(BQ) Part 2 book “A practical approach to clinical echocardiography” has contents: Diastolic function, tissue doppler echocardiography - current status and applications, rotation, twist and torsion, congenital heart disease in adults, pericardial diseases, ischemic heart disease, cardiomyopathies, tumors, masses and infection,… and other contents.
Chapter 11 Echocardiographic Assessment of Right Ventricular Function: Methods and Clinical Applications INTRODUCTION Importance of the right ventricle (RV) in health and disease has seen a sea-change from being just a conduit to an important contractile chamber, which significantly impacts cardiac physiology, hemodynamics and development of symptoms.1 It is the final barrier between compensated versus decompensated heart Right ventricular musculature when stressed expresses several important enzymes and activates several signal transduction pathways involved in hypertrophy, fibrosis and pulmonary vasoconstriction.2 These changes bring new meaning to pharmacotherapy of heart failure and the role of the RV Under normal conditions, the RV is coupled with a low-impedance, highly distensible pulmonary vascular system (Figs 11.1 to 11.3) Compared with the systemic circulation, pulmonary circulation has a much lower vascular resistance and greater pulmonary artery distensibility.3 Under normal conditions, right-sided pressures are significantly lower than comparable left-sided pressures Despite this, the RV ejects similar or somewhat greater volume during systole compared to the left ventricle (LV) 4–6 (Figs 11.4 and 11.5) PECULIARITIES OF THE RIGHT VENTRICLE • The right ventricular systolic function is predominantly afterload-dependent and minimally affected by the preload Fig 11.1: Schematic diagram of low impedance right heart circulation Short-axis view • Unlike the LV, there is no torsion of any significance and hence hardly any circumferential shortening (Fig 11.6) • Radial shortening is unimpressive unlike the LV, partly because myofiber orientation and muscle volume is different (Fig 11.7) • Highly trabeculated and spongy appearance of the cavity allows it to work as an efficient volume pump but poses challenges with regard to geometric volume estimations7 (Fig 11.8) 190 Section 3: Systolic and Diastolic Function Fig 11.2: Distribution of pulmonary artery systolic pressure in normal subjects Fig 11.3: Distribution of pulmonary artery mean pressure in normal subjects A mean pressure ≥ 25 mm Hg indicates presence of pulmonary hypertension Fig 11.4: Right ventricular pressure-volume loop Fig 11.5: Comparison of pressure-volume loop of the right ventricle (yellow) with that of the left ventricle (white) • Presence of a transverse moderator band prevents undue chamber dilatation and hence despite signi ficant combined pressure and volume overload in heart failure, it is not uncommon to see minimum geometric alterations.8 This makes eye-balling highly deceptive in assessing right ventricular function (Fig 11.9) • In advanced diseased states, outflow may become a dominant contractile chamber by virtue of its circumferential muscle orientation Little attention has been given to the importance of this phenomenon (Figs 11.10 and 11.11) FUNCTION PARAMETERS Function of the RV is to transmit blood from the venous system to the LV through pulmonary arteries • As normal adult circulation is in series, right ventricular stroke volume is nearly similar to that of the LV • If we assume the RV as a mechanical pump, function is its behavior in developing pressure at varying volumes during cardiac cycle.9 • There are phases in cardiac cycle, which have variable functional importance and temporal dimension needs to be coupled with a mechanical event for complete Echocardiographic Assessment of Right Ventricular Function: Methods and Clinical Applications Fig 11.6: Right ventricular basal circumferential strain of only -4% in a normal subject Paradoxically, many segments show circumferential lengthening Fig 11.7: Comparison of basal right ventricular radial strain (10%) with the left ventricular basal radial strain (55%) in a normal subject Fig 11.8: Transthoracic echocardiography short-axis view showing spongy right ventricle Fig 11.9: The right ventricle is a tripartite structure with an inflow part including the tricuspid valve apparatus; a trabecular part that includes pronounced trabeculations that function as an absorptive sponge, filling during diastole and releasing blood in systole; and an outflow tract that consists of a muscular infundibulum, separating the tricuspid from the pulmonary valve Fig 11.10: Conceptual diagram The two contractile chambers of the right ventricle with distinct morphologies assessment Thus, a pressure–volume loop during a single beat in temporal domain is possibly the best way of assessing function.10 However, it is clinically impractical to obtain this information by a convenient and reproducible method So, we look for surrogates and correlates • In spatial domain, fractional area change or ejection fraction or volume leftover at end-ejection are parameters of function (Figs 11.12A and B) • In temporal domain, ejection period or filling period or a ratio of time spent during isovolumic phase to ejection phase provide functional information of clinical value 191 192 Section 3: Systolic and Diastolic Function Fig 11.11: Transthoracic echocardiography short-axis view Complex geometry of the right ventricular chamber; inflow on the left side, trabecular portion in the middle and the conus on right side The right ventricular outflow tract (RVOT) becomes an important contractile chamber in diseased states A B Figs 11.12A and B: Estimation of the right ventricle function by optimizing a transthoracic echocardiography four-chamber view Fractional area change and end-systolic volume can be estimated • Typically, the RV spends less time during isovolumic phase compared to the LV and hence it is more energyefficient (Fig 11.13) Increase in this period is the early indication of the failing RV • The right ventricular ejection time is about 30–50 milliseconds longer because of the outflow chamber, which contracts near the end of systole • The right ventricular ejection period shows phasic variation with increase during inspiration • Lack of phasic variation may suggest onset of dysfunction if there is no abnormal interchamber communication (Fig 11.14) • Indirect assessment of the right ventricular function includes integrity of inflow valve and the outflow valve Fortuitously, there are ubiquitous tricuspid and pulmonary valve leaks, which can provide information • • • • on preload, afterload and forward vascular resistance (Figs 11.14 and 11.15) Slopes of tissue velocity propagation during isovo lumic phase correlate with intrinsic contractility (Fig 11.16) Geometric alterations are not an indicator of dysfunction but suggest that the latter may be present or will occur in future Quantum and speed of longitudinal motion of this complex chamber has also found clinical utility, because most deep fibers of the RV are longitudinally arranged Longitudinal motion has fair correlation with ejection performance Patterns of flow and tissue movements also help in detecting abnormalities in pressure–volume loops and provide some meaningful information Echocardiographic Assessment of Right Ventricular Function: Methods and Clinical Applications Fig 11.13: Right ventricle free wall tissue velocity image Note that isovolumic contraction (IVC) and isovolumic relaxation (IVR) periods are very brief Fig 11.14: Continuous wave Doppler interrogation of the right ventricular outflow tract Physiological pulmonary regurgitation with a peak diastolic velocity of m/s is observed Note the duration of regurgitation increasing during expiration and decreasing during inspiration Lack of phasic variation is a sign of dysfunction Fig 11.15: Physiological tricuspid regurgitation jet with a peak velocity of 2.68 m/s Note the respiratory variation A peak transtricuspid velocity ≥ 3.5 m/s is suggestive of elevated right ventricular systolic pressure and velocities between 2.8 and 3.4 m/s are of borderline significance Fig 11.16: Right ventricle (RV) free wall tissue velocity profile Note the difference between acceleration slopes in left (normal subject) and right panel [inferior myocardial infarction (INF MI) with possible RV