Guidelines for Performing a Comprehensive Transthoracic ...

1 Guidelines AND STANDARDSG uidelines for Performing a ComprehensiveTransthoracic Echocardiographic Examinationin Adults: Recommendations from the AmericanSociety of EchocardiographyCarol Mitchell, PhD, ACS, RDMS, RDCS, RVT, RT(R), FASE, Co-Chair, Peter S. Rahko, MD, FASE, Co-Chair,Lori A. Blauwet, MD, FASE, Barry Canaday, RN, MS, RDCS, RCS, FASE, Joshua A. Finstuen, MA, RT(R),RDCS, FASE, Michael C. Foster, BA, RCS, RCCS, RDCS, FASE, Kenneth Horton, ACS, RCS, FASE,Kofo O. Ogunyankin, MD, FASE, Richard A. Palma, BS, RDCS, RCS, ACS, FASE, and Eric J. Velazquez, MD,FASE,Madison, Wisconsin; Rochester, Minnesota; Klamath Falls, Oregon; Durham, North Carolina; Salt Lake City,Utah; Ikoyi, Lagos, Nigeria; and Hartford, ConnecticutKeywords: Transthoracic echocardiography , Doppler echocardiography , Color Doppler echocardiography , Comprehensive examination, ProtocolTABLE OF CONTENTSI.

2 Introduction 3II. Nomenclature 4A. Image Acquisition Windows 4B. Scanning Maneuvers 5C. Measurement Techniques 5 III. Instrumentation 5A. Two-Dimensional Imaging 51. Grayscale Maps 52. B-mode Colorization 63. Dynamic Range 64. Transmit Frequency 65. Harmonic Imaging 76. Sector Size and Depth 87. Transducer Beam Focus 88. Overall Gain and Time-Gain Compensation 8 ThisdocumentisendorsedbythefollowingAmer icanSocietyofEchocardiographyInternation alAlliancePartners:Argentine Federation of Cardiology, Argentine society of Cardiology, ASEAN society of echocardiography ,Australasian Sonographers Association,British society of echocardiography , Canadian society of echocardiography ,Chinese society of echocardiography , Department of Cardiovascular Imaging of the Brazilian society of Cardiology,Indian Academy of echocardiography , Indian Association of Cardiovascular Thoracic Anaesthesiologists, IndonesianSociety of echocardiography , InterAmerican Association of echocardiography , Iranian society of echocardiography ,IsraelWork Group on echocardiography , Italian Association of Cardiothoracic Anaesthesiologists, Japanese society ofEchocardiography, Korean society of echocardiography .

3 National society of echocardiography of Mexico, PhilippineSociety of echocardiography , Saudi Arabian society ofEchocardiography, Thai society of echocardiography ,Vietnamese society of the University of Wisconsin School of Medicine and Public Health, Madison,Wisconsin ( , ); the Mayo Clinic, Rochester, Minnesota ( , );the Oregon Institute of Technology, Klamath Falls, Oregon ( ); DukeUniversity Medical Center, Durham, North Carolina ( , );Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City,Utah ( ); First Cardiology Consultants Hospital, Ikoyi, Lagos, Nigeria ( );and St. Francis Hospital and Medical Center, Hartford, Connecticut ( ).This document is endorsed by the following American society of Echocardiogra-phy International Alliance Partners: the Cardiovascular Imaging Department ofthe Brazilian society of Cardiology, the Chinese society of echocardiography ,the Indian Academy of echocardiography , the Japanese society of Echocardiog-raphy, the InterAmerican Association of echocardiography , the Italian Associationof Cardiothoracic following authors reported no actual or potential conflicts of interest in relationto this document: Peter S.

4 Rahko, MD, FASE, Lori A. Blauwet, MD, FASE, BarryCanaday, RN, MS, RDCS, RCS, FASE, Joshua A. Finstuen, MA, RT(R), RDCS,FASE, Michael C. Foster, BA, RCS, RCCS, RDCS, FASE, Kenneth Horton, ACS,RCS, FASE, Kofo O. Ogunyankin, MD, FASE. The following authors reported rela-tionships with one or more commercial interests: Carol Mitchell, PhD, ACS, RDMS,RDCS, RVT, RT(R), FASE, authored a textbook for Davies Publishing Inc., andauthorship with royalties for Elsevier and Wolters-Kluwer. Richard A. Palma, BS,RDCS, RCS, ACS, FASE, has served on the speakers bureau for Lantheus MedicalImaging and as a faculty speaker for Gulf Coast Ultrasound. Eric J. Velazquez, MD,FASE, received cardiovascular research grants from the National Institutes ofHealth/National Heart, Lung, and Blood Institute, Alnylam Pharmaceuticals, Am-gen, General Electric, Novartis Pharmaceutical, and Pfizer and has served as aconsultant for ABIOMED, Amgen, Merck, New Century Health, Novartis Pharma-ceutical, and Philips Ultrasound.

5 * Reprint requests: American society of echocardiography , Meridian CorporateCenter, 2530 Meridian Parkway, Suite 450, Durham, NC 27713 ASE Members:Visit earn free continuing medical education credit throughan online activity related to this article. Certificates are available for immediate accessupon successful completion of the activity. Nonmembers will need to join the ASE toaccess this great member benefit!0894-7317/$ 2018 by the American society of Zoom/Magnification 810. Frame Rate 8B. Spectral Doppler 81. Velocity Scale 82. Sweep Speed 83. Sample Volume Size 104. Wall Filters and Gain 105. Display Settings 126. Pulsed-Wave Doppler, High Pulse Repetition Frequency Doppler,and CW Doppler 127.

