What is meant by GLS in echocardiography

Sonography: heart

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Echo: Short axis, parasternal through the aorta

Echocardiography

Echocardiography is called the examination of the heart using ultrasound. In addition to the ECG, echocardiography is one of the most important technical non-invasive examination methods of the heart and has meanwhile become an indispensable part of cardiological diagnostics.

TEA and TTE [edit]

There are several ways to reach the heart:

  1. The "normal" way is the ultrasound from the outside through the chest wall (Transthoracic echocardiography, TTE for short). With the acronym "Echo" usually transthoracic echocardiography is meant.
  2. Ultrasound is less necessary and more complex from the esophagus out (Transesophageal echocardiography, called TEE for short). To do this, the patient has to swallow a tube with the ultrasound probe, hence the short name "swallow echo". This method provides a better visualization of some parts of the heart. In this way, the small thrombi in the left atrial appendage that cannot be seen from the outside (transthoracic) can be seen better.
  3. Another method that is rarely used is IVUS, intravascular ultrasound.

Methods of echocardiography [edit]

  • 2-D picture
    • With the 2-D image, you can watch the heart action directly in real time using a black and white cross-sectional image.
    • Especially the size of the heart chambers, the valve function and the pump function of the heart are clearly recognizable
  • M-mode = Motion mode
    • A specific ultrasonic beam is selected from the 2-D image. This linear ultrasonic signal is recorded in its change in the time axis.
    • The exact valve function of the individual valves and a cross-section through the left ventricle can be recorded and measured very precisely with the M-mode. The heart rate and individual time intervals of the heart action are also recorded in M-mode.
    • The TAPSE and the MAPSE can be measured well with the M-mode.
  • PW Doppler = Pulsed-wave Doppler
    • With the Doppler the Blood flow velocity detected. The PW Doppler allows a high spatial resolution, but is limited to speeds below 2 m / sec depending on the depth of penetration.
  • CW Doppler = Continuous Wave Doppler
    • The blood flow velocity is also recorded with the CW Doppler. In contrast to the pW Doppler, the CW Doppler records the speed of the blood along the length of the entire sound beam and allows the detection of accelerated flows of up to 6 or 7 m / sec. This has advantages in the quantitative assessment of valve stenosis or valve insufficiency.
  • Color Doppler
    • The color Doppler is something of a extensive Doppler. The blood flow velocity in a larger area is recorded and then converted into a color signal. The colors can usually be freely specified on the ultrasound devices. As a standard, however, it has become established that the flow towards the ultrasound head is defined as red and away from the ultrasound head is blue. The brightness of the colors defines the speed: light = fast blood flow, dark = slow blood flow. A turbulent, noisy flow can also be seen in the color signal. However, this must be distinguished from the "aliasing effect" (also called aliasing). The maximum measurable speed is exceeded and one color tone changes suddenly into the other color. Paradoxically, the color of the opposite blood flow direction (e.g. blue) appears in a color flow (e.g. red).
  • TDI fabric doubler
    • The tissue Doppler uses the reflection of the sound waves on the myocardium while at the same time suppressing the signals from the bloodstream.
    • The TDI is mostly used to assess the diastolic properties and the filling pressures of the left ventricle.
    • On the right ventricle, the TDI can be used to measure a TAPSE-like parameter, the TASV (tricuspid annular systolic velocity)
  • Stress echocardiography
    • The heart is on ultrasound under pressure examined. Regional wall movement disorders of the left ventricle are recorded, which allows conclusions to be drawn about the coronary blood flow.
  • Contrast medium echocardiography
    • By injecting contrast medium, holes in the heart septum can be seen better. The blood flow to the heart muscle and the regional wall movement can also be better captured using contrast media.
  • IVUS = intravascular/ intravascular ultrasound examination (in the case of PTA, a small ultrasound probe is also inserted into the vessel with which the change in the wall can be measured)
  • ICE = intracardiac echocardiography
Some typical cutting planes in the echo

Benefits of echocardiography

Echocardiography allows a non-invasive, patient-friendly detailed examination of the heart within a very short time. The size of the individual heart chambers, the pumping function and the function of the individual heart valves are clearly visible. Heart defects can also be detected quickly and reliably. With echocardiography, heart defects in a child can be detected in the womb.

Not detectable by echocardiography [edit]

The crucial gap in echocardiography is the assessment of the coronary vessels. These cannot be assessed at all or only indirectly due to possible wall movement disorders. There are approaches to recognize the coronary vessels in the TTE, but the examination is rather error-prone and time-consuming. The stress echo offers a very good opportunity to assess the coronary blood flow by means of an echo. Using TEE, at least the branches of the left and right coronary arteries can be seen very well and an assessment can be made with regard to the branching stenosis. The Ivus is an approach for sonographic examination of the coronary vessels. So far, however, it has hardly caught on because it is too expensive.

