Adult Echocardiography Protocol Parasternal Window from the Long Axis Scan Plane Structure Left Ventricle (LV)

Left Ventricle (LV) Aortic Val e (AV) Aortic Val e (AV) Image Stored Acquire cine loop 2D image at a depth of 15-20cm Acquire cine loop 2D image at a reduced depth so image fills field of view M-mode sweep of aortic valve freeze and acquire DO NOT UNFREEZE THIS IMAGE *Measure the following on the aortic valve M-mode Aortic root end-diastolic dimension Measure the vertical distance from the outer edge of the anterior aortic root to the inner edge !leading edge to leading edge" of the posterior aortic wall at end-diastole# $ormal range 2#0-%#& cm 'A end-s(stolic dimension Measure greatest vertical distance )etween the anterior side of the posterior aortic wall and the anterior side of the posterior left atrial wall !leading edge to leading edge" at end ventricular s(stole when the aorta is in its ma*imal anterior position# $ormal range 1#+-,#0cm Aortic valve s(stolic separation Measure the ma*imal opening of the aortic valve cusps during the initial part of ventricular s(stole- using the internal )orders of the aortic cusps# $ormal range 1#5-2#. cm M-mode sweep of mitral valve freeze and acquire DO NOT UNFREEZE THIS IMAGE *Measure the following with the mitral valve M-mode /-0 slope Measure the distance of the steepest initial portion of the anterior M1 leaflet )( placing a caliper on the steepest point of earl( diastole and then place a caliper at the end of the slope# $ormal range is &0-150 mm2s# / 3oint 4eptal 4eparation !/344" Measure the vertical distance from the M1 / point to the lowest point of the 514# $ormal range is 2-& mm#

!itral Val e (!V) !itral Val e (!V)

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Adult Echocardiography Protocol Parasternal Window from the Long Axis Scan Plane Structure Left Ventricle (LV) Left Ventricle (LV) Image Stored M-mode sweep of left ventricle freeze and acquire DO NOT UNFREEZE THIS IMAGE *Measure the following with the left ventricle !"mode 5nterventricular 4eptum in diastole !514d" Measure the diastolic thic7ness of the 514 as the vertical distance from the 81 side of the 514 to the '1 side of the 514 in end-diastole at a point corresponding to the onset of the 984 comple*# $ormal range 0#.-1#1 cm 'eft 1entricle 5nner diameter in diastole !'15Dd" Measure the vertical distance from the endocardium of the 514 to the endocardium of the 3:'1 in end-diastole at a point corresponding to the onset of the 984 comple*# $ormal range %#& ; 5#. cm 'eft 1entricle 3osterior :all in diastole !'13:d" Measure the vertical distance from the endocardium of the '13: to the epicardium in end-diastole at a point corresponding to the onset of the 984 comple*# $ormal range 0#. ; 1#1 cm 5nterventricular 4eptum in s(stole !514s" Measure the s(stolic thic7ness of the 514 as the ma*imal vertical distance that occurs )etween the 81 and '1 sides of the 514 at ventricular s(stole 'eft 1entricle 5nner Diameter in s(stole !'15Ds" Measure the vertical distance from the endocardium of the 514 at the lowest point of the septal motion to the endocardium of the '13: in end-s(stole# $ormal range 2#0 ; %#< cm 'eft 1entricle 3osterior :all in s(stole !'13:s" Measure the s(stolic thic7ness of the '13: at the ma*imal vertical distance that occurs )etween the endocardium and epicardium at end-ventricular s(stole 0reeze #$ image of left entricle 4croll )ac7 to end diastole and measure the following *8ight 1entricular Minor A*is in diastole !815Dd" Measure the inner edge to inner edge dimension is measured at the same level as the '1 minor a*is dimensions parallel to this measurement# $ormal range is 1#+-%#< cm 5nterventricular 4eptum in diastole !514d" Measure the vertical distance from the 81 side of the 514 to the '1 side of the 514 at end-diastole# $ormal range is 0#. ; 1#2cm '1 minor a*is end-diastole !'15Dd" Measure the vertical distance from the endocardium of the 514 to the endocardium of the '13: at end-diastole# 2

Left Ventricle (LV)