infarction) RIGHT VENTRICLE DIASTOLIC FUNCTION AND PRESSURES • Respiratory variations in filling may be better markers of preload11 (Figs 11.14 and 11.15) • Right atrial pressure or RV end-diastolic pressure can be measured directly during right-heart catheterization or estimated noninvasively by assessing inferior vena cava diameter and collapse index.12 Dilated (≥ 20 mm) and noncollapsing inferior vena cava is suggestive of mean right atrial pressure ≥ 15 mm Hg (Fig 11.17) A dilated inferior vena cava with inspiratory or • Preload is an important determinant of the right ventricular function A crude measure of the preload is right atrial pressure or right ventricular end-diastolic pressure • It is difficult to measure right atrial volume or the right ventricular diastolic volume by echocardiography 193 194 Section 3: Systolic and Diastolic Function Fig 11.17: Dilated inferior vena cava indicates elevated right atrial pressure Reduced inspiratory collapse is specific A collapse index < 50% is highly suggestive of right atrial pressure > 10 mm Fig 11.18: M-mode section of the inferior vena cava with reduced inspiratory collapse Fig 11.19: Transthoracic echocardiography four-chamber view at end-diastole showing bulge of the interatrial septum to the left, indicating right atrial pressure higher than left atrial pressure in diastole Fig 11.20: Prominent diastolic tricuspid regurgitation indicating elevated right ventricle diastolic pressures in a patient with dilated cardiomyopathy sniff-related collapse of < 50% indicates elevated mean right atrial pressure (≥ 10 mm Hg) • The annular tricuspid E/e ratio and annular tissue Doppler relaxation time have also shown moderate correlation with right atrial pressure.13 • Raised right atrial pressure can also be judged from movement of the interatrial septum or the hepatic vein flow spectrum14 (Figs 11.19 and 11.20) A decrease in systolic wave and a marked increased in atrial reversal wave in hepatic veins indicate raised right atrial pressure • Estimation of the right ventricular end-diastolic pressure from the Doppler pulmonary regurgitation signal can be a good surrogate when jugular venous pressure is added to the pulmonary end-diastolic pressure gradient • Elevated right ventricular diastolic pressures can also be judged from the presence of diastolic tricuspid regurgitation, diastolic antegrade flow across the pulmonary valve or from the patterns of pulmonary regurgitation (Figs 11.20 to 11.25) • It is also possible to estimate –dP/dt from tricuspid regurgitation signal (Fig 11.26) Pulsed wave Doppler tricuspid flow velocities can also be used for assessing RV diastolic function An E/A < 0.8 indicates abnormal relaxation A combined flow and Echocardiographic Assessment of Right Ventricular Function: Methods and Clinical Applications Fig 11.21: Flow Doppler alternans of the tricuspid regurgitation with normal right ventricular systolic pressure Doppler alternans is sugg estive of global right ventricle dysfunction Fig 11.22: Operated tetralogy of Fallot in an adult showing antegrade diastolic flow across pulmonary valve (arrows), indicating elevated right ventricular diastolic pressure Fig 11.23: Rapidly decelerating pulmonary regurgitation jet with end-diastolic antegrade flow across pulmonary valve (arrows) sugg estive of raised right ventricle end-diastolic pressure Fig 11.24: Continuous wave Doppler interrogation of the pulmonary regurgitation jet The pattern is classic of normal right ventricular diastolic pressure as estimated by end-diastolic gradient and mid-diastolic dip tissue early diastolic velocity ratio E/e’ > is also abnormal A E/A ratio of > with deceleration time < 120 milliseconds is suggestive of restrictive RV diastolic function Right Ventricular Volumetric Function Fig 11.25: Restrictive transtricuspid pulsed wave Doppler flow velocities A deceleration time varies with respiration, from 100 to 130 milliseconds Averaging five beats in quiet respiration is required to obtain mean values In clinical practice, the right ventricular ejection fraction (RVEF) is the most commonly used index of RV contra ctility Although widely accepted, RVEF is highly depen dent on loading conditions and may not adequately reflect contractility.15 Because the RV chamber is larger than the LV chamber, RVEF is, under normal conditions, lower than LV ejection fraction The normal range of RVEF varies between 40% and 76% depending on the methodology used.16 Magnetic resonance imaging (MRI) is the most accurate method for measuring RVEF According to Lorenz et al.4 the normal value of RVEF is 61 ± 7%, ranging 195 196 Section 3: Systolic and Diastolic Function Fig 11.26: Estimation of dP/dt from tricuspid regurgitation (make it yellow) signal Pressure drop from m/s velocity to m/s is multiplied by the time taken to attain m/s velocity Fig 11.27: Right ventricle short-axis dimension and area in four-chamber view are the two best correlates of the volumes from 47% to 76% RV images can be acquired in the shortaxis or long axial direction Alfakih et al.15 demonstrated that the axial orientation resulted in a better intraobserver and interobserver reproducibility than the short-axis orientation The lower limit of radionuclide-derived normal RVEF ranges from 40% to 45%.17 To be accurate, volume assessment should always take into account the complex shape of the RV Furthermore, the infundibulum should be included in the volume measurement because it can account for as much as 25% to 30% of RV volume.18 • The simplest and most routinely used method for assessing RV volume includes linear dimensions and areas obtained from single tomographic echocar diographic planes The best correlations between single-plane measurements and RV volumes have been obtained with the maximal short-axis dimension and the planimetered RV area (in the four-chamber view; Fig 11.27) • Significant overlap has been noted, however, between normal and volume-overloaded conditions, especially for mild to moderate enlargement.18 • In an effort to be more accurate, different approaches have been sought to directly measure RV volume These include the area–length method and Simpson’s approach In two-dimensional (2D) echocardiography, numerous studies showed that the area–length method that uses an ellipsoid or pyramidal model correlates better with RV volume than Simpson’s rule.18 The main difficulty seen with the application of Simpson’s rule to 2D echocardiographic images is obtaining two appropriate orthogonal views with a common long axis • Three-dimensional (3D) echocardiography is a promi sing technique that could lead to more accurate assessment of RV volume.19,20 Echocardiography is less accurate than the nuclear methods Two-dimensional assess ment of RVEF with Simpson’s rule and the area–length method show moderate correlation with radionuclide- or MRI-derived RVEF.18 In the clinical setting, 3D echocardiography has also shown variable correlations with RVEF,19,20 although there have been some studies that have not supported the strong relationship Diffi culties include delineation of the anterior wall and identification of the infundibular plane • Right ventricle fractional area change represents the ratio of systolic area change to diastolic RV area It is measured in the four-chamber view and can be incorporated systematically into the basic echocardio graphic study A fractional area change of ≤ 35% indicates RV systolic dysfunction In diverse conditions, a good correlation has been reported between RV fractional area change and RVEF21 (Fig 11.28) Assessing Longitudinal Function The RV contracts by three separate mechanisms: Inward movement of the free wall, which produces a bellows effect Contraction of the longitudinal fibers, which shortens the long axis and draws the tricuspid annulus toward the apex (Fig 11.29) Echocardiographic Assessment of Right Ventricular Function: Methods and Clinical Applications A B Figs 11.28A and B: Fractional area change (44%) in a normal person estimated in four-chamber view Fig 11.29: Longitudinal shortening of the right ventricle free wall (-38%), which is nearly twice that of the interventricular septum 197 198 Section 3: Systolic and Diastolic Function Fig 11.30: Right ventricle (RV) apical circumferential strain compared to the left ventricle apical one in a normal subject There is hardly any circumferential