1.
Symptoms or conditions potentially related to suspected cardiac etiology including but not limited to chest pain, shortness of breath, palpitations, TIA, stroke, or peripheral embolic event
2.
Prior testing that is concerning for heart disease or structural abnormality including but not limited to chest X-ray, baseline scout images for stress echocardiogram, ECG, or cardiac biomarkers
3.
Frequent VPCs or exercise-induced VPCs, Sustained or non-sustained atrial fibrillation, SVT, or VT
4.
Clinical symptoms or signs consistent with a cardiac diagnosis known to cause lightheadedness/presyncope/syncope (including but not limited to aortic stenosis, hypertrophic cardiomyopathy, or HF), Syncope when there are no other symptoms or signs of cardiovascular disease
5.
Evaluation of suspected pulmonary hypertension including evaluation of right ventricular function and estimated pulmonary artery pressure, Routine surveillance (>1 year) of known pulmonary hypertension without change in clinical status or cardiac exam, Re-evaluation of known pulmonary hypertension if change in clinical status or cardiac exam or to guide therapy
6.
Hypotension or hemodynamic instability of uncertain or suspected cardiac etiology
7.
Acute chest pain with suspected MI and non-diagnostic ECG when a resting echocardiogram can be performed during pain, Evaluation of a patient without chest pain but with other features of an ischemic equivalent or laboratory markers indicative of ongoing MI
8.
Suspected complication of myocardial ischemia/infarction, including but not limited to acute mitral regurgitation, ventricular septal defect, free-wall rupture/tamponade, shock, right ventricular involvement, HF, or thrombus
9.
Initial evaluation of ventricular function following ACS, Re-evaluation of ventricular function following ACS during recovery phase when results will guide therapy
10.
Respiratory failure or hypoxemia of uncertain etiology
11.
Known acute pulmonary embolism to guide therapy (e.g., thrombectomy and thrombolytics), Re-evaluation of known pulmonary embolism after thrombolysis or thrombectomy for assessment of change in right ventricular function and/or pulmonary artery pressure
12.
Severe deceleration injury or chest trauma when valve injury, pericardial effusion, or cardiac injuries are possible or suspected
13.
Re-evaluation of known valvular heart disease with a change in clinical status or cardiac exam or to guide therapy
14.
Routine surveillance (>3 years) of mild valvular stenosis without a change in clinical status or cardiac exam, Routine surveillance (>1 year) of moderate or severe valvular stenosis without a change in clinical status or cardiac exam
15.
Routine surveillance (>1 year) of moderate or severe valvular regurgitation without a change in clinical status or cardiac exam
16.
Initial postoperative evaluation of prosthetic valve for establishment of baseline, Routine surveillance (>3 years after valve implantation) of prosthetic valve if no known or suspected valve dysfunction, Evaluation of prosthetic valve with suspected dysfunction or a change in clinical status or cardiac Exam, Re-evaluation of known prosthetic valve dysfunction when it would change management or guide therapy
17.
Initial evaluation of suspected infective endocarditis with positive blood cultures or a new murmur, Re-evaluation of infective endocarditis at high risk for progression or complication or with a change in clinical status or cardiac exam
18.
Suspected cardiac mass
19.
Suspected cardiovascular source of embolus
20.
Suspected pericardial conditions, re-evaluation of known pericardial effusion to guide management or therapy
21.
Guidance of percutaneous noncoronary cardiac procedures including but not limited to pericardiocentesis, septal ablation, or right ventricular biopsy
22.
Evaluation of the ascending aorta in the setting of a known or suspected connective tissue disease or genetic condition that predisposes to aortic aneurysm or dissection (e.g., Marfan syndrome), Re-evaluation of known ascending aortic dilation or history of aortic dissection to establish a baseline rate of expansion or when the rate of expansion is excessive, Re-evaluation of known ascending aortic dilation or history of aortic dissection with a change in clinical status or cardiac exam or when findings may alter management or therapy
23.
Initial evaluation of suspected hypertensive heart disease
24.
Initial evaluation of known or suspected HF (systolic or diastolic) based on symptoms, signs, or abnormal test results, Re-evaluation of known HF (systolic or diastolic) with a change in clinical status or cardiac exam without a clear precipitating change in medication or diet, Re-evaluation of known HF (systolic or diastolic) to guide therapy
25.
Initial evaluation or re-evaluation after revascularization and/or optimal medical therapy to determine candidacy for device therapy and/or to determine optimal choice of device
26.
Known implanted pacing device with symptoms possibly due to device complication or suboptimal pacing device settings
27.
To determine candidacy for ventricular assist device, Optimization of ventricular assist device settings, Re-evaluation for signs/symptoms suggestive of ventricular assist device-related complications
28.
Monitoring for rejection in a cardiac transplant recipient
29.
Cardiac structure and function evaluation in a potential heart donor
30.
Re-evaluation of known cardiomyopathy with a change in clinical status or cardiac exam or to guide therapy
31.
Screening evaluation for structure and function in first-degree relatives of a patient with an inherited cardiomyopathy
32.
Baseline and serial re-evaluations in a patient undergoing therapy with cardiotoxic agents
33.
