Cardiac Structures for Echo

Most of the left-lateral and diaphragmatic surface of the heart is formed by the left ventricle (LV), also forming a large part of the apex. It is located left posterior to the right ventricle and left anterior-inferior to the left atrium. The myocardium in the wall of the LV is approximately two to three times thicker than that of the right ventricle. The base of the LV chamber is occupied by the left atrioventricular orifice and the aortic orifice which are located closely. The former is positioned posteriorly and to the left. The aortic orifice is to the right-anterior and slightly superior to the left atrioventricular orifice. (EACVI Textbook, p.123)

It should be pointed out that the spatial descriptions of the two sets of papillary muscles have been made with the heart opened on its obtuse aspect and with the apex pointing down. If reorienting the heart as it should be in the thoracic cavity (i.e. its long axis to the left and inferiorly), the anterior papillary group is in fact superior, mural, and to the left, and the posterior papillary group is inferior, septal, and to the right. (EACVI Textbook, p.123 — attitudinally-correct orientation)

The primary reference points on the heart are the apex, defined as the tip of the LV, and the base, defined by the plane of the atrioventricular (e.g., mitral and tricuspid) valves. (Otto, Clinical Echocardiography 6e, Ch.2)

The RV is the most anteriorly positioned cardiac chamber, located immediately behind the sternum. It is thin-walled with prominent trabeculations and a complex geometry. Under normal loading conditions, the RV has a triangular shape when viewed from the side, and a crescentic shape in the sagittal plane, wrapping around the conical left ventricle. (BSE Right Heart guideline)

Most of the left-lateral and diaphragmatic surface of the heart is formed by the left ventricle (LV), also forming a large part of the apex. It is located left posterior to the right ventricle and left anterior-inferior to the left atrium. (EACVI Textbook, p.123)

The left atrium is seen posterior to the aorta and has an anteroposterior diameter similar to that of the aortic sinuses in normal adults. The coronary sinus is seen in the atrioventricular groove posterior to the mitral annulus. (Otto, Clinical Echocardiography 6e, Ch.2)

The RV is the most anteriorly positioned cardiac chamber, located immediately behind the sternum. (BSE Right Heart guideline)

This is because the anterior retrosternal position of the RVOT in the thorax means that sternum or lung tissue can commonly shadow the RVOT, even if an alternative rib space is attempted. (BSE Right Heart guideline)

Transoesophageal echo is used when transthoracic data is incomplete, although the anterior position of the right heart means that transthoracic imaging is often superior. (BSE Tricuspid & Pulmonary Valve guideline)

The fibrous skeleton of the heart ... is based on three U-shaped cords that form the aortic annulus. Extensions of these cords form the left and right trigones, which together form the mitral annulus. (Practical Perioperative TOE, pp.132–133)

the posterior mitral annulus is muscular. However, the anterior annulus consists of fibrous tissue made up of the left and right trigones, and is continuous with the fibrous skeleton of the heart. (BSE Mitral Valve guideline)

The fibrous continuity between the aortic root and the anterior mitral leaflet (absence of intervening myocardium) helps identify the anatomic LV in complex congenital disease. (Otto, Clinical Echocardiography 6e, Ch.2)

Transthoracic images typically are obtained from parasternal, apical, subcostal, and suprasternal notch acoustic windows. (Otto, Clinical Echocardiography 6e, Ch.2)

Echocardiographic examination is usually performed with the patient in the left lateral decubitus position... Subcostal images are obtained by placing the patient in the supine position... For suprasternal views the transducer should be placed in the suprasternal notch, with the patient in the supine position. (EACVI Textbook, p.15)

Views to be obtained: PLAX Parasternal long axis / PLAX Tilted RV inflow / PLAX Tilted RV outflow / PSAX Parasternal short axis: AV, MV, LV: base, mid, apex / PSAX RV inflow / PSAX RV outflow / A4C Apical four chamber / A5C Apical five chamber / A4C Modified A4C for RV / A4C Optimised for LA volume measure / A2C Apical two chamber / A2C Optimised for LA volume measure / A3C Apical three chamber / SC Subcostal / Subcostal cardiac chambers and IAS / Subcostal IVC, heptic vein and abdominal Ao / SSN Suprasternal. (BSE minimum dataset, Appendix 1)

Each tomographic image is defined by its acoustic window (the position of the transducer) and view (the image plane). The standard three orthogonal echocardiographic image planes are determined by the axis of the heart itself (with the LV as the major point of reference), rather than by skeletal or external body landmarks. (Otto, Clinical Echocardiography 6e, Ch.2)

The parasternal long-axis view in diastole shows: the closed right and noncoronary cusps of the aortic valve; the aortic sinuses, sinotubular junction, and proximal ascending aorta; the open anterior and posterior mitral valve leaflets; the basal and mid-ventricular segments of the anterior septum and posterior LV wall; the RV outflow tract anteriorly, and the coronary sinus in the atrioventricular groove. (Otto, Clinical Echocardiography 6e, Ch.2)

The parasternal long-axis view (PLAX) is obtained with the patient in the left lateral decubitus position and the transducer placed in the left third or fourth intercostal space near the sternum. ... this view is the best plane to measure the dimensions of the left cardiac ventricle. The right ventricle is the upper structure in the image. The left ventricle is found below the right ventricle. This plane allows the anterior septum (up) and the lateral and inferior (classically called posterior, down) walls to be seen. ... The aortic root, with the sinuses of Valsalva, the sinotubular junction, and the most proximal part of the ascending aorta is on the right side of the image. ... In this view, the upper aortic cusp corresponds to the right coronary cusp and the lower one to the non-coronary cusp. ... The anterior leaflet is in close continuity with the non-coronary aortic valve cusp. ... The coronary sinus can be visualized as an echo-free structure at atrioventricular groove level. (EACVI Textbook, p.17)

Imaging in the standard PLAX plane demonstrates MV scallops A2 and P2. (BSE minimum dataset)

Scan depth is reduced to maximise the PLAX view with around 1 cm beyond the pericardium remaining within the image. (BSE minimum dataset)

Short-axis views are obtained from the parasternal window by rotating the transducer clockwise 90° and then moving or angulating the transducer superiorly or inferiorly to obtain specific image planes. At the aortic valve level, the short-axis view demonstrates all three aortic valve leaflets: right, left, and noncoronary cusps. In systole, the aortic leaflets open to a near-circular orifice. At the mid-ventricular (or papillary muscle) level, the normal LV is circular in the short-axis view. (Otto, Clinical Echocardiography 6e, Ch.2)

The PSAX view at the level of the aortic valve is the most basal plane. The aortic valve is clearly seen in the central region of the image with its three leaflets in a characteristic Y-shape configuration. The right ventricular outflow tract is wrapped anterior to the aortic valve; the pulmonary valve can be visualized rightward and anterior to the aortic valve... The tricuspid valve is visualized to the left of the aortic valve. (EACVI Textbook, p.18)

PSAX at mitral valve level: This view is defined by the imaging of the mitral valve as two parallel thin structures, with the anterior leaflet in upper position and the posterior leaflet in the lower portion of the image. The left ventricle is visualized in circular cross-section and the right ventricle is in the left anterior portion of the image. (EACVI Textbook, p.18)

PSAX at papillary muscle level: It is possible to visualize a mid-ventricular circular cross-section of the left ventricle and the anterolateral and posteromedial papillary muscles inside the ventricular cavity at 3 and 8 o'clock positions, respectively. (EACVI Textbook, p.18)

The PSAX imaging plane at the level of the MV is optimised to demonstrate the diastolic excursion of the mitral leaflet tips within the circular LV... The ventricular surface of the MV leaflets is visualised in the PSAX view with scallops three 3 to one 1 seen from left to right. The postero-medial (PM) scallop is adjacent to A3/P3 and the antero-lateral (AL) scallop adjacent to A1/P1. The crescentic RV is seen anterior to the LV. (BSE minimum dataset)

In the apical four-chamber view, the length of the left ventricle is seen in a plane perpendicular to both the short-axis and long-axis planes. The anterolateral wall, apex, and inferior septum lie in this tomographic plane. (Otto, Clinical Echocardiography 6e, Ch.2)

This image shows the main four chambers of the heart, including the ventricles, the atria, the interventricular and interatrial septa, mitral and tricuspid valves, and the crux of the heart. ... it is necessary to check that the tricuspid valve is located slightly more apically than the mitral valve. This precaution is crucial to diagnose some important congenital malformations like Ebstein disease. (EACVI Textbook, p.20)

Optimize image so that all four chambers are seen. LV apex is positioned at the top and centre of sector. (BSE minimum dataset)

Apical five-chamber view: When the transducer is moved with a slight anterior angulation from the A4C position, the aortic valve and the aortic root appear in the place previously occupied by the crux of the heart. ... This is the best plane to study the left ventricle outflow tract and aortic valve flows. (EACVI Textbook, p.20)

