Normal Variants

UPMC Health System Presbyterian Hospital

Procedure:  Transthoracic Echocardiogram (2D, Color Flow and Spectral Doppler)

Request: 

1)      Nursing Unit will schedule inpatients for all echocardiograms via electronic requisition.  Stat requisitions must be followed by a phone call to the charge sonographer or front office.

2)      Physicians’ offices or the patient will call Outpatient Scheduling to schedule all outpatient appointments.  All outpatient requests must have prescription with cardiac diagnosis or symptom, or ICD code, and name the specific test requested.  All outpatients will be pre-registered by Admissions Department or Outpatient Cardiology.

Materials:

·        Ultrasound machine

·        Conduction Gel

·        Alcohol prep pads

·        Electrodes

·        Gloves

·        Gown

·        Towel

Preparation for Procedure:

3)      Identify patient verbally and by checking wristband.

4)      Check patients chart for written order and pertinent history.  Outpatients must have prescription.

5)       “Arrive” patient in Epic and create and encounter in CVIS to get patient accession number.

6)      Enter patient information into ultrasound unit, including accession number and sonographer’s initials.

7)      Explain procedure to patient/answer any questions.

Performance of Procedure:

1)      Position patient left lateral.

2)      Prep skin with alcohol wipes and attach electrodes.

3)      Attach EKG and adjust for clean EKG reading with adequate R wave to allow for proper digital capture.

4)      Apply ultrasound gel to the transducer.

5)      Constantly monitor depth, gains, focus, and frequency for optimum picture quality.

6)      M-Mode may be used when warranted, but is not a requirement. (i.e. MVP, pericardial effusions, etc.)

7)      All images are captured digitally, 1 beat for NSR, 3 beats for A-fib.  Video tape all studies as back up.  Only digital images are archived.

8)      All measurements taken should be captured digitally to show your measurement.

9)      Digitally capture all generated worksheets.

10)   Do appropriate valve measurement packages on any gradient above normal.

11)   Image and Doppler supra-sternal notch when AI more than mild.

Parasternal window

• Plax-2D-Increased depth to r/o pleural/pericardial effusion

·        Plax-2D- Utilize full screen for view.

• 2D measurements:

ü      Move to highest point that can be seen of Arotic root and measure

ü    Left ventricular internal dimension—end diastole

ü      Left ventricular internal dimension—end systole

ü      Left ventricular posterobasal free wall thickness at end diastole

ü      Ventricular septal thickness at end diastole

ü      Left atrial dimension at end systole

ü      Aortic root dimension at end diastole (above the sino-tubular junction)

ü  Zoom 2D image mitral valve.

ü  Zoom 2D image aortic valve.

• Color across AV-maximize any AI jet

·        Color across MV-maximize any MR jet (can do MV and AV in one view)

• RVIT-2D

·        RVIT color-maximize TR jet

·        CW TV for TR- maximize size of spectral flow- adjust sweep speed to allow 3 complete cycles 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 if possible- (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- maximize size of spectral flow- adjust sweep speed to allow 3 complete cycles to show

• CW across PV- maximize size of spectral flow- adjust sweep speed to allow 3 complete cycles to show-include PI velocity.

·        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 complete cycles to show-measure maximum jet velocity

• PSAX MV level-2D –maximize endocardial definition.

• PSAX papillary level-2D–maximize endocardial definition.

·        PSAX apical level-2D–maximize endocardial definition.

·        You can reverse this SAX process from Apex to base as long as all required views are recorded.

Apical Window  

• A4ch including complete LA and RA-2D-decrease depth and width to concentrate on LV endocardium after initial 4ch capture.  You can capture this at end of all apical images also.   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 complete cycles 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 complete cycles to show

·        CW for MR- maximize spectral size- adjust sweep speed to allow 3 complete cycles to show

·        If MR more than mild, 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 ventricular and atrial septae.  Can do this with one wedge over both septae. (Align septum vertically so color wedge covers entire septum.)

·        2D 5 chamber view.

