Hello, this is Doctor Eric Lundquist. How are you doing today? We're going to talk about cardiac or echocardiograms and do's and don'ts.
This is mainly, for the clinical sonographer that's doing echocardiograms, or you're just starting, or you've been doing it for a while, or you don't know our STEP protocol. We're going to take a look at, a proper echocardiogram, based on our protocol, which has been derived from The traditional protocols, and we just found a, a, a nice, efficient way to do a clean echocardiogram for acquired or even congenital disease. We follow the same protocol every time, allows us to see everything that we need to see.
And, then there are some interpretive do's and don'ts, and The common errors that we run across as telemedicine specialists, when we're looking at other people's echocardiograms, what are the common errors? And so, we're gonna address all of those, so you can make the cleanest echocardiogram possible in the shortest amount of time, that you can rely on, that will be, it can be interpreted by anybody. This is, the STEP protocol, if you're not not familiar with it.
It encompasses all the traditional views in a more efficient fashion in about 4 different positions, most of which you're in one position or position one. We're gonna walk through that very quickly. If you wanna do more of a deep dive, Sonopath.com, we have the full SEep unleashed echocardiogram, or, just, Just the STEP echo protocol, ABL for download, for your own teaching or instructional purposes.
These are, this is a cardiac do's and don'ts. If you're already doing echocardiograms traditional or SSTEP, all of this will be helpful for you. So, we're gonna walk through these different, the different presentations that we're See in dogs and cats, and a little bit of pathology and, and how to interpret things, some quick tools on how to interpret your echo and whether it's pathological or not, human dynamically significant or not.
And, some, videos on how to optimise your images with your manual manoeuvres that we're gonna see. You'll see a couple of examples on this page on the bottom right. All righty.
So, a lot of the, cardiac interpretation, and what to do with the pathology. Once you've found it, you'll find it in our second edition of the curbside Guide, all written by a brilliant echocardiographer, cardiologist, surgeon, pretty much everything else in veterinary medicine. Doctor Peter Modler out of Austria wrote those chapters along with me.
And, invite you to take a look at the curbside guide. Abdomen, heart, everything a probe touches, what do you do with it afterwards? That's what the curbside guide deals with, and it's interactive with, videos on QR codes and, access to SonicPath.com, will, enhance the utilizability of, of the curbside guide.
So, echocardiography. When you do an echocardiography, these are the priorities. And doing echoes are actually quite simple if you follow the protocol and some very repetitive tips.
The first thing is you want to do is optimise your acoustic transmission in your imaging planes. That is, find that sweet spot where the acoustic penetration occurs and allows you to, penetrate. Because if your sound beam isn't penetrating, your beam mode image is not going to be clear.
Your measurements are going to be off because you're not going to see the endocardial lines, and your colour flow is going to be mushy. This is the type of view that you want. The acoustic penetration is happy coming through the right ventricular outflow tract here, and therefore, I earned the right to use the Doppler on this PDA case right here, that makes it nice and clean, blues and reds and turbulence, nice anechoic fluid going through the heart.
That's what you want to shoot for in as many views as you can. And Then we want to recognise normal versus abnormal. We definitely don't want to treat something that doesn't need it, and we definitely want to treat something that is abnormal, to help that animal, not develop clinical disease or treat the clinical disease that it has.
And that's all about, is there volume overload or is there pressure overload. That's cardiology in a nutshell right there, and that's what our job is to is to define. We want proper use of Doppler, whether it's spectral Doppler or colour flow Doppler that you see here.
We want it to be clean. If you're, if you're doing everything right and your machine is not producing images of this type of quality, take another look at your machine quality. It's very important in echocardiograms to have solid acoustic penetration and machine quality for.
Echoes, not all machines are echo machines. They may do echo, but that doesn't mean that they are good echo machines. And the first, the sentinel for that is how clean is my Doppler, how solid is my acoustic penetration.
And then our measurements. Now, this varies on, school of thought on which measurements you like. We're gonna talk about that.
The SSTEP protocol does all of them. Do it in 2D or M mode, and we're gonna walk through those. So, you can remember, you can take the STEP protocol and modify it how you want to your needs, but we kind of cover all bases and make sure that, everybody gets the measurements that they're looking for, depending on which school of thought they come from.
We'll talk about that a little bit more. You want the correct equipment for the appropriate patient. So, you know, one minute we may be scanning a ferret, or a Yorkie, or a Great Dane, or a really overweight cat.
This is not a cat from a physics standpoint. This is more like an overweight beagle, you know, so you need the acoustic penetration to, in the right probe, and the right machine to be able to do that. So you definitely want, don't want to use a a catecho setting on a cat like this, right?
So you, we, you wanna use the right setting and the right equipment for the right patient. So, essential reasons to improve echo image quality, incorrect views give disease to normal hearts. If you are offline, you can skew a left atrium large, for example, and your measurements may say that the left atrium is large, but it's not.
So we definitely don't want to give, give disease where it's not present. Good views without measurements are better than bad views with measurements. And what, what does that mean?
Get the views first. The measurements can come later, but if you don't have good solid views, and that step 123, and 4, your measurements are not going to be accurate, right? Or even if you're inaccurate with your measurements cause you're working on a learning curve, as long as you have the clean measure.
