ECHOExpert® v.1.

0 Knowledge Base

Theoretical background

This system can be used to provide measurement and calculations derived from ultrasound images. The quantification
image data is then used in conjunction with other clinical data to make a diagnosis. Following table shows the range of
cardiovascular diagnoses considered in version 1.0 of echoExpert®.

Tab. Diagnostic entities in range of echoExpert® v.1.0

Valvular Heart Diseases
Heart failure (systolic, diastolic)
Ischemic Heart Disease
Pulmonary hypertension
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy/Constrictive pericarditis
Diseases of Thoracic Aorta

Measurements, Calculations and Primitives

Sole use of measurement data to make a diagnosis is not recommended. There are numerous factors to consider when
using quantified data from any ultrasound imaging system. A careful analysis of those factors indicates that the
accuracy of each measurement and subsequent calculation is highly dependent on image quality. Image quality in turn
is highly dependent on system design, operator scanning technique, familiarity with system controls and, most
importantly, patient echogenity. Three of these variables are independent of the system and therefore prevent
specifying a clinical accuracy for the measurements and calculations produced by the system.
System accuracy specifications are given for the measurement primitives frequency, length, time. These specifications
are based on data taken with optimum control settings. Accuracy specifications can be obtained at other control
settings by repeating the calibration at the desired settings. The Depth and Sweep Speed controls have the biggest
impact on measurement accuracy. The accuracy of a 1 cm length or 3 cm2 area measurement on a 24 cm depth
display is different than for the same measurement performed on a 4 cm depth display. Measurements taken at a
sweep speed of 100 mm/s are more accurate than those taken at 25 mm/s.
To produce measurements and calculations, system controls are used to draw graphics on selected image displays.
These graphics are processed by the system and converted into displayed measurement and calculations values.
The clinician can generate a large variety of specific, labeled measurements and calculations for each
echocardiographic application mode, and can collect reports and summarize the measurement and calculation values.
The term “measurement” is used for both standard measurements and for package measurements. “Calculations” are
the values produced when measurements are entered into mathematical formulas.
Measurement “primitives” are the “building blocks” the system assembles to produce the measurements and
calculation values associated with graphics drawn on the image by the clinician in the various imaging modes.
For example, when the clinician draws a straight line on a Doppler spectrum, the system uses the frequency or velocity
primitive to produce to produce frequency or velocity measurements; on a sector in 2D mode, the system uses the
length primitive to produce a length measurement. On a spectral trace, the system assembles several primitives to
produce possible slope, time, and mean values. On a 2D sector trace, the length primitive is used to derive area and
length values.
Some variables listed here as primitive, for example area and circumference, are derived from other primitives
through simple calculations.

Measurement Primitives and Accuracies

Length
The system assumes that the speed of sound is 1540 m/s and that this speed is homogenous in all tissues. Several
sources on ultrasound cite that differences in the speed of sound do exist based on the type of tissue. One source [1]
cites sound speeds from a range of 1500 to 1600 m/s. These differences would produce an inaccuracy of up to 4%.
1. Clinical Sonography – A practical Guide, Second Edition, Roger C. Sanders, ed., Little Brown asdn Company, 1991.
The length measurements on the system are verified using an AIUM standard phantom. The calibrations are performed
using depth settings, which give the greatest resolution for the phantom length being measured. The accuracy of this
calibration should be within +-5%.

Time
Time measurement can be used for calculations performed in the following areas: physio channels, M-mode, and
Doppler. The time calibration is performed using a time-interval signal generator with a calibration traceable to NIST.
The calibration of the display is not expected to drift. Measuring 1-second pulses at the different sweep speeds should
do calibration of the time axis. The accuracy of these measurements should be within +-5% independent of the sweep
speed used.

Calculated Primitives

Area
Area is derived through use of the length measurement primitive. Green’s Theorem is used to calculate the area. The
number of points that are used in the calculation is related to how slowly the operator traces the area of interest.
The clinical accuracy of the circumference measurement is highly dependent on the ability of the operator to
accurately trace the area of interest.
There is an option in the software to use an ellipse to calculate area. This area will be calculated as follows:
area = ∏ x major semi axis length x minor semi axis length

Circumference
Circumference is derived by the addition of several discrete length measurements.
The clinical accuracy of the circumference measurement is highly dependent on the ability of the operator to
accurately trace the area of interest. The circumference measurement accuracy should be within +-5% when using a
phantom. ]
ellipse circumference = ∏ x [ 3/2( A + B ) – SQRT( A x B ) ]
where A = major semi axis length, B = minor semi axis length.

