Tag: Echo

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Echo Cheat Sheet For First Year Cardiology Fellows

When my co-fellow and started our cardiology fellowship we wish we had an echocardiography reference value cheat sheet. So we decide to make one for our new first year fellows! Our hope is that by having all of the reference values organized in one easily accessible place online that we can ease any new cardiology fellow into their new role. Instead of making it a Word document or PDF we wanted to share it with any other fellows who may find this useful. We will continue to update it with useful educational links, images, and videos over time. *Please only use this as a reference. The most reliable sources of information are ASE guideliens*

Echocardiography Reference Values

Normal Values for Aorta via 2D echo (Indexed to BSA)

Normal intervalIndexed interval
Aortic annulus20-31 mm12-14 mm/m2
Sinus of Valsalva29-45 mm15-20 mm/m2
Sinotubular junction22-36 mm13-17 mm/m2
Ascending aorta22-36 mm13-17 mm/m2
Aortic arch22-36 mm
Descending aorta20-30 mm

Aortic annulusSinus of ValsalvaSinotubular junctionAscending aortaAortic arch
AgeMenWomenMenWomenMenWomenMenWomenMenWomen
<3011.4 ± 1.211.4 ± 1.115.3 ± 1.815.5 ± 1.512.7 ± 2.313.5 ± 1.414.3 ± 1.615.1 ± 1.610.1 ± 1.310.7 ± 1.0
30-3911.4 ± 1.111.7 ± 1.015.7 ± 1.316.5 ± 1.613.3 ± 1.314.3 ± 1.514.5 ± 1.416.4 ± 1.810.8 ± 1.311.6 ± 1.6
40-4911.5 ± 0.911.7 ± 1.016.6 ± 1.516.8 ± 1.414.1 ± 1.514.6 ± 1.215.5 ± 1.516.4 ± 1.411.3 ± 1.311.5 ± 1.2
50-5911.5 ± 0.912.0 ± 0.916.8 ± 1.717.9 ± 1.614.1 ± 1.515.7 ± 1.316.2 ± 1.618.0 ± 1.411.3 ± 1.212.7 ± 1.1
60-6912.1 ± 1.011.7 ± 1.117.8 ± 1.617.5 ± 1.715.1 ± 1.614.7 ± 1.617.3 ± 1.717.6 ± 1.712.0 ± 1.112.5 ± 1.4
>7012.0 ± 1.011.6 ± 1.118.1 ± 1.718.2 ± 1.914.7 ± 1.615.5 ± 2.017.5 ± 1.418.2 ± 3.312.2 ± 1.312.7 ± 1.2
All11.6 ± 1.011.7 ± 1.016.6 ± 1.817.0 ± 1.913.9 ± 1.814.7 ± 1.715.7 ± 1.816.9 ± 2.311.2 ± 1.411.9 ± 1.5
Aortic Root Dimensions

Aortic Regurgitation

Primary Parameters
MildModerateSevere
Vena contracta (cm)< 0.30.3 – 0.6> 0.6
PHT (ms) – CW doppler> 500200-500< 200
Diast flow rev – PW desc AortaIf present, early diastolicEarly diastolicHolodiastolic
Primary Parameters

Quantification of Jet
MildModerateSevere
Jet-width / LVOT-width< 0.250.25 – 0.64> 0.64
Jet-area / LVOT-area< 0.050.05 – 0.59> 0.59

Qualitative Parameters
MildModerateSevere
Jet areaSmallVariableLarge if central, variable if eccentric
Coaptation defectMildModerateSevere
CW-profileWeakViableDense
LA sizeNormalNormal or enlargedEnlarged
LV sizeNormalNormal or enlargedEnlarged

PISA Parameters
MildModerateSevere
EROA (cm2)< 0.10.1 – 0.29≥ 0.30
Regurgitant volume (ml/beat)< 3030 – 59≥ 60
Regurgitant fraction (%)< 3030 – 49≥ 50

Aortic Stenosis

Disease Defining Parameters
MildModerateSevere
Valve area (cm2)> 1.51.0 – 1.5< 1.0
Indexed valve area (cm2/ m2)> 0.850.6 – 0.85< 0.6
Measured Parameters
MildModerateSevere
Mean gradient (mmHg)< 2020 – 40> 40
Peak gradient (mmHg)< 3535 – 65> 65
Peak velocity (m/s)2.6 – 2.93.0 – 4.0> 4.0
Dimensionless index (LVOT/AV)> 0.50.5 – 0.25< 0.25

Bioprosthetic Aortic Valve Stenosis

EOA (effective orifice area) index
  • Mild PPM: EOA ⩽ 0.85 cm2/m2
  • Moderate PPM: EOA 0.65–0.85 cm2/m2
  • Severe PPM: EOA < 0.65 cm2/m2
Practice Questions | Echocardiographic Evaluation of Aortic Valve Prosthesis
Prosthesis‐patient mismatch: definition, clinical impact, and prevention