The indication for echocardiography can be made very generously, since the examination is safe and has a high informative value.

  • shortness of breath
  • Angina pectoris
  • other symptoms with suspected cardiac cause
  • Assessment of a known or suspected congenital heart defect.
  • Patients with a heart murmur
  • Patients with hypertensive heart disease
  • Patients with cardiac arrhythmias of unknown cause
  • Patients with valve prostheses
  • Suspected infectious endocarditis
  • Cardiac tumor or thrombus is suspected
  • Suspected pericardial effusion, pericarditis, pericarditis constrictiva.
  • Known or suspected Marfan syndrome
    • Aorta, aortic root, aortic valve and mitral valve.
  • Suspected cardiomyopathy
  • Follow-up checks in cardiac patients
  • Pulmonary embolism is suspected
  • Finding a cardiac source of embolism in a stroke
  • Assessment of cardiac surgical ability

The following sectional planes have proven themselves in the transthoracic echo:

  • Subcostal view
  • Apical view
  • Parasternal gaze
  • Suprasternal view from the jugulum (no routine sectional plane)

All variants and intermediate positions are permitted. The decisive factor is the image quality and the correct interpretation.

Subcostal incision in the supine position [edit]

The right heart in particular can be seen very clearly from Subcostal.

This incision is routinely not made by some echo laboratories. This is actually a shame, because the subcostal view offers an examination of the heart unaffected by the ribs and lungs. However, you have to experiment with the incision, let the patient breathe in and out, press the transducer properly and examine if possible on an empty stomach. Then you will enjoy this derivation point a lot. The epigastric region is also usually well suited for pericardial puncture under echo vision. What do you see well?

  • Width of the vena cava and hepatic veins
  • Return flow into the hepatic veins in severe TI
  • Size of the atria
  • Size of the right heart
  • Shunt at the atrial level
  • Pericardial gap, pericardial effusion
  • Thickness of the wall of the right heart
  • Tricuspid valve
  • Pulmonary valve and pulmonary artery
  • Pleural effusions

You should always use the patient's supine position in order to detect or exclude a pleural effusion, at least to the right and left.

Apex of the heart

Four-chamber view [edit]

What do you see well?

  • Left ventricle and its function
    • this is usually assessed a little too well in the 4-chamber view.
  • Mitral valve
    • Valve sclerosis
    • Mitral stenosis
    • Mitral regurgitation in the Doppler
    • Papillary apparatus
    • Tissue Doppler TVI in the septum or the side wall to estimate E line and more
  • Atrial size in side comparison
  • Ventricle size in a right-left comparison
  • Tricuspid valve
    • Insufficiency in the color Doppler with assessment of the regurgitation volume
    • Insufficiency in the CW Doppler with assessment of the systolic RV and pulmonary pressure on the basis of the reflux velocity.
    • Tricuspid valve endocarditis
    • TAPSE with estimation of the RV function.

Fig .: 4-chamber view, standing somewhat unusually upside down, anatomically correct.

The foot as an aid to understanding the echo

Apical longitudinal section RAO section (three-chamber view) [edit]

The name RAO comes from X-ray. RAO is the right oblique diameter of the thorax. The section corresponding to echocardiography is often referred to as the "three-chamber view". Since the heart lies obliquely to the left in the thorax, one gets an ideal side view of the heart in the right oblique diameter. The resulting image can be compared to a foot looking sideways:

  • The heel is the left atrium
  • The sole of the foot is the back wall
  • the tip of the foot is the LV tip
  • the instep is the front wall

What do you see well?

  • Left ventricle and its function
    • Better assessment of the EF and regional wall movement than in the 4 K view
  • Mitral valve
    • Valve sclerosis
    • Mitral stenosis
    • Mitral regurgitation in the Doppler
  • Aortic valve
    • Aortic regurgitation in the Doppler
    • Aortic valve stenosis in the Doppler
    • HOCM in Doppler
    • Papillary apparatus

Two-chamber view [edit]

What do you see well?

  • Left ventricle and its function
  • Mitral valve
  • the left atrium

5 chamber view [edit]

Similar to the 3-chamber view, only parts of the RV can still be seen. In addition, the 3-K view is usually recorded the wrong way round. The 5-chamber view is usually developed from the 4-chamber view.

Parasternal gaze

Longitudinal section [edit]

What do you see well?

