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Modalities
- TTE (Transthoracic Echocardiogram): standard, non-invasive
- TEE (Transesophageal Echocardiogram): better posterior structures + atria + endocarditis vegetations + valves
- Stress echo: exercise or pharmacologic (dobutamine, vasodilator); ischemia
- 3D echo: chamber quantification, valve morphology
- Strain imaging (speckle tracking): early LV dysfunction detection (GLS â global longitudinal strain)
- Contrast echo: improves endocardial border definition (microbubbles)
- POCUS (Point-of-Care Ultrasound): bedside; ICU + ED
Indications
Heart Failure
- Initial assessment of LVEF, chamber sizes
- HFpEF vs HFrEF differentiation
- Wall motion abnormalities
- Diastolic function
- Pulmonary artery pressure estimation (TR jet)
Valvular Disease
- Severity assessment (AS, MR, AR, MS, TR)
- Etiology (degenerative, rheumatic, congenital)
- Mechanism of regurgitation
- Surgical / TAVR planning
Coronary Artery Disease
- Wall motion abnormalities at rest + with stress
- LV function post-MI
- Complications (LV aneurysm, mural thrombus, septal rupture, papillary muscle rupture)
Endocarditis
- Vegetations (TEE more sensitive)
- Abscess
- Valvular regurgitation new
- Prosthetic valve assessment
Pericardial Disease
- Effusion (size, hemodynamic significance)
- Tamponade signs
- Constrictive pericarditis (Doppler patterns)
Cardiomyopathy
- DCM, HCM, RCM, ARVC, takotsubo
- Wall thickness, chamber size
- Functional assessment
Congenital Heart Disease
- ASD, VSD, PDA, tetralogy, others
- Adult congenital cardiology
Aortic Disease
- Aortic root + ascending dilation
- Coarctation (TTE limited; better with MRI/CT)
- Dissection (TEE often more diagnostic than TTE)
Pulmonary Hypertension
- PA pressure estimation
- RV size + function
- TR jet for PASP
Stroke / Embolic Source
- LV thrombus
- LA thrombus (TEE for left atrial appendage)
- ASD / PFO with bubble study
- Vegetations
- Aortic atheroma
Standard Views (TTE)
Parasternal Long Axis (PLAX)
- LV + LA + aortic root + ascending aorta
- Mitral valve + aortic valve
- LV size + function
- M-mode: traditional measurements
Parasternal Short Axis (PSAX)
- LV from base to apex (sweep through)
- Aortic valve (3 cusps visible)
- Mitral valve (fish-mouth)
- Papillary muscle level
- Apex
Apical 4-Chamber (A4C)
- All 4 chambers
- LV function (Simpsonâs method for EF)
- Mitral + tricuspid valves
- Septal + lateral walls
- Doppler of mitral + tricuspid
Apical 5-Chamber
- Apical 4C + aortic outflow
- LVOT velocity (AS gradient)
Apical 2-Chamber
- LV from apex (anterior + inferior walls)
- LV function (biplane Simpsonâs)
Subcostal
- All 4 chambers (alternative angle)
- IVC (inspiratory collapse â volume status)
- Pericardium
Suprasternal
- Aortic arch
- Coarctation
- Descending aorta
Doppler
Continuous Wave Doppler
- High velocity (jets, regurgitation, stenosis)
- AS peak gradient (Bernoulli equation: 4V²)
- TR jet â RV systolic pressure â PASP estimation
Pulsed Wave Doppler
- Low velocity, location-specific
- LV inflow (mitral E + A waves) â diastolic function
- Pulmonary vein flow
- LVOT velocity (cardiac output calculation)
Color Doppler
- Visualize flow direction + turbulence
- Identify regurgitation + shunt jets
- Pulmonary HTN (RV outflow turbulence)
Tissue Doppler
- Myocardial velocity
- Diastolic function (eâ velocity)
- E/eâ ratio (filling pressure estimate)
LV Function Assessment
Ejection Fraction (EF)
- Visual estimation (gestalt)
- Simpsonâs method (biplane): most accurate
- 3D echo: more accurate than 2D
- Categories:
- HFrEF: †40%
- HFmrEF: 41-49%
- HFpEF: ⥠50%
Global Longitudinal Strain (GLS)
