A HANDBOOK ON

CLINICAL
ECHOCARDIOGRAPHY

C. Sriramalakshmi & Dr. J. JAMUNA

Chennai • Bangalore
CLEVER FOX PUBLISHING
Chennai, India

Published by CLEVER FOX PUBLISHING 2023

Copyright © C. Sriramalakshmi & Dr. J. JAMUNA 2023

All Rights Reserved.

ISBN: 000-00-00000-00-0

This book has been published with all reasonable efforts taken to make the
material error-free after the consent of the author. No part of this book shall
be used, reproduced in any manner whatsoever without written permission
from the author, except in the case of brief quotations embodied in critical
articles and reviews.

The Author of this book is solely responsible and liable for its content including
but not limited to the views, representations, descriptions, statements,
information, opinions and references [“Content”]. The Content of this
book shall not constitute or be construed or deemed to reflect the opinion
or expression of the Publisher or Editor. Neither the Publisher nor Editor
endorse or approve the Content of this book or guarantee the reliability,
accuracy or completeness of the Content published herein and do not make
any representations or warranties of any kind, express or implied, including
but not limited to the implied warranties of merchantability, fitness for a
particular purpose. The Publisher and Editor shall not be liable whatsoever for
any errors, omissions, whether such errors or omissions result from negligence,
accident, or any other cause or claims for loss or damages of any kind,
including without limitation, indirect or consequential loss or damage arising
out of use, inability to use, or about the reliability, accuracy or sufficiency of
the information contained in this book.
 ACKNOWLEDGEMENT

DR. B. SENDILKUMAR
Dean
School of Allied Health Sciences
Vinayaka Mission’s Research Foundation - DU, Salem.

First and foremost thanks to God, the Almighty , the showers

of his blessing throughout the work to complete our book
successfully. We would like to express our deep and sincere
gratitude to our Dean sir, for giving the opportunity to learn and
to explore in my field of expertise as well as providing invaluable
guidance throughout this journey. His dynamism, sincerity and
motivation has deeply inspired us. It was a great privilege and
honour to work and study under his guidance.
C. Sriramalakshmi
Dr. J. Jamuna

iii
 Acknowledgement

Dr. D. K. SRIRAM
MEDICAL DIRECTOR
HINDU MISSION HOSPTAL - TAMBARAM

I Could like to express my profound gratitude to my Medical

Director - Dr. D. K. SRIRAM sir. He gave me an wonderful
opportunity to work in his team which made me motivated to
do this work.

I am extremely grateful to my parents , husband for their love ,

prayers, caring and sacrifices for educating and preparing me for
my future, Also I express my thanks to my siblings who provide
innate support for my passion and jotting down my skills.

I take this as a moment to remember my father , who constantly

guides me from haven with all his blessings. He would have
been the most proud member of my family to have seen my
achievement as a publication.
C. Sriramalakshmi

iv
 CONTENTS

1. Basics of Ultrasound..........................................................1
2. Pulse Wave Doppler........................................................20
3. Views of Echocardiography.............................................27
4. Diastolic Filling of Heart.................................................39
5. Parameters for Evaluating Lvsf.........................................52
6. Regional Wall Motion Abnormalities (Rwma).................67
7. The Assessment of Intracardiac Thrombus.......................80
8. Dressler’s Syndrome........................................................82
9. Cardiac Output and Stroke Volume Assesment
in Echo...........................................................................84
10. Mitral Valve.....................................................................95
11. Anatomy of Aortic Valve...............................................130
12. Tricuspid Valve..............................................................143
13. Pulmonary Valve...........................................................152
14. Infective Endocarditis....................................................164
15. Dilative Cardiomyopathy..............................................185
16. Restrictive Cardiomyopathy..........................................195
17. Constrictive vs Restrictive Pericarditis...........................203
18. Basics of the Pericardium...............................................206
19. Atrial Septal Defect.......................................................217
20. Ventricular Septal Defect...............................................230

v
 1
BASICS OF ULTRASOUND

SOUND
Ultrasound waves can provide tissue information through
reflection-ed at the boundary between different acoustic media.
The subsequently generated echoes are sent back to the transducer,
which is then used for image composition

ULTRASOUND
● The human ear can detect sound waves with a frequency
between 20 Hz to 20,000 Hz.
● Acoustic signals with a higher frequency (=ultrasound)
physically behave just as audible sound waves.
● For medical applications, ultrasound is used with a frequency
in the range of MHz.

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 A handbook on clinical Echocardiography

SOUND WAVES
● Sound waves are mechanical vibrations that can be described in
terms of frequency or Hertz (Hz), ie, the number of repetitions
or cycles per second.
● Other characteristics include wavelength, the distance between
excitations, measured in mm; and the amplitude of excitation,
measured in decibels (dB).
● A 6-dB change results in a doubling (or halving) of the signal
amplitude. Medical ultrasound imaging typically uses sound
waves at frequencies of 1,000,000 to 20,000,000 Hz (1.0 to
20 MHz).

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 Basics of Ultrasound

● Frequency and wavelength are mathematically related to the

velocity of the ultrasound beam within the tissue (approximately
1,5400,000 mm/sec for human tissue) as indicated by the
following equations:

Propagation velocity = Wavelength (mm) x frequency (Hz)

Wavelength (mm) = 1,540,000 mm/sec / frequency (Hz)

Wavelength (mm) = 1.54 / frequency (MHz)

● The resolution of a recording, ie, the ability to distinguish two

objects that are spatially close together, varies directly with the
frequency and inversely with the wavelength.
● High frequency, short wavelength ultrasound can separate
objects that are less than 1 mm apart. Echocardiographic
image resolution is generally 1 or 2 wavelengths.
● Thus, imaging with a 2.5-MHz transducer would result in
a resolution of approximately 1 mm. Imaging with higher
frequency (and lower wavelength) transducers permits
enhanced spatial resolution.
● However, because of attenuation, the depth of tissue penetration
or the ability to transmit sufficient ultrasonic energy into the
chest is directly related to wavelength and therefore inversely
related to transducer frequency.
● As a result, the trade-off for use of higher frequency transducers
is reduced tissue penetration. The trade-off between tissue
resolution and penetration guides the choice of transducer
frequency for clinical imaging.
● As an example, higher frequency transducers can be used
in echocardiography for imaging of structures close to the

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 A handbook on clinical Echocardiography

transducer or the chest wall, such as the apex of the left ventricle
with trans-thoracic imaging.
● When an ultrasonic beam travels through a homogeneous
medium, its path is a straight line. However, when the medium
is not homogeneous or when the beam travels through a
medium with two or more interfaces, its path is altered.
● The relationship between ultrasound waves and tissues can
be described in terms of reflection, scattering, refraction, and
attenuation.
● The last three factors all act to decrease the magnitude of the
ultrasound wave.
● The potential of diagnostic ultrasound to display structures
and tissue is influenced by a number of factors related to the
way ultrasound waves behave in tissue.
● In addition, ultrasound waves undergo attenuation and
therefore have a limited depth of penetration. Most importantly,
ultrasound can create artifacts which may significantly alter
image quality and falsely display structures or tissue.
● Various examples of ultrasound artifacts include attenuation,
acoustic shadowing, near field clutter, reverberations, mirror
artifacts, side lobes, beam width artifacts, stitching artifacts in
3D imaging and erroneous machine settings.
● An overview of a number of possible artifacts is provided in the
below section.

