This video lecture is about echocardiography we will start with cardiac function evaluation these are parasternal long axis views of the heart the right ventricle is seen at the top of the image this is the interventricular septum and this chamber is the left ventricle this valve is the mitral valve and this chamber is the left atrium the M mode or the motion mode is applied the M mode is helpful in examining cardiac function ejection fraction is the percentage of blood that is pumped out of the left ventricle during systole the normal ejection fraction is considered to be between 50 to 65 percent in echocardiography there are various ways to calculate the ejection fraction the first method is to measure the mitral valve e Point septal Separation on M mode place the M mode cursor on the tip of the mitral valve during early diastole when the mitral valve is open the M mode gives us a one-dimensional view of the cardiac structures over time the interior structures or the upper part of the image is seen at the top so the skin is seen at the top then we will see the right ventricle this is the septum and below the septum is the left ventricle these waves are the mitral valve leaflets mainly we will see two waves throughout the cardiac cycle on M mode the first wave is the E point the E point is the upward deflection of the mitral valve leaflet during diastole the second wave is the a point which is the deflection of leaflets during atrial contraction the distance between the E point and the septum is the E Point septal separation or epss we have to measure this distance the normal epss is less than seven millimeters this means that the ejection fraction is within normal range and cardiac function is normal this image on the right is of abnormal epss the epss is 17 millimeters so this is abnormal and epss greater than 7 millimeters is usually suggestive of ejection fraction less than 30 percent keep in mind that epss value directly does not give us ejection fraction it is only an indicator of reduced left ventricular function Al shortening is the percentage of reduction of left ventricular internal diameter during systole the normal range is between 25 to 45 percent it is calculated automatically by the machine after we measure and input the internal diameters of the left ventricle during ancestole and end as tall in these images the ancestral diameter of left ventricle is three centimeters and in N diastole the diameter is 4.4 centimeters these can be measured on M mode place the M mode cursor just below the mitral valve tips you can measure the widest and narrowest regions in the M mode representation of the left ventricle in this manner so these values are used by the machine to automatically calculate fractional shortening this is the formula used and As Told left ventricle internal diameter minus and systole internal diameter divided by n diastole internal diameter into 100 this gives us fractional shortening.
In this image we see how very low value of fractional shortening the left ventricle seems to be dilated and thus gives out a fractional shortening value of only seven percent this means that the heart is not Contracting effectively during systole and indicates heart failure these are Normal and abnormal ejection fraction values they are measured using modified Simpsons method in which the endocardial border is traced in apical four chamber and two chamber views this is used to calculate left ventricle volume head and diastole and ancestor the left ventricle length in this image is 12.2 centimeters and the area is 54 centimeters square the entire stole volume is 194 milliliters the image on the right is of an abnormal ejection fraction you can see a dilated left ventricle the end diastolic left ventricle volume is 233 milliliters these images are of the same case these measurements are taken at systol these are the values we got in the normal image the end systolic volume is 79 milliliters this resulted in an ejection fraction of 60 percent which is normal in the image on the right the volume is 217 milliliters the ejection fraction here is 40 percent which indicates reduced left ventricular function mitral annular plane systolic Excursion or Maps is the term given to displacement of mitral valve during systole and is used to evaluate left ventricle function mitral valve annulus is the ring-shaped structure that surrounds the mitral valve it is located between the atrium and The ventricle at this point Maps is calculated using M mode pass the M mode cursor through the annulus like this during systole we will get this type of wave in M mode we have to measure the size of the wave in this manner this measurement is the maps in normal cases this measurement is more than 10 millimeters and indicates a preserved