Two Dimensional and M-Mode Echocardiography - Boon
Two Dimensional and M-Mode Echocardiography - Boon
Echocardiography
fo r rhc
Small Animal
Practitioner
June A. Boon
BA. MS
Teton NewMedia
P.O. Box 4833
4125 South Hwy 89
Jackson, WY 83001
1-888-770-3165
www. tetonnm.com
www. veterinarywire .corn
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ISBN# 1-893441-28-8
Print number 5 4 3 2 1
tal and acquired cardiac diseases. This handbook does not elabo~
Section 3
M-Mode Echocardiography:
A Quantitative Assessment
Principles of M-Mode Echocardiography ....... 40
M-Mode of the Left Ventricle . . . . . . . . . . . . . . . 40
Cursor Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
M-Mode of the Aorta and Left Atrium ........ 43
Cursor Placement . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
M-Mode of the Mitral Valve . . . . . . . . . . . . . . . . 45
Cursor Placement . . . . . . . . . . . . . . . . . . . . . . . . . . .4 5
Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Assessment of M-Mode Measurements . . . . . . . . 4 7
Diastolic Measurements . . . . . . . . . . . . . . . ... .. .. .4 7
Systolic Measurements . . . . . . . . . . . . . . . . . . . . . . . .48
Types of Enlargement . . . . . . . . . . . . . . . . . . . . . . . . .48
Assessment of Left Ventricular Function . . . . . . . 49
Fractional Shortening . . . . . . . . . . . . . . . . . . . . . . . .49
Section 4 Echocardiographic
Reference Values
Echocardiographic Reference Values for
Parameters in the Cat . . . . . . . . . . . . . . . . . . . 56
Echocardiographic R eference Values for
Parameters Unrelated to Body Size in the ' Dog .. 57
Echocardiographic R eference Values for
Parameters Related to Body Size in the Dog .. 58
Abbreviations ....................... 99
3
Applications
Evaluation of
• Valvular lesions
• Chamber sizes
• Myocardial function
• Pericardial effusions
• Differentiation of congenital heart diseases
Aid in the diagnosis of
./ Acquired heart disease
Degenerative mitral valve disease
Endocarditis
Cardiomyopathies (hypertrophic, dilate'!, restrictive)
Pericardial effusions
Cardiac neoplasia
Thoracic masses
./ Congenital heart disease
Patent ductus arteriosus
Ventricular septal defects
Subaortic stenosis
Pulmonic stenosis
Tricuspid dysplasia
Combination of defects
Indications for an echocardiogram
./ When the clinical picture implies heart disease and any of the
following are present:
Coughing Cyanosis
Exercise intolerance Lethargy
Arrhythmia's Weak pulses
Pulmonary edema Murmurs
Radiographic evidence Pulmonary congestion
of heart enlargement Collapse or syncope
4
Cardiac Anatomy
From the body To the body
Figure 1-1. This diagram shows the chambers and vessels of the heart.
Flow through the heart is indicated. Notice the relationships between the
mitral valve and the aorta (the aortic wall is continuous with the septal leaflet
of the mitral valve), the pulmonary artery and the tricuspid valve (the pul-
monic valve is continuous with the septal leaflet of the tricuspid valve), and
the two semilunar valves .
5
Orientation of the
Heart in the Thorax
Figure 1-2 This lateral radiograph of a cat's thorax shows how the long axis of the
heart is aligned. This image indicates how the sound plane should be aligned on the
thorax to obtain good long axis images. Notice how much sternal contact there is,
this is why the transducer in cats is much closer to the sternum than in dogs.
6
Figure 1-3 This lateral radiograph of a dog's thorax shows how the long axis
of the heart is aligned more upright than the cat. The axis extends more from
xyphoid to shoulder, with less sternal contact than the cat.
7
8
Section 2
Obtaining the
Image and
Subjective
Assessment
9
Right Parasternal Long
Axis Left Ventricular
Outflovv Vievv
Techniq ue in the Dog 0
./ Place the dog in right lateral recumbency over a cutout in an
exam table, area of the heart over the cutout .
./ Feel for the apical impulse on the right side (point on the
thorax where you can feel the heart beat) .
• Place the transducer at that location, holding it in the following
manner (Figure 2,1):
• Crystals point toward the lumbar spine ,
• Cable of the transducer extends toward the elbows
• Reference mark directed toward the neck
• Angle of about 45 degrees between the chest wall
and the transducer
• Without changing how you are holding the transducer, move
the transducer around the thorax. Move ventral and dorsal in
that intercostal space, move forward a space and repeat. Move
back a space and repeat. Continue until you have found the
location with the best image quality regardless of whether the
imaging plane is perfect. (If you have not changed the way you
hold the transducer it will be almost a perfect long axis)
h To perfect the image:
• If the aorta is not seen, rotate the transducer so the
reference mark moves counterclockwise (towards you and the
front legs of the animal, away from the spine).
• Twist to lengthen the left ventricular chamber.
• Lift transducer up and down (decreasing or increasing the
angle between the transducer and the thorax) without changing
where it is pointing to widen the left ventricular chamber.
• Point more caudal to see more of the left ventricular chamber.
• Point more toward the thoracic spine in order to see more
of the heart base structures.
• Do not lift or drop the transducer in the process of
performing these last two movements.
10
• If these movements do not result in a good long axis outflow
image, then you must slide dorsal or ventral in the intercostal
space because it implies you are not under the heart properly.
• Follow the steps above to perfect the image again after
repositioning in the space.
Figure 2-1A This illustration shows how the right parasternal long axis left
ventricular outflow view of the heart is oriented in the thorax of a dog.
Figure 2-1 B The transducer should be held and positioned as shown in this
image in order to obtain a right parasternal long axis left ventricular outflow
view. See text for details.
11
Modifications in Technique
for the Cat 0
./ Keep the cat stretched out as much as possible (Figure 2,2) .
./ Pull the cat's front legs forward .
h Keep the back straight .
• Hold the transducer the same way as for the dog.
• Start with the transducer way up under the right leg of
the cat right next to the sternum.
• Slide caudal along the sternum with the transducer until
you see something beating.
• Conti nue to slide caudal until the beating structure is
centered on the monitor.
• Stop here and s lid e ventrally or dorsally until the heart
appears clearly on t h e monitor.
h Adjust the imaging plane as directed above in the dog.
Figure 2-2A
This illustration shows
how the right parasternal
long axis left ventricular
outflow view of the heart
is oriented in the thorax
of a cat.
Figure 2-28
The transducer should be
held and positioned as
shown in this image in
order to obtain a right
parasternal long axis left
ventricular outflow view.
See text for details.
12
Subjective Assessment of the
Left Ventricular Outflow View
in the Dog
(Figure 2-3) 0
./ Straight interventricular septum
• Upward curvature suggests left ventricular volume overload.
• Downward curvature suggests one of the following:
Left ventricular volume contraction
Right ventricular volume overload
Septal hypertrophy
./ The aorta and left atrium are similar in size .
./ The mitral valve:
• Is thin with the same thickness from the- base of the leaflets
to their tips
• Does not prolapse (bend) back into the left atrium
./ The ventricular septum does not protrude downward in front
of the aorta .
