUIDELINE

Eka Sriayu Wulandari

KARDIOLOGI UDAYANA
ECHO BASIC – VIEW
PARASTERNAL LONG AXIS VIEW –
PLAx (DIASTOLIC FRAME)
▪ Patient in left lateral decubitus position
▪ The transducer placed near the
sternum in the left third or fourth
intercostal space.

PARASTERNAL LONG AXIS VIEW

(SYSTOLIC FRAME)
▪ Patient in left lateral decubitus position
▪ The transducer placed near the
sternum in the left third or fourth
intercostal space.

PARASTERNAL LONG AXIS VIEW OF

LVOT
▪ Patient in left lateral decubitus position
▪ From an upper intercostal space of the
PLAx view
 PARASTERNAL VIEW OF RV INFLOW
▪ By tilting the transducer inferomedially
from parasternal view

PARASTERNAL SHORT AXIS VIEW AT

AORTIC LEVEL
▪ 90-degree clockwise rotation from
PLAX
▪ Tricuspid regurgitation jets are usually
well aligned for accurate Doppler
evaluation, which is useful for
pulmonary pressure estimation
▪ Sometimes it is possible to visualize
the origins of the coronary arteries,
with the left main coronary artery at 4
o’clock position in the aortic annulus
and the right coronary artery at 11
o’clock position.

PARASTERNAL SHORT AXIS VIEW OF

RVOT
▪ From the parasternal view by angulating
the transducer in the opposite direction,
i.e. laterally (towards the left shoulder of
the patient).

.
 PARASTERNAL SHORT AXIS VIEW AT
MITRAL VALVE LEVEL
▪ Inferior and rightward tilting of the
transducer

PARASTERNAL SHORT AXIS VIEW AT

PAPILLARY MUSCLE LEVEL
▪ Tilting the transducer more apically

FOUR CHAMBER APICAL VIEW (A4C)

▪ The transducer is placed in the fifth
intercostal space in the median axillary
line, right upon the cardiac apex.
▪ The transducer has to be positioned in
the lowest intercostal space and in the
most lateral position
FOUR CHAMBER APICAL VIEW
(ZOOMED)

TWO CHAMBER APICAL VIEW (A2C)

▪ 60°–90° counterclockwise rotation from
A4C view

THREE CHAMBER APICAL VIEW (A3C)

▪ By rotating the probe another 60°from
A2C view
SUBCOSTAL 4 CHAMBER VIEW
▪ Patient in supine position, with the
transducer in the centre of the
epigastrium.
▪ Pointing the ultrasound beam to the
patient’s left shoulder

SUBCOSTAL INFERIOR VENA CAVA

VIEW
▪ 90° counterclockwise rotation of the
transducer from the subcostal four-
chamber view.
▪ Further rotation of the transducer to a
fully vertical position gives a long-axis
view of the abdominal aorta.

SUPRASTERNAL VIEW
▪ Transducer is placed in the patient’s
suprasternal notch.
▪ The long axis of the transducer oriented
parallel to the trachea
▪ Visualization of the ascending aorta and
the aortic arch with the origins of the
right brachiocephalic, the left common
carotid, and subclavian arteries.
 GUIDELINES AND STANDARDS
CARDIAC CHAMBER QUANTIFICATION
AMERICAN SOCIETY OF ECHOCARDIOGRAPHY
AND THE EUROPEAN ASSOCIATION OF CARDIOVASCULAR IMAGING
2015

LEFT VENTRICLE AND ATRIUM

LV WALL MOTION
LV VASCULARIZATION
LV MASS
RIGHT VENTRICLE

ASE 2010
▪ RA area end sistole : 18 cm2
▪ RV area end diastole : 22 – 34 cm2
RV FUNCTION
AORTIC ROOT
DIASTOLIC DYSFUNCTION
Parameter Normal Grade I Grade II Grade III
LA Relaxation Normal Impaired Impaired Impaired
LAP Normal Low or Normal Elevated Elevated
Mitral E/A Ratio ≥ 0.8 ≤ 0.8 >0.8 to < 2 >2
Average E/e’ ratio < 10 < 10 10-14 >14
Peak TR Velocity <2.8 < 2.8 >2.8 >2.8
LA Volume Normal Normal or Increased Increased
Increased

