Table Of ContentTEXTBOOK of
CLINICAL
ECHOCARDIOGRAPHY
SIXTH EDITION
TEXTBOOK of
CLINICAL
ECHOCARDIOGRAPHY
Catherine M. Otto, MD
J. Ward Kennedy-Hamilton Endowed Chair in Cardiology
Professor of Medicine
University of Washington School of Medicine;
Director, Heart Valve Disease Clinic;
Associate Director, Echocardiography Laboratory
University of Washington Medical Center
Seattle, Washington
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
TEXTBOOK OF CLINICAL ECHOCARDIOGRAPHY: SIXTH EDITION ISBN: 978-0-323-48048-2
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PREFACE
Echocardiography is an integral part of clinical cardiology, with important applications
in diagnosis, clinical management, and decision making for patients with a wide
range of cardiovascular diseases. In addition to examinations performed in the
echocardiography laboratory, ultrasound imaging is now used in many other clinical
settings, including the emergency department, coronary care unit, intensive care unit,
operating room, catheterization laboratory, and electrophysiology laboratory, both
for diagnosis and for monitoring the effects of therapeutic interventions. Echocardio-
graphic applications continue to expand because of the detailed and precise anatomic
and physiologic information that can be obtained at the bedside with this technique
at a relatively low cost and with minimal risk to the patient.
This textbook on general clinical echocardiography is intended to be read by
individuals new to echocardiography and by those interested in updating their knowledge
in this area. Thus, this book is aimed primarily at cardiology fellows on their basic
echocardiography rotation but also will be of value to residents and fellows in general
internal medicine, radiology, anesthesiology, and emergency medicine, as well as to
cardiac sonography students. For physicians in practice, this textbook provides a
concise and practical update.
Textbook of Clinical Echocardiography is structured around a clinical approach to
echocardiographic diagnosis. First, a framework of basic principles is provided
with chapters on ultrasound physics, normal tomographic transthoracic and trans-
esophageal views, intracardiac flow patterns, indications for echocardiography, and
evaluation of left ventricular systolic and diastolic function. A chapter on advanced
echocardiographic modalities summarizes basic concepts for 3D echocardiography,
myocardial mechanics, contrast echocardiography, and intracardiac echocardiog-
raphy. Clinical use of these modalities is fully integrated into subsequent chap-
ters, organized by disease categories aligned with the current practice of clinical
cardiology.
Each of these chapters summarizes basic principles, the echocardiographic approach,
differential diagnosis, technical considerations, and alternate diagnostic approaches.
Schematic diagrams illustrate core concepts; echocardiographic images and Doppler
recordings show typical findings for each disease process. Transthoracic and trans-
esophageal images, Doppler data, 3D imaging, and other advanced imaging modalities
are used throughout the text, reflecting their use in clinical practice. Tables are used
frequently to summarize studies validating quantitative echocardiographic methods
and to highlight the clinical correlates for each echocardiographic finding. A selected
list of annotated references is included at the end of each chapter for those interested
in reading more about a particular subject.
Some special features of this book that grew out of my experience teaching physicians
and sonographers include The Echo Exam and Echo Math boxes. The Echo Exam
consists of concise tables that summarize key concepts at the end of each chapter.
Echo Math boxes provide examples of the quantitative calculations used in the
day-to-day clinical practice of echocardiography. My hope is that The Echo Exam
and Echo Math boxes will serve as quick reference guides in daily practice.
In this sixth edition, each chapter has been revised to reflect advances in the field,
suggested readings have been updated, and the majority of the figures have been
replaced with recent examples that more clearly illustrate the disease process. Most
figures now have a linked video; on your smart device, simply click the video icon
to see the echo images in motion. Detailed tables for normal reference values and
v
vi
Preface
evidence tables summarizing validation of quantitative echocardiographic methods
are provided in Appendices at the end of the book.