./ The right ventricular chamber is approximately 1/3 the size of
the left ventricular chamber.
./ The right ventricular wall is approximately 1/2 the thickness
of the left ventricular free wall.
• Make sure the left ventricular wall is normal in thickness
based on M-Mode measurements.
• If the relationship of right to left wall thickness is normal
and the left wall is thick, so is the right.
13
Subjective Assessment of the
Left Ventricular Outflow View
in the Cat
(Figure 2-4) 0
./ The septum may bow slightly upward .
./ The left atrium may be up to 1.7 times larger than the aorta .
./ The ventricular septum may normally protrude down in front
of the aorta to a small degree (arrow).
• The width of the left ventricular outflow tract should not
change as the heart contracts .
./ Normal mitral va lve appearance
• Thin pliable leaflets
./ The right ventric ular wall is about 1/2 the thickness of the
left ventr ic ula r wall.
• Make sure the left ventricular wall is normal in t hickness
based on M -M ode m easurements.
• If the relat io n ship of right to left wall thickness is normal
and the left wall is thick, so is the right .
./ The right ventricular ch a mbe r is approxim ately 1/3 the size of
the left ventricular c h a mbe r.
Figure 2-4. The ventricular septum can extend down into the left ventricular
outflow tract (arrow) and the left atrium can be larger than the aorta in normal
feline hearts, as seen in this right parasternal long axis left ventricular outflow
view from a cat. See the text for other features that make this echocardiographic
image normal.
14
Right Parasternal Long
Axis Four Chamber Vievv
Technique in the Dog and Cat
(Figure 2~5) 0
Figure 2-5A
Th is illustration shows
how the right parasternal
long axis fou r chamber
view of the heart is
oriented in t he thorax.
Figure 2-58
The transducer should be
held and posit ioned as
shown in this image in
order to obtain a right
parasternal long axis four
chamber view.
See t ext for details .
15
~ Be s ure n ot t o con fu se t h e ven a cava fo r a n e n larged right
atrium. Lifting the t r a n sducer too muc h b r in gs in the caudal
ven a cava a nd c reates t h e app ear a n ce of a la rge right atrium
(Figure 2,6A) . C o ntinuing t o lift t h e t ra n sducer a llows visuali,
zation o f b o th cava (Fig ure 2 , 6 B) .
• When the ven a cava is seen, the angle between the transducer
and ch est wall is too small.
./ Point t h e crystals toward the thor acic sp ine in order to see
m o re of the r igh t atrium.
Figure 2-6A Lifting the transducer up towards the animal's thorax from a
good right parasternal four chamber view allows part of the caudal vena ca va
to be seen This can make the right atrium appear artifactually large .
Figure 2-68 Continuing to lift the transducer upwards towards the an imal 's
thorax will bring both the caudal and cranial vena cava into view.
16
Subjective Assessment of
the Four Chamber View In the
Dog and Cat
(Figure 2- 7) 0
17
./ The mitral valves are normal.
h This is probably the best imaging plane to see lesions without
artifactually creating them .
./ Right ventricular wall thickness is about half the thickness of
the left ventricular wall.
• Make sure the left ventricular wall is normal in thickness
based on M-Mode measurements.
• If the relationship of right to left wall thickness is normal
and the left wall is thick, so is the right.
h Do not assess right ventricular size in this imaging plane.
• It is easy to create a very large right ventricle with slightly
different transducer placement.
Right Parasternal
Transverse Vievvs
Technique in the Dog and Cat 0
(Figures 2-8, 2-9, 2-10, and 2-11)
./ Start with a good left ventricular outflow view.
• Pay attention to the long axis of the heart and how it is aligned
within the thorax. Imagine a line along the length of the heart.
• Very deep-chested dogs, for instance, may have a heart
that is oriented straight up and down in the thorax from
spine to sternum.
• Most dogs typically have hearts that are oriented from
shoulder to xyphoid (see Figure 1-3).
• The long axis in cats is oriented a little more along the
sternum (see Figure 1-2).
• This line is how you will fan and point the crystals as you
move from base to apex to obtain these transverse views .
./ Twist the transducer so the reference mark moves away from
the spine toward the animal's elbows .
./ Drop the transducer slightly but keep at least a 60-degree
angle between the transducer and the thorax .
./ Twist until a round left-ventricular chamber or aorta is seen.
• You have twisted enough when the left ventricle is
symmetrical and both papillary muscles are seen clearly or
18
• When the aorta in the center of the image is a complete
and closed circle or cloverleaf shape .
./ Pivot the transducer so that the crystals point from the base of
the heart to the apex a long the lo n g axis of the heart (as visualized
in step 1).
h Keep the angle between the transducer and the thorax; do
not become perpendicular to the chest wall.
Figure 2-SA This illustration shows how the right parasternal transverse view
of the left ventricle at the level of the papillary muscles is oriented in the thorax.
Figure 2-S8 The transducer should be held and positioned as shown in this
image in order to obtain this right parasternal transverse view of the left ven-
tricle. See text for details.
19
Figure 2-9A This illustration shows how the right parasternal transverse view
of the mitral valve is oriented in the thorax.
Figure 2-98 The transducer should be held and positioned as shown in this
image in order to obtain a right parasternal transverse view of the mitral valve.
See text for details.
20
Figure 2-10A This illustration shows how the right parasternal transverse
view of the heart base at the level of the aorta and left atrium is oriented in
the thorax.
Figure 2-1 OB The transducer should be held and positioned as shown in this
image in order to obtain a right parasternal transverse view of the aorta and left
atrium. See text for details.
21
Figure 2-11A This illustration shows how the right parasternal transverse view
of the heart base at the level of the pulmonary artery is oriented in the thorax.
Figure 2-11 B The transducer should be held and positioned as shown in this
image in order to obtain a right parasternal transverse view of the heart base at the
level of the pulmonary artery. See text for details.
22
Subjective Assessment of the
Transverse Views in the Dog
and Cat 0
Left ventricle at the papillary muscles (Figure 2-12):
23
Figure 2-13 This is a normal right
parasternal transverse image of the
chordae tendinae. See the text for fea-
tures that make this echocardiographic
image normal.
RV
& LV /
MV
24
Heart base~aorta and left atrium (Figure 2-15):
. / The aorta and left atrium are similar in size based upon an
imaginary line drawn through the middle of the aorta and the
main body of the left atrium.
~ Make sure all three cusps of the aortic valve are visible and
that the aorta is a closed circle when making this comparison .
./ Atrial septum is straight .
./ The left atrial wall makes a smooth transition into the left auricle.
• This is important in cats where the body of the left atrium
may appear to be normal but the auricle is enlarged as seen
by bulging at the atrial and auricular junction.
Heart base-aorta and pulmonary artery (Figure 2-16):
./ Aorta and pulmonary artery are similar in diameter.
./ The pulmonary artery remains the same width from the level of
the valves down to the bifurcation into right an? left branches .
./ The left main pulmonary artery is just barely seen .
./ The pulmonic valves move well toward the walls of the pul-
monary artery. Cineloop is often required to visualize the valve
motion well.
Figure 2-15 This is a normal right
parasternal transverse image of the
heart base at the aorta. See the text
for features that make this echocar-
diographic image normal.