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Aortic Val e %oomed

Aortic Val e %oomed

!itral Val e %oomed Aortic and !itral Val e

Adult Echocardiography Protocol $ormal range is %#5 ; 5#. cm# '1 3osterior :all Diastolic =hic7ness !'13:d" > Measure the vertical distance from the endocardium of the '13: to the epicardium at end-diastole# $ormal range is 0#. ; 1#2cm Acquire still frame DO NOT UNFREEZE THE IMAGE! 0rom the previous frozen image- scroll forward to end s(stole and measure the following '1 minor a*is end-s(stole !'15Ds" Measure the vertical distance from the endocardium of the 514 to the endocardium of the 3:'1 at end-s(stole# $ormal range is 2#0-,#0 cm# 'A end-s(stole !'As" Measure the 'A at the aortic valve plane- also perpendicular to the aortic root# =his is an inner edge to inner edge measurement# $ormal range is 2#% ; %#< cm# Acquire still frame 0reeze 2D image of aortic valve 4croll )ac7 to end diastole Measure aortic root at end-diastole with the valve plane perpendicular to the wall of the aortic root at the sinus of 1alsalva# Measure inner edge to inner edge# $ormal range 2#1 ; %#5 cm Acquire still frame w2measurement DO NOT UNFREEZE THE IMAGE! 0rom the previous frozen image- scroll forward to mid s(stole Measure left ventricular outflow trac7 diameter !'1?=" from the )ase of the aortic valve 866 leaflet to the )ase of the anterior M1 leaflet# $ormal measurement 2#cm Acquire still frame w2measurement Acquire cine loop of 2D image of mitral valve Acquire cine loop of 6olor Doppler across )oth mitral valve @ aortic valve

Parasternal Window from the Long Axis Scan Plane Structure 6w2)ac7up2protocols2adult echo protocol 1% Image Stored %

&VI' &VI' &VI' )&V*' )&V*' )&V*' )&V*'

Adult Echocardiography Protocol 8ight ventricular inflow trac7 !815=" Acquire cine loop of 2D image of right ventricular inflow trac7 !815=" Acquire cine loop of color Doppler across the tricuspid valve!=1" Acquire continuous wave Doppler across the tricuspid valve I( tricuspid regurgitation present 8ight ventricular outflow trac7 !81?=" Acquire cine loop of 2D image of right ventricular outflow trac7 !81?=" Acquire cine loop of color Doppler across the pulmonar( valve !31" Acquire pulsed wave Doppler across the pulmonar( valve and measure pea7 velocit( Acquire continuous wave Doppler across the pulmonar( valve I( pulmonar( regurgitation present Parasternal Window from the Short Axis Scan Plane

Structure AV+ 'V+ PV Pulmonary Val e Pulmonary Val e Pulmonary Val e Aortic Val e %oomed Aortic Val e not %oomed 'ricuspid Val e Left Ventricle , !itral Val e Left Ventricle , !itral Val e Left Ventricle , Papillary muscles Apex of LV

Image Stored Acquire cine loop of 2D image of aortic valve- tricuspid valve- and pulmonar( valve Acquire cine loop of color Doppler across the 3ulmonar( arter(2valve Acquire pulse wave at pulmonar( leaflet tips @ measure ma*imum velocit(# $ormal range 0#.-1#0 m2s Acquire continuous wave through pulmonar( valve for pulmonar( valve flow and pulmonar( insufficienc( with measurements Acquire cine loop of 2D image of the aortic valve @ atrial septal wall Acquire cine loop of color Doppler across the aortic valve Acquire cine loop of color Doppler across the tricuspid valve for tricuspid regurgitation Acquire cine loop of 2D image of left ventricle at level of the mitral valve Acquire cine loop of color Doppler of left ventricle at level of the mitral valve across the septal wall @ mitral valve Acquire cine loop of 2D image of left ventricle at level of the papillar( muscles Acquire cine loop of 2D image of left ventricle ape*