Clean M mode and B mode, images, then your specialist can help you with the, with the measurements and make sure that they're fitting what you and he or she are seeing, OK? Inappropriate treatment causes, inappropriate treatment causes, or is caused by incorrect measurements. So, if you're doing your measurements incorrectly, you may treat something that doesn't need to be treated or treated erroneously.
And your image are a reflection of our professionalism, your professionalism, our professionalism. So, you can't have a garbage in, garbage out, or garbage in and nice images out. It's if you give the telemedicine specialist garbage, or you aren't getting clean images to start with, you can't make great out of inadequate, right?
And so, it's important to have good solid images upfront, and then derive the images that are gonna be on the report from a good solid image set that you start with. OK? So, Brightness and contrast, OK?
This is this is the two battles that we fight all the time, especially in obese animals, you know, the acoustic penetration has to go through all of those tissues. And when you have big fat pads or respiratory interference, that's gonna dampen the acoustic penetration, then your images are gonna be excessively dark. You can't just turn up the gain, because that's not doing anything other than amplifying your, your, your brightness on your screen.
It's not doing anything about the signal penetrating, right? You need good, solid acoustic penetration and low enough frequency to be able to penetrate those tissues, right? And if you don't have a clean B mode, your Doppler is not going to be useful at all.
It's going to be inadequate in velocity. If you don't have good acoustic penetration, you're gonna have subnormal values on what you should have. We'll talk about that in a minute, or your colour is going to be mushy or inexistent, OK?
And so, your Doppler. Yeah, I always say earn the right to use the Doppler. So your B mode needs to be cleaned first to earn the right to push the Doppler button.
OK? So what do you do when your image is too dark? First thing you do is reduce your frequency on your probe.
That you can do, and it will help you penetrate. Your, your image quality may drop a little bit, but at least you can penetrate further and get more, more global pathology visible on the screen, but you won't have an image as dark. The other thing is, Reduce the, reduce the frequency on your probe.
If you have a probe that does like, you know, 6 to 10 megahertz, you want to drop it to 6, if you're 8 or 10 megahertz is giving you a, a dark image. And if that's not gonna work, you need to lower to an even lower frequency transducer, like a 3 or a 4, so you may have to change the transducer. So, reduce your frequency first, and or change your transducer.
Now, if that doesn't work, you can reduce your dynamic range a little bit. That'll help a little bit. But if these three don't work, look at your machine.
It may not have the acoustic power to penetrate, especially when you're dealing with a really sick patient or a respiratory, dog with chronic respiratory disease, COPD or something like that, or an animal that's, that's exciting. Which tenses up the tenses up the body wall as well as increases respiratory rate. Or if it's a thick animal, thick skin, excessive fat, large body size, all those things test the power of your machine.
So, you may not have a machine that's powerful enough to do a proper echo. So, try these things first. If this isn't working, take a look at that.
OK? So, regarding interpretation of the heart, it's all about Frank Starling's law. So, it's the hemodynamics relating to myocyte stretch and contractility.
It states that the stroke volume of the left ventricle will increase as the left ventricular volume increases due to myocyte stretch. So the bottom line is, the flow that goes in, has to go out, right? And that's Starling's loss.
And if it goes out forward towards the aorta, that's in, and that's measured in stroke volume or called stroke. Volume. But when you have regurgitant jets, it's gonna go backwards.
So, it's all about keeping Frank Starling's laws intact regarding how we're going to manage these patients, right? And how do we take, how do we assess that? Well, it's all about your echo technique.
Just think of it as a 5-chamber pump, and Starling's laws, and if you keep these 3 things in mind, then your echocardiograms are going to be much more solid and consistent, OK? So, first thing we wanna do is, when you're taking your measurements, you get done with your echo, and you look at it. Make sure that the numbers make sense, right?
So when you do your LVM mode, right, make sure your IVSD and your FWD are roughly the same, unless you have sectoral hypertrophy in a cat, usually, then you can have disparity of these numbers, but you always wanna make sure that the IVSD and FWD or PWD depending on your machine, are about the same, because, if they're not, then you may be oblique, first thing to check. Number 2 is make sure your fractional shortening makes sense. So play the, check the fractional shortening game.
I'm looking at the septum, and the free wall, and the contractility. I'm guessing it's in the 30s, maybe 40s. If I get 33%, OK, that makes sense, right?
So these are the things that you wanna double check on whether you're lined up or not. And you always want that left ventricular septum and free-wall perpendicular to the cursor, OK? If it's not perpendicular to the cursor, what happens is you end up being oblique, and you skew your septum in your freewall and you get disparity in these numbers.
So, IVSD and FWD need to make sense, need to be about the same, and your fractal shortening should make sense with what you're seeing, OK? Same thing on your LA Max, right? Your LA Max position in four-chamber, right pair of sternal long axis or what we call the brick, Make sure if you're getting an LA of 5.86 and a terrier dog, or a mid-sized dog, make sure that that makes sense because our atrial septum is deviated here, and therefore we have left atrial enlargement, 5.86, that makes sense, because this should be like 3.5 or 4 centimetres depending on the mid-size dog, right?
Make sure your MR velocity makes sense. All of your MR or my transficiency velocity should be over 5 metres per second. Usually they're in the 5.5 to 6, when it gets above 6, you have to worry about systemic hypertension, and make sure your envelope is clean, and, Your MR velocity makes sense, 5.6 metres per second, that makes sense, OK?