  • Aortic valve
  • Aortic valve in M-mode
  • Aortic root
  • Left atrium width
  • Mitral valve
  • Mitral valve in M-mode
  • Left ventricle
    • in M-mode for measuring diastolic and systolic wall thicknesses and LV diameters
    • Assessment of the posterior wall and anterior wall mobility 2D and M-mode
Parasternal cross section at the level of the aortic valve

Cross section height aorta [edit]

What do you see well?

  • Aortic valve
  • Aortic valve in M-mode
  • LVOT the left ventricular outflow tract
  • Left atrium
  • Pulmonary valve 2D, m-mode and Doppler

Cross-section height of the mitral valve [edit]

What do you see well?

  • Mitral valve
  • Mitral valve in M-mode

Cross-section height LV [edit]

What do you see well?

  • Left ventricle across
  • Wall thickness and contraction of the LV
  • Papillary muscles

Measurement of the course [edit]

The measurement of the left ventricle in cross-section or longitudinal section provides important values ​​for assessing the size and function of the LV.

The most important measured values ​​are:

  • diastolic septum thickness IVS = IVSd
  • End diastolic diameter EDD = LVIDd
  • Diastolic posterior wall thickness HW = LVPWd
  • End systolic diameter ESV = LVIDs

The fractional shortening FS%, the shortening fraction and an estimated value for the EF = ejection fraction of the left ventricle are then calculated from these values.

The derivation of the M-mode is difficult for many beginners and has to be practiced for quite a long time before usable measured values ​​are obtained.

Fig: Cross section through the LV in m-mode. The diastolic and systolic diameter as well as the wall thickness can be measured.

Measurement of the LVOT [edit]

There are always difficulties when measuring the left ventricular outflow tract LVOT. It is best to measure it parasternal in the long axis. Improvement of the measurement

  • Using the zoom
  • is measured from the inside of the wall to the other inside of the wall
  • is measured with systolic
  • measured parallel to the aortic valve
  • the measurement is taken close to the aortic valve at a distance of approx. 1 mm

Some measure at the point where the PW measurement was made in the outflow tract. This then results in considerable measurement and calculation errors, because the Lvot square diameter is included in the calculations. The measurement is mainly inaccurate due to septal hypertrophy and HOCMs.

4. Aortic arch [edit]

Aortic arch with constriction at the aortic isthmus

What do you see

  • Aortic arch
  • Departures from the supra-aortic arteries
  • Aortic isthmus
Left atrium normal size Left ventricle normal size, normal contractile No regional wall movement disorder Normal ejection fraction of LV EF = 65% No left ventricular hypertrophy No diastolic dysfunction Right atrium normal size Right ventricle normal size Tapse = 18 mm i.e. normal right ventricular ejection fraction. Inferior cava and hepatic veins not widened No pericardial effusion, no pleural effusion on both sides Standard frequency, regular sinus rhythm

If you want to make the diagnosis easier, you can use this text as an abbreviation in your word processor. In Word with Alt + F3 in the Autotext. For example, give it the name echo. Then you can with echo F3 save yourself typing in the normal result next time.

Saving the AutoText of Word in Normal.dot

Findings TEA [edit]

Sedation with mg propofol. Problem-free insertion of the device into the esophagus Left atrium normal size, left atrium enlarged with spontaneous echoes Left atrial appendage free typical strong atrial fibrillation waves in the atrial appendage no thrombus in the atrial appendage no ASD, no open foramen oval left ventricle normal size, normally contractile right atrium normal size right ventricle normal Large No pericardial effusion Aortic valve opens normally, no reflux on the valve Mitral valve opens normally, low reflux on the valve Tricuspid valve opens normally, no reflux on the valve Pulmonary valve opens normally, no reflux on the aorta valve: no wall plaques, no aneurysm, no dissection Tachyarrhythmia in atrial fibrillation Normal frequency sinus rhythm Recommendation: electrical cardioversion, anticoagulation, tight pulse and rhythm controls

Normal values ​​in adults [edit]

Aorta --------------------------------------- Aortic valve separation 1.5 - 2.6 cm aortic root diameter 2.0 - 3.7 cm ascending aorta <4 cm aortic arch <3 cm descending aorta <2 cm ---------------------------- ----------- Right heart ------------------------------------- - Right atrium 2.8 - 4.0 cm RA planimetric <20 cm ^ 2

Links [edit]

Normal values ​​LV filling, diastole [edit]

E (cm / s) Early diastolic max.speed PW Doppler 72 ± 14 cm / s A (cm / s) Late diastolic max.speed PW Doppler 40 ± 10 cm / s E / O max ratio E to A PW- Doppler 1.9 ± 0.6 A - duration (ms) Duration of the late diastol. Filling PW-Doppler DT (ms) deceleration time of the E-wave 180 ± 20 ms IVRT (ms) isovolumetric relaxation time 70 ms VP (cm / s) early diast. Color M mode> 55 ms