Grading Diastolic Dysfunction : (1) depressed LVEFs , (2) patients with myocardial
disease, (3) normal LVEF after consideration of clinical and other 2D data
VALVULAR REGURGITATION
Structural Severity
Mild Moderate Severe
Semiquantitative
VCW (cm) <0.3 Intermediate ≥ 0.7 (>0.8 for biplane)
Pulmonary vein flow Systolic Normal/systolic Systolic flow reversal
dominance blunting
Mitral inflow A-wave dominant Variable E-Wave Dominant
(>1.2 m/sec)
Quantitative
EROA, 2D PISA (cm2) <0.20 0.20-0.29 ≥ 0.40
MR 0.30-0.39
RVol (ml) <30 30-44 ≥ 60
45-59
RF (%) <30 30-39 ≥ 50
40-49
Qualitative
PHT Incomplete or Medium 500-200 Steep < 200
Faint Sow > 500
Semiquantitative
VCW (cm) <0.3 0.3-0.6 >0.6
Jet width/LVOT width, central jet (%) <25 25-45 ≥ 65
46-64
Quatitative
RVol (ml/beat) <30 30-44 ≥60
AR
45-59
RF (%) <30 30-39 ≥50
40-49
EROA (cm2) <0.10 0.10-0.19 ≥ 0.30
0.20-0.29
Semiquantitative
Color flow jet area (cm2) Not Defined Not Defined >10
VCW (cm) <0.3 0.3-0.9 ≥0.7
PISA radius (cm) ≤ 0.5 0.6-0.9 >0.9
Hepatic Vein Flow Systolic Systolic Blunting Systolic Flow Reversal
Dominance
Tricuspid Inflow A Wave Dominant Variable E Wave > 1.0 m/sec
TR Quantitative
EROA <0.20 0.20-0.39 ≥0.40
RVol (2D PISA) (ml) < 30 30-44 ≥ 45
Ratio PR Jet Width/Pulmonary Anulus >0.7

Deceleration time of PR spectra dopler Short <260 msec

signal
PHT < 100 msec
PR PR index <0.77 <0.77
Rf <20% 20-40% >40%
VALVULAR STENOSIS
Parameter Aortic Mild Moderate Severe
Sclerosis
Peak velocity (m/s) ≤ 2.5 2.6-2.9 3.0-4.0 ≥ 4.0

Mean gradient (mmHg) - <20 20-40 ≥ 40

AS AVA (cm2) - >1.5 1.0-1.5 <1.0

Indexed AVA (cm2/m2) - >0.85 0.60-0.85 <0.6

Velocity ratio - >0.50 0.25-0.50 <0.25

Valve Area >1.5 1.0-1.5 <1.0

Mean gradient (mmHg) <5 5-10 >10

MS
Pulmonary artery pressure <30 30-50 >50
(mmHg)

Mean pressure gradient ≥ 5 mmHg

TS Inflow time velocity integral >60 cm

T½ ≥ 190 ms

Peak velocity (m/s) <3 3-4 >4

PS
Peak gradient (mmHg) <36 36-64 >64
EVALUASI VALVULAR REGURGITATION
✓ Nyquist limit (velocity scale): Aliasing velocity (VAl) Normal 50-70 cm/sec. Makin rendah nyquist limit,
kecepatan sel darah merah yang lebih rendah juga dapat dideteksi, mengakibatkan jet regurgitan
tampak lebih besar.

✓ Gain: pakai gain tinggi, untuk mengurangi color dari struktur2 sekitar yang tidak bergerak.

✓ Frekuensi transducer:
o TEE: makin tinggi frekuensi, deteksi terhadap sel darah merah dengan kecepatan rendah akan
makin baik, jet akan tampak lebih besar.
o TTE: frekuensi tinggi mengalami attenuasi lebih besar, jet akan tampak lebih kecil pada far field.

✓ LVOT diameter: plg baik diukur saat early systole (PLAx)

✓ Anulus mitral: plg baik diukur pada mid diastole (A4C)

✓ Color doppler: makin terang warna, menandakan kecepatan yang lebih tinggi dalam Nyquis limit.

