Adult Echocardiography Protocol 13

Adult Echocardiography Protocol
Patient Position
o
For parasternal and apical views have the patient lie in the left lateral decubitus
(LLD) position with left arm raised above the head. Obtain an adequate ECG which
includes visualization of the P wave, QRS complex, and T wave.
For subcostal view have the patient lay on their back and bend their knees to soften
the abdominal muscles.
For suprasternal notch view have the patient lay on their back with a pillow under
their shoulders to allow for the probe to be rotated correctly
Cardiac Heart Beats

o
Capture 2 cardiac heart beats per cine loop unless an abnormal rhythm is present
Change the number of cardiac heart beats captured from 2 to 4-5 for patients with
the following abnormalities: atrial fibrillation, significant arrhythmias, rapid heart
rate (with a R wave to R wave greater than 500 m/sec on the ECG)
Gray Scale Imaging

o
Color Doppler
o
Adjust overall gain and TGC so that the ventricular and atrial cavities are anechoic
Adjust color gain until Doppler noise is seen, then decrease the gain down just
enough to eliminate the noise.
Too
Correct
Keep your color box narrow for better resolution
wide
Spectral Doppler
o
The angle of incidence should be less than 20
Obtain 3 consecutive waveforms, measuring the middle waveform
Continuous wave Doppler

o
Perform continuous wave Doppler tracing on all valves with a velocity greater than
2m/sec
For the mitral valve, include the pressure time
Perform continuous wave Doppler tracing on all valve replacements and repairs
Cw/backup/protocols/adult echo protocol 13

1

*Asterisk within the protocol indicates images or measurements may not be
utilized at all clinical sites. Students are still responsible for knowing how to
correctly obtain the images or measurements.
Parasternal Window from the Long Axis Scan Plane

Structure
Image Stored
Left
Ventricle
(LV)
Acquire cine loop 2D image at a depth of 15-20cm
Left
Ventricle
(LV)
Acquire cine loop 2D image at a reduced depth so image fills field of view
Aortic Valve
(AV)
M-mode sweep of aortic valve freeze and acquire DO NOT UNFREEZE THIS
IMAGE
Aortic Valve
(AV)
*Measure the following on the aortic valve M-mode:

Aortic root end-diastolic dimension
Measure the vertical distance from the outer edge of the anterior
aortic root to the inner edge (leading edge to leading edge) of the
posterior aortic wall at end-diastole.
Normal range 2.0-3.7 cm

LA end-systolic dimension
Measure greatest vertical distance between the anterior side of the

posterior aortic wall and the anterior side of the posterior left atrial
wall (leading edge to leading edge) at end ventricular systole when
the aorta is in its maximal anterior position.
Normal range 1.9-4.0cm

Aortic valve systolic separation
Measure the maximal opening of the aortic valve cusps during the
initial part of ventricular systole, using the internal borders of the
aortic cusps.

M-mode sweep of mitral valve freeze and acquire DO NOT UNFREEZE THIS
IMAGE
Mitral Valve
(MV)
Mitral Valve
(MV)
*Measure the following with the mitral valve M-mode:

E-F slope
Measure the distance of the steepest initial portion of the anterior

MV leaflet by placing a caliper on the steepest point of early
diastole and then place a caliper at the end of the slope.
Normal range is 70-150 mm/s.

E Point Septal Separation (EPSS)
Measure the vertical distance from the MV E point to the lowest

point of the IVS.
2

Normal range is 2-7 mm.

Structure
Image Stored
Left
Ventricle
(LV)
M-mode sweep of left ventricle freeze and acquire DO NOT UNFREEZE THIS
IMAGE
Left
Ventricle
(LV)
*Measure the following with the left ventricle M-mode:

Interventricular Septum in diastole (IVSd)
Measure the diastolic thickness of the IVS as the vertical distance

from the RV side of the IVS to the LV side of the IVS in end-diastole
at a point corresponding to the onset of the QRS complex.