- Strain imaging (speckle tracking) â measures myocardial deformation
- Normal GLS: -18% to -22% (more negative)
- Early LV dysfunction: GLS less negative (-15%)
- Subclinical detection in cancer chemotherapy + cardiotoxicity + early HFpEF
- Increasingly used in cardio-oncology + heart failure
Wall Motion Abnormalities
- Hypokinetic: reduced wall motion
- Akinetic: no wall motion
- Dyskinetic: paradoxical (outward) motion
- Hyperkinetic: increased (compensatory)
- Coronary territory correlation
- Stress echo for ischemia (new wall motion abnormality with stress)
Diastolic Function
Parameters
- Mitral inflow: E wave (early) + A wave (atrial contraction)
- E/A ratio: normal 1-2; reversed (< 1) = impaired relaxation
- Pseudonormal pattern (intermediate)
- Restrictive (E >> A, short decel time) â severe HFpEF
- Tissue Doppler eâ: lateral / septal mitral annulus
- E/eâ ratio: estimates LV filling pressure
- E/eâ < 8: normal
- E/eâ > 14: elevated filling pressure
- 8-14: intermediate
Diastolic Dysfunction Grades
- Grade 1: impaired relaxation (E/A < 1, normal filling pressure)
- Grade 2: pseudonormal (E/A 1-2 but elevated E/eâ)
- Grade 3: restrictive (E/A > 2, E/eâ > 14)
Valvular Disease Assessment
Aortic Stenosis (AS)
- Severe AS criteria:
- Peak velocity > 4 m/s
- Mean gradient > 40 mmHg
- Valve area < 1 cm² (or < 0.6 cm²/m² indexed)
- Symptom triad: dyspnea + angina + syncope â consider valve replacement
- TAVR vs SAVR consideration
Mitral Regurgitation (MR)
- Primary (organic; degenerative MVP, rheumatic, endocarditis, ruptured chordae)
- Secondary (functional; HFrEF with mitral annular dilation)
- Severity: vena contracta, PISA, effective regurgitant orifice area (EROA), regurgitant volume
Aortic Regurgitation (AR)
- Severity: jet width, vena contracta, holodiastolic flow reversal in descending aorta
Mitral Stenosis (MS)
- Mostly rheumatic worldwide
- Mean gradient + valve area assessment
- Pressure half-time method for valve area
- Severe MS: valve area < 1 cm²
Tricuspid Regurgitation (TR)
- Often functional from RV dilation + PHTN
- Severe TR: severe RV dilation, dilated annulus, vena contracta > 7 mm
1ïžâ£ TEE Specific Indications
TTE Limitations â TEE Considered
- Endocarditis: vegetations (TEE > TTE; especially prosthetic valve, posterior valves, paravalvular abscess)
- Atrial / mitral pathology: LAA thrombus (especially pre-cardioversion AF), mitral disease (rheumatic, MVP, posterior leaflet)
- Aortic dissection: TEE highly sensitive (especially ascending)
- Embolic source: LAA thrombus, PFO/ASD, aortic atheroma
- Intraoperative TEE: cardiac surgery + structural intervention (TAVR, MitraClip, MitraValve, etc.)
- Obese / COPD / mechanical ventilation: poor TTE windows
TEE Procedure
- Conscious sedation (often midazolam + fentanyl)
- Topical anesthesia
- Probe inserted through esophagus â mid-esophageal + transgastric views
- 30-60 min typically
TEE Risks
- Esophageal injury (rare)
- Esophageal perforation (very rare)
- Aspiration
- Sedation-related (respiratory depression)
- Bacteremia risk (transient, low; antibiotic prophylaxis no longer routine per IDSA 2024)
TEE Views
- Mid-esophageal: 4-chamber, 2-chamber, long axis
- Transgastric: short axis (LV, valves)
- Aortic views: ascending, descending
2ïžâ£ Stress Echo
Types
Exercise Echo
- Treadmill or bicycle (supine or upright)
- Most common
- ECG + echo at rest + peak + recovery
Pharmacologic Echo
- Dobutamine: progressive infusion â inotropic stress (max HR + contractility)
- Vasodilator (dipyridamole, adenosine, regadenoson): induces coronary steal (less used)
Indications
- Ischemia evaluation in patients unable to exercise (joint disease, etc.)