ejection fraction over here we have an abnormal Maps value the M mode cursor is passing through the mitral annulus and it gives a very flattened wave so by measuring the size of this wave the maps value is only 6 millimeters which is abnormal a value less than eight millimeters usually indicates an ejection fraction less than 50 percent that is an impaired EF if the value is below 7 millimeters it usually indicates EF less than 30 percent it is a severely impaired ejection fraction fractional area change can also help us in measuring systolic function of left ventricle it is calculated by measuring the difference in the end diastolic and an systolic areas of the left ventricle and expressing it as a percentage of the end diastolic area it is automatically calculated by the machine once we input and diastolic and end systolic areas of the left ventricle in systol and diastole fractional area change is expressed in percentage and is normally between 35 to 65 percent Now we move on to right ventricle function tricuspid annular plane systolic Excursion or taps is a measure of the longitudinal motion of tricuspid annulus in the right ventricle during systole Taps is measured by placing an M mode cursor through the tricaspid annulus in the apical 4 chamber View and the distance that the annulus moves during systole is measured in millimeters similar to maps the cursor passes through the tricuspid annulus which is located here and gives us this m mode tracing this wave is measured in normal cases this value is more than 17 millimeters in this image the tabs value is less than 17 millimeters these are the tabs values which correspond to an approximate ejection fraction percentage this is the fractional area change for the right ventricle right ventricle area is measured in apical four chamber View the normal fractional area change is between 33 to 60 percent approximately systolic Excursion velocity is a measure of the velocity of the tricuspid annulus during systole typically obtained using spectral Doppler we can call it S Prime it reflects the longitudinal contraction of the right ventricle and can be used as a parameter of right ventricular systolic function S Prime is usually measured at the lateral tricuspid annulus and a reduced S Prime May indicate right ventricular dysfunction Doppler gate is placed at the lateral wall of right ventricle slightly above tricuspid annulus and we will get this waveform this is the systolic Excursion velocity normally it is more than 10 centimeters per second this case is of an abnormal systolic Excursion velocity we see a reduced velocity it is less than 10 centimeters per second this is our normal heart in apical four chamber View we can see all four chambers Wells and the septum clearly here we measure the right atrium two measurements are taken the longitudinal axis is the major axis this measurement is usually less than 5.2 centimeters approximately the horizontal axis is the minor axis it is usually less than 4.5 centimeters approximately these two measurements give an approximate area of less than 18 centimeters squared and in this image we see right atrium enlargement we see a dilated right atrium the left atrium is measured by tracing the endocardial border and we get an approximate volume of 35 milliliters per meter Square in this image and over here we have left atrial enlargement we can see our dilated left atrium.
Now we will discuss heart valves starting with mitral
valve here is the mitral valve in apical four chamber view with color Doppler
applied the flow is smooth no color mixing or turbulence is seen mitral regurgitation
is a heart condition in which blood flows backward through the mitral valve
from the left ventricle to the left atrium during systole in a mild case of
mitral regurgitation a small jet of turbulent flow is seen in left atrium
during systole the central jet with occupies less than 20 percent of the left
atrium Vena contractor is the narrowest part of the turbulent jet in mild cases
it measures less than three millimeters the regurgitating volume is less than
30 milliliters per beat and the regurgitant fraction is less than 30 percent in
moderate regurgitation the central jet occupies between 20 to 40 percent of the
left atrium also mild flow conversions is seen near the mitral valve which is
the narrowing of regurgitant jet as it flows through the orifice of the mitral
valve in severe regurgitation the central jet width occupies more than 40 percent
of the left atrium during system the entire Atrium is filled with turbulent
regurgit and jet a large flow convergence is observed near the mitral valve the
vena contractor measures greater than seven millimeters the regurgitate and
volume is greater than or equal to 60 ml per beat and the regurgitant fraction is