25
Left Parasternal
Cranial Left Ventricular
Outflovv Vievv
Technique in the Dog and Cat 0
(Figure 2~17)
26
h Find the image as fa r c r a ni a l as yo u c a n.
h Yo u will feel the a nima l 's trice p s aga inst your h a nd .
./ Lift the tra n sducer up a nd d o wn until a n aorta is seen .
./ Twis t the tra n sducer clockwise a nd c o unte rclock w ise until t h e
aorta is a lo n g as poss ible.
h M ost of the time, when images h e re a re poor, it is b ecau se t h e
tran sducer is not positioned far enou gh aw ay fro m the st e rnum.
M ove d o rsally a n d cranial to try and improve this image.
Figure 2-18 This is a normal left parasternal cranial long axis left ventricular
outflow view . See the text for features that make this echocardi ographic
image normal.
27
Left Parasternal Right
Atrium and Auricle Vievv
Technique in the Dog and Cat
(Figure 2-19) 0
• Start with a good long axis left ventricular outflow view on
the left .
./ Make sure the aorta is as long as poss ib le .
./ M ake sure you are as far cranial and dorsal as you can get for
a clear image .
./ Drop the cab le slightly until the auricle comes into view.
./ Rotate in and out of the auricle to see a ll aspects.
28
Subjective Assessment of the Left
Parasternal Right Atrium and
Auricle View
(Figure 2-20) 0
. / The auricle should be clear of soft tissue densities.
Figure 2-20 This is a normal left parasternal cranial long axis view of the right
atrium and auricle. See the text for features that make this echocardiographic
image normal.
29
Left Parasternal
Pulmonary Artery Vievv
Technique in the Dog and Cat
(Figure 2-21) 0
." Start w ith a good long axis left ventricu lar outflow view.
./ M ake sure the aorta is as long as possib le .
./ M ake sure you are as far cranial and dorsal as you can get fo r
a clear image .
./ Lift the transducer slightly unti l the pu lmonary artery comes
into view.
Figure 2-21A
This illustration shows
how the left parasternal
cranial long axis view of
the pulmonary artery is
oriented in the thorax.
Figure 2-218
The transducer should be
held and positioned as
shown in this image in
order to obtain a left
parasternal view of the
pulmonary artery.
See text for details.
30
Subjective Assessment of the Left
Parasternal Pulmonary Artery View
(Figure 2-22) 0
./ The pulmonic valve should look normal and move well towards
the walls of the pulmonary artery.
./ There should be no post-stenotic dilation.
Figure 2-22 This is a normal left parasternal cranial long axis view of the
pulmonary artery. See the text for features that make this echocardiographic
image normal.
31
Left Parasternal Cranial
Transverse Heart
Base Vievv
Technique in the Dog and Cat
(Figure 2-23) 0
• From any of the cranial long axis views
./ Twist the transducer so that the reference mark is directed
towards the spine .
./ Drop the cab le down away from the chest wall so that the trans-
ducer is a lmost perpendicular to the c h est wall.
./ Fanning towards the heart base (shou lders) with the sound
beam will bring in the pulmonary a rtery and fanning caudally
should bring in the tricuspid valve and right atrium.
Figure 2-23A
This illustration shows
how the left parasternal
cranial transverse view of
the heart is oriented in
the thorax.
Figure 2-238
The transducer should be
held and positioned as
shown in this image in
order to obtain a left
parasternal transverse.
view of the heart.
See text for details.
32
Subjective Assessment of the
Left Parasternal Cranial
Transverse Heart Base View
(Figure 2~2 4) 0
./ The tricu spid valve should move well and look thin in this
imaging plane .
./ The pulmonary valves should have normal conformation
a n d motion.
Figure 2-24A This is a normal left parasternal transverse image of the heart base
emphasizing the tricuspid valve. See the text for features that make this echocard io-
graphic image normal.
Figure 2-248 This is a normal left parasternal transverse image of the heart base
emphasizing the pulmonic valve. See the text for features that make this echocar-
diographic image normal.
33
Left Parasternal Apical
Four Chamber Vievv
Technique in the Dog 0
(Figure 2-25)
./ R eference mark directed toward the spine
h Point the crystals toward the neck (cable to knees) .
. / About 30 degrees between chest wall and transducer
h Keep the edges of the sound p lane equidistant t o the
scanning table .
./ Find the liver n ear the last intercostal space, close to the sternum.
Figure 2-25A
This illustration shows
how the left parasternal
apical four chamber view
of the heart is oriented in
the thorax of the dog.
Figure 2-258
The transducer should
be held and positioned
as shown in this image
in order to obtain a left
parasternal apical four
chamber view in the
dog . See text for details.
34
./ Stay next to the sternum and slide forward until the liver
disappears and the h eart is seen.
• The h eart will typically not look good right here
./ Lift the transducer up towards the chest wall to e longate the heart
and clear up the image .
./ If the ventricle is not long, you have slid forward too far; slide
back, and keep the transducer up.
Figure 2-26 The transducer should be held and positioned as shown in this
image in order to obtain a left parasternal apical four chamber view in the cat.
See text for details.
35
Subjective Assessment of the
Left Parasternal Apical Four
Chamber View 0
(Figure 2-27)
./ Use this view for valve appearance and motion .
./ Check for prolapse and rupture of the chordae .
./ Necessary for Doppler
36
Figure 2-28A This illus-
tration shows how the
left parasternal apical
five chamber view of the
heart is oriented in the
thorax of the dog .
37
Subjective Assessment of the
Left Parasternal Apical Five
Chamber View 0
(Figure 2-30)
.,/ Use this view for valve appearance and motion .
.,/ Check for prolapse and rupture of the chordae
.,/ Check for post-stenotic aortic dilation
.,/ Necessary for Doppler
Figure 2-30. This is a normal left parasternal apical five chamber view of the
heart. See the text for features that make this echocardiographic image normal.
38
Section 3
M-Mode
Echocardiography:
A Quantitative
Assessment
39
Principles of M-Mode
Echocardiography
h One single sound beam is selected over the real time image .
./' This is selected with the cursor on your ultrasound image .
./' The structures under the cursor are seen on the M-Mode image .
./' The M-Mode diagram has depth on the y-axis and time on
the x-axis .
./' The M-Mode scro lls across the screen showing the cardiac
structures as they change during diastole and systole .
./' An appropriate M-Mode is frozen for measuring .
./' Freeze an image with clearly defined structural boundaries.
40
h The wall and the septum are parallel to each other when
left ventricular size is optimized.
h If the image is too tipped (apex up) to position the cur-
sor perpendicular to the wall and septum, move forward
one intercostal space and dorsally in that space. Then point
the crysta ls more cauda lly.
./ Place the cursor perpendicular to the septum and free wall
at the largest ventricular dimension between the tips of the
mitral valve and the papillary muscles.
~ Make s ure you are not placing the cursor over the thinner
part of the septum within the left ventricular outflow tract .
• The short-axis image should be the right parasternal trans-
verse view at the level of the chordae tendinae (Figure 3-2) .
./ Fan the sound beam between the mitral valves and papillary
muscles in order to find the chordae .
