ARDMS AE-Adult-Echocardiography - AE Adult Echocardiography Examination

The Valsalva maneuver transiently reduces preload, which can unmask or exaggerate diastolic dysfunction during mitral inflow Doppler assessment. During Valsalva, changes in mitral E and A wave velocities can differentiate between normal and pseudonormal filling patterns by observing alterations in filling pressures.

Hand grip, leg air cycling, and squatting affect afterload and preload differently but are less specific for assessing diastolic dysfunction via mitral Doppler.

This technique is outlined in the "Textbook of Clinical Echocardiography, 6e", Chapter on Diastolic Function Assessment and Maneuvers【20:210-215†Textbook of Clinical Echocardiography】.

Aortic stenosis (AS) is the valvular lesion most commonly requiring evaluation with a non-imaging (pedoff) continuous wave Doppler transducer. This specialized probe allows the operator to align the Doppler beam parallel to high-velocity aortic jets to accurately measure peak and mean gradients across the stenotic aortic valve.

While imaging Doppler can estimate gradients, non-imaging CW Doppler is essential for precise quantification, especially in difficult acoustic windows or when maximal velocities need to be captured.

Mitral and tricuspid regurgitations and pulmonic stenosis are typically assessed with imaging transducers, as jet orientation is more variable.

This is highlighted in the "Textbook of Clinical Echocardiography, 6e", Chapter on Doppler Hemodynamics and Valvular Stenosis Assessment【20:310-315†Textbook of Clinical Echocardiography】.

Comprehensive and Detailed Explanation From Exact Extract:

The parasternal short axis view at the level of the aortic valve is optimal for evaluating valve morphology, including detection of bicuspid aortic valve (BAV). This view clearly visualizes the valve leaflets en face during systole.

Right sternal border and apical views provide hemodynamic information but are less optimal for detailed valve anatomy. Apical long axis is better for left ventricular and outflow tract evaluation but limited for valve leaflet number.

This is described in the "Textbook of Clinical Echocardiography, 6e", Chapter on Aortic Valve Morphology and Congenital Anomalies【20:350-355†Textbook of Clinical Echocardiography】.

The most reliable technique to distinguish a trileaflet aortic valve from a bicuspid valve is to visualize all three leaflets simultaneously during diastole when the valve is closed. During diastole, the aortic valve leaflets coapt, and the three cusps form a characteristic “Y-shaped” or “Mercedes-Benz” sign on short-axis echocardiographic views, clearly demonstrating the number of leaflets.

Visualization during systole is less reliable because the valve is open, and the leaflets are moving rapidly. Doppler techniques (pulsed or continuous wave) assess flow velocities but do not definitively determine leaflet number, only stenosis severity.

This approach is well documented in adult echocardiography textbooks and ASE valvular imaging guidelines, which emphasize the diastolic short-axis view for valve morphology assessment【16:Textbook of Clinical Echocardiography, 6e†p.190-195】【12:ASE Valve Imaging Guidelines†p.180-185】.

The echocardiographic image shows measurement of the ascending aorta, identified by its position above the aortic valve and before the arch vessels. The ascending aorta is a critical region assessed for dilation or aneurysm.

The sinus of Valsalva refers to the dilated portion just above the aortic valve cusps, while the aortic root includes the annulus, sinuses, and sinotubular junction. The descending aorta is posterior and visualized in other windows.

This measurement and its importance are detailed in the "Textbook of Clinical Echocardiography, 6e", Chapter on Aortic Root and Ascending Aorta Evaluation【20:380-385†Textbook of Clinical Echocardiography】.

Comprehensive and Detailed Explanation From Exact Extract:

The recommended method to measure left atrial diameter in the parasternal long axis view is the inner edge to inner edge technique, perpendicular to the aortic root, measured at end-diastole. This approach provides the most reproducible and standardized measurement.

Measurement parallel to the aortic root or at end-systole is less accurate. Outer edge measurements overestimate size.