more than or equal to 50 percent mitral stenosis is a condition in which the
mitral valve opening is narrowed restricting blood flow from the left atrium to
the left ventricle of the heart a turbulent flow is seen in the left ventricle
during diastole so in stenosis the turbulent jet is seen in The ventricle
during diastole whereas in regurgitation the turbulent jet is seen in the
atrium during systole in mild cases of stenosis the mitral valve area is
greater than 1.5 centimeter Square the mean gradient is less than 5 millimeters
of mercury these parameters are calculated by tracing the outline of the mitral
valve orifice using two dimensional Imaging to measure the area in moderate
stenosis we see a larger turbulent jet in the left ventricle the valve area is between
1 to 1.5 centimeter Square and the mean gradient is between 5 to 10 millimeters
of mercury in severe stenosis the valve area is very narrow it is less than one
centimeter Square and the mean gradient is greater than 10 millimeters of
mercury this is a spectral waveform of a normal mitral valve mainly it gives
two prominent waves the first wave is the E wave or the early diastolic filling
wave and the second wave is the a wave or the atrial contraction wave the peak
velocity of e wave is between 0.6 to 1.3 meters per second or 60 centimeters to
130 centimeters per second and the a wave velocity is between 0.6 to 0.9 meters
per second or 60 to 90 centimeters per second the EA ratio is the ratio of
velocities of e and a wave the normal ratio is between 0.8 to 1.5 approximately
the normal deceleration time is between 160 to 240 milliseconds it is the time
it takes for the peak velocity to come down to zero and over here we have a spectral
waveform of severe mitral stenosis we will find spectral broadening and very
high velocity flow the velocities are reaching almost 200 centimeters per second
in this case continuous wave Doppler is used because it is able to detect very
high velocity flows this is an image of severe mitral regurgitation there is a
high velocity flow reversal with spectral broadening the velocities are
reaching 4 meter per second or 400 centimeters per second so that is a very
high velocity this is an image of a normal aortic valve with color Doppler
applied and these are the normal values the aortic valve velocity is between
2.5 to 3.5 meters per second and the pressure gradient is usually around 10 and
20 millimeters of mercury in aortic stenosis diuretic valve is narrowed and does
not open properly this leads to turbulent flow in the aortic root also we will
find non-mobility or reduced mobility of the valves these are images of aortic
valve without color Doppler we can see the aortic valve right here it is open
the curves are thin and will move normally throughout the cardiac cycle this is
a case of aortic stenosis the valves are hyperechoic and are less mobile than
usual here is a spectral Doppler waveform of a normal aortic valve this is how
the waveform will look like the peak velocity is usually less than 200
centimeters per second and over here we have a case of mild aortic stenosis we
can see spectral broadening because of turbulent flow and the peak velocity is
between 2.5 to 2.9 meters per second the mean gradient is less than 20
millimeters of mercury and the aortic valve area is greater than 1.5 centimeter
Square the area is usually between 1.5 and less than 2 centimeters square in
moderate aortic stenosis the aortic jet velocity can be between 3 to 4 meters
per second or 300 to 400 centimeters per second you can see the aortic jet
velocity here is more than 300 centimeters per second also there is spectral
broadening the main gradient is between 20 to 40 millimeters of mercury and the
aortic valve area is between 1 to 1.5 centimeter Square in severe aortic
stenosis the jet velocity will be more than 4 meters per second here you can
see the velocity is above 4 meters per second the mean gradient will be more
than 40 millimeters of mercury and aortic valve area will be less than 1
centimeters squared these are cross-sectional images of the aortic valve during
systole and diastole and over here we have mild aortic valve calcification you
can see a small hyperechoic region on the aortic valve this is due to
calcification this image shows moderate aortic valve calcifications you can see
a greater extent of hyperechoic areas on the aortic valve this image shows
severe aortic valve calcifications the entire valve is filled with hyperechoic
calcifications in aortic regurgitation the aortic valve does not close properly
this causes blood to flow back into the left ventricle from the aorta during
diastole in mild aortic regurgitation the central jet with occupies less than
25 percent of left ventricular outflow tract that means only a small area of the
