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AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data
Page 1 of 10
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: [email protected]
AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data
Page 2 of 10
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
Page 3 of 10
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
AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data
Page 4 of 10
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
AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data
Page 5 of 10
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
AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data
Page 6 of 10
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
AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data
Page 7 of 10
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
Page 8 of 10
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.
AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data
Page 9 of 10
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
AT Dennis, doi:10.1016/j.ijoa.2010.11.007, Appendix A. Supplementary data
Page 10 of 10
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.