AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data

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REVIEW ARTICLE

Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness

A. T. Dennis

The Royal Women’s Hospital, Parkville, Australia, University of Melbourne, Parkville, Victoria,

Australia

Correspondence to: Dr Alicia Dennis, MBBS, PhD, PGDipEcho, FANZCA, Director of

Anaesthesia Research, The Royal Women’s Hospital, Parkville, Australia, University of

Melbourne, Parkville, Victoria, Australia

E-mail: adennis@unimelb.edu.au

AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data

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The following is a worked example of the abbreviated transthoracic echocardiography (TTE)

examination* in a healthy pregnant woman: gestation 37+1

weeks, blood pressure 118/76 mmHg,

height 167 cm, weight 67 kg

The parasternal and apical acoustic windows are demonstrated. From these images the following

data have been obtained:

Table 1 TTE Data

Systolic function

Cardiac output = 3204 mL/minute

Septal s′ velocity = 7.5 cm/s

Fractional area change = 63 %

Fractional shortening = 43 %

Left ventricular end diastolic diameter = 4.4 cm

Left ventricular end diastolic area = 17.5 cm2

Diastolic function

Mitral valve E/A = 1.6

Mitral valve E/septal e′ = 7.8

Mitral valve deceleration time = 170 s

Isovolumetric relaxation time = 80 ms

Structural information

No significant pericardial effusion

Fetal Heart Rate

126 beats/min (not shown)

* comprehensive data sets are recommended (see text)

Mitral valve E/A = mitral valve E wave peak velocity / Mitral valve A wave peak velocity

Mitral valve E/septal e′ = Mitral valve E wave peak velocity / septal tissue Doppler e′ wave peak

velocity

AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data

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Figure 1 Parasternal long axis view in a healthy pregnant woman - cardiac model and

probe position.

Image on the left shows the left atrium (1), mitral valve, left ventricle (2) and left ventricular

outflow tract (3) and aortic valve in a model of the heart (the parasternal long axis image). The

image on the right shows the position of the cardiac probe on the chest to acquire the parasternal

long axis image. Note the index maker (red dot) on the probe is directed to the right shoulder tip

and the probe is held softly and perpendicular to the chest.

Figure 2 Parasternal long axis image in a healthy pregnant woman – transthoracic

echocardiography images.

The view on the left is obtained from freezing the two dimensional video image. The image on

the right is the frozen zoomed image of the left ventricular outflow tract during systole with the

red line showing the left ventricular outflow tract measurement. The left ventricular outflow tract

diameter is 2.0 cm. 1 = left atrium, 2 = left ventricle, 3 = left ventricular outflow tract.

LVOTd = left ventricular outflow tract diameter

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Figure 3 Apical 5 chamber view in a healthy pregnant woman – cardiac model and probe

position.

The image on the left shows (1) left atrium, (2) left ventricle, (3) left ventricular outflow tract, (4)

right atrium and (5) right ventricle in a model of the heart (the apical 5 chamber image). The

image on the right shows the position of the cardiac probe on the chest to acquire apical 5

chamber image. Note the index maker on the probe is directed to the left hand side of the subject

adjacent to the bed. The probe is held softly and directed under the left breast towards the sternal

notch at an angle that guides the ultrasound beam just below the sternum.

Figure 4 Apical 5 chamber image in a healthy pregnant woman – transthoracic two

dimensional image and velocity time integral and R-R interval.

The view on the left is obtained by freezing the two dimensional video image. This image is

taken during diastole with the mitral valve open. The image on the right is the pulse wave

Doppler waveform of left ventricular outflow tract during systole. Tracing around the waveform

gives the left ventricular outflow tract velocity time integral (VTI) (green outline). In this case

the left ventricular outflow tract velocity time integral is 17.0 cm. Heart rate (HR) (60/R-R

interval) is 60 beats/min. The cardiac output = (LVOTd/2) 2

× π × VTI × HR = 3204 mL/minute.

1 = left atrium, 2 = left ventricle, 3 = left ventricular outflow tract, 4 = right atrium, 5 = right

ventricle, LVOTd = left ventricular outflow tract diameter

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Figure 5 Parasternal short axis view in a healthy pregnant woman – cardiac model and

probe position.

The image on the left shows the short axis of the left ventricle with the right ventricle at the

lower part of the picture (the parasternal short axis image). The image on the right shows the

position of the cardiac probe on the chest to acquire the parasternal short axis image. Note the

index maker (red dot) on the probe is directed to the left shoulder tip and the probe is held softly

and perpendicular to the chest.