./ Make sure the image is symmetrical.
h Make sure the transverse p lane is the smallest one you can
obtain at the level of the chordae, and that the RV is clearly seen.
h If there is no RV, the transducer is too close to the apex.
Follow directions under Key #3 above.
h Place the c ursor through the middle of the left ventricular
chamber making two similar halves-mirror images of each other.
Figure 3-2 When the transverse view is used for an M-Mode of the left ventri-
cle, the cursor should be placed so that it creates two halves which are mirror
images of each other, at the level of the chordae tendinae.
41
Measurements
(Figure 3-3)
Diastolic
./ These should be made at the onset of the QRS complex, if
you have an ECG .
./ Otherwise measure at the largest left ventricular dimension
just before the wall and septum contract .
./ When there is filling secondary to the atrial contraction,
measure just before this point.
Figure 3-3 The arrows show where measurements are taken on left ventricular
M-Modes. See the text for details.
Systolic
./ These are made at the smallest left ventricular chamber size .
• Measure both diastolic and systolic indices in the following
manner:
• Septum-from the top of the septum to the bottom of the
septum, including the lines that define its boundaries
• Left ventricular chamber-from the bottom of the septum
to the top of the wall. Do not include the lines defining the
septal and wall boundaries.
• Left ventricu lar wall-from the top of the wall to the top
of the pericardial sac. Include the line defining the wall and
chamber boundary.
42
M-Mode of the Aorta and
Left Atrium
Cursor Placement 0
./ These images may be obtained from right parasternal long~ or
short~axis images .
43
• Do not have any pulmonary artery in the image.
• The cursor should be aligned through the body of the left
atrium, not the auricle.
• The image may have to be oriented toward the left side of
the monitor for this to work.
Measurements
(Figure 3-6)
./ Aorta-measured at the end of diastole
• These measurements are made to coincide with the onset
of the QRS complex.
• If an ECG is not available, measure at the lowest point of
aortic wall motion .
./ Measure from the top of the anterior (top) aortic wall to the
top of the posterior (bottom) aortic wall.
./ The line representing the top of the aorta is included in the
measurement but the bottom line is not .
./ Left atrium
• These measurements are made at the largest left atrial
chamber size when the aortic walls are at their highest point .
./ Measure from the top of the posterior aortic wall to the top of
the pericardium.
• The line representing the bottom of the aorta is included
in this measurement.
• If a left atrial wall is seen, ignore it and measure down to
the top of the pericardium.
44
Figure 3-6 The arrows show where measurements are ta~n on aortic - left
atrial M-Modes. See the text for details.
M-Mode of the
Mitral Valve
Cursor Placement 0
./ This image may be made from either the right parasternal
long axis or short axis views .
./ From the long axis (Figure 3-7)
• Find the best long axis left ventricular outflow view.
• Make sure the mitral valves move well and that the aortic
valves are also seen.
45
• Place the cursor over the tips of the mitral valve leaflets.
• The cursor shou ld be fairly perpendicular to the septum
and n o t diagonal through the left ventricular chamber.
./ From the sh ort axis (Figure 3~8)
• Find the transverse view where both leaflets are seen (the
fish mouth view).
• Make sure the image is symmetrical.
• Place the cursor through the middle of the chamber across
the middle of the mitral valves.
Figure 3-8 When the transverse view is used for an M-Mode of the mitral valve,
the cursor should be placed so that it divides the mitral valve into equal halves.
Measurement
./ At slower h eart rates, the mitral valve sh ould h ave an "M"
configuration (Figure 3~9)
• The first peak of the M represents rapid ventricular filling
a nd is called the E point.
• The a trium h as been filling throughout ventricular systo le
a nd, at the beginning of diastole, the pressure gradient from
left atrium to left ventricle cau ses the mitral valves to
passively but rapidly open towards the septum and free wall.
• After the initial filling phase, pressures equilibrate
somewhat and flow decreases. The mitral valves move toward a
partially closed position.
• The atria l contraction toward the end of diastole causes
the valve to actively open toward the septum and free wall again.
46
• This creates the second peak of the "M" and is referred to
as the A point .
./ The only consistent measurement of mitral valves is the E
Point to Septal Separation (EPSS) .
. / Measure from the top of the E point to the septum (Figure 3-9) .
./ Do not include the line defining the bottom of the septum in
the measurement.
Assessment of M-Mode
Measu rements
Diastolic Measurements
h Used to assess chamber sizes
• L a rger diastolic measurements reflect increased volume within
that chamber or vessel.
• Smaller measurements reflect reduced volumes .
h Used to assess wall and septal thicknesses
• Increased diastolic wall or septal measurements reflect hypertrophy
(real or pseudo, see discussion later)
• Decreased diastolic wall or septal measure mens reflect a lack
of hypertophy
47
Systolic Measurements
h Used to assess function
• Increases in wall or septal thicknesses during systole do not
necessarily mean hypertrophy; it could simply be due to
increased function .
• Increased systolic left ventricular chamber size reflects decreased
function of the heart not necessarily increased volume.
Types of Enlargement
Concentric
• Hypertrophy with normal or reduced diastolic left ventricular
chamber size
• Increased septal and/or free wall thickness with no increase in
chamber size '
Causes of concentric hypertrophy
h This may be idiopathic hypertrophy
./ Hypertrophic cardiomyopathy
h It may be secondary to increased workload (afterload) on
the heart .
./ Subaortic stenosis
./ Systemic hypertension
h It may be "psuedo" hypertrophy
./ Volume contraction decreases chamber size and makes the
walls appear thick when they are simply not as stretched as
they normally would be (like in the bladder).
• Dehydration
• Hemorrhage
• Addison's disease
• Pulmonic stenosis (decreased flow into the left heart)
• Pulmonary hypertension (decreased flow into the left heart)
Eccentric
./ Hypertrophy of the septum and wall with increased diastolic left
ventricular chamber size, secondary to increased volume in the heart
Causes of eccentric hypertrophy
./ Valvular insufficiencies
• Mitral
• Aortic
48
./ Shunts
• Patent ductus arteriosus (PDA)
• Ventricular septal defect (VSD)
./ Miscellaneous
• Chronic anemia
• Systemic hypertension (later stages)
./ Dilated cardiomyopathy (typically no increased wall thicknesses)
Assessment of Left
Ventricular Function
Fractional Shortening
• This is an index of overall cardiac function. '
h Many things affect it, but these three things are important
to consider: preload, afterload, and finally contractility itself.
./ Preload
• Increased preload stretches the myocardial fibers.
• This allows the muscle fibers to slide over each other to a
greater extent (Frank Starling) and fractional shortening
increases (Figures 3-10 and 3-11) .
h Therefore, hearts with increased preload and no myocardial
dysfunction should always have elevated fractional shortenings.
h How high should it go?
./ No matter how dilated a heart becomes, if the intrinsic
ability of the muscle to contract is not compromised, it
will shorten down to normal systolic dimensions .
./ So both an elevated fractional shortening and normal
systolic dimensions for that dog's body size should be seen
in the presence of increased volume and normal muscle.
• Decreased preload decreases the amount of stretch on the
muscle myofibers.
• This diminishes their ability to slide over each other and
fractional shortening is decreased (Figures 3-10 and 3-12).
