<unk>  directional flow in CW and PW in apical, parasternal short:
Below the line for pulmonic and aortic valves (systole)
Above the line in tricuspid and mitral valves (diastole)
Coronary artery distributions
LAD, circumflex, RCA
Left marginal = obtuse marginal
Right marginal
Below the line for pulmonic and aortic valves (systole)
Above the line in tricuspid and mitral valves (diastole)
LAD, circumflex, RCA
Left marginal = obtuse marginal
Right marginal
Assess for mitral valve prolapse, systolic anterior motion
Differentiate pleural effusion from pericardial effusion
Pericardial effusion is anterior to descending aorta
Pleural effusion posterior to descending aorta
Pericardial effusion is anterior to descending aorta
Pleural effusion posterior to descending aorta
Pericardial effusion vs. pleural effusion
Wall motion assessment obtains LAD and Circumflex coronary artery distributions
EPSS, E-Point Septal Separation in PSL view
M-mode distance in mm between anterior leaflet of MV and septum in diastole
E-point is shortest distance
LVEF = 75.5 - 2.5 x EPSS in mm
EPSS and MRI LVEF correlated ~0.80 in study that generated equation
Excluded MV prostheses, asymmetrical septal hypertrophy, significant aortic regurgitation
Values as calculated by above study
< 5 mm,<unk> 
> 7 mm, EF < 50%
> 18 mm, EF < 30%
Falsely elevated EPSS in:
Mitral stenosis, rheumatic heart disease
Mitral calcification
Aortic regurgitation
LV dilation
M-mode distance in mm between anterior leaflet of MV and septum in diastole
E-point is shortest distance
LVEF = 75.5 - 2.5 x EPSS in mm
EPSS and MRI LVEF correlated ~0.80 in study that generated equation
Excluded MV prostheses, asymmetrical septal hypertrophy, significant aortic regurgitation
Values as calculated by above study
< 5 mm,<unk> 
> 7 mm, EF < 50%
> 18 mm, EF < 30%
Falsely elevated EPSS in:
Mitral stenosis, rheumatic heart disease
Mitral calcification
Aortic regurgitation
LV dilation
EPSS and MRI LVEF correlated ~0.80 in study that generated equation
Excluded MV prostheses, asymmetrical septal hypertrophy, significant aortic regurgitation
< 5 mm,<unk> 
> 7 mm, EF < 50%
> 18 mm, EF < 30%
Mitral stenosis, rheumatic heart disease
Mitral calcification
Aortic regurgitation
LV dilation
See Aortic stenosis regarding evaluation of cuspidity
Evaluate kinetics of LV motion anatomically by coronary artery flow
Best obtained in left lateral decubitus with left arm above head to open up ribs
EF estimation
LVEF by Simpson, LV volume change
LVEF by Teichholz method, using M-mode (estimation of LV volume by diameter measured just beyond mitral tips in diastole)
EF visual assessment:
>65% = hyperdynamic
55-65% =<unk> 
45-54% = mildly depressed
30-44% = moderately depressed
<30% = severely depressed
Evaluation for wall motion abnormality
LVEF by Simpson, LV volume change
LVEF by Teichholz method, using M-mode (estimation of LV volume by diameter measured just beyond mitral tips in diastole)
EF visual assessment:
>65% = hyperdynamic
55-65% =<unk> 
45-54% = mildly depressed
30-44% = moderately depressed
<30% = severely depressed
>65% = hyperdynamic
55-65% =<unk> 
45-54% = mildly depressed
30-44% = moderately depressed
<30% = severely depressed
Infrequently used unless concern exists for full evaluation of wall motion abnormality in LV
Obtains better views of RCA and LAD distribution
See Aortic stenosis for<unk>  echo evaluation
See Mitral stenosis for<unk>  echo evaluation
Worsening diastolic dysfunction corresponds to less fluid responsive hypotension and more volume overload
Septic/hypotensive patients with baseline diastolic dysfunction will not have reliable IVC ultrasounding for fluid responsiveness
Pts in impaired relaxation states can stand to be volume resuscitated just until impaired relaxation becomes pseudonormal
Otherwise seen as the E wave ≈ A wave (give fluids until E wave increases up to A wave)
If still hypotensive at that point, pt volume resuscitated, then start vasopressors
Patients with pseudonormal or worse diastolic dysfunction require vasopressors, not more fluids
Measure E and A waves, then e' and a' waves with tissue doppler
PW Doppler across MV in apical view bisecting across MV tips during opening, diastole
Tissue doppler at MV annulus (base) at either septum or lateral position to measure tissue velocity
E/e' ratio ≅ LVEDP (PCWP)
Septic/hypotensive patients with baseline diastolic dysfunction will not have reliable IVC ultrasounding for fluid responsiveness
Pts in impaired relaxation states can stand to be volume resuscitated just until impaired relaxation becomes pseudonormal
Otherwise seen as the E wave ≈ A wave (give fluids until E wave increases up to A wave)
If still hypotensive at that point, pt volume resuscitated, then start vasopressors
Patients with pseudonormal or worse diastolic dysfunction require vasopressors, not more fluids
PW Doppler across MV in apical view bisecting across MV tips during opening, diastole
Tissue doppler at MV annulus (base) at either septum or lateral position to measure tissue velocity
E/e' ratio ≅ LVEDP (PCWP)
The following rules will apply to most patients(Video)
Evaluate the E' and A' in tissue doppler to differentiate<unk>  diastolic function from pseudonormalization
Septal MV annulus TD, E' magnitude less than 8 cm/s suggestive of diastolic dysfunction
Lateral MV annulus TD, E' < 10 cm/s suggestive of diastolic dysfunction
Septal MV annulus TD, E' magnitude less than 8 cm/s suggestive of diastolic dysfunction
Lateral MV annulus TD, E' < 10 cm/s suggestive of diastolic dysfunction
Formal echocardiography
Cardiac ultrasound
Bubble study
Thrombolytics for STEMI
Aortic ultrasound
Age adjusted D-dimer
CT brain interpretation
Thromboelastography 