Apical Echo and Doppler

Question 1

Standard echo views:

Answer 1

Parasternal
Apical
Subcostal
Suprasternal

Question 2

The apical views:

Answer 2

apical 4-chamber
apical 5-chamber
apical 2-chamber
apical long-axis(a.k.a. apical 3-chamber)

Question 3

Views from the apical long axis window are used for

Answer 3

assessment of wall motion

Doppler assessment of valve function

Question 4

What are you looking at in the Apical window:

Answer 4

Looking at the heart from the lower-left corner of the ribcage: PMI(point of maximal impulse)The apex of the heart is closer to the surface than the base is.

Question 5

What is your Transducer placement as your home based view:

Answer 5

PMI, with beam-edge indicator toward patient’sLEFT shoulderfor the 4-chamber view(use this as your home-base view)

Question 6

The heart is upside down?Apex is at the top?

Answer 6

Yes, because the probe is closest to the apex.The convention is to leave the view this way.

Question 7

How do you get a Apical 5-chamber view:

Answer 7

From the 4-chamber view,lay the probe down toward the patient’s chest a bit, so that the plane includes theaortic root.

Question 8

The four probe movements:

Answer 8

RockAngleRotateSlideUse them to fix the image.

Question 9

Slide to

Answer 9

bring the apex to the right or left of the screen (put it in the middle)

Question 10

Rock to

Answer 10

make the heart vertical(i.e., to move the base of the heart)

Question 11

Angle to

Answer 11

get the atria backor to get 5-chamber view

Question 12

Rotate to

Answer 12

open up all four chambersor to move from 4-chamber to 2-chamber, etc.

Question 13

Looking for two things with Doppler in cardiac work.

Answer 13

1. Direction of flow (i.e., regurgitation)
2. Velocity (i.e., stenosis)

Smaller opening (stenosis) leads to faster flow: = V x CSA

Question 14

Doppler angle relative to flow:

Answer 14

90° is the worst
(cosine is 0, and 0 times anything is 0, so no frequency shift)
0° gives the maximum frequency shift possible.

Apical view has valve flow almost directly toward the beam or away from the beam: 0°
(flow is parallel to the Doppler beam)

Question 15

Which valves have flow toward the beam?

Answer 15

Tricuspid and Mitral valve

Question 16

Which have flow away from the beam?

Answer 16

Aortic

Question 17

What if you’re a bit off from 0°?

Answer 17

Not a big problem, since even 30° off = only 5% error in velocity estimate.

Still, try for as close to 0° as possible.

Question 18

PW has a sample volume (gate):

Answer 18

scanner pays attention only to that one portion of the Doppler beam, ignoring the rest.

Question 19

CW has a continuous

Answer 19

CW gives you everything along the beam

Question 20

Can you change the size of the gate?

Answer 20

You can change the size of the gate, though it’s usually best to leave it fairly small for precise evaluation.

Question 21

In the real world, why what doppler do techs use for the Aortic valve? Why?

Answer 21

techs will often use CW Doppler for the aortic valve, because of the “aliasing” phenomenon that occurs with PW Doppler: PW processing can’t keep up with higher frequencies, so the waveform wraps around the spectral display. This gets worse with more depth and with higher velocities/higher frequency-shifts.

Question 22

What is flow direction on the spectral display below the baseline?

Answer 22

is away from the beam

for cardiac work-it is different in the vascular lab

Question 23

What is flow direction on the spectral display above the baseline?

Answer 23

is toward the beam

for cardiac work-it is different in the vascular lab

Question 24

Remember the flow directions in the heart relative to the Doppler beam! Think which sites are proximal/distal—where flow comes from, where it goes to.

Answer 24

a

Question 25

In this apical 4-chamber illustration, what disorder are you looking for with this placement of the gate?

Answer 25

The gate is in the LA, behind the valve when it’s closed, so you’re looking for regurgitation (insufficiency) of MV.

Question 26

Where would you place the sample volume to look for aortic valve stenosis?(Where is the flow going?)And again, what part of the cardiac cycle?

Answer 26

a

Question 27

Where do you put the gate for evaluating stenosis?

Answer 27

put the gate at the tips of the open leaflets.

Question 28

Where do you put the gate for regurgitation?

Answer 28

get the gate behind the leaflets. and check for flow when valve is closed.

Question 29

What Characteristic shape do AV valves have?

Answer 29

M shape, sort of like the M-mode, and for the same reason: passive then active filling moving the valve leaflets.This is above baseline, since flow should betoward the beam in apical view.Flow should cease when the valve closes.

Question 30

What kind of wave form do Semilunar valves have?

which way is flow from the beam?

Answer 30

a single-phase waveform below the baseline. (Flow away from beam)

Question 31

What units do they use for echo?

Answer 31

m/sec for units, though some use cm/sec.

You just move the decimal two places to the right: 1.33 m/sec = 133 cm/sec

Question 32

In the right heart, are there higher or lower velocities and pressures?

Answer 32

There are lower velocities in the right heart, since there are lower pressures
(and lower pressure-gradients) there.

Question 33

Why are the velocities in the right heart lower?

Answer 33

because the pressures are lower

There are lower pressure gradients

Question 34

WNL values for valve velocities:
Ao		
MV		
PV		
TV		
Where are velocities lower? Why?

Answer 34

Ao 1.7 m/sec
MV 1.2 m/sec
PV 0.9 m/sec
TV 0.7 m/sec

Velocities are lower in the tricuspid valve because the right heart

Question 35

What happens if the velocity in the valves gets appreciably higher than the normal limits?

Answer 35

than the opening to the valves must be smaller than normal (stenosis).

For example, an aortic-valve velocity of 3 m/sec is abnormal, and 5 m/sec suggests severe stenosis.

Question 36

How can the pressure gradient across the valve be calculated?

Answer 36

Pressure gradient across valve can be calculated with the velocity information—remember Bernoulli?

Question 37

How can area be calculated in a stenotic valve?

Answer 37

area of a stenotic valve can be calculated with velocity and area—remember continuity equation?

Question 38

Waveforms should include EKG because:

Answer 38

EKG for timing of cardiac events.

Question 39

What do you have with cardiac Doppler waveforms?

Answer 39

you have big chambers,
churning flow patterns,
which means waveforms aren’t always tidy.(Reynolds…)

Question 40

Timing with EKG:
Semilunar valve opens at_______________, closes at ____________.

AV valve opens at___________,closes at _________.

Again: When is end-diastole?

Answer 40

Semilunar valve opens at peak of R wave, closes at end of T wave.

AV valve opens at end of T wave, closes at peak of R wave.

(Remember ~50 msec delay between electrical and physical events…)

Again: When is end-diastole? beginning of R wave

Question 41

What does MV regurge look like?

Answer 41

Flow away from the beam is evident during systole(when there should be no flow).

Question 42

Controls:

Answer 42

Doppler beam, gate
Gain
Baseline
Scale
Freeze & measure

Question 43

What is a common mistake when doing apical view?

Answer 43

Don’t get the probe out too far lateral

Question 44

Beware of rounded apex—

What does the apex evaluate?

Answer 44

no good, oblique section of heart. Must see the apex to evaluate for wall motion, aneurysm, thrombus.

Question 45

What do you want to avoid in a 4 chamber view? What position should the heart be in?

Answer 45

Avoid a tilted heart in the 4-chamber view

Find the window that places it vertical

Question 46

When do you expect the heart to be tilted to the right?

Answer 46

in the 2-chamber and long-axis views.

Question 47

What motion can cause you to lose the view?

Answer 47

Rocking