A more advanced discussion of the impact of echocardiographic data in clinical
medicine is available in a larger reference book, The Practice of Clinical Echocardiography,
fifth edition (CM Otto [ed], 2017), also published by Elsevier. Additional clinical
examples, practical tips for data acquisition, and multiple-choice self-assessment questions
with detailed answers can be found in Echocardiography Review Guide, fourth edition,
by Freeman, Schwaegler, Linefsky, and Otto (Elsevier, 2018), which exactly parallels
the chapters in this textbook.
It should be emphasized that this textbook (or any book) is only a starting point
or frame of reference for learning echocardiography. Appropriate training includes
competency in the acquisition and interpretation of echocardiographic and Doppler
data in real time. Additional training is needed for performance of stress and trans-
esophageal examinations. As echocardiography continues to evolve and new techniques
become practical and widely available, practitioners need to update their knowledge.
Obviously, a textbook cannot replace the experience gained from performing studies
on patients with a range of disease processes, and selected figures with videos do not
replace the need for acquisition and review of complete patient examinations. Guidelines
for training in echocardiography have been published, as referenced in Chapter 5,
and include recommendations for determining clinical competency. Although this
textbook is not a substitute for appropriate training and experience, my hope is that
it will enhance the learning experience of those new to the field and provide a review
for those currently engaged in the acquisition and interpretation of echocardiography.
Every patient deserves a clinically appropriate and diagnostically accurate echocar-
diographic examination; each of us needs to continuously strive toward that goal.
Catherine M. Otto, MD
ACKNOWLEDGMENTS
Many people have provided input to each edition of the Textbook of Clinical Echocar-
diography, and the book is immeasurably enhanced by their contributions—not all can
be individually thanked here. First, my special thanks go to the cardiac sonographers
at the University of Washington for the outstanding quality of their echocardiographic
examinations and for our frequent discussions of the details of image acquisition and
the optimal echocardiography examination. Their skill in obtaining superb images
provides the basis of many of the figures in this book. My thanks to Pamela Clark,
RDCS; Sarah Curtis, RDCS; Maurizio Corona, RDCS; Caryn D’Jang, RDCS;
Margaret Falkenreck, RDCS; Michelle Fujioka, RDCS; Carolyn Gardner, RDCS;
Deanna Knox, RDCS; Yelena Kovolenko, RDCS; Carol Kraft, RDCS; Carin Lodell,
RDCS; Chris McKenzie, RDCS; Irina Nesterova, RDCS; Amy Owens, RDCS;
Becky Schwaegler, RDCS; Joanna Shephard, RDCS; Karl Skinner, RDCS; Hoang
Tran, RDCS; Yu Wang, RDCS; and Todd Zwink, RDCS.
My gratitude extends to my colleagues at the University of Washington who shared
their expertise and helped identify images for the book, with special thanks to Rosario
Freeman, MD; Jim Kirkpatrick, MD; Don Oxorn, MD; and G. Burkhard Mackensen,
MD. The University of Washington Cardiology Fellows also provided thoughtful (and
sometimes humbling) insights and helped identify cases with teaching quality images;
particular recognition goes to James C. Lee. In addition, my gratitude is extended
to those individuals who kindly gave permission for reproduction of previously published
figures. Joe Chovan and Starr Kaplan are to be commended for their skills as medical
illustrators and for providing such clear and detailed anatomic drawings.
My most sincere appreciation extends to the many readers who provided suggestions
for improvement, with particular thanks to Jason Linefsky, MD, and Rosario Freeman,
MD.
Many thanks to my editor, Delores Meloni, at Elsevier for providing the support
needed to write this edition and to Jennifer Ehlers and the production team for all
the detail-oriented hard work that went into making this book a reality.
Finally, my most appreciative thanks to my husband, daughter, and granddaughter
for their unwavering support in every aspect of life.