Slope
Slope is derived from the length and time measurement primitives using a simple slope formula.

Velocity
The velocity value is provided by multiplication of the frequency primitive measurement and the cosine of the angle of
the blood flow. The blood flow angle is a control set by the system operator. The setting of this control varies by
clinical application. There are some uncertainty and assumptions in the setting of this control. Unpredictable high
velocity jet directions and tortuous vessel directions sometimes prevent use of a clinically accurate blood flow angle.

Acceleration
Doppler spectral acceleration is derived from the change in velocity divided by the change in time, using a simple slope
formula.

Velocity-time integral
The velocity-time integral (or flow integral) is the integral of the Doppler spectral instantaneous velocity (Vi) over the
total time interval (T). The integral is approximated by the following sum:
VTI = SUM( Vi x ti )
where t is the total time interval (the sum of all ti time increments).
Mean pressure gradient
Mean pressure gradient (PG mean) is proportional to the integral of the square of the Doppler spectral instantaneous
velocity (Vi) over time (ti). The integral is approximated by the following sum [1]:
1. Nanda, Navin C., Doppler Echocardiography, Second Edition, Lea and Febiger, Philadelphia 1993, p. 29.
PG mean = 4/10000t x SUM( Vi x Vi x ti )
where t is the total time interval (the sum of all ti increments), 4 is the approximate units conversion factor for the
Bernoulli equation, 10000 is the scaling factor from centimeters to meters squared.

Normal values of echocardiographic parameters

Heart chambers dimensions and volumes

Fig. Measurement of heart chambers in PLAX

Tab. Grades of heart chambers dimensions

parameter borderline mild medium severe
LVEDd 55-60 60-70 >70
LVESd 35-40 40-45 45-50 > 50
LA 40-44 44-50 50-60 >60
IVS, PW 10-12 12-13 13-14 >14
RV 25-30 30-35 35-40 > 40

Fig. Measurement of aortic arch diameter

Tab. Normal values of selected echocardiographic parameters
aortic anulus 14 - 26 mm
aortic root 22 - 36 mm
aortic arch 20 - 36 mm
ascending aorta 21 - 34 mm
pulmonary anulus 10 - 22 mm
pulmonary root 10 - 30 mm
vena cava inferior 12 - 23 mm

Fig. Measurement of heart chambers in A4CH view

Tab. Normal values of selected volumes and masses

EDV (men) 60 - 80 ml/m2
EDV (women) 50 - 70 ml/m2
ESV (men) 25 - 35 ml/m2
ESV (women) 25 - 35 ml/m2
LV mass (men) < 125 g/m2
LV mass (women) < 110 g/m2

Fig. Measurement of pulmonary artery pressure using TR jet

Tab. Grades of pulmonary hypertension

grade PGmean [mmHg] PGmax [mmHg]
mild 25 – 35 35 - 45
moderate 35 – 45 45 - 60
severe >45 >60

Tab. List of measured echocardiographic parameters (alphabetical order)

Aortic valve AI end-d vel
AI max vel
Ao acc slope
Ao acc time
Ao dec slope
Ao dec time
Ao isthmus
Ao root area
Ao root diam

Aortic arch
Aortic R-R
Ao V2 max
Ao V2 mean
Ao V2 trace
Ao V2 VTI
asc Aorta
desc Aorta

Heart chambers IVSd

IVSs
LA dimension
LVAd ap2 MOD
LVAd ap4 MOD
LVAd apical
LVAd sax epi
LVAd sax MV
LVAd sax PM
LVAs ap2 MOD
LVAs apical
LVAs sax epi
LVET
LVIDd
LVIDs
LVLd apical
LVLs apical
LVOT area
LVOT diameter
 LVPEP
LVPWd
LVPWs
LV V1 max
LV V1 mean
LV V1 trace
LV V1 VTI

Mitral valve Mitral R-R

MR max vel
MV acc slope
MV acc time
MV annu diam
MV A point

MVA (traced)
MV dec slope
MV dec time
MV DFP
MV diam 1
MV diam 2
MV E point
MV E-F slope
MV excursion
MV PHT max v
MV peak vel
MV V2 mean
MV V2 trace
MV V2 VTI
EPSS