strain in the RV apex Fig 11.31: Tricuspid annular plane systolic excursion (TAPSE) displayed in M-mode in a normal adult patient Traction on the free wall at the points of attachment to the LV There is no twisting or rotation (Fig 11.30) Longitudinal motion is the predominant way of ejection.22 Large surface area due to trabeculations pro duces effective stroke volume at low pressure.23 However, it is difficult to assess area change accurately in any view Tricuspid annular plane systolic excursion is another useful quantitative measurement of RV systolic performance24 (Fig 11.31) This method reflects the longi tudinal systolic excursion of the lateral tricuspid valve annulus toward the apex It is usually measured with 2D-directed M-mode imaging in the four-chamber view Normal values are usually > 15 mm25 (Fig 11.31) Studies showed moderate correlation between tricuspid annular plane systolic excursion (TAPSE) and RVEF measured by radionuclide angiography.26,27 However, some studies show better correlation between RVEF by MRI and TAPSE than with real-time 3D echocardiography.27 Measure ments of tricuspid annular motion are easy to obtain, correlate with RV systolic function and have a high specificity and negative predictive value for detecting abnormal RV systolic function25 (Fig 11.32) TRICUSPID ANNULAR PEAK SYSTOLIC VELOCITY Longitudinal motion of the RV can also be assessed by studying the tricuspid annular velocities Tissue Doppler imaging, which measures myocardial velocities, also allows quantitative assessment of RV systolic function 28,29 Tumors, Masses and Infection Fig 20.40: 3D TEE image showing aneurysm of the anterior mitral leaflet (arrows) A vegetation is seen at the leaflet tip Fig 20.41: Large pseudoaneurysm (P) of sinus of Valsalva obstructing the RV outflow tract secondary to infective endocarditis (IE) of the aortic valve Small vegetations are seen on the aortic valve Fig 20.42: Candida ball attached to mitral and aortic valves in an infant (arrows) Fig 20.43: Healed bright echoes on the aortic valve in the parasternal long-axis view Fig 20.44: Broken chord attached to the anterior mitral leaflet (arrow) • Vegetations that are greater than 10 mm or are pedunculated have high predilection for embolization • Healed vegetations may become more echogenic and still retain their embolic potential (Fig 20.43) • The infective vegetations require to be differentiated from: –– Lambl’s excrescences –– Fibroma of the valve –– Arantius nodules –– Degenerated and rheumatic nodules –– Ruptured chord (Fig 20.44) –– Lupus vegetations20 –– Myxomatous valves (Fig 20.45) • Presence of obstructive vegetations, fistula or abscess formation or embolization portend bad prognosis 393 394 Section 6: Structural Heart Disease Fig 20.45: Myxomatous posterior mitral leaflet with thickening of the distal half of the cusp (arrow) Fig 20.46: Infective vegetations on the tricuspid valve leaflets (arrows) in a subject with fever and on maintenance hemodialysis (IAS: Inter-atrial septum) • Vegetations on the tricuspid valve occur more often in patients with central venous catheters, intravenous drug abusers, patients on hemodialysis and those with pacemakers (Fig 20.46) 10 Klarich KW, Enriquez-Sarano M, Gura GM, et al Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation J Am Coll Cardiol 1997;30(3):784-90 11 Abhishek V, Avinash V Cardiac hydatid disease: literature review Asian Cardiovasc Thorac Ann 2012;20(6):747-50 12 Cecchi E, Chirillo F, Faggiano P, et al For the Italian Registry on Infective Endocarditis (RIEI) Investigators The Diagnostic Utility of Transthoracic Echocardiography for the Diagnosis of Infective Endocarditis in the Real World of the Italian Registry on Infective Endocarditis Echocar diography 2013;30(8):871-9 13 Martos-Perez F, Reguera JM, Colmenero JD Comparable sensitivity of the Duke criteria and the modified Beth Israel criteria for diagnosing infective endocarditis Clin Infect Dis 1996;23(2):410-11 14 Tissières P, Gervaix A, Beghetti M, et al Value and limita tions of the von Reyn, Duke, and modified Duke criteria for the diagnosis of infective endocarditis in children Pedi atrics 2003;112(6 Pt 1):e467 15 Nakagawa T, Wada H, Sakakura K, et al Clinical features of infective endocarditis: Comparison between the 1990s and 2000s J Cardiol 2013;pii:50914-5087 16 Hoen B, Duval X Clinical practice Infective endocarditis N Engl J Med 2013;368(15):1425-33 17 Silbiger JJ, Krasner A, Chikwe J, et al Pseudoaneurysm formation in infective endocarditis Echocardiography 2013 18 Edwards NC, Smith NL, Steeds RP Beyond the artery and ventricle-an aneurysm of the mitral valve leaflet Echocar diography 2013;30(8):E258-9 19 Bruun NE, Habib G, Thuny F, et al Cardiac imaging in infectious endocarditis Eur Heart J 2013 20 Contractor T, Bell A, Khasnis A, et al Antiphospholipid antibody-associated non-infective mitral valve endocar ditis successfully treated with medical therapy J Heart Valve Dis 2013;22(1):36-8 References Egolum UO, Stover DG, Anthony R, et al Intracardiac thrombus: diagnosis, complications and management Am J Med Sci 2013;345(5):391-5 Bakalli A, Georgievska-Ismail L, Koỗinaj D, et al Prevalence of left chamber cardiac thrombi in patients with dilated left ventricle at sinus rhythm: the role of transesophageal echocardiography J Clin Ultrasound 2013;41(1):38-45 Lee JM, Park JJ, Jung HW, et al Left ventricular throm bus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents J Atheroscler Thromb 2013;20(1):73-93 Edwards FH, Hale D, Cohen A, et al Primary cardiac valve tumors Ann Thorac Surg 1991;52(5):1127-31 Nield LE, Mendelson M, Ahmad N, et al Clinical review of obstructive primary cardiac tumors in childhood Congenit Heart Dis 2013 Barreiro M, Renilla A, Jimenez JM, et al Primary cardiac tumors: 32 years of experience from a Spanish tertiary surgical center Cardiovasc Pathol 2013 Burnside N, MacGowan SW Malignant primary cardiac tumours Interact Cardiovasc Thorac Surg 2012;15(6): 1004-6 Ha JW, Kang WC, Chung N, et al Echocardiographic and morphologic characteristics of left atrial myxoma and their relation to systemic embolism Am J Cardiol 1999;83(11):1579–82, A8 Harling L, Athanasiou T, Ashrafian H, et al Minimal access excision of aortic valve fibroelastoma: a case report and review of the literature J Cardiothorac Surg 2012;7:80 Index Index Page numbers followed by f refer to figure and t refer to table A Abdominal aorta 320 Acoustic scattering shadowing 14 speckle tracking 262 Acquired aortopathies 331 Acute anterior myocardial infarction 345f aortic syndrome 335 ischemia 289 pericarditis 345 rupture of subendocardial muscle layer with blood seeping into outer layer 375f American Heart Association Classification of Primary Cardiomyopathies 397t Anderson-Fabry disease 402 Aneurysm confined to descending thoracic aorta 337f dilatation of pulmonary artery 132f formation 375 spreading down and upward from arch of aorta 337f Angle equal to angle of incidence producing less bright echo 6f of incidence Animal pericardium 141 vulvar tissue See Animal pericardium Annular tissue velocities 216 from lateral edge of mitral annulus 181f, 215f Annuloaortic ectasia 332 Annulus 84 paradoxus 355 Anomalous muscle bundle in left ventrical cavity 390f Anterior leaflet of tricuspid valve 305 mitral leaflet 48f, 73f, 102, 113, 113f calcification 50f in transesophageal echocardio graphy, perforation in 392f type of 74 pulmonary leaflet 127f Anterograde velocity of tricuspid inflow 122 Anterolateral commissure 65f Aorta 318 acquired disorders 318 anatomy of 318f congenital disorders 318 parts of 318 properties of 274 Aortic arch 319 coarctation 324 cusps 84 dimensions, normal values of 329t disorders, etiopathogenesis of 322 dissection to ascending aorta 337f Doppler spectrum, incompletely formed 91f interruption with low-velocity continuous flow in thoraco- abdominal aorta 325f regurgitant volume, concept of 104f regurgitation anatomical orifice of 36f by echo-Doppler methods 108 techniques, detection of 102 by vena contracta 105 concept of 102f functional anatomy of 100 of left ventricular outflow tract height 105f severity of 106 volumetric severity of 104 root 318 dilatation with suspected Marfan syndrome 333f sinotubular junction with valvular stenosis 331f sinus See Sinus of Valsalva aneurysm of 308 dilatation triangular aortic valve opening in