But always double-check with a lower frequency here, because this may be 5.6 with this frequency, but if I lower the frequency, it may be 6 metres per second, which makes a difference. So you always want to double check your MR velocity and make sure that it makes sense.
Your LA to AOM mode. Now, this is kind of out of fashion now, but those of you that still do it, we still do it just to honour the history of echocardiograms. Make sure that that number makes sense.
How many aortas can I put in this left atrium? I can put like 1.2, 1.3, 1.4.
I get an LA AO of 1.4, that makes sense. OK?
My. Velocity, OK, it's 90. That makes sense.
It's a clean envelope. I'm gonna, maybe I'm gonna double check it. My aortic velocity at about 40.
I'm lined up pretty clean, just beyond the valve on the aorta. That's a clean envelope, that makes sense. OK?
So, all of these things, I'm double checking when I'm going through my echocardiogram to make sure the numbers make sense with what I'm seeing. OK? And if you just keep that in mind, does that number make sense?
Does that number make sense? Does that number make sense as you work through the protocol? And this will really help you get consistent results, right?
Because I, I'll see echocardiograms where they have one measurement that makes sense and others that don't. And so I go and remeasure it to make sure that the numbers make sense with what I'm seeing, right? So, echo, brief summary of the STE echo, positions 1 through 4.
This is 4 chamber, and then 5 chamber long axis. We're switching, we're twisting into short axis, and then into a short-axis heart base right here, and then moving into left ventricle and flips and mushrooms. View on the short axis of the left ventricle and the papillary muscles and, and, mitral valve respectively.
That's a step one, and we do that in different steps, but this is a quick efficiency clip of all those numbers, or all those positions. And then we go to S step 2, where we're getting the tricuspid valve, and then doing Doppler on that. And then we, when we raise the probe tail, that's when we get the tricuspid valve, we lower the probe tail, we get the pulmonary artery and the colour flow assessment.
You always want your colour flow 1/3 after the valve and 2/3 into the left, into the right atrium, and the tricuspid, and the pulmonary, pulmonic valve, you want it 1/3 before the valve, and 2/3 after the valve. And then you can move it down to the PDA position as well. And then S step 3 is up over the top on, in the.
Animals and right lateral recumbency. We're coming off of the sternum and getting into that right atrium and tricuspid valve. You can do your tricuspid Doppler here.
This is more important for right auricular masses to assess. And then we go subxyphoid, and we're going to show you that here in just a minute, where we get our apical mitral valve and apical aortic outflow, so we can get our colour flow, our E waves, and our left ventricular outflow, Doppler as well. OK?
And these are the positions for position one to get your brick here. And then position 2, where we get our pulmonary artery and our tricuspid valve. And then position 3 where we get our right article, and position 4 subxiphoid where we get our apical, right?
The animals in the right later will come and see the whole time. This makes it nice and easy. We're gonna stay in this position about 70% of the time, then we're gonna go to position 2 to get the right atrium and the right.
And, tricuspid valve, pulmonary artery, pulmonic valve, and deep pulmonary artery, then right ventricle, right atrium from the left side approach off the sternum, and then our apical view on the subxiphoid, where the, probe is in, in line with the linea alba in the subxiphoid position. OK, so, some quick ninja notes, this, I would take a picture of this or screenshot it, whatever you like, but these are some quick references on what we're going to do to adjust to the different positions, right? And we're gonna walk through these one by one.
OK? So when I, as far as terminology goes, when we're in a normal position on right peristternal long axis and S step one, our marker is going to be towards the head of the patient, OK? So that's where our home base is.
If we want a brick, nice four chamber long axis to do our LA max, or mitral valve, and left ventricle LVM modes, this is the position that we're in. Now, when I say we're gonna twist towards you, then the marker comes up to you. You're twisting counterclockwise towards you, where the marker is gonna be towards, you're looking straight down at the marker if you were gonna look at your probe.
And this puts you in short axis. So this is long axis, this is short axis, OK? Now, when we go to position two, where we're going into the right atrium and right, and, and.
Tricuspid valve, the probe tail is going to come up, right? This is the probe tail, probe tail up, right? And then we're going to go into the pulmonary artery, we're going to have probe tail down, but we're in the same position as we are here with the marker towards the head.
So probe tail up, probe tail down. These are our four positions, as far as the position of the probe, and how we're going to adjust it. So, always start here with the brick, right parasternal, four chamber long axis, right?
You want this ventricular septum and free wall to be roughly the same thickness, and you want them as flat as possible. You don't want a vertical heart. You want this as flat as possible, OK?
This is a Shih Tzu, you shouldn't lift, there's no volume overload, you should be able to get this in a. Nice flattened brick position pretty well. OK?
This is the most important view. So, how do you start with that? You start with the probe up in the axilla, right axillary area, and then you slide caudally until you see a beating heart.
That's a start, and then you bring the probe tail up, OK? The markers towards the head of the patient here. And this is what it looks like as you come caudally.
You start to see the beating heart, it's a little bit oblique, so you're gonna bring the probe tail up, and then you get a nice long left ventricle. OK? 123, probe tail up.
You may have to twist a little bit with this as well. Remember, anytime you want, want to lengthen something, it's a twist of the probe, OK? Whether you're dealing in the abdomen with the urethra, or the adrenal, or the intestine, same thing for the heart, twist to lengthen.