Left Ventricle Inner diameter in diastole (LVIDd)
Measure the vertical distance from the endocardium of the IVS to

the endocardium of the PWLV in end-diastole at a point
corresponding to the onset of the QRS complex.
Normal range 3.7 5.6 cm

Left Ventricle Posterior Wall in diastole (LVPWd)
Measure the vertical distance from the endocardium of the LVPW to

the epicardium in end-diastole at a point corresponding to the onset
of the QRS complex.

Interventricular Septum in systole (IVSs)
Measure the systolic thickness of the IVS as the maximal vertical

distance that occurs between the RV and LV sides of the IVS at
ventricular systole
Left Ventricle Inner Diameter in systole (LVIDs)
Measure the vertical distance from the endocardium of the IVS at

the lowest point of the septal motion to the endocardium of the
LVPW in end-systole.

Left Ventricle Posterior Wall in systole (LVPWs)
Measure the systolic thickness of the LVPW at the maximal vertical

distance that occurs between the endocardium and epicardium at
end-ventricular systole

3
Left
Ventricle
(LV)
Aortic Valve
Zoomed
Aortic Valve
Zoomed
Mitral Valve
Zoomed
Aortic and

Freeze 2D image of left ventricle:
Scroll back to end diastole and measure the following:
*Right Ventricular Minor Axis in diastole (RVIDd)
Measure the inner edge to inner edge dimension is measured at the

same level as the LV minor axis dimensions parallel to this
measurement.
Normal range is 1.9-3.8 cm

Interventricular Septum in diastole (IVSd)
Measure the vertical distance from the RV side of the IVS to the LV
side of the IVS at end-diastole.
Normal range is 0.6 1.2cm

LV minor axis end-diastole (LVIDd)
Measure the vertical distance from the endocardium of the IVS to

the endocardium of the LVPW at end-diastole.
Normal range is 3.5 5.6 cm.

LV Posterior Wall Diastolic Thickness (LVPWd) = Measure the vertical
distance from the endocardium of the LVPW to the epicardium at enddiastole.
Normal range is 0.6 1.2cm
Acquire still frame DO NOT UNFREEZE THE IMAGE!
From the previous frozen image, scroll forward to end systole and measure the
following:
LV minor axis end-systole (LVIDs)
Measure the vertical distance from the endocardium of the IVS to the
endocardium of the PWLV at end-systole.
Normal range is 2.0-4.0 cm.

LA end-systole (LAs)
Measure the LA at the aortic valve plane, also perpendicular to the

aortic root. This is an inner edge to inner edge measurement.
Normal range is 2.3 3.8 cm.

Acquire still frame
Freeze 2D image of aortic valve
Scroll back to end diastole
Measure aortic root at end-diastole with the valve plane perpendicular to
the wall of the aortic root at the sinus of Valsalva. Measure inner edge to
inner edge.
Acquire still frame w/measurement DO NOT UNFREEZE THE IMAGE!
From the previous frozen image, scroll forward to mid systole:
Measure left ventricular outflow track diameter (LVOT) from the base of
the aortic valve RCC leaflet to the base of the anterior MV leaflet.
Normal measurement 2.cm
Acquire still frame w/measurement
Acquire cine loop of 2D image of mitral valve
Acquire cine loop of Color Doppler across both mitral valve & aortic valve

4

Mitral Valve

Structure
RVIT
RVIT
RVIT
*RVOT
*RVOT
*RVOT
*RVOT
Image Stored
Right ventricular inflow track (RVIT)
Acquire cine loop of 2D image of right ventricular inflow track (RVIT)
Acquire cine loop of color Doppler across the tricuspid valve(TV)
Acquire continuous wave Doppler across the tricuspid valve IF tricuspid
regurgitation present
Right ventricular outflow track (RVOT)
Acquire cine loop of 2D image of right ventricular outflow track (RVOT)
Acquire cine loop of color Doppler across the pulmonary valve (PV)
Acquire pulsed wave Doppler across the pulmonary valve and measure peak
velocity
Acquire continuous wave Doppler across the pulmonary valve IF pulmonary
regurgitation present
Parasternal Window from the Short Axis Scan Plane
Structure
AV, TV, PV
Pulmonary
Valve
Image Stored
Acquire cine loop of 2D image of aortic valve, tricuspid valve, and pulmonary
valve
Acquire cine loop of color Doppler across the Pulmonary artery/valve
Pulmonary
Valve
Acquire pulse wave at pulmonary leaflet tips & measure maximum velocity.
Normal range 0.6-1.0 m/s
Pulmonary
Valve
Acquire continuous wave through pulmonary valve for pulmonary valve flow and
pulmonary insufficiency with measurements