From the four-chamber view, the transducer is rotated counterclockwise about 60° to obtain the two-chamber view of the LV, mitral valve, and LA. The apical two-chamber view is used for evaluation of the anterior LV wall (seen to the right of the screen) and the inferolateral (posterior) wall (seen on the left). (Otto, Clinical Echocardiography 6e, Ch.2)

Rotating the transducer another 60° from the two-chamber view (120° from the four-chamber view) yields a long-axis view similar to the parasternal long-axis view. The aortic valve, LV outflow tract, and mitral valve are seen in long axis. The LV walls visualized in this view are the anterior septum (on the right side of the screen) and posterior or inferolateral wall (on the left). (Otto, Clinical Echocardiography 6e, Ch.2)

...an image similar to PLAX is obtained by rotating the probe another 60°. This view is called the apical long-axis view or, more commonly, apical three-chamber view (A3C). The main difference is that in A3C true apex is seen. (EACVI Textbook, p.20–21)

Subcostal four-chamber view... The interatrial septum is perpendicular to the ultrasound beam from this window, thus allowing evaluation for atrial septal defects. (Otto, Clinical Echocardiography 6e, Ch.2)

The subcostal four-chamber view is obtained by placing the transducer in the centre of the epigastrium and by tilting downwards pointing to the patient's left shoulder. ... interatrial and interventricular septa lie more perpendicular to the ultrasound beam. This orientation makes this view especially useful to study defects at the level of the atrial septum. ... The rotation of the transducer from subcostal four-chamber view gives a long-axis view of the inferior vena cava joining the right atrium. This view is useful to measure the inferior vena cava and to study its changes of size with respiration, and thus for the right atria pressure estimation. (EACVI Textbook, p.21)

SCSAX (2D): SAX structures AV, IAS, TV, RVOT, PV, PA, LV. PR is often very well aligned with the angle of CW Doppler in the subcostal window. (BSE minimum dataset)

Abdominal aorta (modified view): Anti-clockwise rotation from IVC view. (BSE minimum dataset)

2D and color Doppler views show the ascending aorta (Ao), arch, and proximal descending aorta with the origins of the left carotid and subclavian arteries. The right pulmonary artery (RPA) lies immediately inferior to the arch, with the LA and aortic valve sometimes seen from this window. The short-axis view shows the aortic arch in cross section. The left pulmonary artery can be imaged by rotating slightly laterally. The LA lies inferior to the pulmonary arteries in both long- and short-axis views. (Otto, Clinical Echocardiography 6e, Ch.2)

The suprasternal long-axis view is obtained with the long axis of the transducer oriented parallel to the trachea. The ascending aorta and the aortic arch with the origins of the right brachiocephalic, the left common carotid and subclavian arteries can be seen in the left region of the image, and descending thoracic aorta is visualized in the right region. The right pulmonary artery and the left atrium can be seen beneath the aortic arch. (EACVI Textbook, p.21–22)

SSN (2D) Visual assessment: Aortic arch — Ascending aorta, transverse aortic arch, descending aorta, RPA. Head and neck vessels from left to right of image: BCA/IA: brachiocephalic/innominate artery; LCCA: left common carotid artery; LSA: left subclavian artery. (BSE minimum dataset)

Most echo laboratories follow the American Society of Echocardiography (ASE) recommendations for image orientation, with the transducer position at the top of the image. That means that 'superficial' or 'anterior' structures will be visualized in the 'upper' part of the image, whereas 'deeper' or 'posterior' structures will be displayed in the 'lower' part of the image. Lateral structures are displayed on the right side of the screen and medial structures on the left side. Short-axis views should be considered as if the sonographer were looking from the apex towards the heart base and long views as if he/she were looking at the heart from the left side. (EACVI Textbook, p.16)

In addition to apical versus basal, other standard directional terms are medial versus lateral (the horizontal axis in a short-axis or four-chamber view) and anterior versus posterior (the vertical axis in a short-axis or long-axis view). This standard terminology also applies to visualization of cardiac anatomy with 3D echocardiography. (Otto, Clinical Echocardiography 6e, Ch.2)

Images are collected at four depths: upper esophageal (20-30 cm), midesophageal (30-40 cm), transgastric (40-45 cm), and deep transgastric (45-50 cm). The great majority of images are obtained at the midesophageal and transgastric levels. ... The ASE/SCA recommends 20 standard images for a systematic TEE examination. (Practical Perioperative TOE, p.35)

ME aortic valve short-axis (~40°): the transducer is rotated (to 40 degrees) until the characteristic three leaflets of the AV are seen in short axis (the 'Mercedes-Benz sign'). The noncoronary cusp lies adjacent to the atrial septum (on the left of the display), the right coronary cusp is the most anterior (lowermost on the display), and the left coronary cusp is seen on the right of the display. (Practical Perioperative TOE, p.35)

ME bicaval (~110°): the SVC is seen on the right of the image, and the inferior vena cava (IVC) is on the left. At the junction of the IVC and right atrium, a small flap of tissue is usually seen—the eustachian valve. ... The thin central fossa ovalis is usually well seen, and a patent foramen ovale can be sought. (Practical Perioperative TOE, p.37)

ME four-chamber (0–20°): The inferoseptal wall of the left ventricle is seen on the left, and the anterolateral wall of the left ventricle is on the right. ... The longer anterior mitral leaflet appears on the left, and the shorter posterior mitral leaflet is on the right. (Practical Perioperative TOE, pp.37–39)

Transgastric mid-SAX (mid-papillary, 0°): the transgastric midpapillary short-axis view of the left ventricle. The posteromedial papillary muscle is seen at 1 o'clock, and the anterolateral papillary muscle is at 5 o'clock. The transgastric mid-short-axis view is probably the most widely employed view in perioperative TEE. ... useful for monitoring global and regional LV function and preload. (Practical Perioperative TOE, pp.43–44)

Sector display convention (TOE): The apex of the sector scan is shown at the top of the screen and locates the posterior cardiac structures (i.e., those closest to the transducer). In the transverse image plane (0-degree rotation), the left of the image is toward the patient's right, and the right of the image is toward the patient's left. (Practical Perioperative TOE, p.34)

The nomenclature of LV myocardial segments is based on coronary anatomy. Basically, the ventricle is divided into anterior (septum and free wall), anterolateral, inferolateral (also called posterior), and inferior (free wall and septum) segments for consistent descriptors of the location of abnormalities. The segments are further defined by their location along the length of the ventricle as basal, mid-ventricular, or apical. (Otto, Clinical Echocardiography 6e, Ch.2)

It is recommended that linear internal measurements of the left ventricle and its walls be performed in the parasternal long-axis view. Values should be carefully obtained perpendicular to the LV long axis and measured at or immediately below the level of the mitral valve leaflet tips. ... the electronic calipers should be positioned on the interface between the myocardial wall and cavity and the interface between the wall and the pericardium. (ASE/EACVI chamber quantification)

Left ventricular (LV) wall thickness and internal diameter measures are performed at end-diastole and end-systole. Measurements are made at the same level, perpendicular to the long-axis plane of the LV and immediately below the mitral valve leaflet tips. Care should be taken to ensure that the measurement is of compacted myocardium only and that: trabeculation, mitral valve (MV) apparatus, papillary muscle and right ventricle (RV) moderator band/septomarginal trebeculation are avoided. (BSE minimum dataset)

Normal LV internal dimension (ASE/EACVI Table 2): Diastolic dimension — Male 50.2 ± 4.1 mm (range 42.0–58.4); Female 45.0 ± 3.6 mm (range 37.8–52.2). Systolic dimension — Male 32.4 ± 3.7 mm (range 25.0–39.8); Female 28.2 ± 3.3 mm (range 21.6–34.8). (ASE/EACVI chamber quantification)

BSE LV linear dimensions (normal): Males — LVIDd 37–56 mm; LVIDs 22–41 mm; IVSd 6–12 mm; LVPWd 6–12 mm. Females — LVIDd 35–51 mm; LVIDs 20–37 mm; IVSd 5–11 mm; LVPWd 6–12 mm. (BSE Normal Reference Intervals — Harkness)

LV volumes should be measured from the apical four- and two-chamber views. Two-dimensional echocardiographic image acquisition should aim to maximize LV areas, while avoiding foreshortening of the left ventricle, which results in volume underestimation. The most commonly used method for 2D echocardiographic volume calculations is the biplane method of disks summation (modified Simpson's rule), which is the recommended 2D echocardiographic method by consensus of this committee. (ASE/EACVI chamber quantification)

LV volumes should be obtained using 2D imaging from A4C and A2C. Trace the endocardial border. LV length is defined as the distance between the midpoint of the mitral valve level line and the most distal point of the LV apex... Papillary muscles and trabeculations are excluded from the volumes and considered part of the chamber. Measure at end-diastole and end-systole. Measurement is indexed to BSA. (BSE minimum dataset)