·        Color across AV- rotate slightly clockwise if necessary to open ascending aorta- maximize any AI flow.

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

·        CW thru AV- maximize spectral size- adjust sweep speed to show 3 complete cycles.  

·        Color across TV- maximize TR jet

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

·        You can reverse this process from TV to MV as long as all required views are recorded

 A2ch view-

• 2D- include complete LA in view.  Can decrease depth and width to concentrate on LV endocardium after initial 2ch capture. You can do all apical concentrated views together at end of apical section of protocol.

·        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 or separately.

·        CW thru AV to access flow (may be a better angle than the 5 chamber).

·        Can PW the PV’s from this view if unable to attain from the 4ch view.

Subcostal Window

·        Subcostal 4ch 2D

·        Color across septae- ventricular and atrial separately, to assess for VSD/ASD.  Adjust color scale to pick up discrete color jets.

·        Color on IVC with hepatics.

·        M-mode the IVC with at least one respiratory cycle to show amount of collapse.

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

·        Subcostal SAX base-2D- zoom on AV if you need to confirm 3 leaflet valve.

·        Color subcostal SAX base

·        Subcostal SAX MV level-if possible

·        Subcostal SAX Papillary level- if possible

·        Subcostal SAX apical level- if possible

Appropriately document for inpatients chart.

Preparation for Interpretation:

1)      A sonographer worksheet is filled out on each patient to include indication for study, measurements, and your findings. 

2)      Enter all numerical date into CVIS encounter. 1)      except tricuspid velocity. (This includes acquired valvular measurements for AS or MS)

3)      Send images to Kinetdx and place patient folder in bin.

Interpretation:

1)      Reading physician views digitized images on the Kinetdx workstation.

2)      Physician creates a report using the computerized report generation system.

3)      Report is sent to Cerner and MARS within one hour of being finalized.

4)      Physician prints report and places with patients’ folder.

Additional information requirements:

In the setting of:

Tricuspid Valve Test  -  When repair of TV or ring installed. 

• PW the valve like test for MV stenosis

• PW hepatic Veins for flow reversal.
  

Aortic Stenosis: (Kathy)

• Measure minimum 3 beats of LVOT diameter from a zoomed image at parasternal window.  Make sure outflow tract, valvular apparatus, and aorta are aligned.  This should give you the true diameter. Digitally acquire all measurements.

• Measure minimum 5 consecutive beats for V1 from the apical 5 chamber view at approximately .5 -1.0 cm below the valve leaflets for normal sinus rhythm and a minimum of 10 consecutive beats if patient in atrial fibrillation using pulse wave Doppler.  Utilize full screen for spectral Doppler by adjusting scale and increase sweep speed to allow for no more than 3 beats per screen.  Digitally acquire all measurements.

• Measure minimum 5 consecutive beats for V2 from the apical 5 chamber for normal sinus rhythm and a minimum of 10 beats if patient in atrial fibrillation using continuous wave Doppler.  Rotate the transducer slightly clockwise to open the aorta if necessary.  Align Doppler cursor as parallel as possible with flow by utilizing off axis views if necessary. Utilize full screen for spectral Doppler by adjusting scale and increase sweep speed to allow for no more than 3 beats per screen.  Digitally acquire all measurements.

• Repeat the above measurements from apical 3 chamber view, making sure the sample volume is in the proper area for PW and the aorta is open for the CW. 

• Use the pedoff probe from the apical window, the right parasternal window, and the suprasternal notch for any stenosis more than mild.  Supraclavicular window can be utilized if the suprasternal window was not available or unattainable.  At least one window of spectral Doppler utilizing the pedoff probe should be obtained.  Digitally acquire all measurements. 

Mitral Stenosis: (Kathy)

• Use color flow Doppler to align CW cursor thru the jet of mitral inflow. You may have to utilize an off axis view of the heart to do this. Adjust scale to utilize the full screen for mitral inflow spectral Doppler and adjust sweep speed to allow for no more than 3 beats per screen. Trace a minimum of 5 beats for normal sinus rhythm and 10 consecutive beats for atrial fibrillation. Measure a pressure-halftime on these same beats. Digitally acquire all measurements.