REFLECTION
● When an ultrasound beam “hits” a tissue boundary/interface,
a certain amount of the ultrasound is reflected back to the
transducer, like a mirror.

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 Basics of Ultrasound

● The magnitude of the reflected wave is dependent on the

acoustic impedance of the tissue:

Acoustic impedance = tissue density x propagation velocity

● Tissues with increased density reflect a greater proportion of

the ultrasound beam.
● The magnitude of the reflected beam which is received by the
transducer is dependent upon the angle between the ultrasound
beam and tissue interface.
● Since the angle of incidence equals the angle of reflection, the
“optimal” return of the reflected ultrasound occurs at a 90?
(perpendicular) orientation.

SCATTERING
● Small structures, eg, less than 1 wavelength in lateral dimension,
result in scattering of the ultrasound signal.
● Unlike a reflected beam, scattering results in the ultrasound
beam being radiated in all directions, with minimal signal
returning to the transducer.

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 A handbook on clinical Echocardiography

REFRACTION
Ultrasound waves can all be refracted, or deflected from their
orientation, as they pass into a medium of different acoustic
impedance.

ATTENUATION
● The ultrasound signal strength is progressively reduced due to
absorption of the ultrasound energy by conversion to heat, a
process called attenuation.
● Attenuation is frequency and, from the above formation,
wavelength dependent.
● The depth of penetration is limited to approximately 200
wavelengths, corresponding to a depth of 30 cm for a 1 MHz
transducer, 12 cm for 2.5 MHz transducer, and 6 cm for a 5
MHz transducer.

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 Basics of Ultrasound

● Attenuation is also dependent upon acoustic impedance and

any mismatch in impedance between adjacent structures.
● Air has a very high acoustic impedance, resulting in significant
signal attenuation when imaging through lung tissue,
especially emphysematous lung, or pathologic conditions such
as pneumomediastinum or subcutaneous emphysema.
● In contrast, filling of the pleural space with fluid, generally
enhances ultrasound imaging.

TRANSDUCER
● Ultrasound transducers use piezoelectric crystals to both
generate and receive ultrasound waves. These crystals (quartz
or titanate ceramic) alternately compress and expand the
alternating electric current that is applied, thereby generating
the ultrasound wave.

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 A handbook on clinical Echocardiography

● Following a brief period of transmission, typically 1 to 6

microseconds, the same crystal also acts as a receiver.
● When a reflected ultrasound wave impacts the piezoelectric
crystal, an electric current is generated.
● Image formation, which is related to the distance of a structure
from the transducer, is based upon the time interval between
ultrasound transmission and arrival of the reflected signal.
● The amplitude is proportional to the incident angle and
acoustic impedance, and timing is proportional to the distance
from the transducer.
● The simplest type of ultrasound transducer has a single
piezoelectric crystal and is often used for M-mode recordings.
Generation of a 2D image requires mechanical or electronic
“sweeping” of the ultrasound beam across the plane of interest
or sector.
● Initially, mechanical transducers physically moved a crystal.
Today, phased-array transducers consist of a series of ultrasound
crystals arranged so that they can be “electronically” steered,
with no moving parts.
● The phased-array transducers are the most common type
currently used for clinical echocardiography.
● In contrast to echocardiographic imaging, continuous-wave
Doppler examinations utilize a pair of dedicated crystals: one
for continuous transmission; and one for continuous receiving.

8
 Basics of Ultrasound

TIME ~ DISTANCE
● If the propagation velocity of the ultrasonic waves is fixed (the
time between the transmission of an ultrasound and receiving
the echo) it corresponds to a particular distance traveled.
● Thus, if the speed of the sound is fixed, then the depth of the
reflecting interface is proportional to the time.
● In other words the later the echo, the deeper the reflective
interface.
● Traveling speed depends on the intermediate substance.
● In order to produce images, it is assumed that the propagation
velocity amounts 1540 m/s in soft tissue.

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 A handbook on clinical Echocardiography

A-MODE
● In the most simple (historical) Amplitude-mode, the strength
of the echo is picked up on a scan line plotted as a function of
time (=depth).
● The A-mode echo strength is compensated for attenuation (ie
the depth or time).

RESOLUTION
Image resolution with 2D echocardiography can be considered
in terms of:

“Axial” resolution along the length of the ultrasound beam

“Lateral” resolution

“Elevational” resolution which is the thickness of the

tomographic “slice”

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 Basics of Ultrasound

● Axial resolution is a function of the transducer frequency,

bandwidth, and pulse length. Since the smallest resolvable
distance between two specular reflections is 1 wavelength,
higher-frequency transducers result in enhanced axial
resolution.
● A wider bandwidth also improves resolution by allowing
for a shorter pulse. Lateral resolution varies with transducer
frequency, beam width, bandwidth, aperture (width) of the
transducer, and side lobes.
● At greater depths, beam width diverges so that a point target
results in a reflected signal as wide as the beam width.
● Beam width artifacts appear as a bright linear structure.
● The 2D tomographic image includes reflected and backscattered
signals from the entire thickness.
● The thickness of the 2D image is variable over the image plane
and is dependent upon the transducer design and focusing.
● Most clinical images have a “thickness” of 3 to 10 mm,
depending on depth.
● Strong reflectors near the image plane may appear “in” the
image plane due to elevational beam width.