Left ventricular volumes should be obtained using 2D imaging from the apical 4- and 2-chamber windows using the biplane Simpson's method. ... the apical 4- and 2-chamber windows are separated by 60° of rotation (and not 90°). ... Volumes should be reported after indexing to BSA. (BSE Normal Reference Intervals — Harkness)

Normal LV volumes (ASE/EACVI Table 2): LV EDV — Male 106 ± 22 mL (62–150); Female 76 ± 15 mL (46–106). LV ESV — Male 41 ± 10 mL (21–61); Female 28 ± 7 mL (14–42). LV EDV/BSA — Male 54 ± 10 mL/m² (34–74); Female 45 ± 8 mL/m² (29–61). LV ESV/BSA — Male 21 ± 5 mL/m² (11–31); Female 16 ± 4 mL/m² (8–24). (ASE/EACVI chamber quantification)

Normal LV EF (ASE/EACVI Table 2): Male 62 ± 5% (52–72); Female 64 ± 5% (54–74). LV EFs of <52% for men and <54% for women are suggestive of abnormal LV systolic function. (ASE/EACVI chamber quantification)

BSE LV volumes (normal): Males — LVEDVi 30–79 mL/m²; LVESVi 9–31 mL/m². Females — LVEDVi 29–70 mL/m²; LVESVi 8–27 mL/m². (BSE Normal Reference Intervals — Harkness)

BSE LV ejection fraction: Normal LVEF is defined as an EF ≥55%. LVEF should be derived from 2D volume data using the biplane Simpson's method. Reference intervals (males and females): Severely impaired ≤35%; Impaired 36–49%; Borderline low 50–54%; Normal ≥55%. (BSE Normal Reference Intervals — Harkness)

An estimate of LVEF should be included in all echo reports. A visual estimate should be provided only when image quality is suboptimal for Simpson's biplane estimate. (BSE minimum dataset)

All measurements should be performed at the end of diastole (the frame before mitral valve closure). All methods then convert the volume to mass by multiplying the volume of myocardium by the myocardial density (approximately 1.05 g/mL). (ASE/EACVI chamber quantification)

Linear (cube) formula: LV mass = 0.8 · 1.04 · [(IVS + LVID + PWT)³ − LVID³] + 0.6 g. Where IVS is interventricular septum; LVID is LV internal diameter, and PWT is inferolateral wall thickness. (ASE/EACVI chamber quantification)

calculation of relative wall thickness (RWT) with the formula (2 × posterior wall thickness)/(LV internal diameter at end-diastole) permits categorization of an increase in LV mass as either concentric (RWT >0.42) or eccentric (RWT ≤ 0.42) hypertrophy and allows the identification of concentric remodeling (normal LV mass with increased RWT). (ASE/EACVI chamber quantification)

Reference upper limits of normal LV mass by linear measurements are 95 g/m² in women and 115 g/m² in men. Reference upper limits of normal LV mass by 2D measurements are 88 g/m² in women and 102 g/m² in men. (ASE/EACVI chamber quantification)

Normal LV mass indices (ASE/EACVI Table 6) — Linear method: LV mass Women 67–162 g, Men 88–224 g; LV mass/BSA Women 43–95 g/m², Men 49–115 g/m²; RWT Women 0.22–0.42, Men 0.24–0.42; Septal thickness Women 0.6–0.9 cm, Men 0.6–1.0 cm; Posterior wall thickness Women 0.6–0.9 cm, Men 0.6–1.0 cm. 2D method: LV mass Women 66–150 g, Men 96–200 g; LV mass/BSA Women 44–88 g/m², Men 50–102 g/m². (ASE/EACVI chamber quantification)

LV mass should be calculated using the linear method from 2D imaging and reported after indexing to BSA. BSE LVMi normal: Males 40–110 g/m²; Females 33–99 g/m². LV mass (absolute): Males 72–219 g; Females 51–173 g. (BSE Normal Reference Intervals — Harkness)

Unlike the symmetric prolate ellipsoid shape of the LV, the RV does not have an easily defined long or short axis. In effect, the RV is 'wrapped around' the LV, with an inflow region, an apical region, and an outflow region forming a somewhat anteroposteriorly flattened U-shaped structure. (Otto, Clinical Echocardiography 6e, Ch.2)

The RV apex is heavily trabeculated, whereas the outflow tract (supracristal region) has a smoother endocardial surface. The moderator band, a prominent muscle trabeculation that traverses the RV apex obliquely and contains the right bundle branch, is seen in both parasternal and apical views. The papillary muscles are more difficult to identify in the RV than in the LV. Typically, two principal papillary muscles (anterior and posterior) are seen, with a smaller supracristal (or conus) papillary muscle. The moderator band attaches near the base of the anterior RV papillary muscle. (Otto, Clinical Echocardiography 6e, Ch.2)

Anatomy of the right ventricle. The crista supraventricularis separates the inflow part of the ventricle from the infundibulum, or conus arteriosus. Note the great distance between the septal leaflet of the tricuspid valve and the pulmonary valve. (Otto, Clinical Echocardiography 6e, Ch.2, Fig. 2.8)

Under normal loading conditions, the RV has a triangular shape when viewed from the side, and a crescentic shape in the sagittal plane, wrapping around the conical left ventricle. The right ventricle has a unique crescent shape, which adds complexity to the quantification of its size and function. (BSE Right Heart guideline; also ASE/EACVI chamber quantification)

The orientation of RV myofibres and their arrangement into layers is responsible for the distinct contraction pattern of this chamber, with an outer layer of circumferential subepicardial fibres, and an inner layer of longitudinal subendocardial fibres. These layers are responsible for the peristaltic, or wave-like, RV contraction pattern, starting at the inflow portion and progressing towards the infundibulum and outflow tract. (BSE Right Heart guideline)

RV dimensions are best estimated from a RV-focused apical four-chamber view obtained with either lateral or medial transducer orientation. Care should be taken to obtain the image with the LV apex at the center of the scanning sector, while displaying the largest basal RV diameter and thus avoiding foreshortening. All linear dimensions should be obtained using inner-edge-to-inner-edge method. (ASE/EACVI chamber quantification)

RVD1: Basal RV diameter. Measured at the maximal transverse diameter in the basal one third of the RV. RVD2: Mid RV diameter measured at the level of the LV papillary muscles. RVD3: RV length, from the plane of the tricuspid annulus to the RV apex. As RV size may be underestimated due to the crescentic RV geometry, all RV dimensions should be measured at end-diastole in the focussed RV view. (BSE minimum dataset / BSE Right Heart guideline)

RVD1 ≤47 mm in males, or ≤43 mm in females, is considered normal. RVD2 ≤42 mm in males, or ≤35 mm in females, is considered normal. RVD3 ≤87 mm in males, or ≤80 mm in females, is considered normal. (BSE Right Heart guideline)

RVOTPLAX ≤43 mm (males) or ≤40 mm (females) is considered normal. RVOT1 (proximal) ≤44 mm (males) or ≤42 mm (females). RVOT2 (distal) ≤29 mm (males) or ≤28 mm (females). RV wall thickness >5 mm is consistent with RV hypertrophy. (BSE Right Heart guideline)

Normal values for RV chamber size (ASE/EACVI Table 8): RV basal diameter 33 ± 4 mm (25–41); RV mid diameter 27 ± 4 mm (19–35); RV longitudinal diameter 71 ± 6 mm (59–83); RVOT PLAX diameter 25 ± 2.5 mm (20–30); RVOT proximal 28 ± 3.5 mm (21–35); RVOT distal 22 ± 2.5 mm (17–27); RV wall thickness 3 ± 1 mm (1–5). (ASE/EACVI chamber quantification)

A ratio (RV/LV basal diameter) of >1 measured at end-diastole suggests RV dilatation. (BSE Right Heart guideline / BSE minimum dataset)

Normal values for RV function (ASE/EACVI Table 10): TAPSE 24 ± 3.5 mm (abnormal <17); Pulsed Doppler S wave 14.1 ± 2.3 cm/sec (abnormal <9.5); Color Doppler S wave 9.7 ± 1.85 cm/sec (abnormal <6.0); RV fractional area change 49 ± 7% (abnormal <35); RV 3D EF 58 ± 6.5% (abnormal <45); RV free wall 2D strain −29 ± 4.5% (abnormal >−20). (ASE/EACVI chamber quantification)

TAPSE: A measure of longitudinal RV systolic function. TAPSE <1.7 cm is highly suggestive of RV systolic dysfunction. RV S′: S′ wave velocity ≥9 cm/s indicates normal RV long axis systolic function. FAC: RV FAC ≥30% in males, or ≥35% in females, is considered normal. In general, RVEF ≥45% by 3DE can be considered a cut-off to define normal RV systolic function. (BSE Right Heart guideline)