Catherine M. Otto, MD
vii
GLOSSARY:
Abbreviations Used in Figures, Tables, and Equations
2D = two-dimensional D = diameter
3D = three-dimensional DA = descending aorta
dB = decibels
A = late diastolic ventricular filling velocity with dP/dt = rate of change in pressure over time
atrial contraction DT = deceleration time
A′ = diastolic tissue Doppler velocity with atrial dT/dt = rate of increase in temperature over
contraction time
A2C = apical two-chamber D-TGA = complete transposition of the great
A4C = apical four-chamber arteries
AcT = acceleration time dyne • s • cm−5 = units of resistance
a = pulmonary vein a-velocity duration
dur
A = transmitral A-velocity duration E = early diastolic peak velocity
dur
AF = atrial fibrillation E′ = early diastolic tissue Doppler velocity
A-long = apical long-axis ECG = electrocardiogram
A-mode = amplitude mode (amplitude versus echo = echocardiography
depth) ED = end-diastole
AMVL = anterior mitral valve leaflet EDD = end-diastolic dimension
ant = anterior EDV = end-diastolic volume
Ao = aortic or aorta EF = ejection fraction
AR = aortic regurgitation endo = endocardium
AS = aortic stenosis epi = epicardium
ASD = atrial septal defect EPSS = E-point septal separation
ATVL = anterior tricuspid valve leaflet ES = end-systole
AV = atrioventricular ESD = end-systolic dimension
AVA = aortic valve area ESV = end-systolic volume
AVR = aortic valve replacement ETT = exercise treadmill test
BAV = bicuspid aortic valve Δf = frequency shift
BP = blood pressure f = frequency
BSA = body surface area FL = false lumen
F = near field
n
c = propagation velocity of sound in tissue F = resonance frequency
o
CAD = coronary artery disease F = scattered frequency
s
cath = cardiac catheterization FSV = forward stroke volume
cm = centimeters F = transmitted frequency
T
Cm = specific heat of tissue
cm/s = centimeters per second HCM = hypertrophic cardiomyopathy
CMR = cardiac magnetic resonance HPRF = high-pulse repetition frequency
imaging HR = heart rate
CO = cardiac output HV = hepatic vein
cos = cosine Hz = Hertz (cycles per second)
CPB = cardiopulmonary bypass
CS = coronary sinus I = intensity of ultrasound exposure
CSA = cross-sectional area IAS = interatrial septum
CT = computed tomography inf = inferior
CW = continuous-wave IV = intravenous
Cx = circumflex coronary artery IVC = inferior vena cava
xi
xii
Glossary
IVCT = isovolumic contraction time PVC = premature ventricular contraction
IVRT = isovolumic relaxation time PV = pulmonary vein diastolic velocity
D
PVR = pulmonary vascular resistance
kHz = kilohertz PWT = posterior wall thickness
l = length Q = volume flow rate
LA = left atrium Q = pulmonic volume flow rate
p
LAA = left atrial appendage Q = systemic volume flow rate
s
LAD = left anterior descending coronary artery
LAE = left atrial enlargement r = correlation coefficient
lat = lateral R = ventricular radius
LCC = left coronary cusp RA = right atrium
LMCA = left main coronary artery RAE = right atrial enlargement
LPA = left pulmonary artery RAO = right anterior oblique
LSPV = left superior pulmonary vein RAP = right atrial pressure
L-TGA = corrected transposition of the great RCA = right coronary artery
arteries RCC = right coronary cusp
LV = left ventricle R = Reynolds number
e
LV-EDP = left ventricular end-diastolic pressure RF = regurgitant fraction
LVH = left ventricular hypertrophy RFR = regurgitant instantaneous flow rate
LVID = left ventricular internal dimension RJ = regurgitant jet
LVOT = left ventricular outflow tract R = radius of microbubble
o
ROA = regurgitant orifice area
MAC = mitral annular calcification RPA = right pulmonary artery
MI = myocardial infarction RSPV = right superior pulmonary vein
M-mode = motion display (depth versus time) RSV = regurgitant stroke volume