The left ventricle, OK. If your, if your left ventricle is too rounded like we are here, you're just gonna twist like Peter is doing. This is Peter, Doctor Peter Modler, and he's twisting the probe to lengthen the ventricle.
You always want to lengthen that ventricle, so you don't have a rounded left ventricle, OK? Now, let's say you have a, you wanna go from 4 chamber long axis here, and we're gonna go to what we call the tilted brick, OK? And the tilted brick is great for mitral valve Doppler here, right?
Because most mitral valve jets shoot here towards the left atrial freewall. Some of them go central, and we're gonna map that out in this view, right? And so, when we wanna go from flat brick to tilted brick, then we do this.
We just slide towards the spine. So the spine of the patient's here, sternum is down here, head's over here, right? And we're just, we wanna tilt the brick, we're gonna go.
We either bring it down towards the sternum. If you bring it down towards the sternum, it's gonna tilt the brick. If you wanna flatten the brick, you bring it up towards the spine, OK?
So what Peter's doing here is he's starting with a tilted brick, and then he's flattening it out by bringing the probe tail up. But if you want to tilt the brick from a flat left ventricle and go to a tilted brick with a mitral valve pointing more towards the probe here, then you bring it towards the sternum. So tilted brick towards the sternum, flattened brick towards the spine.
Now, if you want to go from 4 chamber, which is what we have here, left atrium, mitral valve, left ventricle, to 5 chamber, it's just a little twist and a little tilt, OK? A little twist, and a little tilt of the probe, and that'll go 4 chamber to 5 chamber, right? So you see the aortic valve come in, that's the 5th chamber, the aorta and the aortic valve, and if you want to do your LADOM mode, you're gonna drop the cursor right through here, which we'll see that in just a minute.
So now let's go for 5 chamber long axis to short axis. So we want to go from long axis to short axis, so we go 4 or 5. And then twist the short axis.
So we're going from here to here, so the marker towards you now, and that will bring in what we call the Mercedes-Benz sign, and the short axis, OK? And then from here we're going to sweep from the Mercedes-Benz. Sign down through the left ventricle, and we're gonna catch the mitral valve here in a minute.
And the way we do that is we're just bringing the probe tail up, the probe tail down, and or sliding towards the spine to be the big dogs, so we're gonna slide a little bit, may jump a rib space, and this is a view that we're gonna get, is Mercedes-Benz sign or heart base of the aorta. And then through the mitral valve, and then through the left ventricle, where you have the papillary muscles, all right? It's a nice efficiency sweep.
Now let's say our papillary muscles are, are not at 4 and 8 o'clock, we've got a papillary at 6 o'clock here in the short axis. If we want to straighten that out, we bring our probe tail forward. So probe tail forward, And again, all of these manoeuvres are on that one screen that I showed you before, quick manoeuvre, so you can print that out and have it next to your, your machine, and when you're having trouble, the answers are all right there for you.
So we don't want a tilted mushroom, we want a flatted mushroom, so these papillaries are at 4 and 8 o'clock. And that's how you do it, you just bring your probe tail forward. OK.
So, now that we got the positions down, what we're going to do is we're gonna take, take our, look at our measurements, right? And we want to adapt it to common pathology that we're seeing, like in this DCM case, or in this hypertrophic cardiomyopathy case, we wanna make sure that our measurements make sense and we're measuring the right position, right? So, here's our B mode, and here's Our M mode, right?
So, here's the mitral valve, or the, the, the M mode cursor coming through, and it's perpendicular to the septum, perpendicular to the free wall. Therefore, my septum and my free wall in diastole should be about the same. So here we are, 0.53, 0.56, box checked.
I will, I like that measurement, right? And then I look at it here. And I, am I measuring correctly?
So this crosshair has to go through the endocardium of the left ventricular septum. Here's the left ventricular septum, here's the right ventricle, and what you wanna do is let up on the pressure enough to fill this right ventricle, right? So you have a nice interface, a contrast of the anechoic fluid in the right ventricle, to the endocardium of the right ventricle, because that's your.
Start point. This start point here, we mentally ignore all these other hyperchoic lines in the myocardium. We want to focus on the one that's continuous, that hypeechoic line of the endocardium that's continuous from frame to frame, right?
Well if you look at these other striations of the myocardium, they kind of disappear and they're not consistent. So we want to focus on that. So my start point would be there, that's where my crosshair is gonna go.
And I'm gonna start in that position, and I'm gonna go down to the endocardium of the left ventricle and measure the left ventricle, and then the endocardium, and here it starts to kind of fail a little bit. So what I'm going to do is extrapolate from this contraction, this contraction, see where that endocardium is. And I'm gonna say it's right about there, cause I think I'm catching just a touch of papillary here.
And then I'm going to measure to the free wall. The end of the free wall is the, endocardium meets the, pericardium here, that's at this point right there, right? So then, once I get those measurements down in diastole, I'm gonna do the same thing in systole, and I'm gonna check my IVSD MIFWD and make sure they're about the same.
I'm gonna look at the fractal shortening, 39, yeah, that looks like 39 to me, right? And you can do it also in short axis, same sort of thing, but remember, let up on the pressure and let that right ventricle fill. So you have that interface with the endocardium, so you're not measuring a line that isn't the endocardium, all right?
Because you can really skew your measurements that way. And you definitely don't want to pick up a papillary in your measurements. If you do, you're going to get disparity.
Like, this is papillary here. This is papillary coming in here. The rest of my contractions are pretty solid.