6 Doppler Tissue Imaging 15C. Color Doppler Imaging 17 Abbreviations2D= Two-dimensional3C= Three-chamber (apical long axis)3D= Three-dimensional4C= Four-chamber5C= Five-chamberA2C= Apical two-chamberA4C= Apical four-chamberAbd Ao= Abdominal aortaALPap= Anterolateral papillary muscleAMVL= Anterior leaflet mitral valveAo= AortaAR= Aortic valve regurgitationAsc Ao= Ascending aortaASE= American society of EchocardiographyAV= Aortic valveCDI= Color Doppler imagingCS= Coronary sinusCW= Continuous-waveDesc Ao= Descending aortaDTI= Doppler tissue imagingHPRF= High pulse repetition frequencyHvns= Hepatic veinIAS= Interatrial septumInnom a= Innominate arteryIVC= Inferior vena cavaIVS= Interventricular septumLA= Left atrialLCC= Left coronary cuspLCCA= Left common carotid arteryL innom vn= Left innominate veinLSA= Left subclavian arteryLV= Left

7 VentricularLVIDd= Left ventricular internal dimension diastoleLVIDs= Left ventricular internal dimension systoleLVOT= Left ventricular outflow tractLVPW= Left ventricle posterior wallMPA= Main pulmonary arteryMR= Mitral valve regurgitationMS= Mitral stenosisMV= Mitral valveNCC= Noncoronary cuspPA= Pulmonary arteryPFO= Patent foramen ovalePLAX= Parasternal long-axisPMPap= Posteromedial papillary musclePMVL= Posterior leaflet mitral valvePR= Pulmonic valve regurgitationPRF= Pulse repetition frequencyPSAX= Parasternal short-axisPulvn= Pulmonary veinPV= Pulmonic valvePW= Pulsed-waveRA= Right atriumRCA= Right coronary arteryRCC= Right coronary cuspR innom vn= Right innominate veinROI= Region of interestRPS= Right parasternalRV= Right ventricularRVIDd= Right ventricular internal dimension diastoleRVOT= Right ventricular outflow tractSC= SubcostalSoVAo= Sinus of ValsalvaSSN= Suprasternal notchSTJ= Sinotubular junctionSVC= Superior vena cavaTAPSE= Tricuspid annular plane systolic excursionTGC= Time-gain compensationTR= Tricuspid valve regurgitationTTE= Transthoracic echocardiographicTV= Tricuspid valveUEA= Ultrasound enhancement agentVTI= Velocity-time integral2 Mitchell et alJournal of the American society of EchocardiographyJanuary 20191.

8 ROI and 2D Sector Size 172. Color Gain 173. Color Maps 174. Color Doppler Velocity Scale 17D. M Mode 181. Color M Mode 182. Steerable M Mode 18E. Electrocardiographic Setup 18IV. Two-Dimensional Imaging Protocol 23A. PLAX View 231. PLAX View: Left Ventricle 252. Right Ventricular Outflow Tract View 253. Right Ventricular Inflow View 25B. PSAX Views 25C. Apical Views 261. A4C View 262. Right Ventricle Focused View 263. Apical Five-Chamber View 264. CS View 265. Two-Chamber View 306. Apical Long-Axis View (Three-Chamber View) 307. A4C and A2C Views Demonstrating the Atria and Pulvns 30D. SC Window and Views 311. SC Four-Chamber View 312. SC Short-Axis View 31E. SSN Long-Axis View 31V. Two-Dimensional Measurements 31A.

9 PLAX View 311. Left Ventricle 312. Proximal RVOT 313. Anterior to Posterior LA Measurements 314. LVOT and Aortic Annulus 315. Asc Ao 32B. PSAX View 331. RVOT 332. PA 33C. Apical Views 331. LV Volume 33a. Biplane Disk Summation 33b. Three-Dimensional LV Volume 332. LAVolume 333. RV Linear Dimensions 334. RVArea 335. Right Atrial Volume 33D. SC Views 371. IVC 37VI. M-Mode Measurements 37A. TAPSE 37B. IVC 37C. AV 37 VII. CDI 37A. RVOT, Pulmonary Valve, and PA 41B. RV Inflow and TV 41C. LV Inflow and MV 41D. LVOT and AV 42E. Aortic Arch 42F. Pulvns 42G. Hvns 42H. IVC 42I. Atrial Septum 42 VIII. Spectral Doppler Imaging Measurements 42A. RVOT and Pulmonary Valve 43B. TV 43C. MV 43D.

10 LVOT and AV 43E. Aortic Arch and Desc Ao 46F. Hvns 46G. Pulvns 46H. Tissue Doppler of the Mitral and Tricuspid Annuli 48IX. Additional Techniques 48A. Agitated-Saline Imaging 48B. UEA Imaging 491. Indications 492. Instrumentation and Administration 543. Image Acquisition 54C. Strain Imaging 54D. Three-Dimensional Evaluation of LV Size and Systolic Function 55X. The Integrated Complete Transthoracic Examination 55XI. The Limited Transthoracic Examination 55A. Pericardial Effusion 55B. LV Function 55C. Limited Right Ventricle and Pulmonary Hypertension 55 XII. References 56 XIII. Appendix: Additional Alternative Views 59A. PSAX Coronary Artery View 59B. RVA2C View 59C. SC SVC (Bicaval) View 59D.