Apical Window - .ham/er Scan Plane 6w2)ac7up2protocols2adult echo protocol 1% ,

Structure - .ham/er - .ham/er - .ham/er

Adult Echocardiography Protocol Image Stored Acquire cine loop of 2D image showing all , cham)ers Acquire cine loop of color Doppler of flow across mitral valve @ left atrium for mitral regurgitation Acquire pulse wave Doppler at the tips of the mitral valve leaflets and freeze image Measure / to A @ descending slope Acquire image with measurement Acquire continuous wave Doppler across mitral valve and freeze image Measure pea7 velocit( of mitral regurgitation if present Acquire image with measurement Acquire pulse wave Doppler at the opening of the pulmonar( vein and freeze image Documenting the s(stolic and diastolic forward flow Acquire 2D image with a decreased depth demonstrating the left ventricle and 12% of the left atrium Acquire cine tissue Doppler imaging !=D5" of left ventricle and 12% of the left atrium Asing =D5 acquire pulse Doppler from the lateral aspect of the mitral valve annulus Measure / prime Acquire image with measurement Apical Window 0 .ham/er Scan Plane

- .ham/er

- .ham/er Left Ventricle , Left Atrium Left Ventricle , Left Atrium Left Ventricle , Left Atrium

Structure 0 .ham/er 0 .ham/er 0 .ham/er

Image Stored Acquire cine loop 2D image of left atrium- left ventricle- aorta- right atrium- @ right ventricle Acquire cine loop color Doppler across the aortic valve Acquire continuous wave Doppler across the aortic valve Measure pea7 velocit( !5f continuous wave Doppler gradient is over 2 m2sec trace the spectral envelope" $ormal range is 1#0 ; 1#& m2s Acquire image with measurement Acquire pulse wave Doppler of left ventricle outflow trac7 Measure pea7 velocit( of the left ventricle outflow trac7# $ormal range is 0#& - 1#1 m2s Acquire image with measurement

0 .ham/er

Apical Window -+ 1+ , # .ham/er Scan Plane Structure &V+ 'V+ &A &V+ 'V+ &A Image Stored Acquire cine loop of color Doppler across the tricuspid valve Acquire continuous wave Doppler across the tricuspid valve I( tricuspid regurgitation Measure tricuspid regurgitation 5

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- .ham/er

Adult Echocardiography Protocol Acquire image with measurement *Biplane 4impsonCs Method Acquire an apical , cham)er image and freeze 4croll to end-diastole and trace the '1 cavit( and store image Measure the length of the '1/D from the mid mitral annulus to the cardiac ape* and store image =his will give (ou the '1 /D volume DO NOT UNFREEZE THE IMAGE 4croll to end-s(stole and trace the '1 cavit( and store image Measure the length of the '1/D from the mid mitral annulus to the cardiac ape* and store image =his will give (ou the '1 /4 volume *Biplane 4impsonCs Method Acquire an apical , cham)er image and freeze 4croll to end-diastole and trace the '1 cavit( and store image Measure the length of the '1/D from the mid mitral annulus to the cardiac ape* and store image =his will give (ou the '1 /D volume DO NOT UNFREEZE THE IMAGE 4croll to end-s(stole and trace the '1 cavit( and store image Measure the length of the '1/D from the mid mitral annulus to the cardiac ape* and store image =his will give (ou the '1 /4 volume Acquire cine loop of 2D image of the left atrium @ left ventricle Acquire cine loop of color Doppler across the mitral valve Acquire cine loop of 2D image decreasing depth to demonstrate the left ventricle @ 12% of the left atrium Acquire cine loop of 2D image of the left atrium- left ventricle- @ aortic valve Acquire cine loop of color Doppler across the mitral valve @ aortic valve Acquire cine loop of 2D image decreasing depth to demonstrate the left ventricle @ 12% of the left atrium Acquire cine loop of 2D image of , cham)er demonstrating the left ventricle on the '/0= side of the 468//$ @ the right ventricle on the 85DE= side of the 468//$ !Ma(o 6linic"

# .ham/er LV+ !V+ LA

# .ham/er # .ham/er # .ham/er 1 .ham/er 1 .ham/er 1 .ham/er - .ham/er

Su/costal Window Long Axis Scan Plane Structure - .ham/er - .ham/er - .ham/er Image Stored Acquire cine loop 2D image of , cham)ers Acquire cine loop color Doppler across the 5nteratrial septum !5A4" Acquire cine loop color Doppler across the interventicular septum .

