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Chamber Quantification

Echocardiographic and Doppler Evaluation
A. CARDIAC STRUCTURES

The following cardiac and vascular structures are generally be evaluated as part of a
comprehensive adult transthoracic echocardiography report:
1) Left Ventricle
2) Left Atrium
3) Right Atrium
4) Right Ventricle
5) Aortic Valve
6) Mitral Valve
7) Tricuspid Valve
8) Pulmonic Valve
9) Pericardium
10) Aorta
11) Pulmonary Artery
12) Inferior Vena Cava and Pulmonary Veins
It should be emphasized that identification and measurement of some of the structures
listed may not always be possible or necessary to provide a comprehensive, clinically
relevant report. However it is important for the echocardiography report to include
comments on the left ventricle, left atrium, mitral valve and aortic valve. When images of
these structures cannot be recorded or interpreted, the report should state that imaging was
suboptimal or impossible. In addition, the indication for a particular echocardiographic
study may make it crucial to image a particular anatomic structure or to obtain specific
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Doppler recording(s). In this case, it is important for the report to comment on the crucial
findings or to note that an adequate recording was not possible.
B. MEASUREMENTS
As a general rule, quantitative measurements are preferable. However, it is recognized that
qualitative or semi-quantitative assessments are often performed and frequently adequate.
The following types of measurements are commonly included in a comprehensive
echocardiography report.
1) Left Ventricle:
a) Size: Dimensions or volumes, at end-systole and end-diastole
b) Wall thickness and/or mass: Ventricular septum and left ventricular posterior wall
thicknesses (at end-systole and end-diastole) and/or mass (at end-diastole)
c) Function: Assessment of systolic function and regional wall motion. Assessment
of diastolic function
2) Left Atrium:
Size: Area or dimension
3) Aortic Root:
Dimension
4) Valvular Stenosis:
a) For Valvular Stenosis: Assessment of severity. Measurements that provide an
accurate assessment of severity include trans-valvular gradient and area.
b) For Subvalvular Stenosis: Assessment of severity. Measurement of subvalvular
gradient provides the most accurate assessment of severity and is, therefore,
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recommended.
5) Valvular Regurgitation: Assessment of severity with semi-quantitative descriptive
statements and/or quantitative measurements
6) Prosthetic Valves:
a) Transvalvular gradient and effective orifice area
b) Description of regurgitation, if present
7) Cardiac Shunts: Assessment of severity. Measurements of QP:QS (pulmonary-tosystemic
flow ratio) and/or orifice area or diameter of the defect are often helpful.


Figure 1 Measurement of left ventricular end-diastolic
diameter (EDD) and end-systolic diameter (ESD) from
M-mode, guided by parasternal short-axis image (upper
left) to optimize medial-lateral beam orientation.

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Figure 2 Transesophageal measurements of left ventricular
length (L) and minor diameter (LVD) from midesophageal
2-chamber view, usually best imaged at multiplane
angle of approximately 60 to 90 degrees.


Figure 3 Transesophageal echocardiographic measurements
of left ventricular (LV) minor-axis diameter (LVD)
from transgastric 2-chamber view of LV, usually best imaged
at angle of approximately 90 to 110 degrees after
optimizing maximum obtainable LV size by adjustment of
medial-lateral rotation.
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Figure 4 Transesophageal echocardiographic measurements
of wall thickness of left ventricular (LV) septal wall
(SWT) and posterior wall (PWT) from transgastric shortaxis
view of LV, at papillary muscle level, usually best
imaged at angle of approximately 0 to 30 degrees.

Figure 6 Two methods for estimating LV mass based on
area-length (AL) formula and the truncated ellipsoid (TE)
formula, from short-axis (left) and apical four-chamber
(right) 2-D echo views. Where A1 _ total LV area; A2 _
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LV cavity area, Am _ myocardial area, a is the long or
semi-major axis from widest minor axis radius to apex, b is
the short-axis radius (back calculated from the short-axis
cavity area) and d is the truncated semimajor axis from
widest short-axis diameter to mitral anulus plane. Assuming
a circular area, the radius (b) is computed and mean wall
thickness (t) derived from the short-axis epicardial and
cavity areas. See text for explanation.