Visual Assessment of LV RWMA 

Type of motionDefinitionWall Motion Score
Normal Normal thickening (>30% thickening end-systole to end-diastole)1
Hypokinesia Reduced thickening (10-30%)2
Akinesia Markedly reduced thickening (<10%)3
Dyskinesia Paradoxical thinning and/or outward motion during systole4
Aneurysmal Diastolic deformation5

LV Dimension and Volume

LV Dimension
 Women Men 
 Normal Mild Moderate Severe Normal Mild Moderate Severe 
Diastolic diameter 3.9-5.3 5.4-5.7 5.8-6.1 >6.2 4.2-5.9 6.0-6.3 6.4-6.8 >6.9 
Diastolic diameter/BSA cm/m22.4-3.2 3.3-3.4 3.5-3.7 >3.8 2.2-3.1 3.2-3.4 3.5-3.6 >3.7 

LV Volume
 Women Men 
 Normal Mild Moderate Severe Normal Mild Moderate Severe 
Diastolic volume, mL 56-104 105-117 118-130 >131 67-155 156-178 179-201 >201 
Diastolic volume/BSA mL/m235-75 78-86 87-96 >97 35-75 76-86 87-96 >97 
Systolic volume, mL 19-49 50-59 60-69 >70 22-58 59-70 72-83 >83 
Systolic volume/BSA 12-30 31-36 37-42 >43 12-30 31-36 37-42 >43 

LV Ejection Fraction (EF %)

Women Men 
Normal Mild Mod Severe Normal Mild Mod Severe 
54-74 41-53 30-40 <30 52-72 41-51 30-40 <30 

Right Ventricle Dilation

Base (RVD1)> 42mm
Mid (RVD2)> 35mm
Longitudinal dimension (RVD3)> 86mm
RV focused apical 4 chamber
PLAX Distal RVOT (left side)> 30 mm
PSAX Proximal RVOT (middle)> 35 mm
PSAX Proximal RVOT (right side)> 27 mm

RV dimensions
 Normal Dilated Moderate Severely 
RV diameter (RVD 1) 2.0-2.8 2.9-3.3 3.4-3.8 ≥3.9 
RV diameter (RVD 2) 2.7-3.3 3.4-3.7 3.8-4.1 ≥4.2 
Base-to-apex length 7.1-7.9 8.0-8.5 8.6-9.1 ≥9.2 

RV diameter
 Normal Mild Moderate Severely 
Above aortic valve 2.0-2.8 2.9-3.3 3.4-3.8 ≥3.9 
Above pulmonic valve 2.7-3.3 3.4-3.7 3.8-4.1 ≥4.2 

PA diameter
 Normal Mild Moderate Severe
Below pulmonic valve 1.5-2.1 2.2-2.5 2.6-2.9 ≥3.0 

RV size and function
 Normal Mild Moderate Severe
RV diastolic area, cm2 11-28 29-32 33-37 ≥38 
RV systolic area, cm2 7.5-16 17-19 20-22 ≥23 
RV fractional area change, % 32-60 25-31 18-24 ≤17 

Left Atrial Size and Volumes

Atrial dimensions
 Women Men 
 Normal Mild Mod Severe Normal Mild Mod Severe 
LA diameter 2.7-3.8 3.9-4.2 4.3-4.6 ≥47 3.0-4.0 4.1-4.6 4.7-5.2 ≥5.3 
LA diameter/BSA 1.5-2.3 2.4-2.6 2.7-2.9 ≥3.0 1.5-2.3 2.4-2.6 2.7-2.9 ≥3.0 
RA minor axis, cm 2.9-4.5 4.6-4.9 5.0-5.4 ≥5.5 2.9-4.5 4.6-4.9 5.0-5.4 ≥5.5 
RA minor-axis/BSA (cm/m2) 1.7-2.5 2.6-2.8 2.9-3.1 ≥3.2 1.7-2.5 2.6-2.8 2.9-3.1 ≥3.2 

LA area (cm2)
Women Men 
Normal Mild ModSevere Normal Mild ModSevere 
<20 20-30 30-40 >40 <20 20-30 30-40 >40 

Atrial volumes
 Women Men 
 Normal Mild ModSevere Normal Mild ModSevere 
LA volume 22-52 53-62 63-72 ≥73 18-58 59-68 69-78 ≥79 
LA volume/BSA 22±6 29-33 34-39 ≥40 22±6 29-33 34-39 ≥40 

Mitral Regurgitation

Primary parameters
 Mild ModSevere 
Vena Contracta <0.3 0.3-0.69 ≥0.7 
EROA (cm2) <0.2 0.2-0.39 ≥0.4 
Jet size <4 cm2 or <20% of atrial size 4-10cm 2 or 20-40% of atrial size >10cm 2 or >40% of atrial size 
Jet orientation Central Variable Eccentric 
Pulmonary vein flow S-dominant Reduced S-wave Systolic flow reversal 