FAC = (RVA diastole − RVA systole)/RVA diastole × 100%. (BSE Normal Reference Intervals — Harkness)

a tentative cut-off of −23% for RV free wall global longitudinal strain could be considered to define normality. (BSE Right Heart guideline)

The left atrium acts as a (1) contractile pump that delivers 15% to 30% of the entire LV filling, (2) reservoir that collects pulmonary venous return during ventricular systole, and (3) conduit for the passage of stored blood from the left atrium to the left ventricle during early ventricular diastole. (ASE/EACVI chamber quantification)

TTE is the recommended approach for assessing LA size. TEE should not be used to assess LA size. LA size should be measured at the end of LV systole, when the LA chamber is at its greatest dimension. When tracing the borders of the left atrium, the confluences of the pulmonary veins and the LA appendage should be excluded. The atrioventricular interface should be represented by the mitral annulus plane, not by the tip of the mitral leaflets. (ASE/EACVI chamber quantification)

The anteroposterior diameter of the left atrium can be measured in the parasternal long-axis view perpendicular to the aortic root long axis, and measured at the level of the aortic sinuses by using the leading-edge to leading-edge convention. AP linear dimension should not be used as the sole measure of LA size. (ASE/EACVI chamber quantification)

the biplane disk summation technique should be the preferred method to measure LA volume in clinical practice. The upper normal limit for 2D echocardiographic LA volume is 34 mL/m² for both genders. (ASE/EACVI chamber quantification)

Maximum LA volume/BSA (ASE/EACVI Table 4): Normal range 16–34 mL/m²; Mildly abnormal 35–41; Moderately abnormal 42–48; Severely abnormal >48 (both genders). (ASE/EACVI chamber quantification)

Using the biplane Simpson's method, normal LAVi is ≤34 mL/m². An LAVi of more than 38 mL/m² is enlarged. the upper reference limit for LAVi using the Simpson's method is 38 mL/m² and using the area-length method it is 42 mL/m². BSE LAVi: Normal <34; Borderline 34–38; Dilated >38 mL/m². (BSE Normal Reference Intervals — Harkness)

quantification of RA size is most commonly performed from the apical four-chamber view. The minor-axis dimension should be taken from a plane perpendicular to the long axis of the right atrium, extending from the lateral border of the right atrium to the interatrial septum, at the midatrial level defined by half of RA long axis. RA area: Measured in the apical four-chamber view at end-systole, on the frame just prior to tricuspid valve opening, by tracing the RA blood-tissue interface, excluding the area under the tricuspid valve annulus. (ASE/EACVI chamber quantification)

The recommended parameter to assess RA size is RA volume, calculated using single-plane area-length or disk summation techniques in a dedicated apical four-chamber view. The normal ranges for 2D echocardiographic RA volume are 25 ± 7 mL/m² in men and 21 ± 6 mL/m² in women. (ASE/EACVI chamber quantification)

Normal RA size (ASE/EACVI Table 13): RA minor axis dimension Women 1.9 ± 0.3 cm/m², Men 1.9 ± 0.3; RA major axis dimension Women 2.5 ± 0.3 cm/m², Men 2.4 ± 0.3; 2D RA volume Women 21 ± 6 mL/m², Men 25 ± 7. (ASE/EACVI chamber quantification)

RAA ≤22 cm² (≤11 cm²/m²) in males, or ≤19 cm² (≤11 cm²/m²) in females is considered normal. RA area is measured in the RV focussed view at the end of ventricular systole on the frame just prior to TV opening. (BSE Right Heart guideline / BSE minimum dataset)

careful angulation between the long-axis and RV inflow views allows examination of the atrial septum with recognition of the thick primum septum at its junction with the central fibrous body, the thin fossa ovalis in the central portion of the atrial septum, the ridge-like limbus located superior to the fossa, and the ridge adjacent to the junction with the coronary sinus. (Otto, Clinical Echocardiography 6e, Ch.2)

The thin central fossa ovalis is usually well seen, and a patent foramen ovale can be sought. (Practical Perioperative TOE, p.37, ME bicaval)

The interatrial septum is perpendicular to the ultrasound beam from this [subcostal four-chamber] window, thus allowing evaluation for atrial septal defects. (Otto, Clinical Echocardiography 6e, Ch.2)

The aortic valve apparatus consists of three semilunar leaflets, three interleaflet triangles, three commissures, and the aortic wall. (EACVI Textbook, p.231)

The 3D anatomy of the attachment line of the aortic leaflets to the aortic root is shaped like a crown with the three commissures attached near the tops of the sinuses of Valsalva and the mid-portion of each leaflet attached near the base of each sinus. Each aortic leaflet has a coaptation (COAPT) zone, with overlap between adjacent leaflets and a thicker region, the nodule of Arantius, at the center of each cusp. (Otto, Clinical Echocardiography 6e, Ch.2, Fig.2.5)

The normal valve leaflets are thin at the base with an area of thickening on the ventricular aspect in the middle of the free edge of each cusp... These nodules normally enlarge with age (nodules of Arantius) and can have small, mobile filaments attached on the ventricular surface (Lambl excrescences). (Otto, Clinical Echocardiography 6e, Ch.2)

Three different annuli or rings can be considered: the basal ring, which is the lowest attachments of the leaflets and corresponds to the 'surgical' ring; the crown-shape ring delineated by leaflet attachments to the sinusal aortic wall; and the circular commissural ring, corresponding to the sinutubular junction where the commissures are inserted. (EACVI Textbook, p.231)

The aortic root extends from the basal attachments of the aortic valve leaflets within the LV outflow tract to their distal attachment at the tubular portion of the aorta (the sinotubular junction). The aortic root is a geometrically complex structure that includes (1) the aortic valve annulus, (2) the interleaflet triangles, (3) the semilunar aortic leaflets and their attachments, (4) the aortic sinuses of Valsalva, and (5) the sinotubular junction. (ASE/EACVI chamber quantification)

The 'aortic annulus' is not a true or distinct anatomic structure but is a virtual ring that may be defined by joining the basal attachments, or nadirs, of the three aortic leaflets. Approximately two-thirds of the circumference of the lower part of the aortic root is attached to the muscular interventricular septum, while the remaining one-third is in fibrous continuity with the anterior mitral valve leaflet. (ASE/EACVI chamber quantification)

The aortic root is the part of the aorta between [the annulus and the sinotubular junction], containing the sinus[es] of Valsalva, a dilatation of the aortic root. (Practical Perioperative TOE, p.160)

At the aortic valve level, the short-axis view demonstrates all three aortic valve leaflets: right, left, and noncoronary cusps. In systole, the aortic leaflets open to a near-circular orifice. (Otto, Clinical Echocardiography 6e, Ch.2)

The rule to identify the cusps is to remember that non-coronary cusp is in continuity with interatrial septum and that the right coronary cusp is the nearest to the right ventricle outflow tract; the left coronary cusp is the third one. (EACVI Textbook, p.18)

ME aortic valve short-axis (~40°, TOE): the characteristic three leaflets of the AV are seen in short axis (the 'Mercedes-Benz sign'). The noncoronary cusp lies adjacent to the atrial septum (on the left of the display), the right coronary cusp is the most anterior (lowermost on the display), and the left coronary cusp is seen on the right of the display. (Practical Perioperative TOE, p.35)

The leaflets and sinuses are topographically distinguished into two anterior (right and left) and one posterior or non-coronary. The latter is in fibrous continuity with the anterior ('aortic') leaflet of the mitral valve. (EACVI Textbook, p.231)

From parasternal view, two cusps are seen: the right coronary cusp (RCC) is positioned anteriorly and extends from the ventricular septal aspect of AV annulus. However, the more posterior cusp in view may be either the non-coronary (NCC) or the left-coronary (LCC) cusp depending on the degree of beam tilt. (BSE minimum dataset)

In the long-axis view, the right coronary cusp of the aortic valve is anterior and the noncoronary cusp is posterior (the left coronary cusp is lateral to the image plane). (Otto, Clinical Echocardiography 6e, Ch.2)

ME aortic valve long-axis (~130°, TOE): The right coronary cusp is the most anterior of the three cusps and is therefore seen lowermost on the display, adjacent to the right ventricular outflow tract (RVOT). The cusp seen adjacent to the anterior mitral leaflet is either the noncoronary (usually) or the left coronary cusp. (Practical Perioperative TOE, p.35)

The left main coronary artery arises from the superior aspect of the left coronary sinus of Valsalva and divides into (1) the left anterior descending (LAD) artery... and (2) the circumflex (Cx) artery. The right coronary artery (RCA) arises from the superior aspect of the right coronary sinus of Valsalva. (Otto, Clinical Echocardiography 6e, Ch.8)

the origins of the coronary arteries, with the left main coronary artery at the 4 o'clock position in the aortic annulus and the right coronary artery at the 11 o'clock position. (EACVI Textbook, p.18, PSAX-AV level)