5
Aortic Valve
Zoomed

Acquire cine loop of 2D image of the aortic valve & atrial septal wall
Aortic Valve
not Zoomed
Acquire cine loop of color Doppler across the aortic valve
Tricuspid
Valve
Acquire cine loop of color Doppler across the tricuspid valve for tricuspid
regurgitation
Left
Ventricle &
Mitral Valve
Acquire cine loop of 2D image of left ventricle at level of the mitral valve
Left
Ventricle &
Mitral Valve
Acquire cine loop of color Doppler of left ventricle at level of the mitral valve
across the septal wall & mitral valve
Left
Ventricle &
Papillary
muscles
Apex of LV
Acquire cine loop of 2D image of left ventricle at level of the papillary muscles
Acquire cine loop of 2D image of left ventricle apex
Apical Window 4 Chamber Scan Plane

Structure
Image Stored
4 Chamber
Acquire cine loop of 2D image showing all 4 chambers
4 Chamber
Acquire cine loop of color Doppler of flow across mitral valve & left atrium for
mitral regurgitation
Acquire pulse wave Doppler at the tips of the mitral valve leaflets and freeze
image:
Measure E to A & descending slope
Acquire image with measurement
Acquire continuous wave Doppler across mitral valve and freeze image:
Measure peak velocity of mitral regurgitation if present
Acquire pulse wave Doppler at the opening of the pulmonary vein and freeze
image:
Documenting the systolic and diastolic forward flow
Acquire 2D image with a decreased depth demonstrating the left ventricle and
1/3 of the left atrium
4 Chamber
4 Chamber
4 Chamber
Left
Ventricle &
Left Atrium
Left
Ventricle &
Left Atrium
Acquire cine tissue Doppler imaging (TDI) of left ventricle and 1/3 of the left
atrium:

6
Left
Ventricle &
Left Atrium

Using TDI acquire pulse Doppler from the lateral aspect of the mitral valve
annulus:
Measure E prime
Apical Window 5 Chamber Scan Plane
Structure
5 Chamber
5 Chamber
5 Chamber
5 Chamber
Image Stored
Acquire cine loop 2D image of left atrium, left ventricle, aorta, right atrium, &
right ventricle
Acquire cine loop color Doppler across the aortic valve
Acquire continuous wave Doppler across the aortic valve:
Measure peak velocity (If continuous wave Doppler gradient is over 2
m/sec trace the spectral envelope)
Normal range is 1.0 1.7 m/s
Acquire pulse wave Doppler of left ventricle outflow track:
Measure peak velocity of the left ventricle outflow track.
Normal range is 0.7 - 1.1 m/s
Apical Window 4, 3, & 2 Chamber Scan Plane

Structure
Image Stored
RV, TV, RA
Acquire cine loop of color Doppler across the tricuspid valve
RV, TV, RA
Acquire continuous wave Doppler across the tricuspid valve IF tricuspid

regurgitation:
Measure tricuspid regurgitation
*Biplane Simpsons Method:
Acquire an apical 4 chamber image and freeze
Scroll to end-diastole and trace the LV cavity and store image
Measure the length of the LVED from the mid mitral annulus to the cardiac
apex and store image
This will give you the LV ED volume DO NOT UNFREEZE THE IMAGE
Scroll to end-systole and trace the LV cavity and store image
This will give you the LV ES volume
4 Chamber
2 Chamber
LV, MV, LA
*Biplane Simpsons Method:

Acquire an apical 4 chamber image and freeze
Scroll to end-diastole and trace the LV cavity and store image