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 A handbook on clinical Echocardiography

B-MODE
● B-mode imaging, or brightness modulation, displays the
varying intensities of the returning echoes as varying degrees of
brightness, instead of the vertical deflections used in A-mode.
● The brightness of the amplitudes in B-mode is represented as
pixels. Echoes with greater intensity are displayed with greater
degrees of brightness. Multiple scan lines are combined to one
image.
● These scan lines are sequentially obtained by to steer the
ultrasound beam in different directions.

M-MODE
● Motion or “M”-mode echocardiography is among the earliest
forms of cardiac ultrasound.
● With this technique, a single crystal rapidly alternates between
transmission and receiver modes with rapid updating (>1000
Hz); as a result, rapidly moving structures (eg, valve leaflets)
can be monitored for their characteristic motion.

12
 Basics of Ultrasound

● M-mode data can be recorded on paper or displayed on the

video monitor at sweep speeds of 50 to 100 mm/sec.
● Although originally performed using dedicated crystals,
alignment of the M-mode beam is now typically performed
with 2D imaging guidance.

DOPPLER
● A moving target will backscatter an ultrasound beam to the
transducer so that the frequency observed when the target is
moving toward the transducer is higher and the frequency
observed when the target is moving away from the transducer
is lower than the original transmitter frequency.
● This Doppler phenomenon is familiar to us as the sound of
a train whistle as it moves toward (higher frequency) or away
(lower frequency) from the observer.
● This difference in frequency between the transmitted frequency
(F[t]) and received frequency (F[r]) is the Doppler shift:
Doppler shift (F[d]) = F[r] – F[t] Blood flow velocity (V) is
related to the Doppler shift by the speed of sound in blood (C)
and α, the intercept angle between the ultrasound beam and
the direction of blood flow. A factor of 2 is used to correct for
the “round-trip” transit time to and from the transducer.

F[d] = 2 x F[t] x [(V x cos α)] / C

● This equation can be solved for V, by substituting (F[r] – F[t])

for F[d]: V = [(F[r] -F[t]) x C] / (2 x F[t] x cos α). Note that
the angle of the ultrasound beam and the direction of blood
flow are critically important in the calculation.

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 A handbook on clinical Echocardiography

CONTINUOUS WAVE DOPPLER

● Continuous wave Doppler employs two dedicated ultrasound
crystals:
● one for continuous transmission and a second for continuous
reception of ultrasound signals.
● This permits measurement of very high frequency Doppler
shifts or velocities. The “cost” is that this technique receives
a continuous signal along the entire length of the ultrasound
beam.
● Thus, there may be overlap in certain settings, such as stenoses
in series (eg, left ventricular outflow tract gradient and aortic
stenosis) or flows that are in close proximity/alignment (eg,
aortic stenosis and mitral regurgitation).
● Differentiation of the signal from each component may still be
determined from the characteristic timing and/or profile.
● An ideal Doppler profile is one with a smooth “outer” contour,
well-defined edge and maximum velocity, and abrupt onset
and termination.
● The continuous wave Doppler profile is usually “filled in”
because lower-velocity signals proximal and distal to the
point of maximum velocity are also recorded. Although the
maximum frequency shift depends on α, the profile, onset,
and termination of the Doppler signal are not dependent upon
this value, resulting in inappropriate underestimation of true
velocity.
● For this reason, continuous wave Doppler positioning is often
integrated with two-dimensional (2D) and color flow imaging
to allow for good alignment with flow (ie, angle less than 20°).

14
 Basics of Ultrasound

Continuous wave Doppler is typically used to measure higher

velocities as in pulmonary hypertension and aortic stenosis.

PULSED WAVE DOPPLER

● In contrast to continuous wave Doppler, which records signal
along the entire length of the ultrasound beam, pulsed wave
Doppler permits sampling of local blood flow velocities about
a specific region.
● This modality is particularly useful for assessing the relatively
low velocity flows associated with transmitral or transtricuspid
blood flow, pulmonary venous flow, left atrial appendage
flow, or for confirming the location of eccentric jets of aortic
regurgitation and mitral regurgitation.

15
 A handbook on clinical Echocardiography

● To permit this, a pulse of ultrasound is transmitted and then

the receiver “listens” during a subsequent interval defined by
the distance from the transmitter and the sample site.
● This transducer mode of transmit-wait-receive is repeated at an
interval termed the pulse-repetition frequency (PRF).
● The PRF is therefore depth-dependent, being greater for near
regions and lower for distant or deeper regions.
● The distance from the transmitter to the region of interest is
called the sample volume, with the width and length of the
sample volume varied by adjusting the length of the transducer
“receive” interval.
● In contrast to continuous wave Doppler, which is sometimes
performed without 2D guidance, pulsed Doppler is always
performed with 2D guidance to determine the sample volume
position Because pulsed wave Doppler echo repeatedly samples
the returning signal, there is a maximum limit to the frequency
shift or velocity that can be measured unambiguously.
● Correct identification of the frequency of an ultrasound
waveform requires sampling at least twice per wavelength.
Thus, the maximum detectable frequency shift or the Nyquist
limit is one-half the PRF.
● If the velocity of interest exceeds the Nyquist limit,
“wraparound” of the signal occurs first into the reverse channel,
then back to the forward channel; this is known as aliasing.
● Techniques that can minimize aliasing during pulsed Doppler
include using a lower frequency transducer and shifting the
baseline.
● Another solution is to increase the number of sample volumes,
or high PRF.

16
 Basics of Ultrasound

● As noted above, when a pulse is transmitted, backscatter along

the entire length of the beam is received.
● Depth resolution is achieved with pulsed Doppler using the
duration of the “wait” period. However, signals from exactly
twice (or 3x, 4x, etc) the distance will reach the transducer
during the “receive” phase of the next (or subsequent) cycle.
● As a result, signals from 1x, 2x, 3x, 4x, 5x, etc have the potential
for confounding the analysis.
● The latter signals are generally of low amplitude and do not
interfere with the spectral display.
● If, however, the sample volume is deliberately placed at one-
half the depth of interest, backscattered signals from the 2x
sample volume, the true depth of interest, will return to the
transducer during the “receive” phase of the following cycle.
● This recording of signal at a higher PRF permits measurement
of higher velocities without signal averaging. Even greater
velocities could be achieved using additional sample volumes.
● In the pulsed Doppler multiple short ultrasound pulses are
transmitted by a transmitter and the echo is recorded by the
same transmitter.
● Comparison of the emitted with the signals received supplies
again the Doppler shift, and therefore the velocity of the blood.
The advantage of the technique is that the Doppler shift can be
measured at a pre-selected depth.
● Which, after all, is equivalent to echoes at a given time after
the transmission of the pulse.
● The disadvantage of the art is that no high blood velocities can
be measured. This technique can be combined with B-mode;
This is called duplex.