Fine tilting of the probe at this level [PSAX AV] can reveal the ostia of the right and left coronary arteries in the respective sinus. (BSE minimum dataset)

A normal AVA in adults is ~3.0–4.0 cm². (ESE/ASE valve stenosis recommendations)

Posteriorly, the RA, interatrial septum, and LA lie in proximity to the noncoronary cusp of the aortic valve. (Otto, Clinical Echocardiography 6e, Ch.2)

The right coronary artery, AV node and bundle of His are located close to the anterior leaflet [of the tricuspid valve]... [and the] commissure between the septal and anterior leaflets is typically the largest and is found near the non-coronary sinus of Valsalva. (BSE Tricuspid & Pulmonary Valve guideline — anatomical relations relevant to conduction tissue near the NCC)

The normal mitral valve (MV) sits at the junction between the left atrium (LA) and left ventricle (LV). It is a complex anatomical structure composed of several distinct but contiguous structures: a fibro-muscular annulus, two leaflets, tendinous chords and papillary muscles. (BSE Mitral Valve guideline)

The mitral valve is a complex anatomical apparatus that includes the valve tissue (leaflets), the left atrioventricular junction (annulus), and the valve suspension system (chordae tendineae, papillary muscles, and left ventricle). (EACVI Textbook, p.267)

The mitral valve apparatus includes the leaflet, annulus, chordae, and papillary muscles. (Otto, Clinical Echocardiography 6e, Ch.2, Fig.2.6)

The posterior leaflet is short in length, usually, 11–14 mm, inserting along two-thirds of the annular circumference. In contrast, the anterior leaflet is longer, normally 18–24 mm, but involves only one-third of the total annular circumference; the anterior and posterior leaflets meet in the margins at the antero-lateral and postero-medial commissures. (BSE Mitral Valve guideline)

Along the free edge of the posterior leaflet are a series of indentations that divide the posterior leaflet into three scallops of roughly equal size: P1, P2 and P3. Although similar indentations are not present on the anterior leaflet, the corresponding regions opposing the posterior scallops are labelled A1, A2 and A3. Where the two leaflet tips meet is described as the zone of coaptation. The coaptation zone (leaflet apposition) is at least 5 mm in height in a competent mitral valve. (BSE Mitral Valve guideline)

According to the conventional Carpentier nomenclature, there are two commissures and two clefts leading to a three-scalloped posterior leaflet, named P1 (lateral), P2 (middle), and P3 (medial) starting from the lateral commissure. The posterior leaflet scallops are a reference for the segmentation of the facing regions of the anterior leaflet (A1, A2, A3, respectively). The middle scallop is the largest, while the lateral scallop is the smallest. (EACVI Textbook, p.267)

The mitral leaflets insert at the transition between atrial and ventricular myocardium, the atrioventricular junction. As a result, the posterior mitral annulus is muscular. However, the anterior annulus consists of fibrous tissue made up of the left and right trigones, and is continuous with the fibrous skeleton of the heart. The annulus is a saddle-shaped structure with high points anterior and posteriorly. The muscular posterior annulus region is more prone to dilation than the rigid fibrous anterior annular region, owing to the anterior region being in fibrous continuity with the skeleton of the heart. (BSE Mitral Valve guideline)

The mitral annulus (the attachment between the mitral leaflets, LA, and LV) is an anatomically well-defined fibrous structure shaped like a bent ellipse, with the more apical major axis bisected in the four-chamber view and the more basal minor axis bisected in the long-axis view. (Otto, Clinical Echocardiography 6e, Ch.2)

The mitral annulus is a 3-D, saddle-shaped, ellipsoid fibrous ring... The mitral annulus is weakest posteriorly. (Practical Perioperative TOE, pp.132–133)

The classification of either primary, secondary or tertiary chords describes the insertion point, which in turn identifies the degree of systolic load-bearing. Primary chords insert into the free edge of the leaflets, adjacent to the zone of coaptation. Primary chords prevent leaflet prolapse by ensuring leaflet tip coaptation throughout systole; primary chords do not bear significant loads. Secondary chords insert into the body of the ventricular surface of the leaflets and bear the significant systolic load by spreading it evenly throughout the leaflets. Tertiary chords insert into both the base of the posterior leaflet and basal LV wall, connecting the posterior leaflet and annulus to the papillary muscle, thereby maintaining ventricular-valve continuity. (BSE Mitral Valve guideline)

Chordae branch at three levels (primary, secondary, and tertiary) between the papillary muscle tip and mitral leaflet with a progressive decrease in chordal diameter and increase in the number of chordae from approximately 12 at the papillary muscle to 120 at the mitral leaflet. Most chordae attach at the free edge of the leaflets (called marginal chordae), but some (called basal or strut chordae) attach to the LV surface of the leaflet. (Otto, Clinical Echocardiography 6e, Ch.2)

chordae tendineae typically extend from two groups of papillary muscle (PM) and are described according to their position within the LV: antero-lateral or postero-medial. The antero-lateral (A-L) PM is usually the largest, comprised of two heads arising from a single projection at the mid to apical border between the lateral and infero-lateral wall. The postero-medial (P-M) PM extends from multiple myocardial projections from the mid to apical inferior wall, comprising three heads (anterior, intermediate and posterior). Each PM supplies chords to both leaflets: the antero-lateral PM to P1, A1 and medial aspect of P2 and A2, while the postero-medial PM supplies P3, A3 and lateral aspect of P2 and A2. (BSE Mitral Valve guideline)

The postero-medial papillary muscle is typically perfused by a single coronary artery, the posterior descending artery (PDA). The PDA extends from the right coronary artery in around 70–80% of patients, the left circumflex artery in 5–10% and from both left and right coronary systems in 10–20% of patients. The A-L PM is typically perfused by the left anterior descending (LAD) coronary artery and the diagonal or marginal branch of the circumflex. (BSE Mitral Valve guideline)

PLAX: the imaging plane is through the centre of the mitral valve, demonstrating A2 of the longer anterior leaflet and P2 of the shorter posterior leaflet. With an inferior tilt of the ultrasound beam it is possible to image scallops A3/P3 and further tilting will bring into view the postero-medial commissure. A superior tilt of the beam will demonstrate scallops A1/P1 and eventually the antero-lateral commissure. (BSE Mitral Valve guideline)

PSAX: At the level of the mitral valve leaflets, the ventricular surface of all scallops and both commissures can be visualised in their entirety. From the level of the valve, tilting inferiorly (towards the apex) will bring into view both papillary muscles; the postero-medial PM is seen on the left and the antero-lateral on the right. (BSE Mitral Valve guideline)

A4C: An oblique plane of the anterior leaflet is seen in the A4C with scallops A3 and A2 seen from left to right, P1 of the posterior leaflet is seen. A2C (bi-commissural): the plane of imaging is along the line of leaflet coaptation, such that A2 is seen in the centre of the valve with P3 and P1 seen on the left and right, respectively. A3C: Similar to the PLAX view, A2 and P2 are visualised. (BSE Mitral Valve guideline)

Which TOE view shows which mitral scallop: ME four-chamber → A2/P2; ME commissural → P3 / A2 / P1 (anterior leaflet floats between P1 right and P3 left); ME two-chamber → P3 / A2 / P1; ME long-axis → A2 / P2; TG basal SAX → en face view of all leaflet segments ('fish-mouth'); TG two-chamber → MV subvalvular apparatus. (Practical Perioperative TOE, Table 3-1, p.36)

TOE landmarks: aortic valve adjacent to anterior leaflet, left atrial appendage identifies lateral portion of valve P1/A1/ALC, inter-atrial septum (IAS) identifies medial portion of MV, typically P3/A3. (BSE Mitral Valve guideline)

3D 'surgeon's view': by displaying the aortic valve at the top centre of the image (12 o'clock) and the left atrial appendage to the left (9 o'clock), scallops one to three are seen from left to right. (BSE Mitral Valve guideline)

No single numeric normal mitral valve area value is stated in the BSE mitral valve guideline; the document focuses on disease assessment. Related normal anatomical figures it does give: posterior leaflet 11–14 mm, anterior leaflet 18–24 mm, coaptation ≥5 mm, normal inter-annular (MV–TV) offset 5–11 mm. (BSE Mitral Valve guideline)

There is normally 3 to 5 mm of overlap between the leaflets along the coaptation line during systole. (Practical Perioperative TOE, pp.132–133)

The TV is the largest and most apically located valve in the heart. The TV consists of an annulus, leaflets, papillary muscles, and chordae tendinae. (BSE Tricuspid & Pulmonary Valve guideline)