• Therefore, poor fractional shortening may simply be due
to poor preload, not poor contractility.
• Check the diastolic dimension of the left ventricle ro
assess preload.
49
Effects of preload
on muscle function
1 1
Normal Preload
1 1
Increased Preload
11 _ _- Decreased Preload
Figure 3-10 These lines represent the thick and thin filaments of a muscle cell.
The vertical lines in the middle of each diagram represent how far the filaments
slide over each other during contraction and represent systolic length.
A) Under normal preload conditions, the filaments slide over each other towards
the center of the cell and a normal amount of shortening (fractional shortening)
is achieved .
B) When preload is increased the fibers start out in a less overlapped state, dur-
ing contraction they still shorten down to the normal systolic length and as a
result the degree of shortening (fractional shortening) is increased .
C) When preload is decreased, the fibers start out in a more overlapped state.
During systole they slide towards the normal systolic length but the degree of
shortening (fractional shortening) is reduced as a result of starting out at a
shorter length.
50
na I SI S
: M-mode
Calculiltlons
aln Menu
nal Sl5.
: H-mode
CalculatIons
51
.,/ Afterload (Figure 3-13)
h Increased afterload without chronic training diminishes
the ability to contract (think of pressing a free weight you are not
used to) even if the muscle is normal (Figure 3-14) .
.,/ Therefore fractional shortening is depressed.
h Decreased afterload makes it easier for the muscle
to contract .
.,/ Therefore fractional shortening is increased .
.,/ Contractility
.,/ This is the intrinsic contractile property of the muscle fibers.
h When fractional shortening is decreased and increased
afterload and decreased preload are ruled out as causes of poor
function, then contractility can be blamed (Figure 3-14).
h Volume overloaded hearts with normal contractility
should have elevated fractional shortening because of the
increased preload (see Figure 3-11).
Effects of afterload
on muscle function
--.-
_, r,.
~ . .
Decreased Afterload
Figure 3-13 Afterload, the load the heart has to contract against, affects
the degree of muscle shortening. In this illustration, lifting weights you are
trained for, allows muscle to shorten normally. Increasing the amount of
weight, however, without training, prevents the muscle from shortening ade-
quately, even though your muscle is normal. Decreasing afterload makes it
easier for the muscle to work.
52
~ Volume overloaded hearts with normal fractional shorten-
ing (as opposed to increased) and increased systolic dimensions have
some degree of myocardial failure (Figure 3-15).
Figure 3-14 When preload is normal or increased, and blood pressure is nor-
mal, a decreased fractional shortening is consistent with the diagnosis of
myocardial dysfunction . If blood pressure is elevated however, it may be the
cause of poor fractional shortening.
53
54
Section 4
Echoca rd iog ra ph ic
Reference Values
55
Echoca rd iog ra ph ic
Reference Values in
the Cat
The reference ranges in this table are not significantly correlated
to body weight in the cat. Most normal cats shou ld have
echocardiographic values that fall within these parameters.
Parameter 95% Cl
Ao (mm) 6.0 - 12.1
LVET (msec) 100 - 180
LA (mm) 7.0-17.0
EPSS (mm) 0 .0 - 2.0
LVd (mm) 10.8-21.4
LVs (mm) 4.0 - 11.2
% FS 40 - 67
VSd (mm) 3.0 - 6 .0
VSs (mm) 4.0 - 9.0
LVWd (mm) 2.5 - 6.0
LVWs (mm) 4.3 - 9.8
LNAo .88 - 1.79
Data from:
Sisson D, Helinski C, et ai , Plasma tau ri ne concentrations and M-Mode echocar-
diographic measures in healthy cats and cats with dilated cardiomyopathy. J Vet
Int Med 1991 ;5:232-238.
Jacobs G, Knight D, M-Mode echocardiographic measurements in non-anes-
thetized healthy cats: effects of body weight, heart rate, and other variables.
Am J Vet Res 1985;46: 1705-1711.
56
Echoca rd iog ra ph ic
Reference Values for
Parameters Unrelated to
Body Size in the Dog
Parameters of function, ratios, and EPSS are independent of
body size and weight. Most dogs, r egard less of s ize, should fall
within these 95% confidence inte rvals.
Parameter 95% Cl
LVET (msec) 161 - 195
PEP (msec) 20 - 94
PEP/LVET .1 - .54
LA/AO .83 - 1.13
EPSS (mm) .30-7.7
% FS 33 - 46
VSd/LVd .22 - .34
HR 49 - 146
Data from:
Boon J, Wingfield W, Miller C. Echocardiographic indices in the normal dog. Vet
Rad 1983;24:214-221.
Boon J. Manual of Veterinary Echocardiography, Williams & Wilkins, Philadelphia,
1998.
57
Echocardiographic
Reference Values for
Parameters Related to
Body Size in the Dog
All parameters of chamber size and wall thicknesses are dependent
upon the animal's weight. Using the following tables look up weight
along the left hand column; follow the row along to the right to see
the range of normal size or thickness for that weight. Parameters are
listed across the top. These represent 95% confidence intervals; real-
ize that 5% of individuals will fall outside of these reference ranges.