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 A handbook on clinical Echocardiography

CONTINUOUS VERSUS PULSED WAVE DOPPLER

● The velocity of blood flow are usually shown as a graph in
function of time. Positive blood flow velocity away from the
transducer, negative blood flow velocity towards the transducer.
● Due to the fact that high speeds lead to aliasing in Pulsed
wave Doppler, these measurements are not reliable with this
technique and are to be measured with Continuous wave
Doppler.

COLOR DOPPLER
● Color flow imaging is a form of pulsed wave Doppler. A scan
line uses several short successive pulse-echo sequences.
● Moving structures in the scanline are to cause a phase shift
This will bedisplayed on the image in color.
● These measurements are less accurate than when measured
with pulsed wave Doppler. However, the advantage of Color
Doppler is that information from various depths are obtained
immediately.
● Pulse 1 reaches the moving reflector. Pulse 2, emitted shortly
after pulse 1, will reach the moving reflector at a different
point, as the moving reflector in the meantime has travelled
a distanced.
● By the time the echo of the second pulse reaches the reference
point, the echo from pulse 1 has travelled a distance of 2 x d
(for the surface).
● By comparison of the two echoes and the resulted phase shift
due to the moving reflector, the Doppler shift can be derived.
● Flow towards the ultrasound transducer appears in red. Flow
away, from the transducer appears in blue.

18
Basics of Ultrasound

19
 2
PULSE WAVE DOPPLER

● The pulse wave doppler sends short pulses of ultrasound and

analyses reflected sound between the pulses.
● This is accomplised by using the same piezoelectric crystals, to
send and analyze sound waves.
● The crystals alternate rapidly between sending and analysing
ultrasound.
● Therefore, emitted sound waves can be associated with reflected
sound waves, making it possible to determine the distance of
the reflector (I.e, the structure reflecting the sound waves).
● The pulsed wave doppler can analyze sound waves reflected
from a specific location.
● This is the main advantage of pulsed wave doppler,namely its
ability to determine the location of the measured velocities.
● However, the pulsed wave doppler requires time to analyze
reflected sound waves.
● This reduces maximum velocity that can be measured using
pulsed wave doppler.
● Generally, velocities above1.5m/s to 1.7m/s cannot be
measured correctly.

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 Pulse Wave Doppler

SAMPLE VOLUME:
● The major advantage of pulsed wave doppler is the ability to
specify where (along the doppler line ) to measure velocities.
● This is possible because the pulsed wave doppler sends and
analyses sound waves sequentially.
● The ultrasound machine is programmed to ignore all signals,
except those reflected from a certain speed of ultraound is
constant in a body.
● The investigator specifies where the masurment should be
performmed by moving the sample volume along the doppler
line.
● The sample volume is depicted with two lines perpendicular
to doppler line.

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 A handbook on clinical Echocardiography

PULSE REPETITION FREQUENCY (PRF):

The number of ulytrasound pulses sent per second is called as
PRF

● PRF is determined by the speed of sound and the distance it

must travel.
● Since the speed of sou nd in the body is constant (1540m/s)
-or otherwise known as velocity of blood,the PRF depends
only upon the distance of the wave must travel back and forth,
which reseults in LOWER PRF ( only fewer ultrasound pulses
can be sent per second)
● PRF increases with increase in distance
● PRF decreases with decrease in distance
● PRF must be high in order to meaasure the direction of blood
flow, if it reduces then the values may be uncertain.
● This is explained by the fact that each ultrasound pulse
generates the snapshot of blood flow.

22
 Pulse Wave Doppler

NIQUIST THEOREM :
● The importance of high PRF is explained mathametically by
NIQUIST’s Theorem (Harry Niquist) , which demonstrates
that a wave must be sampled (I.e, recorded) at last twice per
cycle in order to be reliably measured .
● For pulsed wave doppler , this implies that PRF must be at
least twice the doppler shift.
● Recall that the doppler shift is directly related to the velocity
of blood flow; the greater the velocity, the greater the doppler
shift.
● Thus, the maximum velocity that can be determined is half the
PRF and this limit is called NIQUIST LIMIT.

Niquist limit = PRF/2

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 A handbook on clinical Echocardiography

ALIASING PHENOMENON:
● Aliasing occurs if the velocity of blood flow exceeds the
Niquist limit. This implies that are ultrasound machine cannot
determine the velocity and direction of the flow.
● On the ultrasound image, the velocities exceeding the Niquist
limit will be presented on the opposite side of the baseline.
● Postive velocities (I.e, velocities normally exceeding the Niquist
limit will be shown as negative velocities and vice versa).
● The PRF depends on the depth being investigated.
● The depth is set by moving the sample volume along the
doppler line.
● The deeper the structures studied, the lower the PRF and
thus , the lower the maximum velocities that can be measured
correctly, and vice versa.

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 Pulse Wave Doppler

ALIASING SPEED:
● It is straightforward to calculate the maximum velocity that
can be measured using pulse wave soppler.
● Aliasing occurs when the velocity exceeds this maximum
velocity(which is therfore reffered to as the aliasing speed or
aliasing velocity).

EXTENDED RANGE DOPPLER:

● PWD analyses reflections from a specific location (I.e, the
sample volume) along the doppler line.The maximum velocity
that can be calculated is determined by the PRF , which is
determined by the distance between the sample volume and
the transducer.
● By using , multiple sample volumes, the PRF is ↑sed .

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 A handbook on clinical Echocardiography

● This is reffered to as high PRF DOPPLER or EXTENDED

RANGE DOPPLER.

Advantages:
Greater velocity can be measured

Disadvantage :
It is difficut to determine the location of the velocities recorded.

26
 3
VIEWS OF ECHOCARDIOGRAPHY

E chocardiography is now not restricted to the echocardiographic

laboratory. It is used in the emergency department, at bedside, in
the intensive care unit as well as in the operating room. Hence
a basic knowledge is needed for all physicians and paramedics.
Transthoracic echocardiography is often done from four echo
windows. Echo windows are regions on the chest which permit
imaging of the heart with least covering by the lungs.

ECHOCARDIOGRAPHIC WINDOWS
The four common locations at which the echocardiographic
transducer is placed for imaging are the

● parasternal,

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 A handbook on clinical Echocardiography

● apical,
● subcostal, and
● suprasternal.