left ventricle is filled with a turbulent jet turbulent flow is seen during
diastole starting from the aorta and reaching the left ventricle the vena
contractor measurement is less than three millimeters this is a spectral
Doppler waveform of mild aortic regurgitation there is spectral broadening and
a high velocity flow the velocity is almost 4 meters per second here is an
image of moderate aortic regurgitation the turbulent jet is larger than in the
mild case it is going from the aorta to the left ventricle during diastole in
severe regurgitation the central jet width occupies more than 65 percent of the
left ventricular outflow tract the vena contractor will measure greater than 6
millimeters here is a spectral Doppler waveform of severe aortic regurgitation there
is flow reversal during diastole and a high velocity flow is seen the
velocities are more than 5 meters per second so that is a very high velocity Now
we move on to pulmonary valves this is an image of a normal pulmonary valve this
image shows the right ventricular or flow tract the normal valves are visible
during diastole and are invisible during systole in pulmonary regurgitation a
turbulent flow jet can be seen going from the pulmonary artery to the right
ventricle during diastole this is a normal spectral Doppler waveform of pulmonary
valve the PSV is usually less than 150 centimeters per second the acceleration
time is less than 120 milliseconds and the ejection time is between 180 to 200
milliseconds and over here is a spectral waveform of pulmonary regurgitation we
can see diastolic flow reversal over here and there is high diastolic velocity as
well as high systolic velocity here is an image of pulmonary stenosis the turbulent
flow jet can be seen going from the right ventricle to the pulmonary artery
during systole now we will see spectral Doppler analysis of pulmonary stenosis
in mild cases the peak velocity is less than 3 meters per second there is some
spectral broadening and the velocity here is approximately 3 meters per second
the peak gradient is less than 35 millimeters of mercury and the right
ventricular systolic pressure is between 31 to 49 millimeters of mercury in
moderate pulmonary stenosis the PSV is between three to four meters per second the
peak gradient is between 36 to 64 millimeters of mercury and the right
ventricular systolic pressure is between 50 to 79 millimeters of mercury in
severe pulmonary stenosis we see a very high peak systolic velocity it is
greater than 4 meters per second the peak gradient will be more than 64
millimeters of mercury and the right ventricular systolic pressure will be
greater than 80 millimeters of mercury now we will move on to tricuspid valves
in this epical four chamber view with the color Doppler applied in the right
ventricle and atrium we can see normal blood flow through the tricuspid valve there
is no turbulence or color mixing over here and over here we have a case of mild
tricuspid regurgitation a turbulent regurgitate and Jet is seen in right
ventricle the central jet area is usually less than 5 centimeters squared in
severe tricuspid regurgitation we see a large turbulent jet in the right
ventricle the central jeteria is more than 10 centimeters square this is a
normal spectral Doppler waveform of tricuspid valve the peak velocity is
usually less than 2 meters per second and the pressure gradient is usually less
than 25 millimeters of mercury and over here we have severe tricuspid regurgitation
we can see a very large jet velocity exceeding 300 centimeters per second the vena
contractor measurement is more than seven millimeters in severe cases here is a
case of tricuspid stenosis the valves are thick and hyper-equoic thick hyperechoic
valves are often the cause of stenosis the mean pressure gradient is more than
5 millimeters of mercury the trans Striker speed velocity timing drag roll is
more than 60 centimeters and the valve area is usually less than one centimeter
Square here is a case of tricuspid stenosis with its spectral Doppler waveform the
peak velocity can Exceed 2 meters per second and there are other features such
as spectral broadening the normal pericardium appears hyperechoic like this pericardial
effusion is the accumulation of fluid blood or pus in the pericardial cavity
here is a mild pericardial effusion there is anechoic fluid a small amount of
fluid in the pericardial cavity here is a case of moderate pericardial effusion
there is a larger amount of fluid in the pericardial cavity in this image we
can see a very large amount of pericardial fluid this can lead to a condition known
as cardiac tamponade here is a parasternal short axis view of the left
ventricle and we can see some fluid in the pericardial cavity cardiac tamponade