Qualitative parameters
 Mild Mod Severe 
Mitral valve apparatus Normal-mildly abnormal Often abnormal Abnormal, possibly flail 
CW-profile Weak Variable Dense 
Shape CW-profile Parabolic Variable Early peak, triantriangular 
LA sizeNormalNormal or dilatedDilated

Additional PISA-parameters
     Mild Mod Severe 
Regurgitation volume (mL/beat) <30 30-59 ≥60 
Regurgitation volume (EROA x TV)   
Regurgitation fraction (%) <30 30-49 ≥50 
PW-doppler A-dominant Variable High E values 

Miscellaneous parameters
    Mild Moderate Severe 
PW-doppler A-dominant Variable High E values 

Mitral Stenosis

Primary parameters
   Mild Mod Severe 
Valve area>1.5cm21.5-1.0m2<1.0cm2
Mean gradient<5mmHg5-10mmHg>10mmHg
PAP<30 mmHg30-50>50

Pulmonary Regurgitation

 MildModSevere
Pulmonary valve morphologyNormalNormal/abnormalAbnormal
Density CW-dopplerWeak, slow decalVariableDense, steep deceleration, early termination of diastolic flow
Jet width color DopplerSmall, <10 mm length, narrow originVariableLarge, wide origin
Ratio pulmonic to aortic flowNormalVariableSignificantly increased

Pulmonary Stenosis

 MildModSevere
Peak velocity (m/s)<33-4>4
Peak gradient (mmHg)<3636-64>64

Tricuspid Regurgitation

 MildModSevere
PISA radius<0.60.6-0.9>0.9
Vena contracta (cm_Not defined<0.7>0.7
Liver vein flowS-dominantReduced S-waveSystolic flow reversal, jet reaching liver vein

Additional Quantitative Parameters
 Mild Moderate Severe 
Jet size<5 cm25-10 cm2>10 cm2
IVC size<2.1cm, compressibleIn between>2.1cm, not compressible
 
Additional Qualitative Parameters 
 Mild Moderate Severe 
Coaptation defectMildModSevere
RV sizeNormalNorma/enlargedEnlarged
RA sizeNormalNormal/enlargedEnlarged
CW-profile tricuspid regurgitationWeak VariableDense
Shape CW-profile TRParabolicVariableEarly peak, triangular

Tricuspid Stenosis

Mean PG≥ 5 mmHg
Valve area ≤ 1cm2
VTI of TV inflow>60cm
Pressure half time≥190 ms
RASeverely enlarged
IVCElnarged

Pulmonary Artery Pressure

 RA pressure
IVC <2.1cm, >50% sniff3 mmHg
All others or if not visualized8 mmHg
>2.1cm, sniff <50%15 mmHg

Pulmonary HTN (pHTN)

Mild30-50 mmHg
Moderate51-65 mmHg
Severe> 65mmHg

LV Region Identification

Diastolic Function

  • In patients with normal EF
  • Mitral inflow table
  • Practical approach to grade diastolic dysfunction
  • Diastolic dysfunction table

Mitral Valve Leaflets on TEE

https://thoracickey.com/role-of-transesophageal-echocardiography-in-mitral-valve-repair/

Useful Websites

Additional Reading and Primary Sources

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How to Differentiate Pericardial and Pleural Effusions on Ultrasound/Echo

Although it is relatively easy to spot the difference between pericardial and pleural effusions on a chest x-ray, in medical training we have less exposure to ultrasound and it takes much more time to get comfortable looking at ultrasounds and knowing what you are looking at.

The first thing to remember with ultrasound and echocardiography is to get multiple windows! Just like any imaging study, ultrasound has its limitations. That’s why we try to squeeze our probe between or under the ribs in various areas of the chest to try and see the heart in different angles. An effusion can be obvious in one angle but be hiding in a different perspective.

This image below shows both a pericardial and pleural effusion. It’s one of my favorite images in the parasternal long (PSL) axis view via echocardiography. The quick and dirty way to tell if this fluid is a pericardial or pleural effusion is to find the descending aorta. The descending aorta is outside of the pericardium. It travels posterior to the heart down the chest. So when we see the heart in this PSL axis view we are cutting the aorta cross-sectionally. This should help bring you to identify the second important structure- the pericardium, or the connective tissue sac that the heart sits in. Knowing where these two structures are will allow you to more easily identify this fluid accurately as either a pericardial or pleural effusion.

View Image
Pericardial and pleural effusion

The second tip to correctly identify pericardial versus pleural effusions on ultrasound or echocardiography is to practice and get multiple windows! Getting multiple windows, or ultrasound view points of the heart, has the same importance in getting a 2-view chest x-ray. Multiple vantage points lets you better see the same structure from different angles and can help you clarify what you are looking at when it is not so obvious.

For further resources check out the following links I found helpful. A lot of these blogs are fantastic ultrasound information for individuals who want to dive deeper into echocardiography as well as ultrasound.

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