58
ECHOCARDIOGRAPHIC VALUES IN THE DOG (mm)
LVW -d
~ Lbs VS - d LV - d VS-s LV -s LVW -s AO LA
0.5 1 4.4 - 6.8 -7.7 - 4.2 3.5 - 5.4 6.7 - 9.4 -8.7 - 1.6 6.1 - 8.5 -11.3 - 2.6 -14.2-1.2
0.9 2 4.7 - 6.9 -1.2-10.7 3.7 - 5.5 7.1 - 9.6 -4.2 - 6.1 6.4 - 8.7 -6.7 - 7.2 -8.4 - 7.1
1.4 3 4.9-7.1 2.7 - 14.5 3.9 - 5.6 7.4 - 9.8 -1.5-8.8 6.7 - 8.9 -4.0 - 9.9 -5.0 - 10.5
1.8 4 5.1 - 7.2 5.4 - 17.2 4.0 - 5.7 7.7-10.0 0.3 - 10.7 6.9 - 9.1 -2 .1 - 11.8 -2.6 - 12.9
2.3 5 5.3 - 7.3 7.5 - 19.3 4.2 - 5.8 7.9-10.2 1.8 - 12.1 7.1 - 9.2 -0.6 - 13.3 -0.7 - 14.8
2.7 6 5.4 - 7.4 9.2-21.0 4.3 - 5.9 8.2 - 10.3 3.0 - 13.3 7.3 - 9.3 0.6 - 14.5 0.9-16.3
3.2 7 5.6 - 7.4 10.7 - 22.5 4.4 - 6.0 8.4 - 10.5 4.0 - 14.3 7.5 - 9.4 1.7 - 15.5 2.2 - 17.6
3.6 8 5.7 - 7.5 11.9 - 23.7 4.5 - 6.0 8.6 - 10.6 4.9 - 15.2 7.7 - 9.6 2.6 - 16.4 3.3-18.7
4.1 9 5.8 - 7.6 13.0 - 24.8 4.6-6.1 8.8 - 10.8 5.6 - 15.9 7.8 - 9.7 3.3-17.2 4.3-19.7
4.5 10 6.0 - 7.7 14.0 - 25.8 4.7 - 6.2 9.0 - 10.9 6.3 - 16.6 8.0 - 9.8 4 .1 - 17.9 5.2 - 20.6
5.0 11 6.1 - 7.8 14.9 - 26.7 4.9 - 6.2 9.2 - 11.1 6.9-17.2 8.1 - 9.9 4 .7-18.5 6.0-21.4
5.5 12 6.2 - 7.8 15.7-27.5 5.0 - 6.3 9.4 - 11.2 7.5 - 17.8 8.3 - 10.0 5.3-19.1 6.7-22.1
5.9 13 6.3 - 7.9 16.5 - 28.3 5.0 - 6.4 9.5 - 11.3 8.0 - 18.3 8.4-10.1 5.8 - 19.6 7.4 - 22.8
6.4 14 6.4 - 8.0 17.2-29.0 5.1 - 6.4 9.7-11,.4 8.5 - 18.8 8.6 - 10.2 6.3 - 20.1 8.0 - 23.4
6.8 15 6.6 - 8.1 17.8-29.6 5.2 - 6.5 9.9 - 11.5 9.0 - 19.3 8.7-10.3 6.8 - 20.6 8.6 - 24.0
7.3 16 6.7 - 8.1 18.5 - 30.2 5.3 - 6.5 10.0 - 11.7 9.4 - 19.7 8.8 - 10.4 7.2 - 21.0 9.1 - 24.5
7.7 17 6.8 - 8.2 19.0 - 30.8 5.4 - 6.6 10.2 - 11.8 9.8 - 20.1
, 9.0 - 10.4 7.6-21.4 9.7 - 25.0
8.2 18 6.9 - 8.3 19.6-31.3 5.5 - 6.6 10.3-11.9 10.2 - 20.4 9.1 - 10.5 8.0-21.8 10.1 - 25.5
8.6 19 7.0 - 8.3 20.1 - 31.8 5.6 - 6.7 10.5-12.0 10.5 - 20.8 9.2 - 10.6 8.4 - 22.2 10.6 - 26.0
9.1 20 7.1 - 8.4 20.6 - 32.3 5.7 - 6.7 10.6 - 12.1 10.9-21.1 9.4-10.7 8.7 - 22.5 11.0 - 26.4
9.5 21 7.2 - 8.5 21.0-32.8 5.7 - 6.8 10.8 - 12.2 11.2 - 21.4 9.5 - 10.8 9.0 - 22.8 11.5 - 26.8
10.0 22 7.3 - 8.5 21.5 - 33.2 5.8 - 6.9 10.9-12.3 11.5-21.7 9.6-10.9 9.3 - 23.1 11.8-27.2
10.5 23 7.4 - 8.6 21.9 - 33.6 5.9 - 6.9 11.1 - 12.4 11.8 - 22.0 9.7-11.0 9.6 - 23.4 12.2 - 27.6
10.9 24 7.5-8.7 22.3 - 34.0 6.0 - 7.0 11.2 - 12.5 12.1 - 22.3 9.8-11.0 9.9 - 23.7 12.6-27.9
11.4 25 7.6-8.7 22.7 - 34.4 6.1-7 .0 11.3 - 12.6 12.3 - 22.6 9.9 - 11.1 10.2 - 24.0 12.9 - 28.3
V1
\0
0\
o
0"1
w
0'\
~
0'\
U'1
,.•
0"1
0"1
67
Mitral Valve Disease
Features 0
./ Mitral valve lesions (Figures S~l and S~2)
./ Left ventricular dilation (Figures S~ 1 and 5 ~ 2)
./ Left atrial dilation (Figures 5~ 1, 5~2, and 5~3)
• Dilation usually corellates with the degree of
valvular insufficiency when ventricular function is normal.
./ Increased wall and septal motion
./ Normal EPSS
./ Possible leaflet prolapse
• Leaflet(s) buckle back into the left atrium (see Figure S~ 1)
• May be due to stretch or rupture (Figure SA)
./ Function
h Elevated
h Increased preload results in elevated fractional shortening
if the muscle has not become dysfunctional (Figure 5~5)
h Therefore normal or low fractional shortening equals
myocardial dysfunction (see Figure 3~15).
Figure 5-1 (left) Upward curvature of the ventricular septum seen w ith dilation
of the left ventricle, dilation of the left atrium, and thickened mitral valve
leaflets are seen in t his long axis left ventricular outflow view of the heart.
Figure 5-2 (right) Upward bowing of both the atrial and ventricular septums,
representing dilation of the left side of the heart and mitral va lve lesions are
seen in this long axis four chamber view of the heart.
68
Figure 5-3 This transverse
image of the heart base shows
a dilated left atrial chamber.
69
Endocarditis
Features 0
./ Valvular lesions (Figure 5-6)
• Small to medium lesions cannot be differentiated from
degenerative lesions.
• Large irregular lesions are highly suspicious for endocarditis.
h Aortic valve lesions should alway be suspect for endocarditis .
./ Left ventricu lar dilation
./ Diastolic mitral valve flutter if there is aortic insufficiency
(Figure 5-7).
Figure 5-7 Diastolic mitral valve flutter (saw tooth type of motion) (arrow) is
seen with aortic insufficiency.
70
Hypertrophic
Cardiomyopathy
Features 0
./ Concentric left ventricular hypertrophy (Figures 5-8 and 5-9)
• This may be symmetric or asymmetric
• Left atrium may be normal or dilated (Figures 5-8, 5-9, and 5-10).
h A large LA with LV hypertrophy implies diastolic dysfunction .
./ Septum u sually impinges down into the LV outflow tract
(Figures 5-8, 5-9, a nd 5-10) .
Figure 5-8 (left) This long axis outflow view of a heart with hypertrophic car-
diomyopathy shows severe symmetrical hypertrophy, left ventricular outflow
obstruction, and a normal left atrial chamber.
Figure 5-9 (right) There is asymmetric hypertrophy involving the ventricular
septum, mild narrowing of the left ventricular outflow tract, and a normal left
atrium in this heart with mild hypertrophic cardiomyopathy. This is a long axis
left ventricular outflow view of the heart.
71
./ Systolic Anterior Motion (SAM) with moderate to severe obstruc-
tion to o u tflow (Figure 5-11)
./ Syst o lic aortic valve closure with moderate t o severe dynamic
obstruction ( Figure 5-12)
./ Function usually elevated until end-stage (Figures 5-13 and 5-14)
./ Thrombus possible within the left atrium and auricle (Figure 5-15).
Figure 5-11 Systolic anterior motion (SAM) (arrow) is seen secondary to high flow
velocities creating a venturi effect in a narrowed left ventricular outflow tract.
Figure 5-12 Systolic closure of the aortic valve (arrow) is seen secondary to
dynamic obstruction to outflow and a reduction in flow through the valve.
72
Figure 5-13 Function in
hearts with hypertrophic
cardiomyopathy is
typically excellent.