Figure 7 Two-dimensional measurements for volume calculations
using biplane method of disks (modified Simpsons
rule) in apical 4-chamber (A4C) and apical 2-chamber
(A2C) views at end diastole (LV EDD) and at end
systole (LV ESD). Papillary muscles should be excluded
from the cavity in the tracing.
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Figure 8 Segmental analysis of LV walls based on schematic views, in a
parasternal short- and long-axis orientation, at 3 different levels. The apex
segments are usually visualized from apical 4-chamber, apical 2 and 3-
chamber views. The apical cap can only be appreciated on some contrast
studies. A 16-segment model can be used, without the apical cap, as described
in an ASE 1989 document.2 A 17-segment model, including the apical cap, has
been suggested by the American Heart Association Writing Group on
Myocardial Segmentation and Registration for Cardiac Imaging.


Figure 9 Typical distributions of the right coronary artery (RCA), the left
anterior descending (LAD),and the circumflex (CX) coronary arteries. The
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arterial distribution varies between patients. Some segments have variable
coronary perfusion



Figure 10 Methods of measuring right ventricular wall thickness (arrows) from
M-mode (left) and subcostal transthoracic (right) echocardiograms.


Figure 11 Midright ventricular diameter measured in apical 4-chamber view at
level of left ventricular papillary muscles.
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Figure 12 Transesophageal echocardiographic measurements
of right ventricular (RV) diameters from midesophageal
4-chamber view, best imaged after optimizing maximum
obtainable RV size by varying angles from approximately 0 to
20 degrees


Figure 13 Measurement of right ventricular outflow tract diameter at
subpulmonary region (RVOT1) and pulmonic valve annulus (RVOT2) in
midesophageal aortic valve short-axis view, using multiplane angle of
approximately 45 to 70 degrees.
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Figure 14 Measurement of right ventricular outflow tract at pulmonic valve
annulus (RVOT2) and main pulmonary artery from parasternal short-axis view.


Figure 15 Measurement of left atrial diameter (LAD) from M-mode, guided by
parasternal short-axis image (upperb right) at level of aortic valve. Linear
method is not recommended.

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Figure 16 Measurement of left atrial (LA) volume from
area-length (L) method using apical 4-chamber (A4C) and
apical 2-chamber (A2C) views at ventricular end systole
(maximum LA size). L is measured from back wall to line
across hinge points of mitral valve. Shorter L from either
A4C or A2C is used in equation.

Figure 17 Measurement of left atrial (LA) volume from
biplane method of disks (modified Simpsons rule) using
apical 4-chamber (A4C) and apical 2-chamber (A2C) views
at ventricular end systole (maximum LA size).


Figure 18 Measurement of aortic root diameters at aortic
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valve annulus (AV ann) level, sinuses of Valsalva (Sinus
Val), and sinotubular junction (ST Jxn) from midesophageal
long-axis view of aortic valve, usually at angle of
approximately 110 to 150 degrees. Annulus is measured by
convention at base of aortic leaflets. Although leading edge
to leading edge technique is demonstrated for the Sinus Val
and ST Jxn, some prefer inner edge to inner edge method.
(See text for further discussion.)

Figure 19 Measurement of aortic root diameter at sinuses
of Valsava from 2-dimensional parasternal long-axis image.
Although leading edge to leading edge technique is shown,
some prefer inner edge to inner edge method. (See text for
further discussion.)