MR = mitral regurgitation RV = right ventricle
MS = mitral stenosis RVE = right ventricular enlargement
MV = mitral valve RVH = right ventricular hypertrophy
MVA = mitral valve area RVol = regurgitant volume
MVL = mitral valve leaflet RVOT = right ventricular outflow tract
MVR = mitral valve replacement
s = second
n = number of subjects SAM = systolic anterior motion
NBTE = nonbacterial thrombotic endocarditis SC = subcostal
NCC = noncoronary cusp SEE = standard error of the estimate
SPPA = spatial peak pulse average
ΔP = pressure gradient SPTA = spatial peak temporal average
P = pressure SSN = suprasternal notch
PA = pulmonary artery ST = septal thickness
PAP = pulmonary artery pressure STJ = sinotubular junction
PCI = percutaneous coronary intervention STVL = septal tricuspid valve leaflet
PDA = patent ductus arteriosus or posterior SV = stroke volume or sample volume (depends
descending artery (depends on context) on context)
PE = pericardial effusion SVC = superior vena cava
PEP = preejection period
PET = positron emission tomography T1 = pressure half-time
2
PISA = proximal isovelocity surface area TD = thermodilution
PLAX = parasternal long-axis TEE = transesophageal echocardiography
PM = papillary muscle TGA = transposition of the great arteries
PMVL = posterior mitral valve leaflet TGC = time-gain compensation
post = posterior (or inferior-lateral) ventricular wall Th = wall thickness
PR = pulmonic regurgitation TL = true lumen
PRF = pulse repetition frequency TN = true negatives
PRFR = peak rapid filling rate TOF = tetralogy of Fallot
PS = pulmonic stenosis TP = true positives
PSAX = parasternal short-axis TPV = time to peak velocity
PV = pulmonary vein TR = tricuspid regurgitation
xiii
Glossary
TS = tricuspid stenosis
Symbols Greek Name Used for
TSV = total stroke volume
TTE = transthoracic echocardiography α alpha Frequency
TV = tricuspid valve γ gamma Viscosity
Δ delta Difference
v = velocity
θ theta Angle
V = volume or velocity (depends on context)
VAS = ventriculo-atrial septum λ lambda Wavelength
Veg = vegetation µ mu Micro-
V = maximum velocity
max π pi Mathematical constant
VSD = ventricular septal defect (approx. 3.14)
VTI = velocity-time integral
ρ rho Tissue density
WPW = Wolff-Parkinson-White syndrome σ sigma Wall stress
τ tau Time constant of
Z = acoustic impedance ventricular relaxation
Units of Measure
Variable Unit Definition
Amplitude dB Decibels = a logarithmic scale describing the amplitude
(“loudness”) of the sound wave
Angle degrees Degree = (π/180)rad. Example: intercept angle
Area cm2 Square centimeters. A 2D measurement (e.g., end-systolic area) or
a calculated value (e.g., continuity equation valve area)
Frequency (f) Hz Hertz (cycles per second)
kHz Kilohertz = 1000 Hz
MHz Megahertz = 1,000,000 Hz
Length cm Centimeter (1/100 m)
mm Millimeter (1/1000 m or 1/10 cm)
Mass g Grams. Example: LV mass
Pressure mmHg Millimeters of mercury, 1 mmHg = 1333.2 dyne/cm2, where dyne
measures force in cm-mg-s2
Resistance dyne • s • cm−5 Measure of vascular resistance
Time s Second
ms Millisecond (1/1000 s)
µs Microsecond
Ultrasound intensity W/cm2 Where watt (W) = joule per second and joule = m2 • kg • s−2 (unit
mW/cm2 of energy)
Velocity (v) m/s Meters per second
cm/s Centimeters per second
Velocity-time integral cm Integral of the Doppler velocity curve (cm/s) over time (s), in units
(VTI) of cm
Volume cm3 Cubic centimeters
mL Milliliter, 1 mL = 1 cm3
L Liter = 1000 mL
Volume flow rate (Q) Rate of volume flow across a valve or in cardiac output
L/min L/min = liters per minute
mL/s mL/s = milliliters per second
Wall stress dyne/cm2 Units of meridional or circumferential wall stress
kdyn/cm2 Kilodynes per cm2
kPa Kilopascals where 1 kPa = 10 kdyn/cm2