This is papillary or corta coming in here. We don't want to measure those. We want to measure the clean endocardium that is consistent frame to frame, OK?
Again, same thing here, B mode, M mode. Our IVSD is our ventricular septum and diastole. Our LVIDD is ventricular internal diameter and diastole, and PWD or FWD is the posterior wall and diastole.
That's the IVSD 1.3, LVIDD 1. And 3.9, FWD 1.16, roughly the same.
I'll take it. I look at my cursor, my hash is right on that endocardium. That endocardium is consistent frame to frame.
That endocardium of the left ventricle is consistent frame to frame. So that's my. That's my point of reference.
My endocardium here is clean, my endocardium superimposes with the pericardium, and those are the targets. I just mentally forget about all these other hyperechoic lines, and I can see that first endocardium of the right ventricle on the septum here, because I have a. Space in that right ventricle.
I'm not pushing too hard to close that down. Because if I close that down, I may mistake and get an excessive ventricular septal thickness here, which won't give me, a nice parity here between the IVSD and the FWD. OK?
And again, our fractal shortening and our ejection fraction, ejection fraction isn't as important, but fractal shortening is important. Does this look like a 33%? Yes, this looks like a 33%.
Which is normal, OK? Again, we have the right ventricle, ventricular septum, internal diameter left ventricle, and the free wall, and in the and that's in the B mode, and these correspond to the M mode. As we work our way down.
Now fractal shortenings typically, the smaller the dog, the higher the fraction shortening, the bigger the dog, the lesser the fractal shortening. There are some differences with that. But, you know, if you have a Labrador, you should be expecting a 30, 35% fractal shortening.
If you have a cat, you should be expecting a 45 to 50%, even 55% if he's excited. You know, a Yorkie's gonna be, you know, normally about 40 to 45, roughly off the top of my head, those are the numbers that I'm looking for. Now, when you start to have volume overload like B2 valve disease, where the left atrial size is enlarged, as is the left ventricular internal diameter, we're gonna have a hyperdynamic state, because Starling needs to be happy, therefore, the heart has to contract more and increase its fractional shortening.
So, same thing here. Bad me, I didn't give myself much in the right ventricle to give myself a space here, but I'm lucky enough that my machine is is clean enough that I'm going to get a nice endocardium to work with here. So here's my IVSD would be measured here.
Here to here, and then internal diameter, and then posterior diameter, and they do the same thing insistently here, here, here, and here. And I'm looking at this as a hyperdynamic state. My fractional shortening, I would guess would be in the high 40s to early 50s, because I'll be owing to this micro insufficiency, and this volume overload, the heart is working harder in this chihuahua to be able to keep Starling happy and keep the push going out that aorta.
Enough to keep pressures up, and Starling happy. Now, if we move over to this cat, same sort of thing, IVSD LVIDD. PWD working on this continuous endocardium, I'm gonna forget about these papillaries if they get in the way, and you can take, take it in 5 chambering cats, it's not a problem, doesn't have to be in 4 chamber, the difference is gonna be minor.
And if I'm looking at my B mode, I see my cursor, where's my cursor going through? It's going through that septum, which is here, and then it hits. It's this papillary, and that is that, OK?
So, I'm just gonna ignore this papillary here. I'm gonna stick to the septum, internal diameter, and free wall, and work on these endocardial lines here. And that's, and I look at my IVSD, my FWD, that makes sense.
1.5 makes sense. Fracture shortening, 33, that makes sense.
Everything makes sense. OK? Now, when we have DCM and volume overload.
So when you have a left-sided volume overload, and you wanna flatten out your brick as much as you can, this is a boxer, so they can be charged they can be challenging to flatten out the brick. What you wanna do is you wanna slide the probe towards the spine, and that will flatten this brick out enough to where you can get your cursor, your MO cursor through that septum, through that free wall in perpendicular fashion, you're not hitting it at an angle. Right?
And you can also get your mitral valve Doppler here, colour flow, your sector is 1/3 to the left of the valve, 2/3 of the right of the valve, so you can see the direction of the jet. And this is a centralised jet. So I'm not going to use my my CW or my spectral Doppler on this, because I'm not going to be able to hit it in a, in an angle that's within 15 degrees theta, which is what you have to do, right?
And we're gonna play with that here in a minute. I'm gonna check my septum and my free wall. They're 1 to, they're about the same.
My 6.3 volume overload is excessive, that that fits with what I'm seeing, right? My fractal shortening is really low, which is what I'm seeing, because we basically have a flattened septum and freewall, there's no kinesis going on there at all.
And, Same thing here, my EPSS is going to be excessive. All those parameters make sense. We have volume overload, left atrium, left ventricle, we have poor contractility, no matter where I measure, I'm in the single digits, and my EPSS is big, that's DCM.
Those are DCM criteria. We'll talk about more of that in a minute. Or here, same thing here, I have a centralised jet because the volume overload is pulling that mitral valve annulus apart, and therefore, I'm getting a regurg here, a volume overload, this is a muscular disease, we're gonna expect a fractional shortening, whether it's a dog or a cat, and the under 20%.
DCM according to the, the literature, you're gonna have you're gonna have CHF in fractal shortenings. Around 13% or less, but low fractal shortening is not exclusive for DCM, OK? So, that just means myocardial failure, we're not contracting enough to keep Starling happy.