- Pre-operative cardiac risk assessment
- Viability assessment (low-dose dobutamine â biphasic response)
- Valve assessment under stress
Findings
- Inducible wall motion abnormality â ischemia
- Worsening EF at peak stress â ischemia
- Increased gradient at peak (AS) â worsening AS
Sensitivity / Specificity
- ~ 85% / 85% for CAD
- Comparable to nuclear stress
- Operator-dependent
3ïžâ£ POCUS (Point-of-Care Ultrasound)
Indications
- ED + ICU + clinic rapid assessment
- Cardiac arrest: PE, tamponade, severe LV dysfunction
- Shock: volume status, RV / LV function
- Acute dyspnea: HF vs PE vs pneumothorax vs effusion
- Trauma: pericardial effusion (FAST exam)
- Volume status: IVC, B-lines (lung POCUS)
Skills
- Basic 4-chamber + parasternal views
- IVC assessment
- Lung POCUS (B-lines, sliding sign)
- FAST exam (focused abdominal)
Training + Competence
- POCUS becoming standard in EM, IM, ICU, primary care
- Multi-specialty training programs
- Increasing literature on impact
4ïžâ£ Contrast Echo
Indications
- Suboptimal endocardial border definition
- LV thrombus assessment
- Right-to-left shunt (PFO with bubble study)
Contrast Types
Microbubbles (Definity, Optison, Lumason)
- Improves endocardial border
- Safe (perflutren-based)
- Rare allergic reactions
Agitated Saline (âBubble Studyâ)
- For right-to-left shunt detection (PFO, intra-pulmonary)
- During Valsalva for PFO
5ïžâ£ Strain Imaging + Advanced Techniques
Global Longitudinal Strain (GLS)
- Measures myocardial fiber shortening longitudinally
- Speckle tracking technology
- More sensitive than EF for early dysfunction
- Normal: -18% to -22% (more negative = better)
- Cardio-oncology: detects chemotherapy cardiotoxicity early
- HFpEF: GLS reduced despite normal EF
3D Echo
- More accurate chamber volumes + EF
- Valve morphology
- Real-time / intra-procedural guidance (TAVR, MitraClip)
Cardiac Magnetic Resonance Imaging (CMR â see Ch 261)
- Gold standard for myocardial structure + tissue characterization
- Echo complement for specific assessment
AI in Echo
- Automated EF estimation
- LV strain analysis
- Valvular assessment
- Image acquisition guidance
- FDA-approved AI tools (2023+)
6ïžâ£ Specific Patterns + Pearls
LV Hypertrophy Patterns
- Concentric (HTN, AS): thickened walls, normal chamber
- Eccentric (volume overload â AR, MR): thickened walls + dilated chamber
- HCM (asymmetric septal hypertrophy): septum disproportionate to free wall (ratio > 1.3)
- Athleteâs heart: physiologic hypertrophy (sometimes difficult to differentiate from HCM)
RV Dysfunction Patterns
- RV dilation
- RV hypokinesis
- RV/LV ratio > 1 in apical 4-chamber
- McConnellâs sign (RV free wall akinesis + apical sparing) â acute PE
- Septal flattening (D-shaped LV) â pressure / volume overload of RV
Pericardial Effusion
- Anechoic space surrounding heart
- Small / moderate / large / massive
- Tamponade signs:
- RA collapse during diastole
- RV collapse during early diastole
- IVC plethora (no inspiratory collapse)
- Doppler respiratory variation in MV inflow (> 25%) + TV inflow (> 40%)
LV Thrombus
- Often apical (post-MI)
- Apical akinesis + thrombus
- Contrast echo improves detection
Bicuspid Aortic Valve
- 2-cusp configuration
- Often associated with aortic dilation
- AS / AR more common
- Family screening for relatives
Hypertrophic Cardiomyopathy (HCM)
- Asymmetric septal hypertrophy (septum / free wall > 1.3)
- LVOT obstruction (SAM â systolic anterior motion of mitral valve)
- Dynamic obstruction with Valsalva
- Mitral regurgitation (often)
Cardiac Amyloidosis
- Concentric LVH (often disproportionate to clinical HTN)
- âSparklingâ echo texture
- Diastolic dysfunction
- Apical sparing on strain imaging (pathognomonic â cherry-on-top pattern)
- Right ventricular involvement
- Subtype: AL vs ATTR