is a condition in which the large pericardial effusion starts to affect the cardiac
cycle the heart function is compromised we see a very large effusion
surrounding the heart usually the right side of the heart is affected the right
ventricle is collapsed and there is improper or absent diastolic filling of the
right atrium and right ventricle pericarditis is the inflammation of the pericardium
usually it is associated with pericardial diffusion but we can also find
thickened pericardium in some cases ventricular interdependence is a term used to
describe the changes when a change in pressure of one ventricle affects the functioning
of the other ventricle in conditions such as pulmonary hypertension we may find
interventricular septal flattening we see a flat interventricular septum as
compared to the rounded configuration in normal cases we also find a d shaped
left ventricle also there will be reduced left ventricular filling we also find
pericardial effusion in this image a sigmoid shaped septum is an anatomical
variant in some individuals there is some thickening of the septum over here it
can cause mild obstruction of left ventricular outflow tract cardiomyopathy
refers to heart muscle disease restrictive cardiomyopathy is a rare type in
this type the right atrium and the left atrium are dilated this is a spectral
Doppler analysis of restrictive cardiomyopathy we will find a small a wave the
deceleration time will be less than 160 milliseconds and the EA ratio will be
more than 2. there is diastolic dysfunction in hypertrophic cardiomyopathy
there will be asymmetric septal hypertrophy we can see a thickened septum the
septal thickness will be more than 15 millimeters due to the thickened septum a
condition known as systolic anterior motion of the mitral valve occurs in which
the anterior mitral valve leaflet moves towards the interventricular septum
during systole this causes obstruction in the left ventricular outflow tract this
is usually associated with hypertrophic cardiomyopathy we will also find
abnormal EA ratio and diastolic dysfunction in epical aneurysm there is
localized dilation of the left ventricular Apex we can see a dilation of the
region this is usually associated with hypertrophic cardiomyopathy non-compaction
cardiomyopathy is rare a spongy appearance of myocardium is seen in this type
of cardiomyopathy this is how the myocardium will look like in dilated
cardiomyopathy we will find dilated ventricle most commonly in the left
ventricle is dilated the normal internal diameter of the left ventricle in hand
as tall is between 4 to 5.6 centimeters in dilated cardiomyopathy this diameter
can exceed six centimeters here is an image of a normal pulmonary artery the
normal diameter is less than 25 millimeters and over here we have an image of
pulmonary hypertension we find a dilated pulmonary artery the diameter will be
more than 25 millimeters here is a spectral Doppler waveform of pulmonary
hypertension the velocity at the tricuspid valve will be very high it is more
than 4 meters per second in this graph it is associated with tricuspid
regurgitation transposition of the great arteries is a congenital heart anomaly
in which the aorta and pulmonary artery are switched the aorta rises from the
right ventricle and the pulmonary artery arises from the left ventricle in
echocardiography diorta and pulmonary artery are seen parallel to each other in
a parasternal long axis View in a short axis view we can also see the parallel
configuration of aorta and pulmonary artery the aorta is seen anterior to the
pulmonary artery truncus arteriosis is another congenital heart defect in which
only a single artery arises from the heart we only find one artery over here which
drains both the left and right ventricles also it is associated with a
ventricular septal defect patent doctors arteriosis is a condition in which the
doctors arteriosis which is a fetal blood vessel fails to close after birth the
connection remains between the pulmonary artery and the aorta here in the
normal image we see a normal aortic Arch and normal ascending and descending
aorta but in this image we see a small connection between the pulmonary artery
and the aorta this connection is more clearly seen with color Doppler in a
suprasternal view this right here is the connection between the pulmonary
artery and the aorta technology of fallow is a congenital heart anomaly
consisting of four features it consists of ventricular septal defect and overriding
aorta in which the aorta is centered right above the ventricular septum between
both the ventricles also there will be right ventricular hypertrophy and the
fourth feature will be right ventricular outflow obstruction thank you so much
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