Now, you can have other things that can drop your fractional shortening, usually not this much, but if you're expecting a Labrador, and you're usually getting a 30, 35% fraction shortening, he's got like a 25%, things that'll do that off the top of my head, systemic disease or shock. Addison's, for example, hypothyroidism, other things, any systemic disease that's affecting the heart, from a a lack of solicitation is gonna cause that myocardium to drop in its contractility, right? So these are things that we want to look for.
We don't want to give something DCM that doesn't have it. When you're clinical, it's usually a fracture shortness is gonna be under 20%, or they may be at 22%, and then Then they get a paroxysmal arrhythmia, and that drops that fractional shortening even further. So when you're taking the echo, you may get 22%, but if he's blasting the arrhythmia, do a Holter monitor, you have a paroxysmal episode that's gonna drop that fractal shortening into more of these ranges, and this is when they're gonna have the exercise intolerance.
So, remember, you're taking an echo in a moment of time, you don't know what's going on in 24 hour period, right? So, other things that can cause what we call secondary DCM is nutritional cardiomyopathy, myocarditis, which I think is much is, is very underdiagnosed, cause it can look just like DCM like this one. This was a, this was a Parvo-induced, parvovirus-induced myocarditis case, looks just like DCM.
End-stage valve diseases Well, can look like DCM but usually they're in really bad shape. They're in D1, category here when they're dropping the C1, D1, dropping the fractal shortening, huge volume overload, none of the meds are working anymore. So, it, it, they can, they can kind of look like DCM but not.
And then there's the breed differences and so forth, that's beyond the, the, scope of this. Talk, but just realise, make sure your fractal shortenings make sense with what you're seeing, because we can, and then when you do have a confirmation of a DCM-like presentation, think of those other diseases as well, and don't just put a DCM label on it, because it may be something that is medication responsive for myocarditis, for example, right? So, When you have a hyperdynamic heart, expect the fractal shortenings up in the 45 to 60%, right?
Because the heart is trying to push that volume out in the left atrium, but it's regurging more volume into the left atrium, it's trying to push it out the aorta, excuse me, and it's regurging excessive volume. It regurgs more volume into the left atrium and it's getting out to the aorta. So what it has to happen is, you have to really contract hard to make up for that regurgitant deficit, And, you know, hyperdynamic hearts, so you have valve disease, you want hyperdynamic hearts in the 45s, 50s, even 60s.
In cats, they'll do that just because they're excited, right? And so, those are the numbers you, you should see 45s to 50s, 55% in fracture shortenings in cats pretty regularly. EPSS positioning.
So, EPSS is essentially DCM or not, it's one of the criteria for DCM. Just because you have a high EPSS doesn't mean there's necessarily DCM, OK? But a lot of that depends on your positioning, right?
So if my cursor is coming through that septum, and it is perpendicular to the septum, and then catching the mitral valve, And, in the end point of septal separation is going to be normal. Now, if you come at this at an angle, you can create an abnormal, excessive EPSS. You can create a 1 centimetre EPSS if you're not perpendicular to the tip of that mitral valve as it excurs, as it has its excursion towards the ventricular septum.
So you wanna make sure that you're perpendicular to the septum, and the mitral valve as it opens up when you do your EPSS, right? So, Correct EPSS is in, in Dobies, they should be less than 0.65, in giant breeds, less than 0.9, in cats, they should be less than 0.4.
So that's normal on your correct EPSS values, right? And see this excursion of the of the mitral valve, that looks like about 23 millimetres, so we're good with that, right? Whereas the DCM you're gonna have this big space between the septum and the mitral valve, as it extends, and you see this big big space here, right?
And we're not exactly perpendicular here, but we can see this bowing of the ventricular septum, that all fits. And everything, all the other criteria fit for DCM. So, Our, Peter, now the, this, this talk is more about Peter Modler and my approach, and it may vary a little bit depending on who, who you talk to, but we are LA Max people, as far as I wanna say, what's that left atrial size doing?
Is it normal, like this one, where the atrial septum is flattened and it's in line with the ventricular septum. That means the left atrium is in normal size. It's normal size.
So, that atrial septum deviates, then I'm concerned I should get a, an enlarged left atrium on my measurement, right? And so, if I see a flattened sept atrial septum here, and it's in line with the free will, I should have a number that makes sense to normal left atrial size. And this is the most reproducible left atrial size that you can go from one month.
To the next month to the next month to see how that animal is doing, because you have a nice long brick here, and the septum and freewall are the same. So you want to eyeball these, do I have a nice long brick or is it rounded, right? You don't want a rounded brick, you twist to lengthen, to lengthen out that left ventricle before you start doing your measurements.
And the cool thing about the, the brick or the right parasternal long axis, for. Chamber long axis, you can get your LVM mode, you can get your EPSS and you get your LA Max when you're in that position, boom, boom, boom. So if you have a critical patient, you get those measurements right there, you know if there's volume overload or not, right?
So you can immediately, if that animal is, is not in a stable position, you can immediately get that animal going in the right direction with the correct medications and then let them stabilise a bit to get a proper complete echo after that, right? So it's a great point of care position here. But regarding the LA max, you make sure that you are measuring it equidistant from the base of the left atrium to the mitral valve annulus, has to be right in the middle there, perpendicular to an imaginary line.