diastole 334f stenosis 286 anatomy of 86 etiology of 85 valve 127f area 83 for judging severity 90t cross-section of 83f fibroelastoma of 388f guards 83 opening 177 regurgitation 98 to annular dilatation, type I 333f stenosis 83 Aortopulmonary window 329 types of 329 Apical 4-CV large pericardial effusion with right atrial collapse 350f aneurysm in presence of mid-cavity obstruction 404f dyskinesis and increased echogenicity of mid-septum 368f five-chamber 18f, 19f four-chamber apical intramural hematoma 412f ball thrombus in left atrium 49f congenital tricuspid stenosis 120f dilated right atrium 370f 415 416 A Practical Approach to Clinical Echocardiography free wall pericardial effusion 375f rupture 375f in systole 366f mitral leaflets 48f rheumatic tricuspid 116f with normal left ventricle end diastolic volume 406f long axis 19f view left ventricle cavity 406f view with sonovue contrast injection 412f muscular ventricular septal defect 303f myocardial dissection with hematoma 373f rotation reduced 289f values true apex, difference in 285f two-chamber view with structures 19f Apicoanterior myocardial infarction seven days after onset 369f Applications of strain and strain rate imaging 276 Arrhythmogenic right ventricular cardiomyopathy 409 dysplasia 397 Ascending aorta 319 with normal aortic root, dilatation of 324f Assess severity of MR, methods to 76 Assessing longitudinal function 196 Asymptomatic patient with aortic stenosis, increased torsion in 286f Atheroma in aortic arch 336f with penetrating ulcer 336f Atherosclerosis 334 Atria with doughnut thrombus in left atrium, dilated 384f Atrial flow reversal of pulmonary vein 220f kick 209 septal defect 295 types of 295 Atrialized ventricle 306 Atrioventricular septal defect with large right ventricle in tetralogy of Fallot 312f primum defect 301f Atrium in adult subject with tricuspid atresia 302f Attenuation Augmented expiratory flow reversal in hepatic vein with constrictive pericarditis 357f Axial versus lateral resolution 11f B Ball-in-cage mechanical prosthesis 139f in aortic position 139f valve 138 Basal chordae 47, 66 left ventricle 365f right ventricular radial strain with left ventricular basal radial strain, comparison of 191f rotation versus apical rotation 283f Base-to-apex from end diastole to end systole, rotation of 282f Bernoulli’s equation 28 principle 28 Best lateral resolution in parasternal long axis view 78f Bicuspid aortic valve 85 in three-dimensional echocardio- grapic 87f with conjoined leaflet to fusion of left and noncoronary cusps 86f with proximal aortic dilatation in parasternal long-axis 323f with stenosis 87f Bifurcation of pulmonary artery 20f Bileaflet mitral prosthesis in diastole 142f, 143f systole three physiological regurgitant jets 145f prostheses, types of 33 prosthetic valves 140 Bimodal deceleration slope in third beat of transmitral flow 55f Bioprosthesis 141 Bioprosthetic degeneration 152 heart valves 141 valves 141 Biphasic longitudinal expansion of left ventricle diastole 210f mitral flow with tips of mitral leaflets 212f Biplane area-length method See Biplane ellipsoid formula ellipsoid formula 173 to estimate LV end-diastolic volume 173f multilobed apical thrombus 374f simpson 174f Both mitral and aortic valves 99f Bowditch effect 170 Broad bandwidth transducer with wide range of resonant frequency 9f Bulky leaflets of MV in Barlow’s syndrome 71f Bull’s eye 269f Bullet formula 173 method to estimate left ventricle volume 173f C Calcific mitral annulus mimicking tumor, caseous degeneration of 390f Calcified atheromatous ulcer in anterior wall of ascending aorta 336f pericardium restricting transverse expansion of heart with dilated left atrium 354f Cardiac cycle of left heart, phases of 206f LV, phases of 168f manifestations of masses 383 masses in left ventricle 390f movement, vectors of 259t resynchronization therapy See Torsion resynchronization therapy tamponade 349, 384 tumors 385, 389 Cardiogenic shock with isolated right ventricle infarction 370f Cardiomyopathies 395 dilated 397 Carpentier’s functional classification 67 Carpentier-Edwards bioprosthesis in mitral position stenosis of orifice in diastole 153f mitral bioprosthesis severe trans prosthetic mitral regurgitation 155f Index Causing left ventricle volume overload 99f Caveats for Bernoulli’s equation 28 Cavity without walls in diastole and systole 261f Central processing unit Chemla equation 41 Chordae tendineae 47, 66 Chords, types of 66f Chronic ischemia 289 Circumferential fiber shortening estimation of 177f velocity of 177f flow around ball in Starr-Edwards ball-in-cage prosthesis in mitral position 139f radial shear strain apex 262f strain 263 of ascending aorta with hypertension 276f wall thickening with reduced lumen of left subclavian artery 334f Circumflex artery 364f Cleft anterior mitral leaflet 314f Clinical utility of TDI 239 Color Doppler flow reversal in descending thoracic aorta 107f interrogation in mid-cavity obstruction 405f of narrow communication of pseudoaneurysm 376f jet of aortic regurgitation 36f myocardial from interventricular septum 233f imaging 231 velocities from basal septum to basal lateral wall 234f velocity pattern of septum 400f of right ventricular outflow tract 129f Color flow Doppler evaluation of aortic regurgitation 104 of mitral regurgitation proximal isovelocity surface area 35f jet area in LA 76 mapping 121 Color kinesis in apical four-chamber view apical akinesis 371f Color-flow map-adjusted wave Doppler to obtain transpulmonary gradients 132f Combined mitral valve stenosis 62f Commissures 85 Common atrium 300 Comparing mild aortic regurgitation with severe aortic regurgitation 108f versus large pericardial effusion 347f Congenital aortic sinus aneurysm 309 bicuspid aortic valve in diastole regurgitant orifice 99f disorders of aorta 322 heart disease in adults 295 parachute tricuspid valve causing TS 121f Conical fibroserous sac of pericardium 343f Constrictive pericarditis 287 case of 358f Continuity equation, limitations of 29 Continuous wave Doppler interrogation 155f Coronary artery disease 365 sinus 295 vascular territory 363 Cresentic intrapericardial mass with pericardial effusion 349f Curved anatomical M-mode TVI 231 Cushing’s syndrome 387 CW Doppler interrogation in MR 81 signal alternans of TR 124f spectrum in acute aortic regurgitation 108f of acute MR 81f of functional MR 73f of mild versus severe aortic valve stenosis, comparison of 91f CW profiles of varying degree of aortic valve stenosis 91f D Deceleration time of mitral early filling wave 208f Decreasing mitral flow early diastolic velocities 356f Degeneration of aorta 334 Degenerative aortic aneurysms 336 MV disease 68 tricuspid valve disease 118 Dehiscence of Starr-Edwards mitral prosthesis 156f ventricular septal defect 392f Dense continuous wave 76 Depth of presumably severe MR 76f Descending aorta 319 Diaphragm-like aortic valve orifice 92f Diastole, physiology of 204 Diastolic dysfunction 210 and twist, grades of 290 in clinical sense 205f flow fraction 221f reversal in descending aorta 106 fluttering of interventricular septum with exaggerated respiratory motion 355f function 204, 210, 239 function See Tissue motion significance of 205 MR with functional systolic MR 76f pulmonary artery pressures from PR jet velocity, estimation of 41f right ventricular collapse 350f stress test 224 in normal person 224f tricuspid indicating elevated right ventricle diastolic pressures with dilated cardio myopathy 194f wave 219f Dilated cardiomyopathy 397 pulmonary artery, absent pulmonary valve with 131f Dimensionless index for tilting-disc aortic prosthesis, measurement of 151f Disk summation method See Modified Simpson’s rule Dissecting flap fluttering in left ventricle 373f myocardial hematoma in apical myocardium after delayed angioplasty 372f Dominant medial commissure fusion, asymmetric commissural fusion with 59f Doppler echo, types of 25 equation 25f interrogation left ventricle outflow and inflow 207f of aortic flow, continuous 352f of mitral orifice from apical view velocity profile 52f measure of contractility 183 principle for estimating velocity 25 417 418 A Practical Approach to Clinical Echocardiography signal from left ventricular inflow 206f spectrum suggests nonobstructed valve 147f tissue imaging 224 Double-chambered right ventricle 307, 307f with aneurysm of