Asynchrony parameters [edit]

The measurement of the asynchrony parameters is used to improve the selection of patients for biventricular stimulation. Next to the Main criterion QRS broadening Over 130–150 ms in the ECG, further parameters in the echo for quantifying the asynchrony have been worked out. Three echo parameters in particular have proven themselves quickly and have proven themselves in practice:

  • septal-posterior contraction delay in M-mode of the left ventricle SPWMD
  • right and left ventricular pre-ejection intervals
  • diastolic transmitral filling time

Asynchrony and desynchronization have the same meaning ( synonym) .

Overview [edit]

  • M-mode
    • Septal-posterior contraction delay calculated in milliseconds
      • (English "septal-posterior wall motion delay" SPWMD)
  • Doppler echo:
    • Aortic - pulmonary pre-ejection time
      • interventricular asynchrony
      • (English "interventricular mechanical delay" IVMD)
    • Mitral fill time
    • Aortic VTI (stroke volume)
    • LV dP / dt using CW Doppler
  • 2D / 3D echo:
    • Endocardial wall movement analysis using 2D / 3D echo
  • Tissue Doppler (TDI):
    • Regional myocardial velocities
    • Strain rate imaging

Right-left asynchrony [edit]

PET = Pre-ejection time

The pre-ejection times are measured on the left and right as the time interval between the

  • Beginning of electrical activation (beginning of the QRS complex)
    • and the onset of Doppler flow at the pulmonary valve (RV-PET) and
    • the beginning of Doppler flow at the aortic valve (LV-PET).

Typically, when a left bundle branch block is present, values ​​are around 100 ms on the right (RV-PET) and around 150 ms on the left (LV-PET). One speaks of significant interventricular asynchrony (IVMD) in one Difference DPET (LV-PET - RV-PET) of over 40 ms.

Example:

measured PET aortic valve 188, 172 and 193 ms >> 186 ms on average measured PET pulmonary valve 134, 144, 150 ms >> 143 ms on average -------------------- ---- Delta Ao- Pu = 186 ms - 143 ms = 43 ms

Literature [edit]

  • Wasted septal work in left ventricular dyssynchrony:
    • a novel principle to predict response to cardiac resynchronization therapy
      • European Heart Journal Cardiovascular Imaging, Oxford University Press
        • J. Vecera, M. Penicka, [...], and O.A. Smiseth
        • Interesting article about a new echocardiographic measurement method that allows the success of resynchronization therapy to be predicted.

Links [edit]

RV in the echo [edit]

Assessment of the function of the right ventricle and pulmonary hypertension

  • Size of the RV in different levels, especially from the subcostal
    • Right ventricular diameters in the parasternal long axis
  • Size of the RA, planimetric and volumetric based on the RV or the KÖF
  • Ventricular septum thickness, mobility
    • paradoxical septal movement parasternal long and short axis as well as in the ventricular views
    • LV-EI (LV Eccentricity Index)
  • Tricuspid valve
    • Color Doppler over the tricuspid valve
    • cw Doppler over the tricuspid valve
      • Estimation of the systolic pulmonary pressure on the basis of the maximum flow velocity of the tricuspid regurgitation
      • sPAP by TI
    • TAPSE measured in the 4- (5-) chamber view and / or from subcostal with the M-mode
    • TAPSE (tricuspid annular plane systolic excursion)> 17 mm
    • TASV (tricuspid annular systolic velocity) <15 cm / s
    • measured by TDI
  • Pulmonary valve
    • Acceleration time over the pulmonary valve
    • PI severity
    • PHT of PI
  • Partial index of the right ventricle
    • Tei index (myocardial performance index)> 0.50
  • Inferior cava and hepatic veins
    • Diameter and breath modulation of the VCI
  • Atrial septum
  • Pleural effusions
  • Pericardium
  • systolic strain> 25%

Links [edit]

Literature [edit]

Rudski LG, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2010 Jul; 23 (7): 700.

TAPSE [edit]

The TAPSE (tricuspid annular plane systolic excursion) is an easy-to-measure parameter for assessing right ventricular function. The forward movement (apical) of the tricuspid ring is measured in the M-mode in the 4-chamber view. If you concentrate on the systolic movement of the tricuspid ring in the direction of the apex of the heart, you can estimate the tapes quite well from the 2-D image even without a measurement.

Normal value> 17 mm

The TAPSE allows a quick assessment of the right ventricular EF

Tap * 3 = RV-EF

What's the tapse?