• Make sure all calculations for valvular stenosis are entered into machines calculation package. If an erroneous measurement is entered into the calculation package, please make sure it is deleted before acquiring the image of the report page. All information is entered into the CVIS work page.

Pericardial Effusion:

• M-mode in the PLAX view to document amount of effusion anteriorly and posteriorly.  Zoom the m-mode of the RV free wall in this view to aid in documenting diastolic collapse.  M-mode in the short axis view at the level of the valves, zoom in on the RVOT to document diastolic collapse. 

• In the apical windows, show any fluid accumulations by using off axis views if necessary.  M-mode thru the RA if there is collapse of the RA wall to evaluate timing of collapse.  Pulse wave Doppler at the tips of the mitral leaflets at a sweep speed of 25 mm/s.  Align sample volume parallel to flow as possible and just at the tips of the MV leaflets to produce good clean Doppler signal.  Adjust scale to optimize the spectral flow signal.  Most machines have a respiratory wave available that works off the ECG leads.  Turn this on—it will help to monitor respiratory cycles for measurement.

• From the sub-costal window- angle anteriorly in the 4ch view to evaluate for anterior effusion.  M-mode the RV free wall to look for diastolic collapse—zoom the m-mode to concentrate on the RV free wall area.

Use the pedoff probe  

• From the apical window, the right parasternal window, and the suprasternal notch for any stenosis more than mild. Supraclavicular window can be utilized if the suprasternal window was not available or unattainable. At least one window utilizing the pedoff probe should be obtained. Digitally acquire all

Measurements.

Aortic stenosis  (Heather)

PLAX

• Zoom AO 2D

• Measure 1 or 2 LVOT diameters – try to keep it around 1.7 – 2.2

• M-Mode AO and measure the leaflet excursion – usually correlates with AVA

• Go to higher intercostals space and measure AO root

PSAX

• Zoom AO 2D measure by Planimetry AoV - here as well show image with and

• without measurements

• Zoom and color – to see how much turbulence flow there is

APICAL 4/5

• Show good color signal

• Make sure you are a parallel as possible to AoV Flow

• PW LV – sweep speed of 50 measure peak jet show 5 beats

• CW AoV – want a good solid signal with valve clicks when possible, - if in

• regular sinus rhythm 2-3 beats, if irregular rhythm 3-4 beats

In 4 chamber angle for AoV and show CW signal of AoV show also in short

axis view

APICAL 3

• Good color

• Always CW AoV in this view – if in regular sinus rhythm 2-3 beats, if

• irregular rhythm 3-4 beats – can do more if this is a higher signal than

• in Apical 5

• SUBCOSTAL

SSN

• Show color on SSN view

• PW descending ARCH – drop filter

• CW ascending arch and pedoff ascending arch

• Right PARA

• Pedoff

• Look for AoV signal can have PT turn to right side

• Measure and show peak elevation signal

Aortic insufficiency Heather

PLAX

• Measure Aortic root from higher intercostal space

• Zoom and color AV

• Measure vena contracta (at cusp)

• can also color M-Mode of AV

PSAX

• Zoom and color AV

• Make sure you have a good 2D zoom of AoV to rule out Bi-cuspate valve

Apical 5

• Good color signal - want to see how wide the jet of AI is and how far

• back into the LV the jet travels

• Good CW of AI jet - want to see how the signal is along with the

• slope of the jet - don't need to measure.

Apical 2

• can look at thoracic aortic root by looking posterior with your probe

Apical 3

• Good color signal of AI

• Good CW signal of AI again focus on slop of the AI get

Subs

• Show abdominal AO (can doppler here if no SSN is available

• Show good short axis AO view

SSN

• Show good 2D image if dilated or coaracated

• show good color

• PW descending arch set filter to 2 or 3 on Philips

• good to show 1 sweep 50 speed and 1 at 100 speed