Comprehensive
Epicardial Echocardiography Examination
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Figure 1 Epicardial aortic valve (AV) short-axis (SAX) view (transthoracic
echocardiographic parasternal AV SAX equivalent). A, Porcine anatomic
specimen demonstrating ultrasound transducer oriented above AV annulus so
that ultrasound beam can be aligned in SAX plane to AV. B, When orientation
marker (indentation) on transducer is pointed toward patients left, right
coronary cusp (R) will be at top of monitor screen, left coronary cusp (L) will be
on right, and noncoronary cusp (N) will be on left side of screen adjacent to
interatrial septum. PA, Pulmonary artery.
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Figure 2 Epicardial aortic (AO) valve (AV) long-axis (LAX) view (transthoracic
echocardiographic suprasternal AV LAX equivalent). A, Porcine anatomic
specimen demonstrating ultrasound transducer oriented along AO root, and
directing ultrasound beam posteriorly to visualize left ventricular outflow
tract (LVOT) and AV. B, AV and LVOT are well visualized. PA, Pulmonary
artery.
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Figure 3 Epicardial left ventricle (LV) basal short-axis (SAX) view
(transthoracic echocardiographic odified parasternal mitral valve [MV] basal
SAX equivalent). A, Porcine anatomic specimen demonstrating
proper probe positioning for developing epicardial LV basal SAX view. B, MV
annulus is well visualized with its typical fish mouth appearance. MV anterior
leaflet (AL) appears on top of screen and posterior leaflet (PL) is underneath.
When transducer orientation marker is directed toward patients left,
MVanterolateral commissure will be on right and posteromedial commissure
will be on left of screen. RV, Right ventricle.

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Figure 4 Epicardial left ventricle (LV) mid short-axis (SAX) view
(transthoracic echocardiographic parasternal LV mid-SAX equivalent). A,
Porcine anatomic specimen demonstrating proper epicardial probe positioning
toward right ventricle apex for developing epicardial LV mid-SAX view. B,
With transducer orientation marker directed toward patients left, LV
anterolateral papillary muscle will be on right and posteriomedial papillary
muscle will be on left of ultrasound sector displayed on monitor. Septal
(S) wall of LV is displayed on left followed by anterior (A), lateral (L), and
inferior (I) walls, respectively, in clockwise rotation. The right ventricle is not
visualized in this image.

Figure 5 Epicardial left ventricle (LV) long-axis (LAX) view (transthoracic
echocardiographic parasternal LAX equivalent). A, Porcine anatomic specimen
demonstrating proper probe positioning with ultrasound beam angled superiorly
and toward patients left shoulder to obtain epicardial LV LAX view. B, Porcine
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anatomic specimen with resected anterior ventricular wall demonstrating
visualization of LV and right ventricle (RV), left atrium (LA), LV outflow tract
(LVOT), interventricular septum (IVS), aortic valve (AV), and mitral valve (MV).
C, Corresponding epicardial LV LAX echocardiographic view.



Figure 6 Epicardial 2-chamber view (transthoracic echocardiographic modified parasternal
long-axis [LAX] equivalent). A, Porcine anatomic specimen demonstrating proper probe
positioning with ultrasound transducer rotated 90 degrees from epicardial left ventricle (LV)
LAX view to obtain epicardial 2-chamber view. B, Porcine anatomic specimen with resected
anterior ventricular wall demonstrating left atrium (LA), mitral valve (MV), and LV. To
completely eliminate right ventricle, transducer must be placebo directly on LV, which is
possible only in patients with severe LV dilation (not shown). C, Corresponding epicardial 2-
chamber echocardiographic image in a patient with LV dilation.
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Figure 7 Epicardial right ventricular (RV) outflow tract (RVOT) view (transthoracic
echocardiographic parasternal short-axis equivalent). A, Porcine anatomic specimen with
resected anterior ventricular wall demonstrating proper probe positioning for developing
epicardial RV inflow tract/RVOT view. B, RVOT, pulmonic valve (PV), proximal main
pulmonary artery, and aortic valve (AV) can be visualized.