7

This will give you the LV ED volume DO NOT UNFREEZE THE IMAGE
Scroll to end-systole and trace the LV cavity and store image
This will give you the LV ES volume
2 Chamber
Acquire cine loop of 2D image of the left atrium & left ventricle
2 Chamber
Acquire cine loop of color Doppler across the mitral valve
2 Chamber
3 Chamber
Acquire cine loop of 2D image decreasing depth to demonstrate the left ventricle
& 1/3 of the left atrium
Acquire cine loop of 2D image of the left atrium, left ventricle, & aortic valve
3 Chamber
Acquire cine loop of color Doppler across the mitral valve & aortic valve
3 Chamber
Acquire cine loop of 2D image decreasing depth to demonstrate the left ventricle
& 1/3 of the left atrium
Acquire cine loop of 2D image of 4 chamber demonstrating the left ventricle on
the LEFT side of the SCREEN & the right ventricle on the RIGHT side of the
SCREEN (Mayo Clinic)
4 Chamber
Subcostal Window Long Axis Scan Plane

Structure
Image Stored
4 Chamber
Acquire cine loop 2D image of 4 chambers
4 Chamber
Acquire cine loop color Doppler across the Interatrial septum (IAS)
4 Chamber
Acquire cine loop color Doppler across the interventicular septum
4 Chamber
Acquire cine loop color Doppler across the mitral valve & tricuspid valve
IVC
Aorta
Acquire cine loop 2D image of inferior vena cava for collapse (change EKG to 5
beats)
Acquire cine loop 2D image of the aorta
Aorta
Acquire cine loop color Doppler of the aorta
Subcostal Window Short Axis Scan Plane

Structure
8
Image Stored

Acquire cine loop color Doppler across inferior vena cava & hepatic vein (change
EKG to 2 beats)
IVC
Suprasternal Notch Window Long Axis Scan Plane

Structure
Image Stored
Aortic arch
and
Descending
aorta
Acquire cine loop 2D image of the aortic arch and descending aorta
Aortic arch
and
Descending
aorta
Acquire cine loop color Doppler flow of the descending aorta
Aortic arch
and
Descending
aorta
Acquire continuous wave Doppler through the descending aorta
Tips
Pharmaceutical Contrast
o
May be utilized upon receiving a written order from the physician.
Pharmaceutical contrast is indicated for use in patients with 2 or more suboptimal

wall segments of the left ventricular endocardial borders.
Pharmaceutical contrast is contraindicated for patients with known or suspected:
Right-to-left and bi-directional cardiac shunts
Cardiovascular or pulmonary compromise
Hypersensitivity to perflutren (lipid micro gas), blood products or albumin

(egg white allergy)
Aortic Stenosis Additional Views

o
Interrogate the aortic outflow with non-imaging pedoff probe from the suprasternal
notch window.

9

Reposition the patient to right lateral decubitus (RLD) position and interrogate the
aortic outflow with non-imaging pedoff probe from the right Parasternal window.
Acquire multiple spectral Doppler waveforms from both windows and measure to
determine the highest velocity documented.
Technically difficult exams

o
Document normal cardiac windows with limited views
Utilize modified views to acquire diagnostic images for physician interpretation
Biplane Simpsons Method of Discs: Uses the summation of the areas from the diameters of 20
cylinders or discs of equal height is used to calculate the end- diastolic volume, end-systolic
volume, stroke volume, cardiac output, cardiac index, and ejection fraction.
Labs:
Troponin: an elevated troponin may indicate a myocardial infarction
BNP (Brain natriuretic peptide: an elevated BNP is an indication of the myocardial

tissue being stretched as in the case of CHF

10

Adult Echocardiography Protocol 13

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Adult Echocardiography Protocol

Cardiac Heart Beats

Gray Scale Imaging

The angle of incidence should be less than 20

Obtain 3 consecutive waveforms, measuring the middle waveform

Continuous wave Doppler

For the mitral valve, include the pressure time

Cw/backup/protocols/adult echo protocol 13