membranous ventricular septal defect 308f with pulmonary valve stenosis 308f Double-outlet right ventricle variant of tetralogy of Fallot 312f with absent pulmonary valve 313f with pulmonary stenosis 132f Dressler’s syndrome 370 Ductus closure device projection in pulmonary artery 332f Duplex scan of left common carotid artery with color Doppler 335f Dysfunctions of prosthetic heart valves 152t Dysplastic pulmonary valve filling right ventricular outflow tract and causing obstruction 130f with redundant distal parts 131f E Early amyloid infiltration with mild thickening of left ventricle walls 403f systolic functional MR 80f longitudinal lengthening 269 measures 259 Ebstein’s anomaly 119, 119f, 304, 306f carpentier classification of 306 in parasternal long-axis 305f type C 306f D 307f Eccentric aortic regurgitation jet to perforation 104f jet of severe aortic regurgitation with bicuspid aortic valve 105f Eccentrically placed medtronic-hall valve in aortic position 34f Echo, concept of 5f Echocardiographic examination, sequence of 16 imaging 365 methods of studying twist 284 parameters related to prognosis after myocardial infarction 377t Echocardiography basic principles display in IHD 369 interpretation technique Echo-Doppler for assessing mitral stenosis, comparison of various 53f signs of cardiac tamponade 350t Effective orifice area 30 Effusive-constrictive pericarditis in young female 357f Ehlers-Danlos syndrome 309 Elongated MV leaflets in fibroelastic degeneration 69f EMF echocardiographic features 406 En face mitral leaflets with free margin 47f of atrioventricular septal defect from right side 305f of interventricular septum 302f End-diastolic pressure See End-diastolic volume volume 171f Endocardial border delineation 174 shortening fraction level of chordae tendinae 178f End-systolic points, greater dispersion of regional 181f Energy loss using simple formula, coefficient of 34f Estimating energy loss index, method of 92f pulmonary pressures from TR and PR jets 40f European classification of cardiomyopathies 397 Doppler alternans of tricuspid regurgitation with normal right ventricular systolic pressure 195f regurgitation from membrane in diastole 315f types of 25 Foramen ovale membrane, aneurysm of 300f Force developed and heart rate, relationship between 171f Four cardiac valves, anatomical position of 128f Free wall rupture 374 Full volume data set recorded from apical view 179f three-dimensional transthoracic echocardiography of ascending aorta 340f Functional PR with structurally normal pulmo- nary valve 135f tricuspid regurgitation 114 types of MR 67 Functioning medtronic-hall tilting-disk prosthesis aortic position 147f Functions of aorta 320 Fundamental basis of TDI 236 of torsion 280 F Hagen-Poiseuille equation See Ohm’s law of fluids Heart failure 287 with normal ejection fraction 240 muscle 257 Helical orientation of myocardial fibers with figure of 166f Hemispheric proximal isovelocity surface area 132f Hemodynamic assessment of prosthetic valves 141 evaluation 24 by echo-Doppler techniques 24 Fabry’s disease 402 Factors contributing to diastole 205 False tendons in left ventricle cavity 412f Fibro-muscular strand extending between anterior interventicular septum and posterior wall of left ventricle 167f Flail anterior mitral leaflet coapting 67f Flow abnormality precedes wall-motion abnormality 366f continuity of 28 G Global diastolic performance 248 longitudinal strain and strain rate 183 systolic performance 248 H Index introduction 24 of aortic regurgitation 98 valve stenosis 88 of mitral stenosis 50 of MR 74 Hepatic vein flow in assessment of TR 123 High transesophageal echocardiographic view dissection in ascending aorta 340f Holodiastolic flow reversal in abdominal aorta 107f Holosystolic longitudinal stretch with post-systolic shortening 272f Hyperkinesis 366 Hypertension cardiomyopathy 286 Hypertensive functional tricuspid regurgitaion 115f in mitral stenosis 115f Hypertrophic cardiomyopathy 286, 397 asymmetric septal hypertrophy in 401f types of 404f I Idiopathic functional tricuspid regurgitaion 115f Image acquisition, technique of 12 Infective endocarditis 389 Inferior cava cava 295 indicates elevated right atrial pressure, dilated 194f Innominate artery 319 Inter-atrial septum 84 Interior tricuspid leaflet 153 Intermediate chordae 66 Intermittent transprosthetic mitral regurgitation 148f Internal dependency of velocities 235 Interventicular septum 166 part of 168f structure of 166f Intimal hyperplasia and medial hypertrophy 51 Intramural hematoma 339, 372f in arch of aorta 340f Intramyocardial hematoma 371 Intrinsic reduced myocardial compliance in restrictive cardiomyopathy 354f Irregular mass right ventricular free wall 391f Ischemia imaging 365 on regional deformation metrics, effects of 268 Ischemic heart disease 363 MR 71 Isovolumic acceleration 200f contraction 205 time 168 relaxation 205 time 206 L Labeling of tissue velocity waveforms 229 Laminar flow cylinder 25f versus turbulent flow 25f Laplace’s law 171 Large color jet area 76f Large diastolic tissue velocity waves 358f left-sided pleural effusion f 349 mitral E velocity and velocity 76f muscular ventricular septal defect in posterior septum 303f perimembranous ventricular septal defect with transventricular peak gradient 304f vena contracta 78f ventricular septal defect 305f Lateral edge mitral annular velocities 216f leaflets to la appendage 65f mitral annular velocities 241f Leaflets coaptation 65f of mitral bioprosthesis in open position 144f of pulmonary valve without any definite fibrous annulus 127f with narrow orifice, thickening of 49f Left anterior descending artery 364f atrial appendage 384 function by deformation imaging 273 longitudinal strain ventricular systole 276f volume 210 common carotid artery 107f coronary sinus and left atrium aortic valve replacement, communi cation between 330f heart circulation 26f panel large pericardial effusion in parasternal long-axis view 352f parasternal long-axis view 245f tissue velocities of medial mitral annulus 243f pulmonary artery 107, 319 ventricle 319 apex by velocity vector, rotation of 283f base in normal, rotation of 283f cavity by 3D echo, conical shape of 167f ejection fraction with shape of left ventricle, relationship of 170f in short-axis view 375f morphology of 165 physiology of 167 ventricular ejection fraction 174 filling pressure 239 free wall rupture 374 outflow tract 83, 139f, 142, 165, 319 in calculation of mitral valve 57f peak velocity 26f velocity time integral 183 pressure-volume loop 168f, 205f pseudoaneurysm 349f systolic function 165, 241 tension-time sequence 169f Leteral commissure 48f Localized pericardial effusion adjacent to lateral wall 347f Loeys-Dietz syndrome 309 Long axis akinesis of mid anterior septum 367f greater septal hypertrophy 402f LV function 171 Longitudinal oscillations strain rate analysis, advantages of 185 Low systolic tissue velocities 248 Lower panel depicts annular velocities 215f Low-gradient low-flow severe aortic valve stenosis, types of 93 Low-velocity biphasic inflow across mitral valve 26f Lunula, thicker free margin of cusp 85f 419 420 A Practical Approach to Clinical Echocardiography LV ejection time from box-like opening of aortic valve, measurement of 176f systolic function, determinants of 170 volume estimation by Simpson method, technical tips for 178 volumetry 172 L-wave, importance of 209 M Main pulmonary artery 387f Malignant tumors 388 Mapse estimation, method for 172 Marfan syndrome 309, 331 Marginal chordae 66 Massive pseudoaneurysm adjacent to inferolateral wall of left ventricle 376f pulmonary artery dilatation with vestigial pulmonary valve tissue 131f Mauve color versus apex 413f Mean pulmonary artery pressures from PR jet velocity, estimation of 41f velocity gradient over segment of fixed length 237f Medial commissure 48f calcification 50f mitral annular tissue velocities 240f versus lateral mitral 357f Medtronic-hall valve in aortic position 145f Membranous subaortic stenosis 96f Metallic aortic prosthesis, acoustic shadow to 14f Microbubble formation 152 Mid and late systolic MR in presence of MV prolapse 81f anterior septum and posterior wall thickness in diastole and systole, comparing basal and 367f left ventricle 365f muscular ventricular septal defect 372f portion of descending thoracic aorta in parasternal