With the, that goes through the mitral valve annulus. So it should be parallel to that imaginary line right there, right? You don't want it going this way because you're gonna skew it wide, you don't wanna measure here, you don't wanna measure too close to the mitral valve annulus because it's stiffer here.
The dilation occurs in the middle of the atrial septum, it usually bows like that, so you wanna be able to catch. That Boeing in the LA max position. But I highly encourage you to use this.
This is the gold standard, to get one left atrial measurement, this is the one that we really like. And you can see this volume overload here with this mitral valve prolapse, and you see this Boeing left atrial septum, right? And you see the measurement here that we're using.
OK? It's right in the middle, it's parallel to the mitral valve annulus, right? That's what, as opposed to this one is a normal left atrium, atrial septum is in line with the ventricular septum, there's no volume overload, RLA should measure normal 2.58 here.
Or in this DCM case, you see this bowing of this atrial septum, and you measure Right in the middle here, or this valve case where you have this, this atrial septum deviating. This one, I would probably measure maybe a little bit over here, but, this one is kind of big as big, you know, so, don't get, don't get too critical. You may measure this 3 or 4 times, and it may vary by 0.5 centimetre or so.
Big is big, you know. OK. So, that's what's, that's what's important.
Now, old school LA to AOM mode, you can do it in short and long axis or in short axis. Mainly, the key point here is, is you want to measure at the end of the aortic valve closure right before it opens. I would probably measure here from The wall of the aorta here, right?
Wall of the aorta, right before the AV opening, and then the maximum of the left atrial size, which is right at the AV closure. So you're getting a ratio between the aorta and the left atrium in this position. They're not in the same line.
One's here and one is here. So, at the beginning of the AV opening, and at the close Closure of the AV opening is where your LA to AO measurement would be from an M mode. But a lot of people don't do this anymore.
I still like to do it, just because I grew up in the age of the LA to AOM mode. But when you do that, make sure that you have a clean aortic valve right in the middle of the aorta. That's important, right?
So I'm gonna start my measurement. Here are the aorta, excuse me. And then go to the left atrial maximum dilation right at the closure, the initial closure of the aortic valve, and measure the left atrium there, right?
Just like it is here, my hash marks are just a little bit off, I want to bury them into that wall of the aorta. Now, the other one, we're gonna twist from 5 chamber long axis to short axis, and we're gonna get this Mercedes-Benz sign. These are the 3 valves of the aorta, the aortic valve, 3 leaflets of the aortic valve, and what we want to do is we want to measure the inner edge to inner edge of this aorta, and then inner edge to inner edge of the left atrium with this imaginary line.
Where the pulmonary veins come in, right? We just wanna connect this line here, that's our position. And you should get about a 1.4, 1.5 ratio normally, or less, right?
And we're gonna talk about that in a minute, OK? And learn to get efficiency clips, because in a situation where an animal is agitated or he's in respiratory distress, you just need to get a quick echo, you can get a nice 4 chamber to 5 chamber and short axis sweep in 3 seconds, right? So you can get all of these positions to do your measurements in one quick sweep.
Sweep. One quick efficiency sweat sweep. So, if you can learn to do that, it will really help you get where you get the full echo image set that you need.
And you won't, just to get that animal in the right direction and give you a good base of parameters to where you can go do your Doppler and other things that are more elaborate when the animal stabilises, right? . OK, so Doppler.
So earn the right to do the Doppler. Make sure your images are clean, good solid acoustic penetration, good blacks and whites, right? Anechoic flow, anechoic blood in the chambers, and nice hypeechoic lines of the endocardium, and the mitral valve.
The tricuspid valve, you want that nice disparity, right? When you have that nice clean image, then you've earned the right to, to use the Doppler. And the Doppler buttonology or knobology, that changes between the different machines, but you're going to have typically a colour flow.
A CW and a PW. So, colour flow first, PW second, CW3, on all the valves, OK? And then if you're looking at congenitals, you want to do that for the ventricular septum, in the short axis and long axis, you want to do that for the deep pulmonary artery, for, for your, your PDAs.
But colour flow first, you're gonna map it out, see where that regurg jet is going, and what that direction is, then you want to be in the position to make sure your PW or your spectral. Doppler is within 15 degrees state of that regurgitant flow, and in case of regurg cases, or in the case of your aortic outflow and your pulmonary outflow, you wanna be in line with that outflow, where the colour is going. So, you wanna localise it with the pulse, pulse wave, and then you quantify it with the CW.
So, CW is there for quantification. How high is that velocity, right? PW is to localise and See what, where the direction of the regurg is and the forward flow.
OK? So, PW to localise and it's gonna A-list about 2, 2.5 metres per second.
So anything that's audible, you're gonna need CW on it to quantify that velocity, right? So, colour flow first to map, PW to localise, CW to quantify. If you just do 1 button, 2-button, 3 buttons, once your probe is in the right position, then it's just knobology, keep the probe in that position, and then knob, knob, knob, right?
So, When we're doing that, right? You want to seek the highest, cleanest velocity, OK, of the envelope. Now, whether that's a mitral valve envelope, or a right ventricular outflow or pulmonic outflow, you want the highest, cleanest envelope that you have, OK?
First thing you want to do is you want to get the structure as close to the probe as you can, right? In, in, in different angles. And that, and for the mitral valve, for example, that's in the tilted brick, as opposed to flattened brick.