Figure 6 Parasternal short axis image in a healthy pregnant woman – transthoracic

echocardiography M-mode midpapillary region left ventricle – fractional shortening.

This image shows the left ventricular end diastolic diameter (red line) (4.4 cm) and the left

ventricular end systolic diameter (red line) (2.5 cm). Fractional shortening = (LVEDD–

LVESD)/LVEDD × 100 = 43%. Note that for accuracy the diastolic measurement should precede

the systolic measurement in each individual cardiac cycle because for each stroke volume the left

ventricle fills (diastole) then empties (systole).

LVEDD = left ventricular end diastolic diameter

LVESD = left ventricular end systolic diameter

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Figure 7 Parasternal short axis image in a healthy pregnant woman – transthoracic

echocardiography midpapillary region left ventricle – fractional area change.

The image on the left is obtained by freezing the two dimensional video at end diastole and

measuring the area (red circle) (17.5 cm2). The image on the right is obtained by freezing the two

dimensional video during systole and measuring the area (red circle) (6.5 cm2). Fractional area

change = (LVEDA–LVESA) / LVEDA × 100 = 63%.35, 36

LVEDA = left ventricular end diastolic area

LVESA = left ventricular end systolic area

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Figure 8 Apical 4 chamber view in a healthy pregnant woman – cardiac model and probe

position.

Image on the left shows (1) left atrium, (2) left ventricle, (4) right atrium and (5) right ventricle in

a model of the heart (the apical 4 chamber image). The image on the right shows the position of

the cardiac probe on the chest to acquire apical 4 chamber image. Note the index maker on the

probe is directed to the left hand side of the subject adjacent to the bed. The probe is held softly

and directed under the left breast and along an imaginary line towards the subject’s thoracic

vertebrae.

Figure 9 Apical 4 chamber image in a healthy pregnant woman – transthoracic two

dimensional image and septal tissue Doppler waveform.

This view is obtained from freezing the two dimensional video image. This image is during

diastole with the mitral valve open. 1 = left atrium, 2 = left ventricle, 4 = right atrium, 5 = right

ventricle

AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data

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Figure 10 Apical 4 chamber view in a healthy pregnant woman – mitral valve Doppler

waveform.

The mitral valve E wave is 78.2 cm/s. The mitral valve A wave is 48.2 cm/s. Therefore mitral

valve E/A ratio = 1.6. The mitral valve deceleration time is 170 ms.

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Figure 11 Apical 4 chamber view in a healthy pregnant woman – septal tissue Doppler

waveform.

This is the appearance of the septal tissue Doppler waveform in a healthy pregnant woman. The

waveform consists of three main deflections. The first deflection above the baseline (0 cm/s line)

that occurs during systole is the s′ wave. The peak velocity is recorded as the s′ velocity. In this

case the s′ velocity is 7.5 cm/s. The first deflection below the baseline in diastole is e′ wave. The

peak velocity of this wave is recorded as the e′ velocity. In this example it is 10.0 cm/s. The time

period between the end of the s′ wave and the beginning of the e′ wave is known as the

isovolumetric relaxation time (IVRT). In this example it is 80 ms. The second downward

deflection during diastole is the a′ wave. The peak deflection is recorded as the a′ velocity and in

this case it is 6.5 cm/s. Therefore the septal e′/septal a′ ratio is 1.5. Using Figure 10 the mitral

valve E/septal e′ = 7.82, 6, 37, 38

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Table 2 Basic image recordings and measurements in the abbreviated study performed for

the parasternal and apical acoustic windows in Figs 1- 11

Transthoracic view Axis or chamber

view

Image recorded Measurements performed

Two dimensional video Long axis

Left ventricular outflow tract

zoomed

Left ventricular outflow tract

diameter

M-mode at mid papillary

region

Left ventricular end diastolic and

left ventricular end systolic

diameter

Parasternal

Short axis

Two dimensional video Left ventricular end diastolic area

and left ventricular end systolic area

Septal tissue Doppler

waveform

Septal s′, e′, a′ measurements, ,

isovolumetric relaxation time,

4 chamber

Two dimensional video

Two dimensional video

Mitral valve pulse wave

Doppler

Mitral valve E and A wave, Mitral

valve deceleration time

Apical

5 chamber

Left ventricular outflow tract

pulse wave Doppler

Left ventricular outflow tract

velocity time integral, heart rate

References

For numbered references refer to main text.