long-axis, visualization of 322f Midesophageal bicaval view inferior vena cavae and interatrial septum 22f superior vena cavae and interatrial septum 22f long axis view aorta 22f left atrium 22f ventricle 22f mitral valve 22f transverse short axis view left atrial appendage 22f Mid-septal left atrial longitudinal strain 275f Midwall fiber shortening 178f Mild leaflet thickening only tips of leaflets 59f MR by color jet area 76f Mitral annular velocities 214 from medial edge 240f annulus 46, 66 plane systolic excursion 172f apparatus in relation to aortic annulus 45f left atrium 45f ventricle 45f bioprosthesis causing mitral valve obstruction 49f E- and pulmonary D-waves 207 E preceding tissue 219f flow propagation by color M-mode 221 inflow acquisition 213 feasibility 213 measurements 213 velocities 212 orifice secondary to mitral annular calcification 48f regurgitation 64 stenosis 45, 60 criteria for 51t left panel 116f pathoanatomy of 48 stroke volume aortic stroke volume, ratio of 74f ratio of 74f valve apparatus components of 64f in mitral stenosis, morphology of 58 valve anatomy of 45 area 53 calculation of 56 consists 46 leaflets 46 opening 177 prolapse 69 regurgitation introduction 64 to measure size of annular caseoma 13f M-mode color Doppler myocardial in apical four chamber view of left ventricle 234f flow map across left ventricle long axis 405f propagation velocity 108 depiction of color-coded tissue velocities of left ventricular short axis 236f description of strain rate of interventricular septum 239f echocardiogram level of aortic valve 15f rapid expansion of left ventricular posterior wall in early diastole 353f echocardiography 14, 102, 175 in LV systolic function, current use of 177 limitations of 177 image of aortic valve 177f mitral valve 177f of aortic root 10f of left atrium 10f section of inferior vena cava with reduced inspiratory collapse 194f ventricles 348f Modified continuity equation for estimating aortic valve area 93f quinones method 174, 174f Simpson’s rule 173 Mono-disk mechanical prosthesis 140f valve See Tilting -disk valve Index Morphological variants of ToF 312 Morphology of MR, functional 64 VSD 302 Motion of heart, vectors of 280 MR etiology of 67 severity vena contracta 78 Multiple anomalous bundles in left ventricle cavity with regional flow obstruction 404f transesophageal echocardiographic views 298f Mural thrombi 374 MVA planimetry 53 Myo-architecture of left ventricle from base to apex 237f Myocardial deformation 257 dissection flap 391f without definite echolucent delimiting cavity 373f without hematoma 372 Doppler imaging of interventricular septum 244f fibers in systole and in diastole 260f infarction 370 complications of 370 evaluation of 369 muscle mechanics 169 performance index 199 from combined right ventricle inflow and outflow Doppler spectra 199f segment nomenclature 363 tissue velocities from posterior wall in short axis 236f twist 260f velocities in short axis 234 wall thickness 165f Myocardium blood supply 363t deformation 257 Myxoma, echocardiographic of 387 N Narrow ascending aorta 92f Natural acoustic reflector in different planes single cardiac cycle, complex motion of 262f Nodular constriction ventriculoarterial junction 131f Nodule of arantius 85f Noncompaction cardiomyopathy 410 left ventricle cardiomyopathy 288f Noncoronary aortic sinus communicating with right atrium, aneurysm of 311f sinus, aneurysm of 309f Non-holodiastolic severe PR judged by rapid deceleration 135f Normal aortic annulus diameter 333f circumferential strain in presence of advanced diastolic dysfunction 223f measurements of aorta 321f MV competence 66 values of left ventricular peak systolic strains and strain rates 262t Normokinesis 366 O Obtuse marginal arteries 364f Ohm’s law of fluids 27 Organic tricuspid regurgitation, causes of 134 valve disorders 115 Orifice of regurgitation to loss of leaflet tissue in anterolateral commissure 67f Orthogonal strain 263 in short-axis direction, vectors of 264f Ostium primum 295 atrial septal defect 299 secundum 295 Override of aortic root to anterior deviation of infundibular septum 311f P Papillary fibroelastoma 388 pattern of 388 muscle 73f and left ventricular wall 48 rupture 374 with head attached to posterior leaflet 374f Paradoxical longitudinal systolic strain See Early systolic longitudinal lengthening low-flow with preserved ejection fraction 95 motion of interventricular septum in large pericardial effusion 348 strain patterns 272 Parallel processing of reflected beam 11 Paraprosthetic regurgitation 153, 154 Parasternal long axis view 17 aortic root 17f valve 17f cusp retraction with calcification 101f diastolic thinning of posterior wall 370f dilated aortic root with stretched out annulus causing malco aptation of aortic leaflets 101f dissection of anterior inter ventricular septum 373f flail aortic cusps with excessive mobility 101f in dilated cardiomyopathy 385f in patient with bileaflet valve in mitral position 152f mitral stenosis and aortic regurgitation 104f large subaortic ventricular septal defect 311f left atrium 17f ventricle 17f mitral valve 17f pericardial effusion 350f right ventricle 17f subaortic membrane 314f thoracic aorta 17f whole cusp prolapse of posterior leaflet 101f short axis view 17 for judging size of ductus 331f level of aortic valve 18f mitral valve 18f mid-LV level 18f three-layered interventicular septum with increased echogenic texture 166f with myocardial flap obliterating cavity 373f 421 422 A Practical Approach to Clinical Echocardiography Parietal pericardium 343 Partial rupture of myocardium 371 Patent ductus arteriosus 330 foramen ovale 299 Peak systolic myocardial velocities 380f tricuspid annular systolic velocity 244f Pedunculated left atrial myxoma protruding mitral orifice 387f Penetrating ulcer in arch 341f Perform two-dimensional strain imaging 266 Pericardial constriction 353 cysts and masses 353 diseases 343 disorders 344 effusion 345 adjacent to intramural hematoma in basal posterior wall with dyskinesis of mid posterior seg- ment 373f posterior to left ventricle 390f Pericardium 343 echocardiographic anatomy of 343 Perimembranous ventricular septal defect 303f versus subarterial ventricular septal defect 303f Physiological hypertrophy in athlete 403f principles governing LV systolic function 170 versus pathological left ventricular hypertrophy 245 Piezoelectric element encased in housing assembly to function transducer 9f in matrix tansducer 16f Pisa method, limitations of 35, 79 Planimetry of aortic valve area in aortic stenosis 87 transthoracic short-axis view in mid-systole 88f mitral valve area in mid-diastole 54f Point-and-click method to extract longitudinal strain curves 267f Posterior atrioventricular groove in parasternal long-axis 347f descending artery 364f mitral leaflet 48f, 66f, 73f tricuspid leaflet 153 ventricular septum causing ventri cular septral defect inferior myocardial infarction, rupture of 371f Postoperative stentless prosthesis in aortic position in diastole 150f Postsystolic annular tissue wave masking 218f longitudinal shortening 270 Predominant left ventricle type of endomyocardial fibrosis 408f right ventricle 408f Pressure drop in prosthesis with eccentric opening 148f gradients in mitral stenosis, depiction of 51f half-time method for MVA 55 of aortic regurgitation signal 107 recovery 33 volume loop of right ventricle with that of left ventricle, comparison of 190f Pre-stenotic flow velocity 30 Primary chordae See Marginal chordae Prognostic value of TDI in diverse cardiac disorders 250 Prominent early diastolic motion of interventricular septum 355f notch in interventricular septum with concavity toward left ventricular in cons trictive pericarditis 355f trabeculations projecting into cavity in dilated cardiomyopathy 400f Prosthetic heart valves evaluation of 138 implantation, number of 138 types of 138t regurgitation 153 valve dysfunction 152 stenosis 155 Proximal isovelocity surface 34 area 57, 79f, 122 and volumetric measurements 34 flow convergence method 105 for calculating mitral regurgitant orifice area 36f method 57, 122, 135 volumetric measurements for severity of MR 78 with hemispheric appearance 106f Pseudoaneurysm 376 containing thrombus 341f of left ventricle posterior wall 376f Pseudonormal pattern with l-wave at end of Valsalva maneuver 215f Pulmonary artery 40 mean