✓ BLUE AWAY, RED TOWARD  TRANSDUCER

MITRAL REGURGITATION
PRIMARY MR
MVP
▪ Paling sering akibat myxomatous degeneration, plg sering berupa MVP.
▪ Pada Mid-late sistole
▪ Prolaps: systolic displacement dari mitral leaflet minimal 2 mm dari mitral anular plane
ke arah LA
▪ Paling baik dilihat pada posisi PLAx atau jika poor view PLAx bisa melalui view apical
long axis
▪ Flail:
o jika bukan hanya badan leaflet yang masuk ke LA tapi juga tepi dari anulus
mitral dengan free motion
o Dikaitkan dengan severe MR
o Akibat ruptur korda marginal atau ruptur muskulus papilaris
▪ MR akut
o Lebih jarang dibandingkan MR kronik
o Akibat ruptur muskulus papilaris alibat MI, ruptur korda akan mengakibatkan
flail, destruksi leaflet akibat endokarditis, atau kardiomiopati onset cepat
(takotsubo, myocarditis, PPCM)
o Ada tanda hemodinamik kompromise  peningkatan tekanan LA, edema paru
 low CO  hipotensi  low jet on color doppler.
 ▪ Sangat dipengaruhi oleh tekanan darah. Low BP jet tampak lebih kecil, high BP 
jet pada color doppler tampak lebih besar, meskipun severitas dari MR sebenarnya
lebih ringan.

Exercise test untuk MR:

▪ Untuk mengetahui kapasitas fungsional pada pasien dengan aktivitas fisik kurang atau
gejala yang equivocal.
▪ Ketidakberhasilan untuk meningkatkan LVEF dengan latihan menandakan fungsi LV
yang buruk pascaoperatif pada primary MR
▪ Peningkatan EROA >13 mm2 menandakan gejala dan adverse outcome pada pasien
dengan secondary MR yag asimtomatik
▪ Peningkatan PA pressure >60 mmHG, menandakan MR severe pada pasien
asimptomatik
Pulmonary Vein Flow
▪ Tidak selalu akurat, karena setiap peningkatan LA akibat kausa apapun (misal akibat
AF) juga akan mengakibatkan flow reversal, PERLU MEMERIKSA PARAMETER LAIN 
systolic blunting lebih tidak bermakna pada secondary MR daripada primary MR
▪ Lebih signifikan jika temuan systolic reversal dijumpai pada lebih dari satu vena
pulmonalis.
AORTIC REGURGITATION
1 TRIKUSPID REGURGITATION
2
PULMONARY REGURGITATION
ALGORYTHM IN DIAGNOSIS VALVULAR REGURGITATION
Grading Pulmonary Hypertension Related to Tricuspid Regurgitation
VALVULAR STENOSIS
Parameter Aortic Mild Moderate Severe
Sclerosis
Peak velocity (m/s) ≤ 2.5 2.6-2.9 3.0-4.0 ≥ 4.0

Mean gradient (mmHg) - <20 20-40 ≥ 40

AS AVA (cm2) - >1.5 1.0-1.5 <1.0

Indexed AVA (cm2/m2) - >0.85 0.60-0.85 <0.6

Velocity ratio - >0.50 0.25-0.50 <0.25

Valve Area >1.5 1.0-1.5 <1.0

Mean gradient (mmHg) <5 5-10 >10

MS
Pulmonary artery pressure <30 30-50 >50
(mmHg)

Mean pressure gradient ≥ 5 mmHg

TS Inflow time velocity integral >60 cm

T½ ≥ 190 ms

Peak velocity (m/s) <3 3-4 >4

PS
Peak gradient (mmHg) <36 36-64 >64
AORTIC STENOSIS
Stress echocardiography:
Penting untuk mengetahui: contractile response dan flow reserve pada pasien dengan AS  melalui evaluasi EF dan SV
setelah pemberian dobutamin.
MITRAL STENOSIS