Pulmonary artery PA acc slope

PA acc time
PA dec slope
PA dec time
PA V2 max
PA V2 mean

PA V2 traced
PA V2 VTI
MPA diam
LPA diam
RPA diam

Pulmonary valve PI end-d vel

 PI max vel
Pulm R-R
Q-to-PV close
Q-to-TV open

The following table summarizes the upper limits for dilation of the right heart chambers
Tab. Upper limits for dilation of right heart chambers
RV diameter (PLAX) 31 mm (22 mm/m2)
RVOT diameter 22 mm
PA diameter 25 mm
RVWd diameter 5 mm

If the right atrial pressure is normal (5-10 mmHg) the inferior vena cava diameter is normal (1.2-2.3 cm) and it
collapses with respiration by at least 50%.

Table. Estimation of right atrial pressure

IVC respiration/sniff change estimated RA pressure
small (<1.5 cm) collapse 0-5 mmHg
normal 1.5-2.5 decrease by >50% 5-10 mmHg
dilated >2.5 decrease <50% 10-15 mmHg
dilated also hepatic veins no change > 20 mmHg

Right ventricle RVAW

RVDd
RVDd major
RVDs
RVET
RVOT diam
RVPEP
RV V1 max
RV V1 mean
RV V1 trace
RV V1 VTI

Tricuspid valve Tricuspid R-R

TV acc slope
TV acc time
TV annu diam
TV dec slope
TV dec time
TV DFP
TV flow diam
TV PHT max v
TV V2 max
 TV V2 mean
TV V2 trace
Max vel(TR)

Diagnostic entities

Hypertrophic cardiomyopathy

Appendix

Tab. Complete list of measured echocardiographic parameters (alphabetical order)

2-D area 2-D area
2-D diameter 2-D diameter
accel slope acceleration slope
accel time acceleration time
ACS aortic cuspis separation
AI end-d vel velocity of aortis insufficienci at end diastole
AI max vel maximum velocity of aortic insufficienci
Ao acc slope aortic acceleration slope

Ao acc time aortic acceleration time

Ao dec slope aortic deceleration slope
Ao dec time aortic deceleration time
Ao isthmus aortic isthmus diameter

Ao root area aortic root area

Ao root diam aortic root diameter
Aortic arch transverse aortic arch diameter
Aortic R-R R-R interval during measurements on aortic valve
Ao V2 max maximum velocity measured distal to the aortic valve
Ao V2 mean mean velocity measured distal to the aortic valve
Ao V2 trace pressure gradient measured distal to the aortic valve
Ao V2 VTI VTI measured distal to the aortic valve
Area area
asc Aorta ascending aortic diameter
Circum circumference
d distance

Dec max vel maximum velocity of measured deceleration slope

Decel slope deceleration slope
Decel time deceleration time
desc Aorta descending aorta diameter

Eject time onset-to-cessation time

EPSS E point to septal separation
IVSd interventricular septal dimension at end diastole
IVSs interventricular septal dimension at end systole
LA dimension left atrial dimension
length length
LPA diam left pulmonary artery diameter
LVAd ap2 MOD left ventricular area at end diastole, apical two-chamber view, by method of discs
LVAd ap4 MOD left ventricular area at end diastole, apical four-chamber view, by method of discs
LVAd apical left ventricular area at end diastole, apical
LVAd sax epi left ventricular epicardial area at the level of the papillary muscle tips at end diastole
LVAd sax MV left ventricular short axis area at mitral valve level at end diastole
LVAd sax PM left ventricular short axis area at papillary muscle level at end diastole
LVAs ap2 MOD left ventricular area at end systole, apical two-chamber view, by method of discs
LVAs apical left ventricular area at end systole, apical
LVAs sax epi left ventricular epicardial area at the level of the papillary muscle tips at end systole

