The standard probe used for TTE is 2-4 MHZ (Transthoracic)
- A) Parasternal long axis:
- B) Parasternal short axis:
- Apical view:
- Subcostal view:
- Suprasternal view
Parasternal Long Axis
The probe is positioned to the left of the lower sternum at the 4th or 5thintercostals space, angled obliquely so the marker points to the right shoulder. This provides long view of the left ventricle, mitral valve, Lt. Atrium, aortic valve, ascending aorta and right ventricle. Demonstrate continuity of the IVS with the anterior wall of the aortic wall.
Note:The anterior portion of the aortic root and the interventricular septum should be continuous and as perpendicular to the sound beam as possible. The posterior portion of the aortic root is continuous with anterior mitral leaflet
Mitral Valve M-Mode
Note: The Mitral Valve is labeled to describe the different phases of its motion:
D — beginning of diastole
E — maximal excursion of the
valve
F — Initial closure, point to
which the valve had closed
following the passive filling
phase
A — atrial contraction
( P wave on the ECG )
C — closure of the valve and beginning
of systole
M-mode of Aortic valve
Displays the aortic root,
Aortic cusps opening in systole and closing in diastole
1. Aortic Root – Should be measured at the end of diastole (at the onset of Q in the EKG) Normally 3 cm.
2. Aortic Cusp Separation – Measured at early Systole, Normally 1.5-2cm 3. Aortic Ejection Time – From the beginning of valve opening to the end of Valve opening
4. Left Atrium: Dimension Measurement are taken at the end of the Ventricular Systole end of T wave. Normally 4cm ( + or – 3mm) -Left atrium more than 6 cm is considered significantly enlarged
Normal M- mode examination of the left ventricle. Left ventricular walls should be perpendicular to sound beam
1. Left Ventricular Diameter end diastole ( LVDD ), Measured at the onset of QRS, the upper limits is 5.4 cm.
2. Left Ventricular diameter end systole measured at the peak downward displacement of the IVS, Measured at the end of T wave on EKG
3. IVS: Measured at the end of diastole, at the start of Q wave in EKG, It is 0.7-1.1 cm.
4. Post Wall: Measured at the end of diastole, at the start of Q wave in EKG,
It is 0.7 – 1.1 cm
Right Ventricular Inflow View
Maintaining the same inter costal space and transducer orientation, angle the transducer inferior and medial, towards the belly button shows the right ventricular inflow view, RV, TV and RA, blood flow on color Doppler will be red towards the transducer
3. Right Ventricular Outflow View
Maintaining the same inter costal space and transducer orientation, angle the transducer superior and lateral towards the left shoulder. This will open the pulmonary artery and allow the assessment of pulmonic valve. Color flow Doppler will show blue color away from the transducer
Parasternal Short Axis
Rotate the transducer 90 degrees from the long axis Parasternal position, Transducer will point to the Lt. Shoulder one O’clock position
Aortic Valve Level
Mitral Valve Level
Papillary Muscle Level
Apical level
The AV should be in the center of the screen with the LA, RA, RV as well as the tricuspid valve (TV) and the right ventricular outflow track (RVOT) can be displayed surrounding it.
Evaluate for the presence of three aortic cusps and thickness and motion of all the valves
- Parasternal short axis mitral valve level:(Fish Mouth)
Tilt transducer a little from the same position down to the right. A cross section of the left ventricle (LV) at the level of the mitral valve and the right ventricle (RV) can be displayed.
- Parasternal short axis (papillary muscle level):
Angling the transducer more downwards, Lt Ventricle with the papillary muscle giving the cavity a mushroom like appearance
Assess ventricular function for focal or global abnormalities
Slide an interspace down if view is not clear
Apical 4 Chamber Vie
Transducer at the point of impulse (PM) pointing laterally (3 o’clock)
LEFT VENTRICULAR INFLOW
– MITRAL VALVE;(Left ventricular inflow)
Mitral valve waveform is obtained from apical 4 chambers view or apical long axis view.
Sample volume should be placed at the tips of the
mitral valve leaflets
Doppler waveform shows two peak velocities
a. E wave reflects early passive diastolic filling
during left ventricular relaxation
Normal peak velocity at E is 0.6- 1.3 m/sec,
b. A wave late diastolic peak velocity related to
atrial contraction
A waveform is 0.2- 0.7 m/sec
Flow is biphasic occurs during diastole and reflects
passive left ventricular filling.
Left ventricular waveform varies with age
E/A ratio >1 young patient
E/A ratio = 1 at age 50-60
E/A ratio <1older patient
Note: If diastole is long enough, a period of no flow or
diastasis is seen between two waves
Apical 5 Chamber View
Angling the transducer upwards you will see the LVOT (Root of Aorta )
Tilt the transducer slightly down. The aortic valve
(AV) can be seen in the middle, between chambers.
Tilting the transducer to the opposite direction,
The coronary sinus can be displayed.
-LEFT VENTRICULAR OUTFLOW TRACT (LVOT)
Waveform is obtained from the apical 5 chambers, or from the apical long axis
Sample volume placed in the ventricular side of the aortic valve.
The normal range is 0.7- 1.1m/sec
Flow occurs in systole
-Ascending Aorta (LVOT)
Flow occurs in systole.
Obtained using the apical 5 chambers or apical long axis view
Normal trans valvular velocity is 1.0- 1.7 m/sec
Apical two-chamber view:
Turn the transducer aprox. 60° counter- clockwise
from the previous position, Transducer orientation
towards patient’s left shoulder,
The left ventricle (LV) and the left atrium (LA)
can be displayed
Apical three-chamber view:
Turn the transducer further, aprox. 60° counter-clockwise
from the previous position, transducer orientation
towards patient’s left shoulder, and side tilt slightly upwards
The left ventricle (LV), the left atrium (LA)
and the aortic bulb (Ao) can be displayed
Subcostal view:
Place the transducer on the subxyphoid region.
The transducer’s index mark is directed towards
the patient’s head. The inferior vena cava (VCI)
can be displayed. Turn the transducer clockwise
slightly to display the right and left ventricle,
as well as the right (RA) and left atrium.
Suprasternal view:
Place the transducer on the suprasternal region.
The transducer’s index mark is directed towards
the patient’s head and turned aprox. 45° to the right.
The aortic arch (*), the neck arteries (TB, CL, SL)
and the right pulmonary artery (RPA) as well as the
left atrium (LA) can be displayed
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