Initial evaluation of known or suspected adult congenital heart disease, Known adult congenital heart disease with a change in clinical status or cardiac exam, Re-evaluation to guide therapy in known adult congenital heart disease
Contraindications
Transthoracic echocardiography has no contraindications, as the use of ultrasound has no adverse effects when used for cardiac imaging. However, ultrasound waves have the potential to cause thermal bioeffects depending on the intensity and length of exposure that are determined by the frequency, focus, power output, depth, perfusion, tissue density; these bioeffects are considered minimal.
Contrast agents, when used, include the following contraindications:
- 1.
Clinical instability with hypotension in such cases as acute myocardial infarction, worsening or clinically unstable heart failure, life threatening ventricular arrhythmias, respiratory failure, severe emphysema, pulmonary embolism;
- 2.
Right-left, bidirectional, or transient right-to-left cardiac shunts;
- 3.
Hypersensitivity to contrast agents.
For additional details about contrast agents, please see Chap. 3 (Contrast echocardiography)
Equipment
The necessary equipment for performing an echocardiographic exam includes the portable echocardiography unit, a suitable ultrasound transducer (typically 2–4 Mhz) and an experienced sonographer or physician. The ultrasound transducer uses a piezoelectric crystal (such as quartz or titanate ceramic) to generate and receive ultrasound waves. The received waves are converted to electrical signals and displayed on the echocardiographic machine. The equipment is portable and allows examination in multiple locations aside from the echocardiography laboratories.
Technique
The echocardiographic examination starts by connecting the ECG electrodes and positioning the patient comfortably in the left lateral decubitus position to obtain optimal images (Obtaining images in supine position are possible if patients are unable to lie on their side). The ultrasound transducer is applied (using a water soluble gel) to the parasternal, apical, subcostal and in some cases suprasternal notch to obtain the usual images of an echocardiographic protocol. Parasternal long axis (PLAX), parasternal short axis (PSAX), apical 4 (A4C), 2 (A2C), and 3-chamber (A3C or long axis), subcostal, and suprasternal notch images are obtained. Doppler echocardiography (color flow, continuous and pulsed wave) is used to determine regurgitant and stenotic flow across valves and measure the velocity, pressure gradients, and volumetric flow. Tissue Doppler (mitral annulus) is used in determining diastolic function.
- 1.
The parasternal long axis view (PLAX) (Fig. 1.1) with the transducer slightly left of the sternum is initiated with the 2D evaluation of a sagittal view of the left ventricle (LV) (long axis view). This view allows evaluation of the structure and systolic function of the LV including LV outflow tract, left atrium (LA), the structure and motion of the aortic valve (AV) right and non-coronary cusps, the proximal aortic size and wall characteristics, and a portion of the right ventricular outflow. The posterior pericardium can also be evaluated for thickening or presence of pericardial effusion and more posteriorly pleural effusion. The septum is visualized and information can be obtained on the presence of a ventricular septal defect (VSD).
Fig. 1.1
Parasternal long axis (PLAX) views: (a) shows PLAX with the LA, LV, MV-mitral valve with anterior and posterior leaflets, AV-aortic valve with RCC-right coronary cusp and NCC-non-coronary cusp. The RV lies anteriorly and posteriorly the pericardium and descending aorta are seen. In the PLAX, the anteroseptal and inferolateral walls of the LV are evaluated for any wall motion abnormalities. Panel (b) shows an RV inflow view with the RV, RA, the TV-tricuspid valve as well as the ostia of the IVC-inferior vena cava and the CS-coronary sinus
- 2.
A parasternal right ventricular (RV) inflow (Fig. 1.1) view can be obtained by medial angulation of the transducer from the parasternal long axis position. This allows visualization of the tricuspid valve (TV), right atrium (RA), coronary sinus (CS), and RV inflow tract. Tricuspid regurgitation can be evaluated and using continuous flow (CW) Doppler, right ventricular systolic pressure (RSVP) can be calculated.
- 3.
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Parasternal short axis view (PSAX) (Fig. 1.2) is orthogonal to the long axis view. It is obtained by rotating the transducer 90°. Cross sectional evaluation of the LV, mitral valve (MV), AV, and LA are obtained, as well as views of the interatrial septum, RA, TV, RV outflow tract, PV, proximal PA and main PA branches. Doppler studies allow assessment of aortic regurgitation, tricuspid regurgitation, PA velocity, and the presence of pulmonic stenosis or regurgitation. Shunts that can be assessed in this view include membranous and supracristal VSD, patent ductus arteriosus (PDA), atrial septal defects (ASD) and patent foramen ovale (PFO)
Fig. 1.2
Parasternal short axis (PSAX) views: (a, b) At the aortic level in diastole (AV closed) and systole (AV open). Note the three cusps: RCC, LCC, and NCC (located at the IAS-interatrial septum). Also seen are the LA, RA, IAS with slight dropout, RV outflow, PV-pulmonary vein and MPA-main pulmonary artery. Panel (c) shows short axis of the LV at the mitral valve level showing the anterior and posterior leaflets. Panel (d) shows a short axis of the LV at the papillary muscle level with the AL-anterolateral and PM-posteromedial papillary muscles from [1]
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