There are usually three TV leaflets of unequal size. All three leaflets cannot usually be imaged in a single echocardiographic view. The anterior leaflet extends from the RV infundibulum anteriorly to the inferolateral wall posteriorly, and is usually the largest and most mobile. The posterior leaflet attaches along the posterior margin of the TVA from the septum to the inferolateral wall, is the shortest circumferentially, and often exhibits several scallops. It is not clearly demarcated from the anterior leaflet in 10% of individuals. The septal leaflet extends from the interventricular septum to the posterior RV. It is the shortest radially and is the least mobile. (BSE Tricuspid & Pulmonary Valve guideline)

The TV tensor apparatus consists of an anterior, a posterior, and in most cases (80%) septal papillary muscle (PM), as well as the associated chordae. The large anterior PM arises from the lateral RV wall and supports the anterior and posterior TV leaflets. The moderator band may join the anterior PM. The posterior PM supports the posterior and septal leaflets. There are usually around 25 chordae. The TV chordae are in general less distensible than those of the mitral valve, which means that leaflet tethering easily occurs as a result of RV dilatation. (BSE Tricuspid & Pulmonary Valve guideline)

The commissure between the septal and posterior leaflets is usually located near the entrance of the CS into the RA. The commissure between the septal and anterior leaflets is typically the largest and is found near the non-coronary sinus of Valsalva. The right coronary artery, AV node and bundle of His are located close to the anterior leaflet. (BSE Tricuspid & Pulmonary Valve guideline)

Coaptation of the TV usually takes place just below (i.e. just on the ventricular aspect) of the TVA. The normal coaptation length is 4–9 mm, which creates some coaptation reserve in case of annular dilatation. (BSE Tricuspid & Pulmonary Valve guideline)

The normal TV orifice area is 7–9 cm², which results in a low-pressure gradient between the RA and RV (<2 mmHg). (BSE Tricuspid & Pulmonary Valve guideline)

The TVA is a D-shaped ellipsoid which has a saddle-shaped rather than planar profile. The superior portion of this saddle is located near the aortic valve and RVOT, whilst the inferior portion is near the coronary sinus (CS). The normal TVA area, circumference, long axis and short axis diameters, respectively, at end-diastole are 8.6 ± 2.0 cm², 10.5 ± 1.2 cm, 36 ± 4 mm and 30 ± 4 mm by 3DE. Annular area changes by approximately 30% during the cardiac cycle, being largest at end-diastole. (BSE Tricuspid & Pulmonary Valve guideline)

Septal-lateral annular dimension measured at end-diastole. The normal TV annulus should measure 28 ± 5 mm. Annular dimension >40 mm (or >21 mm/m²) is considered significantly dilated. (BSE Tricuspid & Pulmonary Valve guideline)

Using transthoracic echocardiography (TTE), the TV is typically imaged in the parasternal long axis (PLAX) RV inflow view (by tilting the probe inferiorly from the conventional PLAX window), in the parasternal short axis (PSAX) view, as well as the apical four-chamber (A4C) view. However, quantification of TV and RV dimensions should be performed using the RV-focused A4C view. (BSE Tricuspid & Pulmonary Valve guideline)

The anterior (A) tricuspid valve (TV) leaflet (A) is seen at the base of the anterior wall. When the inferior RV wall is in view, the posterior tricuspid leaflet (P) is seen. If the septum remains in view, the septal TV leaflet is seen. (BSE minimum dataset, PLAX RV inflow)

In this RV inflow view, the septal and anterior leaflets of the tricuspid valve are well seen. (Otto, Clinical Echocardiography 6e, Ch.2)

ME RV inflow–outflow (~80°, TOE): The posterior leaflet of the TV appears on the left, and the anterior leaflet is on the right. Shows TV + PV + RVOT. (Practical Perioperative TOE, p.37)

The PV is a tricuspid structure which is anatomically very similar to the aortic valve. The cusps are, however, thinner, in view of the lower right-sided pressures. The PV arises from the muscular RV infundibulum and lacks fibrous continuity with the TV, unlike the mitral-aortic continuity. (BSE Tricuspid & Pulmonary Valve guideline)

In adults, evaluation of the leaflets of the pulmonic valve is limited; usually only one or two leaflets are seen well, and a short-axis view often is not obtainable. (Otto, Clinical Echocardiography 6e, Ch.2)

The PV is imaged by TTE from the PSAX view or from the modified, superiorly tilted PLAX window. The subcostal window may also add information when parasternal views are inadequate. Echocardiographic visualisation of the PV is typically more difficult than for other valves, and usually only one or two cusps will be visualised simultaneously. (BSE Tricuspid & Pulmonary Valve guideline)

Live TTE 3DE from the parasternal window can be effective in visualising en face PV short-axis morphology and quantifying cusp number. This information cannot, in general, be obtained using 2D TTE, since the PV can usually only be visualised in its long axis. (BSE Tricuspid & Pulmonary Valve guideline)

The aortic and pulmonic valve planes normally lie perpendicular to each other. Thus, when the aortic valve is seen in the short axis, the pulmonic valve is seen in the long axis. (Otto, Clinical Echocardiography 6e, Ch.2)

The aortic and pulmonic valve planes are perpendicular to each other. (Otto, Clinical Echocardiography 6e, Ch.2, Fig.2.11 — anatomic valve relationships, surgeon's view of cardiac base)

The pulmonic valve and RV outflow tract are seen anterolaterally, adjacent to the left coronary cusp. Note the great distance between the septal leaflet of the tricuspid valve and the pulmonary valve. (Otto, Clinical Echocardiography 6e, Ch.2)

The RVOT view is achieved by tilting the ultrasound beam superiorly from the PLAX view and centralising the RVOT and PV in the image. (BSE minimum dataset)

Aortic measurements should be made at the following sites: (1) the aortic valve annulus, (2) the maximal diameter of the sinuses of Valsalva, (3) the sinotubular junction (usually a demarcated transition between the sinuses of Valsalva and the tubular portion of the ascending aorta), and (4) the maximal diameter of the proximal ascending aorta, including a notation of the distance between the measurement site and the sinotubular junction. (ASE/EACVI chamber quantification)

With 2D TTE, the diameter of the aortic root (at the maximal diameter of the sinuses of Valsalva) should be obtained from the parasternal long-axis view, which depicts the aortic root and the proximal ascending aorta. (ASE/EACVI chamber quantification)

Aortic dimensions should be measured using 2D imaging from the PLAX window. Measurements at three levels: sinus of Valsalva, sino-tubular junction, proximal ascending aorta defined as the region 1 cm above the sino-tubular junction. (BSE Normal Reference Intervals — Harkness)

The ascending aorta diameter is smallest at the annulus and largest at the sinuses of Valsalva. The tubular portion of the ascending aorta is typically approximately 10% smaller than the diameter at sinus level. The normal descending thoracic aorta is smaller than both the aortic root and ascending aorta. (EACVI Textbook, pp.459–460)

Suprasternal view shows the ascending aorta, transverse aortic arch, and descending aorta, with head and neck vessels from left to right: brachiocephalic/innominate artery; left common carotid artery; left subclavian artery. (BSE minimum dataset)

Aortic root dimensions in normal adults (ASE/EACVI Table 14) — Absolute: Annulus Men 2.6 ± 0.3 cm, Women 2.3 ± 0.2; Sinuses of Valsalva Men 3.4 ± 0.3 cm, Women 3.0 ± 0.3; Sinotubular junction Men 2.9 ± 0.3 cm, Women 2.6 ± 0.3; Proximal ascending aorta Men 3.0 ± 0.4 cm, Women 2.7 ± 0.4. (ASE/EACVI chamber quantification)

Normal indexed aortic root dimensions, inner-edge to inner-edge (BSE Table 7): Sinus of Valsalva Male 13.8–21.8 mm/m, Female 13.1–20.7; Sino-tubular junction Male 11.4–18.6 mm/m, Female 11.0–17.8; Proximal ascending aorta Male 11.5–19.9 mm/m, Female 11.4–19.8. (BSE Normal Reference Intervals — Harkness)

Normal indexed aortic root dimensions, leading-edge to leading-edge (BSE Table 8): Sinus of Valsalva Male 14.8–23.2 mm/m, Female 14.1–22.1; Sino-tubular junction Male 12.6–19.8 mm/m, Female 12.2–19.4; Proximal ascending aorta Male 12.6–21.4 mm/m, Female 12.3–21.1. (BSE Normal Reference Intervals — Harkness)

in adults, a diameter of 2.1 cm/m² has been considered the upper normal range in the ascending aorta. (EACVI Textbook, pp.459–460)

The aortic annulus should be measured at midsystole from inner edge to inner edge. All other aortic root measurements (i.e., maximal diameter of the sinuses of Valsalva, the sinotubular junction, and the proximal ascending aorta) should be made at end-diastole, in a strictly perpendicular plane to that of the long axis of the aorta using the L-L convention. the L-L convention provides statistically larger diameters than the I-I convention (by 2–4 mm). (ASE/EACVI chamber quantification)

