Adult Echocardiography Lesson Two Anatomy Review Harry H. Holdorf

Which valve separates the areas of greatest pressure differences? Mitral valve Know the SVC, Ao, and PA vessels. Know the Left anterior descending LAD coronary artery & great cardiac vein. LAD lies in the anterior interventricular groove or SULCUS (groove). Great Cardiac Vein pairs with the LAD. On exam: arrows can point to either the RVOT or the epi-cardial layer (fat pad).

A view from the top Tricuspid = anterior cusp, medial cusp, Posterior cusp Mitral = anterior cusp, posterior cusp Aortic =left, right, posterior cusp Pulmonic = anterior, right left cusp

Posterior aspect of coronary circulation

Parasternal Long Axis (LAX) LV

LAX

Which aortic leaflet is the superior one in the parasternal long axis view? –Right leaflet The left leaflet is the posterior one, and is the non-coronary Know basic anatomy by other imaging techniques such as MRI.

MRI of DAo

Tricuspid Leaflets RV Inflow Tract Name the tricuspid leaflets. –Posterior and anterior Know the Tricuspid inflow tract view: this is the only standard view in which you see the posterior Tricuspid valve leaflet.

Tricuspid (RV) Inflow Tract Hint: Red flow in IVC

Parasternal Short Axis (SAX) Ao Valve

Coronary blood flow The coronary arteries come off the –Sinuses of Valsalva During which phase do the coronaries fill? –Early diastole

Parasternal short axis Coronaries

Coronary blood flow in Diastole

Normal Measurements End diastole, nl 2D= cm End systole, nl 2D = cm Fractional shortening, 2D = >25% End systole = frame preceding MV opening, or the time when the cardiac dimension is smallest. End diastole = frame after mitral valve closure or frame in cardiac cycle where dimension is largest

Ao Measurements- Sinotubular Junction 1.AO-aortic valve annulus (hinge point of aortic leaflets) 2.AO-Sinuses (the maximal diameter in the sinuses of Valsalva) 3.Ao sinotubular junction (transition between the sinuses of Valsalva and the tubular portion of the ascending aorta) 4.Ascending aorta (largest diameter of ascending aorta). Measurements should be performed when the walls of the aorta are best seen.

ASE 17 segments of the Heart wall

17 segments

Suprasternal Arch What vascular structure is often visualized under the aortic arch? –Right Pulmonary Artery Name the vessels coming off the arch via proximal to distal: –Innominate (proximal) –Left carotid –Left Subclavian (distal)

Suprasternal arch

Aortic Coarctation What cardiac pathology is associated with bicuspid aortic valves? –Coarctation of the aorta Where do most aortic coarctations occur? –After the take-off of the left subclavian artery, or within the aortic isthmus

Aortic Coarctation

Apical Four Chamber View Where are the pulmonary veins located? Which ones are seen in this view? –Right and left upper (superior) pulmonary veins

Apical Four Chamber View

Apical Long Axis View Which other view would give you the same information as the parasternal LAX? –Apical LAX

Apical Long Axis

Apical Two Chamber Which standard 2D TTE view typically allows viewing of the LAA? –Apical 2 chamber

Apical Two Chamber View

Coronary Sinus from LAX Where is the coronary sinus located? –Posterior AV groove To visualize the coronary sinus in the apical 4 chamber view, you should tilt the transducer: –Posterior

Coronary sinus from LAX

Which valve sits at the opening of the coronary sinus? –Thebesian

Subcostal IVC IVC, HV, RA

Normal Pulmonary Venous Inflow a wave = atrial contraction s wave = systolic inflow d wave = diastolic inflow What portion of the pulmonary venous PW Doppler represents atrial systole? –a wave

Normal Pulmonary Venous Inflow

TEE Views & Anatomy Conditions suited for TEE Prosthetic valves Aortic Dissection Endocarditis Intracardiac Source of Embolus (SOE) Difficult to image Chest wall Others…

Safety Problems with TEE Patient discomfort Airway compromise Vagal response or other hemodynamic compromise Electrical or temperature hazard Esophageal or tracheal trauma Transmission of infection At what temperature is it unsafe to use a TEE probe? –40-45C

TEE 4 chamber

TEE SAX

Locate the LA appendage by TEE Know TEE views by esophageal level Know mid esophageal-ME and degrees

Aortic leaflets by TEE

LESSON THREE CARDIAC PHYSIOLOGY End Lesson Two