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- .ham/er IV. Aorta Aorta

Adult Echocardiography Protocol Acquire cine loop color Doppler across the mitral valve @ tricuspid valve Acquire cine loop 2D image of inferior vena cava for collapse !change /FD to 5 )eats" Acquire cine loop 2D image of the aorta Acquire cine loop color Doppler of the aorta

Su/costal Window Short Axis Scan Plane Structure IV. Image Stored Acquire cine loop color Doppler across inferior vena cava @ hepatic vein !change /FD to 2 )eats" Suprasternal 2otch Window Long Axis Scan Plane Structure Aortic arch and $escending aorta Aortic arch and $escending aorta Aortic arch and $escending aorta Image Stored Acquire cine loop 2D image of the aortic arch and descending aorta

Acquire cine loop color Doppler flow of the descending aorta

Acquire continuous wave Doppler through the descending aorta

3atient 3osition o 0or parasternal and apical views have the patient lie in the left lateral decu)itus !''D" position with left arm raised a)ove the head# ?)tain an adequate /6D which includes visualization of the 3 wave- 984 comple*- and = wave# 0or su)costal view have the patient la( on their )ac7 and )end their 7nees to soften the a)dominal muscles# &

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Adult Echocardiography Protocol 0or suprasternal notch view have the patient la( on their )ac7 with a pillow under their shoulders to allow for the pro)e to )e rotated correctl(

6ardiac Eeart Beats o o 6apture 2 cardiac heart )eats per cine loop unless an a)normal rh(thm is present 6hange the num)er of cardiac heart )eats captured from 2 to ,-5 for patients with the following a)normalities atrial fi)rillation- significant arrh(thmias- rapid heart rate !with a 8 wave to 8 wave greater than 500 m2sec on the /6D"

Dra( 4cale 5maging o AdGust overall gain and =D6 so that the ventricular and atrial cavities are anechoic

6olor Doppler o o AdGust color gain until Doppler noise is seen- then decrease the gain down Gust enough to eliminate the noise# =oo 6orrect Feep (our color )o* narrow for )etter resolution wide

4pectral Doppler o o =he angle of incidence should )e less than 20H ?)tain % consecutive waveforms- measuring the middle waveform

6ontinuous wave Doppler o 3erform continuous wave Doppler tracing on all valves with a velocit( greater than 2m2sec o 0or the mitral valve- include the pressure I time

3erform continuous wave Doppler tracing on all valve replacements and repairs

*Asterisk within the protocol in ic!tes i"!#es or "e!s$re"ents "!% not &e $tili'e !t !ll clinic!l sites( St$ ents !re still responsi&le )or knowin# how to correctl% o&t!in the i"!#es or "e!s$re"ents(

'ips 3harmaceutical 6ontrast o o o Ma( )e utilized upon receiving a written order from the ph(sician# 3harmaceutical contrast is indicated for use in patients with 2 or more su)optimal wall segments of the left ventricular endocardial )orders# 3harmaceutical contrast is contraindicated for patients with 7nown or suspected <

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Adult Echocardiography Protocol 8ight-to-left and )i-directional cardiac shunts 6ardiovascular or pulmonar( compromise E(persensitivit( to perflutren !lipid micro gas"- )lood products or al)umin !egg white allerg("

Aortic 4tenosis Additional 1iews o 5nterrogate the aortic outflow with non-imaging pedoff pro)e from the suprasternal notch window# 8eposition the patient to right lateral decu)itus !8'D" position and interrogate the aortic outflow with non-imaging pedoff pro)e from the right 3arasternal window# Acquire multiple spectral Doppler waveforms from )oth windows and measure to determine the highest velocit( documented#

o o

=echnicall( difficult e*ams o o Document normal cardiac windows with limited views Atilize modified views to acquire diagnostic images for ph(sician interpretation

Biplane 4impsonCs Method of Discs Ases the summation of the areas from the diameters of 20 c(linders or discs of equal height is used to calculate the end- diastolic volume- end-s(stolic volume- stro7e volumecardiac output- cardiac inde*- and eGection fraction# La/s3 'roponin3 an elevated troponin ma( indicate a m(ocardial infarction 42P (4rain natriuretic peptide3 an elevated B$3 is an indication of the m(ocardial tissue )eing stretched as in the case of 6E0

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