The BSE recommend the inner-edge to inner-edge method for measuring aortic dimensions. Indices should be obtained using the inner-edge to inner-edge (IE-IE) methodology in end-diastole, defined as the onset of the QRS complex. All values should be indexed to height and not BSA. (BSE minimum dataset / BSE Normal Reference Intervals — Harkness)

Echocardiographic measurements continue to be made from leading edge to leading edge, at end-diastole, perpendicular to the long axis of blood flow and at reproducible landmarks for the adult population. (EACVI Textbook, pp.459–460)

MPA dimension is measured in end-diastole halfway between the pulmonary valve and bifurcation of main MPA or at 1 cm above the PV. (BSE minimum dataset)

PA dimension is measured in end-diastole, halfway between the PV and bifurcation of main PA, or 1 cm distal to the PV. A diameter >25 mm is considered abnormal. (BSE Right Heart guideline — i.e. normal MPA ≤25 mm)

ME ascending-aortic SAX (TOE) shows the proximal ascending aorta, main pulmonary artery, right pulmonary artery, and the superior vena cava; at this level, the aorta is separated from the transducer by the right pulmonary artery, not the left atrium. (Practical Perioperative TOE, p.36)

IVC diameter is measured perpendicular to the IVC long axis, 1–2 cm from the RA junction at end-expiration. (BSE minimum dataset)

the diameter of the IVC should be measured in the subcostal view with the patient in the supine position at 1.0 to 2.0 cm from the junction with the right atrium, using the long-axis view. IVC diameter <2.1 cm that collapses >50% with a sniff suggests normal RA pressure of 3 mm Hg (range, 0–5 mm Hg), whereas IVC diameter >2.1 cm that collapses <50% with a sniff suggests high RA pressure of 15 mm Hg (range, 10–20 mm Hg). (ASE/EACVI chamber quantification)

IVC diameter ≤21 mm, with >50% collapse with sniff suggests normal RA pressure (0-5 mmHg). IVC diameter ≤21 mm with <50% collapse with sniff, or >21 mm with >50% collapse with sniff suggests intermediate RA pressure (5-10 mmHg). IVC diameter >21 mm, with <50% collapse with sniff (or <20% with quiet respiration) suggests high RA pressure (15 mmHg). (BSE Right Heart guideline)

Intermediate can be upgraded to high RA pressure if minimal IVC collapse with sniff (<35%), and secondary indices of elevated RA pressure are present (restrictive filling, RV E/e′ >6, or diastolic flow reversal in the hepatic veins). Intermediate can be downgraded to normal RA pressure if no secondary indices are present. (BSE Right Heart guideline)

The left main coronary artery arises from the superior aspect of the left coronary sinus of Valsalva and divides into (1) the left anterior descending (LAD) artery, which extends by the interventricular groove down the anterior wall to (and sometimes around) the LV apex; and (2) the circumflex (Cx) artery, which continues laterally in the atrioventricular groove. The right coronary artery (RCA) arises from the superior aspect of the right coronary sinus of Valsalva and extends inferomedially following the atrioventricular groove. (Otto, Clinical Echocardiography 6e, Ch.8)

The left anterior descending artery supplies the anterior portion of the interventricular septum through septal branches. (Otto, Clinical Echocardiography 6e, Ch.8)

Left anterior descending (LAD): septum, apex, and anteroseptal regions of the left ventricle are typically involved in LAD circulation occlusion. (EACVI Textbook, pp.219–220)

the origins of the coronary arteries, with the left main coronary artery at the 4 o'clock position in the aortic annulus and the right coronary artery at the 11 o'clock position. (EACVI Textbook, p.18, PSAX-AV level)

a 17-segment model is commonly used. Beginning at the anterior junction of the interventricular septum and the RV free wall and continuing counterclockwise, basal and midventricular segments should be labeled as anteroseptal, inferoseptal, inferior, inferolateral, anterolateral, and anterior. In this 17-segment model, the apex is divided into five segments, including septal, inferior, lateral, and anterior segments, as well as the 'apical cap,' which is defined as the myocardium beyond the end of the LV cavity. (ASE/EACVI chamber quantification)

Basal (6): basal anterior, basal anteroseptal, basal inferoseptal, basal inferior, basal inferolateral, basal anterolateral. Mid (6): mid anterior, mid anteroseptal, mid inferoseptal, mid inferior, mid inferolateral, mid anterolateral. Apical (4 + cap): apical anterior, apical septal, apical inferior, apical lateral, plus the apical cap (17th segment). (ASE/EACVI chamber quantification)

Segment numbering: 1 basal anterior; 2 basal anteroseptal; 3 basal inferoseptal; 4 basal inferior; 5 basal inferolateral; 6 basal anterolateral; 7 mid anterior; 8 mid anteroseptal; 9 mid inferoseptal; 10 mid inferior; 11 mid inferolateral; 12 mid anterolateral; 13 apical anterior; 14 apical septal; 15 apical inferior; 16 apical lateral; 17 apex. (EACVI Textbook, Fig.29.1, p.219)

LV segments 1–6 are at the base (mitral valve level), segments 7–12 are in the middle (papillary muscle level), segments 13–16 occupy the apical region, and segment 17 represents the very tip of the apex. The latter does not encroach into the ventricular cavity. (Solomon, Essential Echocardiography, Ch.7)

When using this 17-segment model to assess wall motion or regional strain, the 17th segment (the apical cap) should not be included. The 16-segment model is recommended for routine studies assessing wall motion. (ASE/EACVI chamber quantification)

Although certain variability exists in the coronary artery blood supply to myocardial segments, segments are usually attributed to the three major coronary arteries. (ASE/EACVI chamber quantification)

Standard ASE 17-segment territory mapping (Figure 5; confirm against original figure) — LAD: anterior, anteroseptal, apical anterior, apical septal, apical lateral (anterior portion), apical cap (variable); typically all anterior wall, anterior septum and apex. RCA: inferoseptal (basal/mid), inferior (basal/mid), apical inferior. CX (left circumflex): anterolateral (basal/mid), inferolateral (basal/mid), and apical lateral (lateral portion). (ASE/EACVI chamber quantification — derived from Figure 5)

The LAD typically covers the anteroseptal wall and apex, while the RCA or LCx perfuses the inferolateral wall. The RVOT is perfused by the RCA. Color-coding convention: Blue = left anterior descending artery (LAD), red = right coronary artery (RCA), purple = RCA or left circumflex artery (LCx), green = LAD or LCx. (Maus/Tainter, Essential Echocardiography — Perioperative TEE, Ch.7)

The postero-medial papillary muscle is typically perfused by a single coronary artery, the posterior descending artery (PDA). The PDA extends from the right coronary artery in around 70–80% of patients, the left circumflex artery in 5–10% and from both left and right coronary systems in 10–20% of patients. (BSE Mitral Valve guideline)

Segmental wall motion abnormalities seen by echocardiography correspond closely to the coronary artery blood supply to the myocardium. (Otto, Clinical Echocardiography 6e, Ch.8)

The overlap in the depicted coronary supply is explained by normal anatomic variation in coronary perfusion (e.g., the inferolateral wall may be supplied by the LCx in some patients, but by the RCA in others). This can present as variability in the appearance of the wall motion abnormality during an ischemic event. In one patient, an LAD lesion may lead to a WMA of just the anterior and anteroseptal wall, while in another patient, the WMA may extend to cover the entire anterior wall. (Maus/Tainter, Essential Echocardiography — Perioperative TEE, Ch.7)

Right coronary artery (RCA): most regional wall motion abnormalities arising from RCA occlusion are found at the inferior wall (right dominant coronary circulation). In contrast to LAD infarctions, the apex is often unaffected. obstruction of the proximal RCA, proximal to the RV branches, may infarct the inferior wall of the LV and the RV. Circumflex coronary artery (Cx): the lateral wall may become akinetic in Cx occlusion. (EACVI Textbook, pp.219–220)

Approximately 80% of patients have a right-dominant coronary circulation; the right coronary artery gives rise to the posterior descending artery (PDA), which lies in the inferior interventricular groove. In about 20% of patients the coronary circulation is left dominant; the circumflex artery gives rise to the posterior descending artery. (Otto, Clinical Echocardiography 6e, Ch.8)

Tomographic imaging concept. Echocardiography provides tomographic images of cardiac structures and blood flow, analogous to a thin 'slice' through the heart. Two-dimensional (2D) echocardiographic images provide detailed anatomic data in a given image plane, but complete evaluation of the cardiac chambers and valves requires integration of information from multiple image planes. Small structures that traverse numerous tomographic planes (e.g., the coronary arteries) are difficult to evaluate fully. (Otto, Clinical Echocardiography 6e, Ch.2)