ASE chamber quantification guidelines specify this method for standardization and reproducibility in adult echocardiography practice【12:ASE Chamber Quantification Guidelines†p.90-95】【16:Textbook of Clinical Echocardiography, 6e†p.120-125】.

In severe tricuspid regurgitation (TR), the regurgitant jet flows back from the right ventricle into the right atrium during systole, causing reversal of flow in the hepatic veins during the same phase. On Doppler echocardiography, this manifests as systolic flow reversal in the hepatic veins, which is a hallmark sign of severe TR.

Normally, hepatic vein flow consists of a predominant systolic forward flow into the right atrium. However, in severe TR, the high pressure in the right atrium during systole causes retrograde flow in the hepatic veins. This pattern is diagnostic and aids in severity assessment.

Diastolic flow reversal is uncommon in TR and more associated with other pathologies. Atrial flow reversal in systole or biphasic flow reversal in diastole are not recognized patterns for severe TR.

This is described in detail in the "Textbook of Clinical Echocardiography, 6e", Chapter on Right Heart and Tricuspid Valve Disease, with Doppler patterns illustrated for hepatic vein flow in tricuspid regurgitation【20:330-335†Textbook of Clinical Echocardiography】.

Comprehensive and Detailed Explanation From Exact Extract:

The echocardiographic image shows a structure posterior to the left atrium, pointed to by the arrow. This is consistent with a hiatal hernia, which often appears as an echolucent or mixed echogenicity structure behind the left atrium in the parasternal or apical views. Hiatal hernias occur when part of the stomach herniates through the esophageal hiatus of the diaphragm into the thoracic cavity and may mimic pericardial or pleural effusions on echocardiography.

Pericardial effusions appear as an anechoic (dark) space surrounding the heart but usually anterior or around the entire heart rather than posterior localized structure. Left pleural effusions also appear posteriorly but typically have different echogenicity and anatomical location. Ascites refers to free fluid in the abdomen and would not appear in this thoracic echocardiographic window.

Recognition of hiatal hernia on echocardiography is important to avoid misdiagnosis, as it may cause artifacts or false-positive effusions. The presence of swirling or movement of echogenic material with respiration and positional changes helps in diagnosis.

This finding is described in the "Textbook of Clinical Echocardiography, 6e" (Catherine M. Otto), Chapter on Pericardial Disease and Miscellaneous Echocardiographic Findings, including differential diagnosis of echolucent areas around the heart【20:280-285†Textbook of Clinical Echocardiography】.

The echocardiographic image shows a typical atrial septal defect located in the central portion of the atrial septum, best classified as a secundum atrial septal defect (ASD). Secundum ASDs are the most common type, occurring in the fossa ovalis region.

Sinus venosus ASDs are located near the superior vena cava or inferior vena cava junctions, coronary sinus ASDs involve unroofing of the coronary sinus, and primum ASDs occur low in the atrial septum near the atrioventricular valves.

These anatomic distinctions are critical for diagnosis and surgical planning and are detailed in adult congenital heart disease and echocardiography references【16:Textbook of Clinical Echocardiography, 6e†p.565-570】【12:ASE Adult Congenital Guidelines†p.400-410】.

The combination of chronic elevated Wood units (indicative of pulmonary hypertension), severe back pain, and a new diastolic murmur strongly suggests an acute aortic dissection involving the ascending aorta or aortic valve.

Aortic dissection can cause tearing of the intima and compromise the aortic valve, leading to acute aortic regurgitation manifesting as a new diastolic murmur. Back pain is a classic symptom due to the dissection extending along the aorta.

Aortic aneurysm may cause symptoms but usually not acute severe pain and murmur. Left ventricular rupture and ruptured papillary muscle are typically complications of myocardial infarction and present differently.

This clinical presentation and echocardiographic assessment are described in the "Textbook of Clinical Echocardiography, 6e", Chapter on Aortic Pathology and Emergencies【20:380-385†Textbook of Clinical Echocardiography】.