A good knowledge of the anatomy of the heart is needed for

interpretation of images from each view.

This becomes more difficult in complex congenital heart diseases

where the cardiac chamber positions and size may vary.

PARASTERNAL LONG AXIS VIEW :

● First view to be obtained is often the parasternal long axis view.
● This view images the heart from the base to apex long axis
view.
● Transducer is placed in the left parasternal region and fine
adjustments in angulation are made till a view similar to that
in the left panel is obtained.
● Exact position and angulation will vary between individuals.

28
 Views of Echocardiography

Usual structures imaged in this view are the

● right ventricular free wall and outflow region,

● interventricular septum, aorta, and
● aortic valve,
● left ventricular outflow tract,
● anterior and posterior mitral leaflets,
● left ventricular cavity,
● posterior wall of left ventricle and left atrium.
● Colour Doppler imaging is used to image the flow directions
and abnormal flows if any.

In the parasternal long axis ,Opening and closing movements of

the aortic and mitral valves are visible. Contraction of each region
of the left ventricle is also inspected closely for any abnormalities
of regional wall motion.

Parasternal long axis view

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 A handbook on clinical Echocardiography

PARASTERNAL SHORT AXIS VIEW:

● It is obtained by rotating the transducer almost at right angle
in the same location so that the echo beam is perpendicular to
the base apex axis of the heart.
● Three cuts are usually obtained in this view.
● The aorta, right ventricular outflow tract and pulmonary
artery up to its bifurcation is imaged in the upward angulation
shown in the left panel.
● Colour flow shows the flow in pulmonary artery.

Parasternal short axis view aorta pulmonary artery

● Slight downward angulation of the transducer from this view

gives the left ventricular cross section with mitral valve cross
section within.
● Right ventricular cavity is elliptical in this view and left
ventricular cavity is circular.
● Wall motion of the left ventricle can be assessed in this view
also.

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 Views of Echocardiography

● Planimetry of mitral valve area can be obtained in parasternal

short axis view in case of mitral stenosis.

Parasternal short axis view of left ventricle-mitral valve level

Parasternal short axis view of left ventricle-Papillary muscle

level

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 A handbook on clinical Echocardiography

Parasternal short axis view of left ventricle-apical level

Parasternal short axis view of left ventricle- Pulmonary artery

level

32
 Views of Echocardiography

Parasternal short axis view of left ventricle- Aortic valve level

A quik review

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 A handbook on clinical Echocardiography

APICAL FOUR CHAMBER VIEW:

● Apical views are obtained by keeping the transducer directly

over the apex beat.
● Apical four chamber, two chamber and three chamber views
can be obtained by rotating the transducer. Apical four
chamber view is illustrated here.
● Apical four chamber view shows all four cardiac chambers,
mitral and tricuspid valves, and the septa.
● But as the echo beam is parallel to the interatrial septum, false
echo drop outs can occur in the interatrial septum.
● Apical five chamber view including the proximal aorta can be
obtained by slight tilting of the transducer from this view.

Apical four chamber view

34
 Views of Echocardiography

Apical three chamber view

Apical two chamber view

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 A handbook on clinical Echocardiography

SUBCOSTAL VIEW:
● It is obtained from below the xiphisternum in the epigastrium.
● Transducer rotation is needed to get subcostal four chamber
and short axis views.
● Interatrial septum is best imaged in this view.
● Assessment of the inferior vena cava for checking the hydration
status is also feasible from this view.
● Subcostal view is a favourite view of pediatric echocardiographers.

Subcostal view

36
 Views of Echocardiography

Subcostal view- 4 chamber

Subcostal view- IVC

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 A handbook on clinical Echocardiography

SUPRASTERNAL VIEW :
● It is useful in imaging arch of the aorta and nearby regions
of ascending and descending aorta. Coarctation of aorta and
patent ductus arteriosus can be imaged in this view.
● The image shows the blue coloured descending aortic flow on
colour Doppler.
● Gradient of coarctation can be assessed in this view.
● Apart from these standard views, other modified views may
also be used in certain circumstances.
● A right parasternal view may be used when the heart is enlarged,
to assess the tricuspid regurgitation jet.
● Dilated ascending aorta will also be visible in a right parasternal
view.

Suprasternal view

38
 4
DIASTOLIC FILLING OF HEART

A n Introduction----In this, the LV chamber of the heart gets

filled ( ventricular diastole) and the atrium contracts to fill the
ventricles (atrial systole ).

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 A handbook on clinical Echocardiography

HOW TO ACCESS DIASTOLIC FUNCTION OF

HEART-----
METHOD I : PWD METHOD:
For better understanding :
We must know some basic wordings such as

E - Early diastole

A - Late diastole

IVRT - Isovolemetric Relaxation Time

DT - Decceleration Time

E/A ratio - the mean value between E and A

● IN AP4CH, we have to place sample volume in the mitral

valve orifice area and then PWD is used.
● This shows the pattern of blood flow across the mitral valve,
actually it is represented in 2 pyramid like structure during
each cardiac cycle.
● The 1st pyramid is called as EARLY DIASTOLE
● The 2nd pyramid is called as LATE DIASTOLE
● The time duration between the LVES and the LVED is known
as your IVRT-----(I.e, the the time duration B/W aortic valve
closing and mitral valve opening)
● SO WHEN YOU OBTAIN YOUR VALUES IT MUST
BE NORMAL THEN IT IS KNOWN AS NORMAL
DIASTOLIC FUNCTION.

40
 Diastolic Filling of Heart

SL NO PARAMETERS NORMAL VALUES

1. E/A ratio 0.75–1.5
2. DT < 220 ms
3. IVRT 70–90 ms

METHOD : II ----MITRAL ANNULAR

VELOCITIES OBTAINED BY TISSUE DOPPLER
ECHOCARDIOGRAPHY:
s’ velocity: systolic velocity,

e’ velocity: early diastolic velocity,

a’ velocity: late diastolic velocity,

IVCT: isovolumic contraction time,

ET: ejection time, IVRT: isovolumic relaxation time.

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 A handbook on clinical Echocardiography

STEPS TO BE DONE:
● TDI ( Tissue doppler imaging) must be applied on AP-4Ch
view.
● Then PWD is applied either on the septal side of the mitral
valve or at the lateral side of the mitral valve, The values are
measured.
● Sometimes both medial and lateral velocity are measured and
the mean value is taken.