Cardiac motion terminology. Cardiac motion relative to surrounding structures is described in three dimensions as: Translation (movement of the heart as a whole in the chest); Rotation (circular motion around the long axis of the left ventricle [LV]); Torsion (unequal rotational motion at the apex versus the base of the LV). (Otto, Clinical Echocardiography 6e, Ch.2)

Four standard image planes. Long-axis plane: parallel to the long axis of the LV, intersecting the LV apex and centre of the aortic valve. Short-axis planes: perpendicular to the long axis of the ventricle, giving circular cross-sectional views of the LV, mitral valve, and aortic valve. Four-chamber plane: from apex to base, perpendicular to the short-axis view, including both ventricles and atria. Two-chamber plane: from apex to base, including the LV and LA, rotated midway between the long-axis and four-chamber views. (Otto, Clinical Echocardiography 6e, Ch.2)

Transducer manipulation. The transducer motions used to obtain the desired view: Move the transducer to a different position on the chest. Tilt or point the transducer tip with a rocking motion to image different structures in the same tomographic plane. Angle the transducer from side to side to obtain different tomographic planes somewhat parallel to the original image plane. Rotate the image plane at a single position to obtain intersecting tomographic planes. (Otto, Clinical Echocardiography 6e, Ch.2)

PLAX pericardial vs pleural effusion landmark. Posterior to the LA, the descending thoracic aorta is seen in cross section. The oblique sinus of the pericardium lies between the LA and the descending thoracic aorta so that a pericardial effusion can be seen between these two structures, whereas a pleural effusion is seen only posterior to the descending thoracic aorta. From the parasternal window, the LV apex is not seen; the apparent 'apex' usually is an oblique image plane through the anterolateral wall. (Otto, Clinical Echocardiography 6e, Ch.2)

Probe rotation reference (TOE). At 0 degrees, the sector scan lies in the transverse image plane and runs perpendicular to the shaft of the probe. At 90 degrees, the sector scan lies in the longitudinal or vertical plane and runs parallel to the shaft of the probe. At 180 degrees, the view is a mirror image of the view at 0 degrees. At 45 degrees, the plane of the sector scan runs between the left shoulder and the right leg. At 135 degrees, the plane of the sector scan runs between the right shoulder and the left leg. (Practical Perioperative TOE, p.33)

M-mode (TTE). Standard M-mode lines through aortic root/AV/LA (box-like AV opening in systole), mitral valve (E/A/C/D points), LV at papillary-muscle level (chamber & wall measurements), and TAPSE in A4C for RV global function. (EACVI Textbook, pp.23–24)

Acquisition averaging. All measurements should be performed on more than one cardiac cycle to account for interbeat variability. The committee suggests the average of three beats for patients in normal sinus rhythm and a minimum of five beats in patients with atrial fibrillation. (ASE/EACVI chamber quantification)

LV apex appearance / trabeculation. The LV appears as a truncated ellipse with a longer length than width and a tapered but rounded apex. If the transducer is not positioned at the true apex, the LV will appear foreshortened, with a more spherical shape. Although the RV is more trabeculated than the LV, prominent trabeculation also can be seen at the LV apex and must be distinguished from apical thrombus. An aberrant LV trabecula that traverses the ventricular chamber is an incidental finding, often called an LV 'chord.' (Otto, Clinical Echocardiography 6e, Ch.2)

LV inflow/outflow tracts. the chamber can be divided into inflow and outflow tracts, separated by the anterior leaflet of the mitral valve. The outflow tract of the LV, also called the aortic vestibule or subaortic area, is a narrow cavity with the interventricular septum as the anterior wall, the anterior cusp of the mitral valve as the posterior wall, and the aortic orifice as the outlet. (EACVI Textbook, p.123–124)

RA normal anatomic variants. Another normal anatomic feature of the RA is the crista terminalis, a muscular ridge that courses anteriorly from the superior vena cava to the inferior vena cava and divides the trabeculated anterior portion of the RA from the posterior, smooth-walled sinus venosus segment. The RA appendage is a trabeculated protrusion of the RA that extends anterior to the RA free wall and base of the aorta. (Otto, Clinical Echocardiography 6e, Ch.2)

RA Eustachian valve / Chiari network. In some individuals, a prominent Eustachian valve is seen at the junction of the inferior vena cava and RA. When a more extensive fenestrated valve is present, it forms a Chiari network extending from the inferior to the superior vena cava, attached to the crista terminalis posteriorly and the fossa ovalis medially, with a netlike structure that appears as bright mobile echo densities in the RA. Both these findings are considered normal variants. (Otto, Clinical Echocardiography 6e, Ch.2)

Coronary sinus / IVC entry (RV inflow). The coronary sinus is identified as it enters the right atrium (RA) adjacent to the tricuspid annulus. The inferior vena cava is seen entering the RA inferior to the coronary sinus. (Otto, Clinical Echocardiography 6e, Ch.2)

RV crescent / wall thickness (TOE). The right ventricle appears triangular in shape and normally extends two thirds of the way to the cardiac apex. The short-axis view of the right ventricle has a crescent shape and more extensive trabeculae than the left ventricle. The RV wall thickness is normally half that of the left ventricle. The RV free wall has no formal segmental classification, but the terms basal, apical, anterior, and inferior are used. (Practical Perioperative TOE, pp.38 & 44)

Descending aorta & aortic arch TOE views. The descending thoracic aorta and aortic arch are each imaged in short and long axis with four standard views. From the midesophageal four-chamber view, the shaft of the probe is turned to the left until the circular, short-axis cross section of the descending thoracic aorta is centered on the screen. In the upper esophageal aortic arch short-axis view, the origin of the left subclavian artery can usually be seen in the upper right of the display; the RVOT, PV, and proximal pulmonary artery may be seen to the left of the screen. (Practical Perioperative TOE, pp.45–46)

Ascending aorta TOE blind spot. The most important TOE views of the ascending aorta, aortic root, and aortic valve are the high TOE long-axis (at 120–150°) and short-axis (at 30–60°) views. A short segment of the distal ascending aorta, just before the innominate artery, remains unvisualized owing to interposition of the right bronchus and trachea (blind spot). The descending aorta is easily visualized in short-axis (0°) and long-axis (90°) views. (EACVI Textbook, p.459)

Additional TOE views. ME five-chamber (0°): the five chambers are the right atrium, right ventricle, left atrium, left ventricle, and left ventricular outflow tract (LVOT). ME long-axis (~130°): identified by simultaneously visualizing the LVOT and the MV; the cavity on the far right of the screen is the RVOT. Deep transgastric LAX (0°): shows all four cardiac chambers, the AV, and the LVOT; the ultrasound beam is parallel to blood flow through the AV and outflow tract. Transgastric two-chamber (~90°): usually provides the best images of the mitral subvalvular apparatus. Transgastric RV inflow (~90°): the right ventricle is distinguished from the left ventricle by its diamond shape and thinner walls. (Practical Perioperative TOE, pp.35–45)

Aortic Z-score. The Z-score (the number of SD above or below the predicted mean normal diameter); an aortic diameter can be considered dilated when Z-score is 2 or greater. (EACVI Textbook, pp.459–460)

TV tenting thresholds. A tenting area >1 cm² is predictive of more than mild secondary TR. Measured at end-systole between the plane of the TV annulus, and the leaflet coaptation point; a tenting height >0.76 cm is predictive of significant residual TR after TV surgery. (BSE Tricuspid & Pulmonary Valve guideline)

Pulmonary veins on apical views. The right lower pulmonary vein (RLPV) is most likely adjacent to the atrial septum in the A4C view, with the right upper pulmonary vein likely to be visualised in the A5C view. (BSE minimum dataset)

Segmentation rationale. Segmentation schemes should reflect coronary perfusion territories, result in segments with comparable myocardial mass, and allow standardized communication within echocardiography and with other imaging modalities. The anterior insertion of the right ventricular wall into the left ventricle defines the border between the anteroseptal and anterior segments. (ASE/EACVI chamber quantification)

Bicuspid aortic valve identification. A bicuspid valve most often results from fusion of the right and left coronary cusps (~80% of cases), or fusion of the right and non-coronary cusps (about 20% of cases). Fusion of the left and non-coronary cusps is rare. Diagnosis is most reliable when the two cusps are seen in systole with only two commissures framing an elliptical systolic orifice. (ESE/ASE valve stenosis recommendations)

Aortic valve area planimetry. Aortic valve area planimetry measures anatomic (geometric) AVA by direct visualization of the valvular orifice, either by 2D or 3D TTE or TEE. Caution is needed to ensure that the minimal orifice area is identified rather than a larger apparent area proximal to the cusp tips. (ESE/ASE valve stenosis recommendations)