73
Dilated Cardiomyopathy
Features 0
./ Dilated left ventricle (Figure 5~16)
h Dilation not a lways present (especially in Boxers)
./ Dilated left atrium (see Figure 5~16)
./ Thrombus possible in atrium, auricle, or ventricle (rare in dogs)
(Figure 5~17)
h Poor fractional shortening (Figures 5~18 a nd 5~19)
h R educed fractional sh ortening occurs before dilation
h N ormal to thin wall and septum
./ Increased E peak to septal separation (EPSS) (Figure 5~20)
./ Reduced aortic wall m ot ion
74
Figure 5-18 Poor
fractional shortening is a
feature of dilated
cardiomyopathy.
75
Restrictive
Cardiomyopathy
Features 0
h Normal to mildly dilated left ventricle (Figures 5-21 and 5-22)
h Very dilated left atrium (Figures 5-21,5-22, and 5-23)
./ Possible right atrial dilation as well
h Normal to mildly hypertrophied wall and septum
./ Normal to mildly depressed fractional shortening
./ Irregular endocardial surface (see Figure 5-21)
./ Not a lways visib le
./ Fibrosis within the myocardium and endocardium ""-
./ Not always seen
./ Bright echoes within the myocardium
./ Thrombus or smoke within the left atrium is common
(see Figure 5-23).
Figure 5-21 The endocardial surface may be irregular and the myocard ium can
vary in thickness in hearts with restrictive cardiomyopathy. Left atrial dilation is a
consistent feature of this disease. This is a long axis left ventricular outflow view.
76
Figure 5-22 The only abnormal two dimensional feature in restrictive car-
diomyopathy may be an enlarged left atrial chamber. The left ventricle in this
long axis left ventricular outflow view appears normal. The arrow is pointing at
smoke-like echoes.
77
Pericardial Effusion
Features 0
./ Fluid around the heart appears as a black space (Figure 5-24).
h Fluid generally is not present much beyond the junction of
the atrium and ventricle (Figure 5 -25).
h M ay be idiopathic
h Searching for masses is easiest when fluid is present.
~ Always look before tapping, if only for a few moments.
• Many masses are missed after fluid is tapped from
the sac .
./ Pericardial tamponade (Figure 5-26)
h Right atrial and ventricu lar wall collapse
h Does not have to be a massive effusion
Figure 5-24 Pericardial effusion is seen as a black fluid filled space between the
heart and the pericardial sac (arrows) . There is pleural effusion seen outside the
pericardial sac in this transverse left ventricular image of the left ventricle.
78
Figure 5-25 Pericardial fluid (arrow) is not seen around the heart base. It stops
just beyond the junction of the left atrial wall and left ventricular wall on this
long axis four chamber view of the heart.
Figure 5-26 Right atrial collapse (arrow) and right ventricular collapse are
echocardiographic signs of cardiac tamponade. This is a modified left apical four
chamber view of the heart, but tamponade can be appreciated on right
parasternal long axis views as well.
79
Hemangiosarcoma
Features 0
.,/ Pericardial effusion if the turnor has bled into the sac
h Mass seen most commonly at right atrial appendage (Figures
5~27 and 5~28).
h Best seen from left~sided cranial views
.,/ Masses may be seen anywhere in the right ventricular wall or
right atrium (Figure 5~29) .
.,/ Uncommonly seen within the left side of the heart.
h M asses seen o utside the right auricle on left sided views may
be aortic body tumors or hemangiosarcoma (see Figure 5 ~ 2 7).
h Without effusion, many masses are missed.
~ Stand the animal up and image while standing on both sides in
order to see from a different angle when effusion is present. Masses
may be seen that are missed while the animal is in lateral recumbency.
Figure 5-27 Masses may be seen outside the auricular appendage (arrow).
These are most often hemangiosarcoma, but could potentially be aortic body
tumors. This is a left parasternal cranial long axis image of the right atrium
and auricle.
80
Figure 5-28 This mass (arrow) occupies the right atrial appendage in this left
cranial long axis image of the right atrium and auricle.
Figure 5-29 This mass involves the right atrial wall as well as occupying the right
atrial appendage. This is a modified left parasternal transverse view of the heart.
81
Aortic Body Tumors
Features 0
./ Usually no effusion
h Masses typically seen around the aorta on transverse views
(Figures 5-30) .
./ Seen between the right and left atrium
./ Seen at the pulmonary artery bifurcation
~ Usually not seen on the right side of transvere images
between the pu lmonary artery and aorta
h Masses seen outside the right auricle on left sided views may
be aortic body tumors or hemangiosarcoma (see Figure 5-27) .
./ Large masses may compress the atria or great vessels qlUsing
signs of heart failure .
./ Difficult to assess whether they are in or out of the chambers
(Figure 5-31)
Figure 5-30 Aortic body tumo rs (arrow) are usually found on the left sid e of
transverse views of the heart base between the aorta and atrial chambers or
pulmonary artery.
82
Figure 5-31 Heart base tumors (arrows) may become quite large. They often
appear to be within the chambers of the heart, but it is difficult to determine
how involved the cardiac chambers are. This is a right parasternal four chamber
view of the heart.
83
84
Section 6
Common
Congenital Heart
Diseases
85
Patent Ductus Arteriosus
Features 0
./ Dilated left ventricle (Figure 6~ 1)
./ Degree of dilation depends upon the size of the shunt .
./ Dilated left atrium (see Figure 6-1)
./ Dilated pulmonary artery (Figure 6-2)
./ May or may not have left ventricular hypertrophy
./ Function gen erally within the normal range
./ Despite being volume overloaded, function is not elevated
(Figure 6-3)
h Does n ot necessarily imply permanently poor
myocardial function
t'lp Right ventricle and atrium are normal.
./ Signs of pulmonary hypertens io n develop as pressures elevate .
./ The ductus itself is rarely seen without color flow Doppler.
Figure 6-1 Features of patent ductus arteriosus include dilated left atrial and ven-
tricular chambers. This is a long axis left ventricular outflow view of the heart.
86
Figure 6-2 The pulmonary artery is dilated in patent ductus arteriosus as
shunted blood enters this vessel. The diameter of the pulmonary artery is
greater than the diameter of the aorta. The left and right pulmonary artery
segments are also dilated on this transverse image of the heart base.
Figure 6-3 Fractional shortening is usually not elevated in hearts with patent
ductus arteriosus despite the increased preload .
87
Subaortic Stenosis
Features 0
./ Concentric left ventricular hypertrophy
./ Obstruction typically visible
./ Subvalvular ring (Figure 6-4)
./ Dynamic muscular obstruction (Figure 6-5)
./ Both may be present (Figure 6-6)
h May not be seen in very mild aortic stenosis
h Uncommon to have valvular stenosis but leaflets may be fused .
./ Can h ave hypop lastic annulus (Fig ure 6-7)
88
Figure 6-6 The dynamic component of subvalvular obstruction (arrow)
narrows the outflow tract during systole on this long axis left ventricular outflow
view. There is also a small fibrous band of tissue extending from the'hypertrophied
septum into the outflow tract.
89
Figure 6-8 Systolic anterior motion (SAM) of the mitral valve (arrow) is seen
secondary to increased flow velocities within the left ventricular outflow tract.
SAM is mild in this image.
Figure 6-9 Systolic closure of the aortic valve (arrows) is seen secondary to
reduced flow through the aortic valve as the obstruction to outflow increases
early in ejection . Here, there is very limited opening of the valves .