▪ Rheumatic MS: paling banyak berupa fusi komisura. Selanjutnya berupa pemendekan dan fusi korda,
penebalan leaflet.
▪ Degenerative MS: berupa kalsifikasi anulus, dikaitkan dengan HT, ASHD atau AS.
▪ Mean gradient is the relevant haemodynamic finding. Maximal gradient is of little interest as it derives
from peak mitral velocity, which is influenced by left atrial compliance and LV diastolic function.
▪ In patients with atrial fibrillation, mean gradient should be calculated as the average of five cycles with the
least variation of R–R intervals and as close as possible to normal heart rate.
▪ Careful scanning from the apex to the base of the LV is required to ensure that the CSA is measured at the
leaflet tips. The measurement plane should be perpendicular to the mitral orifice, which has an elliptical
shape
▪ The optimal timing of the cardiac cycle to measure planimetry is mid-diastole.
▪ The normal MVA is 4.0 –5.0 cm2. An MVA area of > 1.5 cm2 usually does not produce symptoms.
▪ Intervention is not considered in patients with MS and MVA > 1.5 cm2, unless in symptomatic patients of
large body size. When MVA is < 1.5 cm2, the decision to intervene is based on the consequences of valve
stenosis (symptoms, atrial fibrillation, pulmonary artery pressure) and the suitability of the patient for
balloon mitral commissurotomy. Exercise testing is recommended in patients with MVA, < 1.5 cm2 who
claim to be asymptomatic or with doubtful symptoms.
TRICUSPID STENOSIS

PULMONARY STENOSIS
WHF CRITERIA – RHD 2012
HEMODYNAMIC PARAMETER
Parameter Equation Normal Range

Mean Pulmonary ▪ 4(PR Vmax)2 + eRAP 9 – 18 mmHg

Artery Pressure ▪ [PASP+(2 x PADP)]/3
(MPAP) ▪ TR mean PG (from TR velocity
profile) + eRAP
▪ 79 - (0.45 X AT).
If AT ≤ 120 msec  90-(0.62 X AT)

Mean Arterial SBP + (2x DBP)/3 70-105 mmHg

Pressure (MAP)

Systemic Vascular (𝑴𝑨𝑷 − 𝑹𝑨𝑷) 𝐱 𝟖𝟎 800-1200 dyns-sec/cm-5

Resistance (SVR) 𝑪𝑶

Cardiac Output HR x SV/1000 4.0-8.0 L/mnt

Stroke Volume 0.785 x (LVOT diam)2 x LVOT VTI 60-100ml/beat

IVC Size/collapsibility (IVC max-IVC min)/IVC max 1. Size ≤ 2.1 cm;collapse >50%
for RAP during sniff (0-5 mmHg)
2. Size >2.1, collapse > 50% during
sniff (5-10 mmHg)
3. Size > 2.1; collapse < 50 %
during sniff ( 10-20 mmHg)
Pulmonary Capillary (E/E rata2 x 1.24) + 1.9 5- 12 mmHg
Wedge pressure
Dengan

E rata2 = (E’septal + E lateral) : 2

Pulmonary Vascular (𝑴𝑷𝑨𝑷−𝑷𝑪𝑾𝑷) 𝐱 𝟖𝟎 < 250 dynes – sec/cm-5

TR (-) =
𝑪𝑶
Resistance (PVR)
TR (+) = 10 x (TR Max PG/ RVOT VTI)
+ 0.16

TR : Tricuspid Regurgitation
PROSTHETIC VALVE EVALUATION – ASE 2009

PPM: Prosthesis-Patient Mismatch

CSA: Cross-sectional area
EOA: Effective orifice area
DVI: Dimensionless Index = ratio of velocity proximal to the valve, to the velocity through the
valve
EVALUATION OF AORTIC PROSTHETIC VALVE
EVALUATION OF PROSTHETIC MITRAL VALVE

EOA Prosthetic mitral valve

▪ EOA is derived as stroke volume throughthe prosthesis divided by the VTI of the mitral jet velocity:

▪ Stroke volume through the mitral valve is equated with that through the LVO when there is no
significant MR or AR.
 St.Jude Medical Bjork-Shiley Hancock Stra Edwad
Bileaflet Tilting disk Bio-stented Caged ball

AVP Vmax, m/s 2.22 ± 0.27 2.63 ± 0.43 2.74 ± 0.39 3.94 ± 0.94
PPG, mmHg 20.0 ± 4.9 28.4 ± 9.0 30.7 ± 8.8 64.4 ± 29.4
MPG, mmHg 7.3 ± 1.3 12.4 ± 4.8 13.8 ± 4.2 22.2 ± 12.6
MVP Vmax, m/s 1.5 ± 0.25 1.68 ± 0.28 1.69 ± 0.29 1.75 ± 0.25
PPG, mmHg 9.2 ± 3.0 11.9 ± 3.7 11.7 ± 4.1 12 ± 5
MPG, mmHg 3.5 ± 1.6 4.9 ± 1.5 4.7 ± 1.9 7±3