pressure, distribution of 190f systolic pressure, distribution of 190f flow acceleration time, estimation of 41f regurgitation 39 assessment of 134 consequences of 136 jet with end-diastolic antegrade flow across pulmonary valve 195f vena contracta 134 stenosis 127 associations of 134 severity 128 systolic wave 219f valve 126 anatomy of 126 disorders 127 in operated tetralogy of Fallot 135f stenosis 131f vascular resistance 40 vein flow and diastolic function 218 parameters 221 pattern 219f signals, acquisition of 220 venous systolic 221f Pulse repetition frequency 26 Pulsed Doppler 135 lateral edge mitral annular velocities 240f ultrasound wave Doppler velocity for assessing severity of MR 80 mitral flow Doppler 240f tissue Doppler velocities 244f Index Q Quadricuspid aortic valve 86 R Radial strain 263 thickening behavior of ischemic segment 366f Rapid filling phase 207 Real-time 3D right atrial view with atrial septal defect 298f TEE examination 299f transesophageal echocardiographic view from left atrium 299f Red blood cells 25 Regurgitant orifice 75t area to assess severity of functional mitral valve regurgitation 75t volume 75t Relationship between effective orifice and anatomical area 30f geometric area 30f Relaxation aids in filling during diastole 204 Remodelling in tricuspid regurgitation 114 Resolution and penetration of transducer probes, relationship between 9f Restrictive cardiomyopathy 242, 397, 404 muscular ventricular septal defect 304f with left-to-right shunt 303f transmitral flow 222f trans-tricuspid pulsed wave Doppler flow velocities 195f Reverse sabre-shaped CW Doppler spectrum of acute MR 75f Rheumatic mitral stenosis in apical four-chamber view with large mobile thrombus with narrow stalk 385f with leaflet thickening and commissural fusion viewed from left atrium 48f MR 71 MV thickening and restriction of leaflets 71f Right atrial angiosarcoma obstruction orifice of superior vena cava with peak instanta neous pressure 384f appendage 112 atrium free wall, angiosarcoma of 389 common carotid artery thickened walls, longitudinal view of 335f coronary artery 364f heart circulation low velocity inflow 26f panel pathological specimen 398f pulmonary artery 84, 319, 387f sided layer inner layer of right ventricular oblique fibers 166f sinus of Valsalva aneurysm of 309f in short-axis view, aneurysm of 326f upper pulmonary vein atrial flow 220f diastolic flow velocity 220f flow with atrial fibrillation 208f ventricle apical circumferential strain compared to left ventricle 198f diastolic function and pressures 193 Doppler myocardial imaging, parameters of 200 extending into 389f free wall aneurysm of 409f longitudinal shortening of 197f longitudinal strain 273f strain in case of pulmonary embolism 274f tissue velocity 193f function by optimizing trans thoracic echocardiography four-chamber 192f introduction 189 outflow tract 99f peculiarities of 189 short-axis dimension 196f strain 200 ventricular basal circumferential strain 191f chamber, complex geometry of 192f deformation 273 function 189 outflow tract 26, 126, 192f pressure-volume loop 190f segmentation 363 volumetric function 195 Rudimentary pulmonary valve 130f tricuspid valve leaflets with normal annular 120f Ruptured aneurysm of noncoronary sinus communicating with right atrium 328f S Saddle-shaped mitral annulus and systolic contraction 66f Schema of echocardiograph 8f Septal annular pulsed wave Doppler tissue velocity pattern 236f mitral leaflet, attachment of 113f tricuspid leaflet 153 Severe aortic valve regurgitation with pressure 39f pulmonary regurgitation causing over-estimation of forward flow velocities 133f thickening of leaflets in parasternal long-axis 59f Severity of mitral stenosis assessment of 51 miscellaneous parameters of 58 TR, assessment of 121 Shelf-like obstruction proximal to pulmonary valve 307f Short axis images in quad screen stages of stress 379f levels to extract radial strain 265f view narrow turbulent color Doppler jet 129f view relationship of pulmonary valve leaflets 126f view with color flow Doppler flow in intertrabecular recesses 412f Shortened tricuspid valve leaflets in carcinoid heart 118f Side lobe artifacts 14 Simultaneous long axis and short axis of aortic root 322f Single atrium See Common atrium Single-plane ellipsoid 173 formula to estimate volume 173f 423 424 A Practical Approach to Clinical Echocardiography Sinus of Valsalva 84, 127 aneurysm of 325 venosus 296 atrial septal defect 300, 301f Sinutubular junction 127 Sliced left ventricular, longitudinally 374f Slight nodularity in center of free margin 85f Small paraprosthetic mitral regurgitation with clear delineation of dehiscence 155f Smaller beam 12 Solid body rotation in patient with left ventricle noncompaction cardio- myopathy 287f Sound beam 12 oscillating wave of mechanical energy 4f waves, behavior of 3f Spatial resolution 11 Speckle derived strain values 263 tracking method to assess torsion, limitations of 285 Spectral pulsed wave tissue velocities from medial edge of mitral annulus 232f Specular reflection 7, 7f Spherical shape in diastole in dilated cardiomyopathy 398f Spongiform heart muscle disease See Noncompaction cardiomyopathy Spontaneous echo contrast 384 in inferior vena cava 351f ischemia 377f Starling’s law 170 of heart 170 Starr-Edwards ball-in-cage valve ball variance to lipid absorption 159f Strain estimation in apical four-chamber, longitudinal 263f four-chamber, longitudinal 266f rate analysis 200 advantages of 185 over fixed segment derived from tissue Doppler method 261f spectrum derived from basal lateral wall 239f with time to obtain strain of right ventricular free wall, inte gration of 239f spectrum from mid-septum 238f types of 262t Stress echocardiography 248, 377 Stroke distance 26 Structural heart disease 361 Structure of aorta 318 Subaortic membrane very close to aortic valve with aortic regurgitation 315f membranous stenosis 314 stenosis 95 with eccentric orifice in child 34f with subaortic ventricular septal defect 315f Subarterial ventricular septal defect in transthoracic echocardiography short-axis 304f Subcostal four-chamber view biventricular origin of aortic root to aortic override 312f rims of secundum atrial septal defect 297f long-axis view 297f short axis view entire right heart structures 20f Subpulmonic stenosis with vestigial pulmonary valve and annular stenosis 131f Superior vena cava 112, 295 Suprasternal long axis view aorta 20f dilatation of aortic root 333f end of arch origin of left subclavian artery 320f right and left aortic sinuses 308f tubular narrowing of descending thoracic aorta 324f view 20 Supravalvular aortic stenosis 330 in child with eccentric jet 34f Syndrome Ehlers-Danlos 309 Eisenmenger 295 Loeys-Dietz 309 Marfan 309, 331 Williams 132f System of mitral valve complex 64 Systolic elastance, degree of 204 filling fraction 220f longitudinal strain 183 rotation of base versus apex 413f thinning of basal inferoposterior wall 370f velocities of mitral annulus 181 velocity 235 T Takayasu arteritis 332 Takotsubo cardiomyopathy 409 TDI in concept of 229 constrictive pericarditis 242 coronary artery disease 248 detection of intraventricular dyssynchrony 246 inherited cardiomyopathies 246 limitations of 251 right ventricular function, significance of 243 Technical details of TDI 231 TEE probe manipulation 21 RV inflow view tricuspid valve 22f Temporal resolution, improving 13 variation in pulmonary regurgitation 358f Terms used in tissue Doppler imaging 231 Tertiary chordae See Basal chordae Testicular tumors 387 Tethering and closing forces acting upon leaflets 73f of aortic valve leaflets to root dilatation causing severe aortic valve 333f Tetralogy of Fallot 311 with atretic outflow tract 312f with narrow right ventricular outflow tract 131f Thoracoabdominal aorta 319 in subcostal long-axis 320f viewed in subcostal long-axis 320f Three arbitrary parts of left ventricle 165f co-ordinates of deformation 258f dimensional cross-sectional image of mid-LV 167f E cross-section three aortic sinuses 308f echo, advantages of 180 Index echocardiographic Tilting disk en face 112f prosthesis in aortic position in en face view of mitral valve 46f diastole 140f four-chamber 49f valve 139 four-chamber view 111 f mono-disk prosthesis in aortic of left ventricle 167f position 140f short-axis 327f Time gain compensation 13 short-axis