90
Pulmonic Stenosis
Features 0
./ Usually va lvular
./ Lea flets may be fused or dysplastic (Figure 6-11)
h The leaflets will dome if they are fused (Figure 6-12)
./ Lea flets thick and stiff if dysplastic
Figure 6-11 These pulmonic valves are fused (arrow). This cannot be appreciat-
ed on a still image and is a diagnosis that must be made from real time motion
of the valve (see video on the CD). The pulmonary artery dilates beyond the level
of the valves representing the post stenotic dilation on this transverse image at
the heart base.
Figure 6-12 Doming of the pulmonic valves (arrow) means that the valve is fused
and does not open completely. The tips of the cusps point toward the center of
the artery during systole. This is a modified transverse image of the heart base.
91
./ They m ay b e b o th fu sed a n d dysp last ic
./ The a nnulus m ay be normal or s m a ller in size (hypop lastic)
( F ig ure 6-13 ) .
h Dila tio n occurs beyond t h e level of the valves = post
s t e n otic d ilat io n (Figu res 6 -13 a nd 6- 14) .
Figure 6-13 This transverse image, at the pulmonary artery level, shows a
hypoplastic pulmonic annulus (arrow) and a dramatic post stenotic dilation
involving a large portion of the left main pulmonary artery.
92
./Right ventricu lar hypertrophy (Figure 6-15)
./No paradoxical septal motion unless a volume overload is present .
./ Tricuspid or pulmonic insufficiency is usually
present if this is seen.
h The left side of the heart is small if stenosis is moderate to severe .
./ Secondary to decreased preload
./ Creates a concentric hypertrophy pattern in the left
ventricle = pseudo-hypertrophy.
93
Ventricular Septal Defect
Features 0
./ Left ventricular, left atrial, and pulmonary artery dilation
(Figure 6~16)
h May not be dilated with hemodynamically insignificant shunts .
./ Right ventricular dilation
h May not be present if blood flows directly into the
pulmonary artery
./ Function normal or high
h Most defects are seen at the junction of the septum and the
aorta on long axis images (see Figure 6~16).
~ Do not use the four chamber view.
h May not actually see small defects .
./ Often the membranous portion of the septum does
appear to be abnormal (Figure 6~ 17) .
./ Defect seen below the tricuspid valve at about 12:00 o'clock
on transverse views (Figure 6~18).
Fi gure 6-1 6 Ventricular septal defects (arrow) are usually seen on left ventricu-
lar outflow views at the junction of the ventricular septum and the aorta.
94
Figure 6-17 Sometimes the hole of a ventricular septal defect is not appreciated
well, but the junction between the septum and aorta is not smooth (arrow).
Figure 6-18 Most ventricular septal defects are seen at about 12 :00 o'clock
(arrow) on the transverse view of the heart base between the aorta and
tricuspid valves.
95
Tricuspid Dysplasia
Features 0
./ Abnormal tricuspid valve apparatus
. / Septal leaflet is usually tethered to the septum with short
chordae (Figure 6-19)
./ The anterior leaflet is usually longer than normal.
./ The papillary muscles may be abnormal (Figure 6-20).
h Use more than one view to diagnose.
~ Do not use only the right parastemal left ventricular outflow view.
./ The severity of tricuspid insufficiency is variable .
./ Right ventricular dilation if insufficiency is significant
./ Paradoxical septal motion if insufficiency is significant
(Figures 6-21 and 6-22)
./ The right atrium appears large regardless of the degree of
insufficiency because of more apical closure of the leaflets.
h Pulmonary artery size is normal.
Figure 6-19 Usually the septal leaflet of the tricuspid valve (arrow) is tethered
to the septum and displays restricted motion in hearts with tricuspid dysplasia.
96
Figure 6-20 Papillary
muscles (small arrow) are
often abnormal in addition to
the restricted septal leaflet
motion (large arrow) in tricus-
pid dysplasia. This is a long
axis four chamber view.
97
98
Abbreviations
A A peak of the mitral valve
AMY anterior mitral valve
AO aorta
AOV aortic valve
CAVC caudal vena cava
CRVC cranial vena cava
CT chordae tendinae
d diastole
E E peak of the mitral valve
EPSS E point to septal separation
FS fractional shortening
IAS interatrial septum
LA left atrium
LAU left auricular appendage
LMPA left main pulmonary artery
LV left ventricle
LVET left ventricular ejection time
LVW left ventricular wall
MV mitral valve
PA pulmonary artery
PE pericardial effusion
PEP pre-ejection period
PL pleural effusion
PM papillary muscle
PMV posterior mitral valve
PV pulmonic valve
RA right atrium
RAU right auricular appendage
RMPA right main pulmonary artery
RV right ventricle
s systole
SAM systolic anterior motion
se spontaneous contrast
TV tricuspid valve
VC vena cava
vs ventricular septum
99
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Recommended Readings
The list below consists mostly of textbooks that provide a good base of knowledge for
endeavors into the field of ech ocardiograph y, its techniques, and its diagnostics.
Further reading of joumal articles is recommended to remain current on information
relating to echocardiography and specific cardiac diseases.
Berne RM, Levy MN. Cardiovascular Physiology, 8th edition. Mosby, St. Louis,
MO 2001.
Boon, JA. Manual of Veterinary Echocardiography, Williams and Wilkins,
Philadelphia, PA, 1998.
Darke P, Bonagura JD, Kelly DF. Calor Atlas of Veterinary Cardiology. Mosby-
Wolfe, London, England, 1996.
Heart Disease, 6th ed ition. Editors: Braunwald E, Zipes DP, Libby P. WB Saunders ,
Philadelphia, PA 2001.
Kirk's Cu rrent Veterinary Therapy Xll, Small Animal Practice. ~ection 9:
Cardiopulmonary Disorders pages 773-930. Editor: Bonagura JD. WB Saunders,
Philadelphia, PA 1995.
Kirk's Current Veterinary Therapy Xlll, Small Animal Practice. Section 9:
Cardiopulmonary Disorders pages 709-830. Editor: Bonagura JD . WB Saunders,
Philadelphia, PA 2000.
Kittleson MD, Kienle RD. Small Animal Cardiovascu lar Medicine. M osby, St
Louis, MO 1998.
Kittleson MD. Left ventricular function a nd failure. Part I. Camp Small Anim
1994; 16: 287-308.
Kittleson MD. Left ventricular function a nd failure. Part Il. Camp Small Anim
1994; 16: 1001-1017.
Manual of Canine and Feline Cardiology, Jrd ed ition. Editors: Tilley LP, Goodwin
JK. WB Saunders, Philadelphia, PA, 200 1.
Principles a nd Practice of Echocardiography, 2nd ed ition. Editor: Weyman AE.
Lea & Febiger, Philadelphia, PA 1994.
T extbook of Canine and Fe line Cardiology. Editors: Fox PR, Sisson D, M o ise N S.
WB Saunders, Philadelphia, PA 1999.
Thomas WP, Gaber CE, Jacobs GJ, et al. R eco mmendations for standards in
transthoracic two-dimensional ech ocardiograph y in the dog and cat.] Vet Int Med
1993, 7:247-252.
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