LV dysfunction for Accreditation protocol

Parasternal window

Plax-2D

2D measurements

Color across AV-maximize any AI jet

Color across MV-maximize any MR jet

Can zoom valves, but not necessary for ICAEL

RVIT-2D

RVIT color-maximize TR jet

CW TV for TR- maximize size of spectral flow- adjust sweep speed to allow 3 beats to show-measure maximum jet velocity and acquire image with measurement

PSAX base-2D

Zoom AV- show 3 leaflets

Adjust view to show bifurcation of main PA- (this can also be shown from the RVOT view if you are more comfortable from that view)

Color across PV –include main PA and branches

PW RVOT for PI- maximize size of spectral flow- adjust sweep speed to allow 3 beats to show

CW across PV- maximize size of spectral flow- adjust sweep speed to allow 3 beats to show

Color on AV slightly inferior to AV leaflets- include LA in the color box

Color across TV- maximize TR jet

CW for TR- maximize size of spectral flow- adjust sweep speed to allow 3 beats to show-measure maximum jet velocity

PSAX MV level-2D –maximize endocardium

PSAX papillary level-2D–maximize endocardium

PSAX apical level-2D–maximize endocardium

Apical Window

A4ch including complete LA and RA-2D-decrease depth and width to concentrate on LV endocardium after initial 4ch capture. If you can’t see RV free wall well, show it in a separate acquisition.

Color across MV- maximize MR jet

PW tips of MV-maximize size of spectral flow-adjust sweep speed to allow 3 beats to show

PWTD of lateral annulus- maximize size of spectrum- include movement above and below baseline- adjust sweep speed to show 3 complete cycles.

CW MV inflow- maximize spectral size- adjust sweep speed to allow 3 beats to show

CW for MR- maximize spectral size- adjust sweep speed to allow 3 beats to show

PW right superior or left superior PV- cursor should be approximately 1 cm into the vein- maximize spectral size to show flow above and below baseline- adjust sweep speed to allow 3 complete cycles to show.

Color across the septum (4ch view)- assessing for ASD/VSD.

Color across AV- rotate slightly clockwise to open ascending aorta- maximize any AI

PW LVOT- approximately 1cm proximal to AV leaflets. Maximize spectral size- adjust sweep speed to show 3 beats.

CW thru AV- maximize spectral size- adjust sweep speed to show 3 beats.

Color across TV- maximize TR jet

CW thru TV- measure highest velocity-Image acquire measured view.

A2ch view-2D- include complete LA in view. Can decrease depth and width to concentrate on LV endocardium after initial 2ch capture.

Color across MV- maximize MR jet. Can PW the PV’s from this view if unable to attain from the 4ch view.

A3ch view- 2D – Include complete LA in view and make sure ascending aorta is in view.

Color across MV and AV – can do both valves at once.

Subcostal Window

Subcostal 4ch 2D

Color across septae- ventricular and atrial separately, to assess for VSD/ASD.

Color on IVC with hepatics- At least 3 beat capture to assess for respiratory variant.

PW hepatic vein –if more than mild TR- cursor should be approximately 1cm into vein.

Subcostal SAX base-2D- zoom on AV if good window

Color subcostal SAX base

Subcostal SAX MV level-if possible

Subcostal SAX Papillary level- if possible

Subcostal SAX apical level- if possible

Complete your worksheet to show all 2D measurements. Note function, and any wall motion abnormalities on work sheet. Note all color Doppler abnormalities.

For AS protocol add:

LVOT: Measure by max velocity or trace (depending on machine setup) a minimum of 5 beats (NSR), 10 beats for A-fib. Image acquire all measurements.

CW AV: You can increase the sweep speed for measurement purposes after you have acquired 1 3beat capture. Trace a minimum of 5 beats (NSR), 10 beats for A-fib. Image acquire all measurements.

Very important: all AS studies submitted for accreditation must contain pedoff from at least one view!

Attempt pedoff now from all views, or do all pedoff at end of study. Image acquire a labeled spectral Doppler tracing from all windows (apical, RPS, SSN, and you can also use supra-clavicular notch if so inclined {SCN}), even if you couldn’t get the flow. Measure the spectral flow of the highest velocities (5-NSR) – (10 averaged A-fib) only if these velocities are the same or higher than the ones acquired from 2D spectral Doppler. Do not measure if less than earlier velocities.