SL NO PARAMETERS NORMAL VALUES

1. Medial velocity <8 cm/s
2. Lateral velocity <10 cm/s
3. Mean velocity < 9 cm/s

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 Diastolic Filling of Heart

E/E’ RATIO AND LVEDP:

● By dividing the E value with e’ value we get the E/e’ and it
is the direct pressure value of Left ventricular End diastolic
Pressure.
● As E/e’ ↑ses, LVEDP also↑

SL NO PARAMETERS NORMAL VALUES

1. E/e’ <15 cm/s

METHOD : III ----HOW TO MEASURE PULMONARY

VEIN FLOW VELOCITIES
1. Image the left pulmonary vein (or the right pulmonary vein)
2. Align cursor with blood flow, use color flow Doppler for
accuracy
3. Place sample volume 1 cm into the pulmonary vein from the
opening into the right atrium
4. Use PW Doppler and record spectral doppler
5. Using the preset measurements under ‘Analysis’ measure:
6. Peak S velocity
7. Peak D velocity
8. Peak AR velocity
9. AR wave duration

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 A handbook on clinical Echocardiography

Diastolic Dysfunction

DEFENITION:
In diastolic dysfunction of the heart, the left ventricle of the heart
is unable to relax properly which leads to impaired filling of left
ventricle and the LVEDV -- DECREASES , as a result there is
change in the parameters of the diastolic filling of the LV.

ETIOLOGY:
Possible causes of diastolic dysfunction are various such as

● Structural heart diseases (hypertrophy, constriction, fibrosis)

● Functional heart disease (ischemia)
● Factors such as -----heart rate,
❍ ventricular function and

❍ compliance,

❍ preload,

❍ atrial systolic function,

❍ heart rhythm and

❍ atrioventricular valve function.

44
 Diastolic Filling of Heart

The main sign and symptom of LVDD includes dyspnea and

heart failure.

SL PARAMETERS ABNORMAL
NO VALUES
1. Mitral E/A ratio - cut off value ≤ 0.8 & > 2

2. Peak E velocity - cut off value > 50 cm/sec

3. Deceleration time (DT) - cut off 140 - 240 msec
value
4. e´ - cut off values septal < 7cm/sec,
lateral < 10cm/sec
5. E/e´ ratio - cut off value average > 14
(septal >15 ,
lateral >13)
6. Left atrial (LA) maximum volume 34mL/m2
index - cut off value
7. Peak tricuspid regurgitation (TR) > 2.8m/sec
velocity - cut off value
8. Isovolumic relaxation time ≤70mm/
(IVRT) - cut off value sec->100mm/sec
9. r - A duration - cut off value >30 msec

METHOD I : PWD METHOD:

A grading of diastolic dysfunction is only relevant in patients with
reduced EF or structural heart disease, because it may change
treatment decisions.

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 A handbook on clinical Echocardiography

Grade I diastolic dysfunction, impaired relaxation:

● First stage of diastolic dysfunction. Decreased suction of the
LV.
● E/A ratio: <1
● Decceleration time: Prolonged >240ms
● IVRT: >90ms

Grade II diastolic dysfunction, pseudonormalization:

● Increased stiffness of the LV, elevated LAP.
● E/A ratio: 1 and 1.5
● Decceleration time: 150 and 200 ms
● IVRT: >90ms

Grade III, restrictive filling (reversible):

● High LAP, noncompliant LV. May be reversible with reduction
of preload (e.g. diuretics).
● E/A ratio: < 150ms
● Decceleration time: >2
● IVRT: >70ms

Grade IV, restrictive filling (irreversible):

● As stage III with no benefit from a reduction of preload.

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 Diastolic Filling of Heart

METHOD : II ----MITRAL ANNULAR

VELOCITIES OBTAINED BY TISSUE DOPPLER
ECHOCARDIOGRAPHY:

SL PARAMETERS ABNORMAL VALUES- E/e’

NO
1. Normal <10
2. Grade I <10
3. Grade II ≥10
4. Grade III ≥10
5. Grade IV ≥10

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 A handbook on clinical Echocardiography

METHOD : III ---- PULMONARY VEIN FLOW

VELOCITIES

Pulsed wave Doppler

systolic deflections
● positive, referred to as S1 and S2, often indistinguishable and
simply referred to as the S wave
● the first (S1) component denotes atrial diastole, with suction
of blood into the left atrium abolished with atrial fibrillation
● the second (S2) component occurs when the mitral annulus is
apically displaced with ventricular systole, decreasing left atrial
pressure and creating a gradient for forward flow blunted by
mitral regurgitation

diastolic deflections
● normally a prominently positive, albeit more diminutive,
deflection following the sequential systolic components
----referred to as the D wave
● atrial reversal (AR)
● the downstroke of the D wave will often dip below the baseline,
indicating flow away from the transducer
● referred to as the AR wave, corresponding to atrial contraction
and “reversal” of flow positively correlated with inotropic
function of the left atrium

Differential diagnosis
● While various pathological entities may disturb flow through
the pulmonary veins, a series of predictable changes in the

48
 Diastolic Filling of Heart

aforementioned waveforms occurs during the progression of

diastolic dysfunction.
● A progressive increase in left atrial pressure will blunt the systolic
flow velocities in the pulmonary veins, with the majority of
forward flow increasingly occurring during diastole.
● The elevation in left ventricular end diastolic pressure,
secondary to lusitropic incompetence, will exaggerate the flow
reversal that occurs with atrial contraction, prolonging the
AR wave .

diastolic dysfunction on pulmonary venous Doppler the S/D

ratio
● normal filling patterns are predominantly systolic, with an

S/D ratio > 1

● a pathologic increase in mean left atrial pressure will reverse

this pattern, resulting in an S/D ratio < 1 and a diastolic filling

predominance progressive increase in amplitude of D wave
and a decrease in S wave with increasing filling pressures atrial
reversal velocity and duration

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 A handbook on clinical Echocardiography

VALUES : Normally the peak of the AR wave is < 35 cm/s

● a peak velocity exceeding this upper limit implies elevated
filling pressures
● the AR wave duration is typically examined in concert with the
mitral inflow velocities
● the transmitral A wave and the pulmonary venous AR wave
should be roughly similar in length
● the duration of the latter should only exceed the former by
< 20 m/s, with greater discrepancies occurring with elevated
filling pressures
● a sensitive indicator of pseudonormalization of the filling
pattern (stage III diastolic dysfunction)

atrial fibrillation on pulmonary venous Doppler

● abolition of organized atrial contraction decreases the peak of
the S1 wave and decreases the peak velocity of the AR wave
● elevated lusitropy on pulmonary venous Doppler
● the enhanced relaxation found in young patients may also
reverse the S/D ratio and mimic advanced diastolic dysfunction
● vigorous left ventricular suction results in elevated peak D
wave velocities, with a restrictive transmitral filling pattern
● if doubt exists regarding the consequence of these findings,
tissue Doppler of the mitral annulus is required