LVET left ventricle ejection time

LVIDd left ventricle internal dimension at end diastole
LVIDs left ventricle internal dimension at end systole
LVLd apical left ventricular length at end of diastole, apical
LVLs apical left ventricular length at end of systole, apical
LVOT area left ventricular outflow tract area
LVOT diameter left ventricular outflow tract diameter
LVPEP left ventricle pre-ejection period
LVPWd left ventricular posterior wall dimension at end diastole
LVPWs left ventricular posterior wall dimension at end systole
LV V1 max maximum velocity measured proximal to the aortic valve, with PW doppler
LV V1 mean mean velocity measured proximal to the aortic valve, with PW doppler
LV V1 trace velocity traced from a PW doppler spectrum taken from proximal to the aortic valve, with PW doppler
LV V1 VTI velocity time integral measured proximal to the aortic valve with PW doppler
Max vel maximum velocity
Max vel(TR) maximum velocity of tricuspid valve regurgitation
Mean PG mean pressure gradient
Mean vel mean velocity
Mitral R-R R-R interval during measurements on mitral valve
MM R-R int M-mode or 2D R-R interval
MM slope MM slope
MPA diam main pulmonary artery diameter
MR max vel maximum velocity of mitral regurgitation
MV acc slope mitral valve acceleration slope
MV acc time time portion of the mitral valve acceleration slope
MV annu diam mitral valve annulus diameter
MV A point mitral valve A point velocity
MVA (traced) mitral valve area from a 2D trace
MV dec slope mitral valve deceleration slope
MV dec time time portion of the mitral valve deceleration slope
MV DFP mitral valve diastolic filling period
MV diam 1 mitral valve orifice major diameter (A4CH)
MV diam 2 mitral valve orifice major diameter (A2CH)
MV E point mitral valve E point velocity
MV E-F slope mitral valve slope of E-F portion of doppler spectrum
MV excursion mitral valve excursion
MV PHT max v mitral valve maximum velocity used for pressure half-time calculation
MV peak vel mitral valve overall peak velocity
MV V2 mean mean velocity measured distal to the mitral valve with CW doppler
MV V2 trace velocity traced from a CW doppler spectrum taken distal to the mitral valve
MV V2 VTI velocity-time integral measured distal to the mitral valve
PA acc slope pulmonary artery acceleration slope
PA acc time time portion of the pulmonary artery acceleration slope
PA dec slope pulmonary artery deceleration slope
PA dec time time portion of the pulmonary artery deceleration slope

PA V2 max maximum velocity measured distal to the pulmonary artery with CW doppler
PA V2 mean mean velocity measured distal to the pulmonary artery with CW doppler
PA V2 traced velocity traced from a CW spectrum taken distal to the pulmonary artery
PA V2 VTI velocity-time integral measured distal to the pulmonary artery
PEP pre-ejection period
PI end-d vel end diastolic velocity of the pulmonic insufficiency
PI max vel maximum velocity of the pulmonic insufficiency
Pulm R-R R-R interval during measurements on pulmonary valve
Q-to-PV close time from Q-wave to pulmonary valve closure
Q-to-TV open time from Q-wave to tricuspid valve opening
RPA diam right pulmonary artery diameter
R-R interval R-R interval
RVAW right ventricle anterior wall dimension
RVDd right ventricle internal diameter at end diastole
RVDd major right ventricle diastolic major (LAX) dimension, 4CH view
RVDs right ventricular systole
RVET right ventricle ejection time
RVOT diam right ventricle outflow tract diameter
RVPEP right ventricle pre-ejection period
RV V1 max maximum velocity measured at RVOT
RV V1 mean mean velocity measured at RVOT
RV V1 trace velocity traced from a PW doppler spectrum taken from RVOT
RV V1 VTI velocity-time integral traced from a PW doppler spectrum taken from RVOT
Time time
Tricuspid R-R R-R interval during measurements on tricuspid valve
TV acc slope tricuspid valve acceleration slope
TV acc time time portion of the tricuspid valve acceleration slope
TV annu diam tricuspid valve annulus diameter
TV dec slope tricuspid valve deceleration slope
TV dec time time portion of the tricuspid valve deceleration slope
TV DFP tricuspid valve diastolic filling period
TV flow diam tricuspid valve orifice diameter, A4CH
TV PHT max v tricuspid valve maximum velocity used for pressure half time calculation
TV V2 max max velocity measured distal to the tricuspid valve with CW doppler
TV V2 mean mean velocity measured distal to the tricuspid valve with CW doppler
TV V2 trace velocity traced from a PW doppler spectrum taken from distal to the tricuspid valve, with PW doppler