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Internal Medicine

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Tips and tricks in Echocardiography


1-Pericardial effusion should be measured in diastole


2-Aortic annulus should be measured in mid systole inner edge to inner edge, other aortic root dimensions measured in end-diastole, leading edge to leading edge, LA is measured in End-systole 


3-Pressure half time is not accruate if there is multivalvular pathology


4-You should use ECG


5-You should auscultate the patient before you start


6-Mitral valve Prolapse  is diagnosed from Parasternal long axis view only not apical 4 chamber


7-Mitral valve Prolpase, the tip of the leaflet is pointing Towards LV, flail the tip of the leaflet is pointing Towards LA


8-Rheumatic pathology is characterized by commissural fusion with involvement of Subvalvular apparatus and usually multivalvular affection (in addition to diastolic doming of the anterior leaflet , thickneing and calcification and restricted mobility of posterior leaflet) 


9-LBBB and other conduction disorders are important causes of Regional wall motion abnormalities


10-The recommended method for assessment of LV dimensions is 2D at the level of tips of mitral leaflets in Parasternal long axis view and LV volumes by biplane simpsons method


11-LA size should be assessd by using LA volume Indexed to body surface area


12-The recommended method for assessment of EF for chemotherapy patients is 3D dervied EF followed by global longitudinal strain then MAPSE


13-Always index your measurements especially for the extremes(too Small or too large body surface area)


14-Organic tricuspid valve disease is characterized by thickened leaflets with restricted mobility, doming, calcification or Prolapse.


15-Do not diagnose ASD from apical 4 chamber view Except with color(usually there is drop out in the IAS by 2D)


16-Subcostal view and suprasternal view should be always part of your study in all patients


17-Frequently missed diagnoses by Echo:

Pulmonary stenosis or pulmonary vegetation, PDA, coarctation, Small ASD in subcostal window


18-Hemodynamics including BP and HR have a Great impacts on your doppler dervied measurements and these measurements should be reassessed again after control of BP and HR


19-AS over estimate the MR severity and MR under estimate the AS severity


20-In assessment of severity of Valvular lesions, do not depend on single parameter, rather you should obtain multiple parameters


21-Do not exclude MR Except in left lateral position and after looking in all  possible views


22-Always try to obtain right Parasternal view in patients with AS, sometimes you can got the highest gradient in this view only


23-Always correlate the 2D findings with doppler findings


(for example high gradient across the aortic valve with adequately opened aortic valve in 2D in Parasternal long axis view is not AS, but it is high Flow state or hyperdynamic circulation)


24-Do not Forget to assess the RV function


25-Bicuspid aortic valve should be suspected in patients with isolated aortic valve disease especially if associated with aortic root diltation


26-ASD should not be  diagnosed or measured in A4Ch. view,also should not be  measured  during CD mapping,to avoid color bleeding &hence overestimate  ASD diameters. 


27-LA volume should be measured using the largest volume we see,not strictly related to cardiac cycles.


Mazen Kherallah
S H
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