TAPSE = tricuspidal annular plane systolic excursion

  • systolic deflection of the tricuspid valve plane towards the apex of the heart.
  • Distance of movement of the tricuspid ring from the end diastole and end systole

The TAPSE score is lowered for:

  • Posterior wall infarction (inferior ischemia)
  • Septal infarction
  • pulmonary hypertension
  • Stenosis of the pulmonary valve

Literature [edit]

Tapse first description [edit]

  • Kaul et al 1984 (Kaul et al. Assessment of right ventricular function using two-dimensional echocardiography. Am Heart J 107: 526, 1984).

Links [edit]

TASV (tricuspid annular systolic velocity)

The TASV (tricuspid annular systolic velocity is very similar to the TAPSE and measures the maximum systolic velocity of the tricuspid ring in the tissue Doppler.

Normal value:> 15 cm / sec

Stroke volume and cardiac output in the echo [edit]

The stroke volume and the cardiac output can be estimated relatively easily in the echo from the flow curves at the aortic valve or the pulmonary valve and the width of the respective outflow tract.

Doppler [edit]

The stroke volume (SV) is calculated as a product using Doppler echocardiography

  • the effective systolic aortic valve opening area (AVAeff) and
  • the integral of the systolic flow velocity (Time velocity integral, TVI = VTI).
SV = AVAeff * TVIao

Exact calculation [edit]

SV = Pi * LVOT / 2 * LVOT / 2 * VTI (LVOT) CO = SV * HR / 1000

Entries [edit]

  • LVOT Left ventricular outflow tract diameter (mm) Width of the outflow tract in mm
  • VTI1 LVOT subvalvular velocity time integral (cm) Velocity time integral in LVOT
  • HR Heart rate (bpm) Heart rate

Calculated values ​​[edit]

  • SV Stroke Volume (mL)
  • CO Cardiac Output (L / min)

Reference values ​​[edit]

  • Stroke volume SV in milliliters ml
  • Cardiac output = cardiac output = CO (liters / min)

Formula [edit]

SV = π * (LVOT / 2) ^ 2 * LVOT VTI CO = SV * HR / 1000

Source [edit]

Huntsman LL, et al. Noninvasive Doppler determination of cardiac output in man-clinical validation. Circulation 1983; 106: 1057-1065.

It is best to enter the measured values ​​into the online calculator:

Limitations [edit]

  • Aortic stenosis
  • Serious aortic regurgitation
  • HOCM

LV 4D recording [edit]

The LV 4D for the Vivid E95 is described below:

  • Connect the ECG and ensure that the ECG lead is stable
  • 4 Set the chamber view nicely with a vertical septum in 2D
  • If necessary press the virtual apex button: Apex is displayed wider
  • Implementation 4 D recording:
    • Press the Multi D button
    • Select the image button Large or Medium
    • Select a frame rate, for example 4 cycles
    • Record and save 4 cycles

Overview [edit]

New display of myocardial movement with echocardiography

  • Tissue Doppler = Tissue Doppler = TDI = Tissue Doppler Imaging
  • Speckle tracking

Age illustration of myocardial movement

  • M-mode
  • Manual 2 D image analysis in different phases, e.g. systole, diastole
    • the LV is painted in different planes and heart phases

Good website for this, see

Definitions [edit]

Strain [edit]

Strain is an English word meaning

  • strain
  • Strain, also muscle strain
  • burden
  • Tension

In echocardiography, it means the change in a certain fiber length of the heart muscle in relation to the initial length

  • Negative strain: Shortening , shown in red, systolic
  • Positive strain: elongation, shown in blue.
  • Zero strain: no movement, shown in green

Numerical values: Negative values ​​mean a contraction and -20 is normal, for example.

Preliminary remark [edit]

The EF = Ejection fraction is a very important value in cardiology, but it fluctuates physiologically and is subject to considerable measurement inaccuracy when measuring. The left ventricular EF, which is a measure of the pumping function of the left ventricle, is usually referred to first. But there is also a right EF, which can be easily assessed using the tapse, and of course an EF of the left and right atrium.

EF = ejection fraction = ejection fraction EF = SV / EDV * 100%

Normal values ​​of the links EF [edit]

60-75% normal 45-60% slightly restricted 30-45% moderately restricted <30% severely restricted> 75% increased EF eg with fever, hyperthyroidism, physical exertion, stress echo, influence of catecholamines
  • Semi-automated-quantification-of-left-ventricular-volumes-and-ejection-fraction-by-real-time-three-1476-7120-7-18-S1.ogv

Automatic EF determination in the echo [edit]