image 130f Time integral suggestive of severe MR 76f short-axis view collapsed Tissue aneurysm of aortic sinus Doppler 329f data for deformation 238 view of aneurysm of right aortic derived strain sinus 328f basal right ventricle free wall, echocardiography 10 comparison of 275f for LV systolic function 179 spectrum from basal septum limitations of 181 238f shape of tricuspid annulus 113f echocardiography 229 short-axis view sinuses of concept of 229f Valsalva 326f of lateral edge of mitral annulus strain by acoustic speckle 235f, 242f tracking 268f of medial TEE of wall-hugging thrombus in edge of mitral annulus 235f left 386f mitral annulus 234f transesophageal 141f interface right angle, reflection from transesophageal echocardio 6f graphic view from top of interfaces with variable acoustic impedance 5f bileaflet mitral valve motion 209 circumferential nodular pannus or blood texture 13 157f To-and-fro flow across neck of mitral bioprosthesis in diastole pseudoaneurysm 341f 153f Torsion 286 tilting-disk mitral prosthesis applications of 285 158f pannus with tilting disk aortic resynchronization therapy 288 Total stroke volume in left ventricular valve prosthesis 158f outflow tract 104f transesophageal image of bileaflet Transducer 143f artifact near apex to back reflects from transthoracic echocardiographic probe 10f atrioventricular septal defect in subxiphoid position 18 303f probe color flow jet area of aortic pulse controls regurgitation narrowest shapes of 8f orifice 106f Transesophageal planimetry of mild aortic echocardiographic 126f, 384f stenosis 88f anatomic secundum atrial septal view of aortic valve with dias defect with left-to-right tolic regurgitant area shunt 296f 99f four-chamber view 141f, 152f, 157f volumetry, method of 179 arrested disk causing high Thrombus bifurcation of pulmonary transprosthetic gradients 160f artery 386f ball-in-cage valve in systole 139f flow jet across mitral bioprosthesis 159f tilting- disk mitral valve with thrombus 158f long axis view aortic regurgitation jet eccentric orifice 106f communication of left aortic sinus 310f eccentric paraprosthetic aortic regurgitation 156f with rightward probe deflection 296f midesophageal short axis 329f of ball-in-cage valve in mitral position 156f of mitral bioprosthesis in young female 154f picture with continuous wave Doppler flow 330f short-axis view quadricuspid aortic valve 87f view 20 of bileaflet mitral valve large thrombus 158f of mitral bioprosthesis 159f echocardiography 133 in pulmonary stenosis 133 long-axis 303f long-axis view 140f Transmitral flow velocities with respiratory signal in normal person 352f strain See Radial strain Transposition of great vessels 315 Transprosthetic flow velocity profile 147f valve gradients with indexed effective orifice 146f Transthoracic apical 4-CV apical dyskinesis with thrombus 345f diastolic left atrial collapse 351f echocardiographic 149 four-chamber view 153f torn leaflet of mitral bioprosthesis 153f modified apical short-axis image ventricular septal defect 130f off-axis 149f 425 426 A Practical Approach to Clinical Echocardiography parasternal long-axis 150f, 337f, 346f view eccentric paraprosthetic mitral regurgitation 155f short-axis view of right ventricular outflow tract 129f echocardiography 10 four-chamber view end-diastole 194f parasternal long-axis 152f, 158f short-axis 191f parasternal long-axis 330f, 351f view aneurysm of right sinus of Valsalva 326f parasternal short-axis 346f short-axis view commissural fusion with calcification 87f Transvalvular velocities, relationship of 90t Transverse midesophageal four-chamber view 21f Transverse oscillations Tricuspid and pulmonary prosthetic valves 160 annular peak systolic velocity 198, 199f plane systolic excursion 198 displayed in M-mode 198f, 199f tissue velocity 245f annulus with leaflets and posterior relationships 111f regurgitation 116f jet with peak velocity 193f stenosis 39 valve 110, 113 apparatus laid open longitudinally 111f disorders 110 functional morphology of 110 stenosis 62f, 120 Trileaflet aortic valve, anatomy of 83 bioprosthesis in pulmonary valve position in case of operated tetralogy of Fallot 160f True aneurysm of inferoposterior wall 376f pseudoaneurysm 377t True apical aneurysm with wall thinning marked by arrows 376f True lumen, characters of 338 Truncus arteriosus 329 Tumor-like infective mass attached to pacing lead 390f invasion of left ventricle free wall to hydatid cyst 391f TVI-based strain of right ventricle free wall 201f Two contractile chambers of right ventricle with distinct morphologies 191f Two-D echocardiographic ejection fraction 178 long axis view 15f minor axis shortening 177 of valvular pulmonary stenosis 129f parasternal long axis 178f unicuspid pulmonary valve 130f Two-D echocardiography 102 and LV systolic function 177 for LV volume estimation, limitations of 179 Two-D longitudinal strain in modified apical long axis 263f of right ventricle 270f Two-D transesophageal echocardio graphic caval 301f four-chamber view with Starr Edwards mitral prosthesis 160f view 153f, 154f arrested lateral disk of bileaflet valve 157f of bileaflet mitral prosthesis 159f of Starr-Edwards mitral prosthesis 157f severe transprosthetic regurgi tation across mitral bioprosthesis 154f U Ultrasound beam flaked by side lobe beams 9f Ultrasound interaction with tissue Unicuspid and bicuspid aortic valve and aortopathy 322 aortic valve 85, 86f, 323f in diastole 85f pulmonary valve with single leaflet and single commissure 130f Unresolved issues in noncompaction 413 Unruptured aneurysm of right sinus of Valsalva 328f Unusual biphasic rotation in heart failure with reduced ejection fraction 288f Upper panel lower panel 221f, 222f middle panel 221f mitral flow 220f, 221f inflow pattern 215f pulmonary flow 221f vein flow 222f restrictive transmitral flow and lower panel 215f septal annular velocities 221f tissue velocities of medial mitral annulus 243f transmitral flow 222f V Valsalva effect of 215f maneuver 214 changing restrictive flow pattern 214f Valve apparatus, components of 46 Valvular heart disease 43 leaflets 64 PS, types of 128 pulmonary stenosis with continuous wave Doppler interrogation in right panel 130f Vegetation on aortic leaflets with incomplete coaptation in infective endocarditis 100f tricuspid valve in presence of central intravenous line 118f Velocity flow paradoxus across mitral 352f ratio 30 time integral 26 vector end-diastole in apical four chamber 267f imaging 264 in short axis of left ventricle 267f Vena contracta 31, 121 advantages of 32, 78 just beyond narrow orifice 32f limitations of 32 Index measurement with aortic regurgi tation by color flow Doppler in parasternal long-axis view 32f of mitral regurgitation jet, width of 32f of PR in transthoracic echocardio graphic short-axis 136f width 77 limitations of 78 Ventricles with dilated cardiomyopathy, cross-sectional view of 398f Ventricular septal defect 300 site-specific classification of 302f rupture 371 Ventriculoarterial junction 127 Ventriculovalvular impedance 34 Visceral pericardium 343 Viscoelastic 261 VSD, pathophysiology of 302 W Wall motion score index 367 stress, method of measuring 171f Wave Doppler and pulmonary regurgitation severity, continuous 136 envelope of valvular PS, continuous 133f interrogation for TR signal, continuous 123 interrogation of coarct segment, continuous 325f pulmonary regurgitation jet 195f pattern of dynamic infundibular obstruction, continuous 133f spectrum of mild versus severe PR, continuous 136f Wavelength after refraction in second medium, decreasing 6f Wide-neck pseudoaneurysm of inferoposterior wall 377f Width of vena contracta 78 Williams syndrome 132f Windkessel phenomenon in proximal aorta 321f Z Zone of apposition 65f 427 ... 12. 27: Monophasic transmitral flow pattern in a patient with advanced diastolic dysfunction and heart failure due to previous anterior wall myocardial infarction evaluation of respiratory variation... time and E /A ratio ≥ Fig 12. 28: Valsalva maneuver changing restrictive flow pattern (left panel) to pattern of impaired relaxation (right panel) (early diastolic) and A (late diastolic) velocities... fractional area change represents the ratio of systolic area change to diastolic RV area It is measured in the four-chamber view and can be incorporated systematically into the basic echocardio