Heart failure with a preserved ejection fraction

● vigorous longitudinal excursion of the mitral annulus during
systole may obfuscate increased filling pressures by preserving
the (S>D) pulmonary venous systolic filling dominance

50
 Diastolic Filling of Heart

● the velocity of the S2 wave is proportionate to the pressure

gradient created by this contraction
● however, increased LVEDP imposes an afterload on the left
atrium, shortening the duration of the transmitral A wave while
simultaneously prolonging the duration of the pulmonary AR
wave
● increasing disparity between the AR duration and the A wave
duration correlates with elevations in filling pressures

51
 5
PARAMETERS FOR EVALUATING
LVSF

METHOD 1: ”EYEBALLING” OF LV FUNCTION

● The so called „eyeballing“ is a visual assessment of left

ventricular function. It is based on observation of the regional
myocardial function in other words the wall thickening and
endocardial motion of several myocardial segments.
● Regional deformation such as thickening and shortening or
displacement should be the center of this observation, taking
into consideration that wall motion abnormalities can be
associated with reduced LVF.
● Each segment should be assessed in multiple views.
According to the guidelines of the American Society
of Echocardiography a 17-segment model is used.
Following scoring system for the visual assessment of wall
motion abnormalities is recommended:

1) normal or hyperkinetic
2) hypokinetic (reduced thickening)
3) akinetic (absent or negligible thickening)
4) dyskinetic (systolic thinning or stretching)

52
 Parameters for Evaluating Lvsf

Following the assessment of these possible wall motion

abnormalities and myocardial contractility LVF can be estimated
visually.
● Concerning wall motion abnormalities stress
echocardiography is an important tool to reveal significant
coronary artery stenosis.
● In Echocardiography, depending on the assessment, LVF

and ischemia can be overestimated or underestimated. It

therefore may prove useful to compare baseline and stress-
echocardiographic images of your patients for a better result.

METHOD 2 :FRACTIONAL SHORTENING

Fractional shortening (FS) is a 2D M-Mode method.
● Using the M-Mode the parameters left ventricular end-systolic

diameter (LVESD) and the left ventricular end-diastolic

diameter (LVEDD) can be derived.
● These parameters refer to the size of the ventricle (captured

with the M-Mode) at the end of systole and diastole.

By using the formula: (LVEDD - LVESD / LVEDD) x 100
● Volume measurements based on linear measurements are

considered to be inaccurate and according to latest guidelines

not recommended anymore.
● The Teichholz formula (Vol = 7D / (2.4+D), where the
3

ventricular diameter D is measured during M-Mode for

example, was used over many years to quantify LVF.
● This formula, as well as the FS, is not mentioned in the current

guidelines.

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 A handbook on clinical Echocardiography

METHOD 3 :EJECTION FRACTION (EF)

● Ejection fraction is derived from the End Diastolic Volume
and End Systolic Volume estimates.
● It is the relation between the amount of blood expelled during
each cardiac cycle relative to the size of the ventricle.
● It can be performed in a 2D or 3D image. Currently the
Simpson method, a biplane method, derived from a 2D
image is recommended to assess the LV EF.

The following formula is applied for LVF:

EF = (EDV-ESV)/EDV X 100

EF= Ejection fraction

EDV= End-Diastolic Volume

ESV= End-Systolic Volume

54
 Parameters for Evaluating Lvsf

Left ventricular Ejection Fraction of lower than 52% in men

and lower than 54% in women are considered abnormal left
ventricular systolic function.

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 A handbook on clinical Echocardiography

Women
NORMAL 74-54
MILD 53-41
MODERATE 40-30
SEVERE < 30

Men
NORMAL 72-52
MILD 51-41
MODERATE 40-30
SEVERE < 30

METHOD 4 :CARDIAC OUTPUT/INDEX/STROKE

VOLUME
● Doppler Echocardiography and 2D imaging can be used to
calculate several hemodynamic parameters such as stroke
volume, cardiac output and cardiac index. These parameters
are important for LVF.
● They can be derived from two measurements: The velocity time
integral (VTI) and the cross-section of the Left ventricular
outflow tract (LVOT).
● The VTI represents the total flow across the area of the sample
volume in systole. Therefore a PW doppler is placed in the
LVOT.
● The diameter of the LVOT = the cross section of the LVOT.

56
 They can be derived from two measurements: The velocity time integral (VTI)
and the cross-section of the Left ventricular outflow tract (LVOT).
 The VTI represents the total flow across
Parameters the area ofLvsf
for Evaluating the sample volume in systole.
Therefore a PW doppler is placed in the LVOT.
● Stroke volume is the result of VTI multiplied with diameter
 The diameter of the LVOT = the cross section of the LVOT.
of LVOT.
 Stroke volume is the result of VTI multiplied with diameter of LVOT.
Keep in mind: Stroke volume cannot be calculated in patients
Keep in mind: Stroke volume cannot be calculated in patients with a LVOT
with a LVOT obstruction!
obstruction!

CO= LVOT
CO= LVOT area
area xx VTI
VTIx xHRHR

57
 45
A handbook on clinical Echocardiography

Some ultrasound
 Some ●ultrasound devices
devices also also Stroke
calculate calculate Strokeonvolume
volume onofthe
the basis Simpson
basis of Simpson Method or M-Mode.
Method or M-Mode.
● Stroke volume is the amount of blood ejected into the aorta
 Stroke volume is the amount of blood ejected into the aorta during systole
during systole

ECHO ASSESMENT PROCEDURE:

ECHO ASSESMENT PROCEDURE:

Stroke volume is calculated

Stroke by measuring
volume is calculated the dopplerthe
by measuring flow in the flow
doppler aorticinvalve
the in
LVOT, and…DIAMETER OF THE
aortic valve in LVOT, AORTIC ANNULUS.
and…DIAMETER OF THE AORTIC
ANNULUS.
Global longitudinal strain rate
METHOD 5:GLOBAL LONGITUDINAL STRAIN RATE
Global longitudinal strain (GLS) is a change in the length of the left ventricle in a
Global longitudinal strain (GLS) is a change in the length of
certain direction related to the baseline length. It is a variation of TDI and provides an
the left ventricle in a certain direction related to the baseline
evaluation of regional myocardial function and therefore directly reveals the
length. It is a variation of TDI and provides an evaluation of
contractileregional
function of the heart.
myocardial It is a sensitive
function and early
and therefore predictor
directly regional LV
revealsof the
dysfunction. This is particularly
contractile function important as contractile
of the heart. dysfunction
It is a sensitive andoften
earlyoccurs
before Ejection fraction
predictor of drops. GLSLV
regional measures the shortening
dysfunction. of the
This is myocardium as a
particularly
correlate to contractility in contrast to the Ejection Fraction, which measures volumes.
58
Strain rate is defined as the change of two velocities divided by the distance of the
measured points. The commonly used formula is:
 Parameters for Evaluating Lvsf

important as contractile dysfunction often occurs before Ejection

fraction drops. GLS measures the shortening of the myocardium
as a correlate to contractility in contrast to the Ejection Fraction,
which measures volumes. Strain rate is defined as the change of
two velocities divided by the distance of the measured points. The
commonly used formula is:

GLS (%) = (MLS-MLD)/MLD

Where MLs refers to the myocardial length during systole and

MLd to the myocardial length during diastole. So a % of changes
in length is the result. As myocardial length during systole is
smaller than during diastole, GLS values are negative. In other
words, negative GLS indicate active contraction whereas positive
values relate to relaxation. A disadvantage in GLS remains - as in
TVI - the angle dependence. This can be circumvented by newer
techniques such as the Strain rate assessed by speckle tracking

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 A handbook on clinical Echocardiography

EXAMPLE-------

METHOD 6:STRAIN AND STRAIN RATE ASSESSED

BY SPECKLE TRACKING
● 2D Speckle tracking is a new technique.
● With 2D speckle tracking, similar as with TDI, myocardial
velocities and deformation parameters such as strain and strain
rate can be calculated.
● It therefore measures different components of myocardial
contraction and delivers information on global contraction
by not only assessing the longitudinal strain, but also the
circumferential and radial strain.
● Speckle tracking is an offline method.

60
 Parameters for Evaluating Lvsf

● The recorded digital loops are processed by a software where

the myocardium is traced and tracked throughout the cardiac
cycle.
● The software then calculates strain and other deformation
parameters.
● The results are then visualised in various forms.
● The strain rate can be color encoded in a “bulls eye” display,
or curves showing the change in strain over time in form of an
anatomical M-mode.
● An additional advantage of speckle tracking is the angle
independence (in contrast to global strain rate).
● It has already become an established prognostic value in several
clinical conditions.

● Strain rate is currently used for the quantification of

regional myocardial function as it delivers exact information
concerning wall motion.
● A strong disadvantage of speckle tracking remains the vendor
dependence of the measurements.

Keep in mind: Because of intervendor and software variability

between ultrasound devices, Strain rate assessed by speckle

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 A handbook on clinical Echocardiography

tracking should be performed using the same equipment and

software.

3D Speckle Tracking Echocardiography (STE) can capture the

motion of speckls independent from their direction. This carries
an advantage in comparison to 2D STE. 3D STE measurements
of LV volumes were comparable to MRT values. Furthermore a
significant higher number of segments can be analysed with 3D
STE. The greatest pitfall of 3D STE is the dependence on image
quality. Normal values still vary among publications and depend
on the equipment used. A consensus document of lower limits of
normal range with Doppler described 18,5% - for longitudinal
and 44,5% for radial strain as well as 1.00 and 2.45 sec ^-1 for
longitudinal and radial SR.

METHOD 7 :CONTRACTILITY (DP/DT)

● Dp/dt is a parameter of myocardial isovolumetric contraction
measuring the rate of pressure increase within the left ventricle
during systole.
● In short words: The faster the left ventricle is able to build up
pressure, the better its function is.
● This rise in pressure can be captured by the mitral regurgitation
profile (CW Doppler over mitral valve - velocities represent
pressure gradients applying the Bernoulli Equation).
● The velocity is measured at two different time points: 1m/s
and 3 m/s. If we calculate the difference between these two
timepoints the result represents the time it takes for a 32
mmHg change to occur within the left ventricle.
● The formula therefore is: dp/dt = 32 mmHg/ time (seconds)

62
 Parameters for Evaluating Lvsf

● This method also carries several pitfalls. For example in

several pathologies and diseases such as LBBB, RV pacing and
WPW syndrome dp/dt may be reduced due to dyssynchrony
and not because of reduced contractility.
● Besides a good Mitral regurgitation signal is needed for this
calculation which can be difficult depending on the image
quality.
● Only small changes in the CW spectrum lead to significant
differences in dp/dt.

------------------------------------------------------------------------------

METHOD 8 :TEI INDEX / MYOCARDIAL

PERFORMANCE INDEX
The Tei index or myocardial performance index (MPI) is
a parameter for global ventricular performance. The Tei index
consists of 3 variables which are derived from Doppler spectrum.

The formula is: MPI = (IVCT + IVRT) / ET

IVCT = Isovolumetric contraction time

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 A handbook on clinical Echocardiography

IVRT = Isovolumetric relaxation time

ET= Ejection time

● When systolic dysfunction is present in patients IVCT will

increase and ET decrease.
● Applied in the formulae this will lead to an increased MPI.
● Normal range is considered at 0,39+/-0,05. An MPI over
0,5 is considered abnormal.

------------------------------------------------------------------------------

METHOD 9 :TDI VELOCITY OF THE MYOCARDIUM

● Tissue Doppler Velocity imaging (TDI) is a signal which
correlates with myocardial motion.
● There is a color display over the anatomical 4 chamber view,
a pulsed wave doppler signal is then placed on different
myocardial regions.

64
 Parameters for Evaluating Lvsf

● Different velocities within the region of interest can hereby

be determined. Usually TDI is placed on the septal or lateral
mitral annulus.
● The annular velocity in systole has shown a correlation with
left ventricular ejection fraction.
● TDI is angle dependent so we can only measure velocities
parallel to the ultrasound beam.
● Disadvantages of TDI is that we asses the LVF only in a specific
area depending on where we place the sample volume.
● TDI is a technique to detect impaired longitudinal systolic
function. It is not present in the current guidelines for
quantification of left ventricular systolic function.

------------------------------------------------------------------------------

65