Now you're gonna tilt your brick, right? Now I bring in the probe towards the sternum, and we wanna get that mitral valve in a position where I can get this cursor within 15 degrees the of that regurgitant flow. And when I have that, if I'm, if my regurgitant flow is in line with my spectral Doppler cursor, then I'm going to get a clean envelope, and it's gonna be around 6 metres per second, or 5.8 metres per second, that makes sense, OK.
But if you get a flow that is 4, 4.5, you're offline, or your frequency is too high, or your machine doesn't have enough acoustic penetration. So you have to reassess your machine, right?
So these are some key self-check parameters. I take a picture, a screenshot of this, and have this ready to double-check yourself, right? Your left ventricular outflow, your aortic outflow can, should be between 1 and 2 metres per second.
Yours is gonna be like 1.3, 1.8.
Boxers can have 2.5 up to being normal, just because they're boxers and they're naturally stenotic. But this is not clinical, OK?
This is not subaortic stenosis. All right, now you get the 2.8 and 3, and then you start to enter in the category of eric stenosis, that isn't clinical.
We'll talk more about that in a minute. Your pulmonic outflow, 0.5 to 1.6, it's a slower flow, and therefore you should have numbers that make sense with that, right?
And you start getting stenotic lesions or hyperdynamic right ventricles, and, and like DR Doctor Vodo in cats, you're gonna get a higher velocity here, right? Your MR velocity needs to be over 5 metres per second. If it's over 6 metres per second.
And these are clean envelope velocities, right? If it's over 6 metres per second, consider systemic hypertension. So, if you're getting your, your, blood pressure readings are up in the 170s, 180s, and you have an MR velocity that's in 6 or higher, that makes sense, right?
We want our numbers to make sense. Now, when you're doing tricuspid velocities, according to the latest research, over 3.4 metres per second is pulmonary hypertension.
But that doesn't mean it is clinical pulmonary hypertension, a whole another thing, OK? Now, under 3.4 can be normal.
All right? So this has changed a little bit. It used to be 3 to 3.5, 3.5 to 4/4.
That's all changed now. You only have to remember 3.4, OK?
Now, typically, in my experience, your pulmonary hypertension is going to be clinical where they're, they're exercise intolerant or turning cyanotic. Because of pulmonary hypertension, that's typically gonna be up in the 4 metres per second or higher. However, when you have right-sided myocardial failure, that number starts to drop, but you have volume overload of the right atrium and the right ventricle, you have hepatic vein dilation, you have flattening of the ventricular septum, all those things that say, I'm failing on the right side, OK?
So, those are, those are some quick tips on it. But just make sure your envelope is clean. Clean, clean, clean envelopes.
OK, not mushy envelopes, all right? So make sure the numbers make sense, it's an aortic velocity of 136, that makes sense. Pulmonic velocity of about 90, that makes sense.
MR velocity of 5.5, that makes sense. Tricuspid velocity up in the 4 metres per second.
I better have significant right-sided changes, like right atrial dilation, right ventricular hypertrophy or over distension, flattening septum, those sort of things, dilated hepatic veins, all those things that make sure that my TR velocity makes sense, OK? OK, Doppler adjustments, right? So we want our colour flow sector to be in the mitral valve.
This is the apical position of the mitral valve. We want it to be about 1/3 before the valve, and then after the valve, it probably move the sector up a little bit more. But I want to catch the direction of that colour flow and the amount that is filling that left atrium with this colour.
Flow assessment. So, it's a centralised jet with mild filling of the left atrium, therefore, it's a centralised mild MR, OK? If it fills that left atrium completely, then that's severe MR.
So, you have mild, moderate, severe MR based on how much colour flow is filling that left atrium, right? And so, here, we have Weak signals, right? So if I have weak signals, that means that I'm not lined up correctly, or in this case, this gate is in the middle of the left atrium, right?
I want that right behind the closure of the mitral, because I'm in the middle of the left atrium, and the jet is going to the side here, the jet is going to the side there, then I'm going to get a A weak signal, which is not what I want, right? And plus I'm barely getting a signal here that's like 4 metres per second, sort of. I can't put that on paper.
That's not right. That's not physiologically possible. It has to be over 5 metres per second, because of the Bernoulli equation and left-sided, blood and left-sided pressures, OK?
So, Doppler double-check, OK? A lot of people underestimate Doppler. Assuming we have a clean B mode position, right?
The first thing we want to do is see where that flow is, OK? And the MR, take an MR, if it's an eccentric jet, an S step one tilted brick, then you can get your 15 degrees the in line, and then you're, you can get a clean Doppler envelope in solid, insufficiency velocities that makes sense, OK? Your colour flow, pulse, repetition, frequency of the PRF setting on your echo on your machine for your echoes should be around 80 to 90.
You can drop it down a little bit for cats, OK? But cats are always special, right? So they need a PRF of 70.
But typically for dogs, it's about 80 to 90. So make sure your presets are there. If your machine was set up properly by your distributor, this number should be there already for you, OK?
Doppler gate. Your colour flow, you want 1/3 before the valve, and the rest of the gate is in the atrium. So in the mitral valve, it's gonna be 1/3 to the left of the valve, the rest of it's gonna be in the left atrium.
Same thing for the tricuspid valve. When you're talking about the left ventricular outflow, you want 1/3 before the aortic valve, and the rest of it in the aorta, OK? And they're just as wide as the aorta.
Same thing with the pulmonary, pulmonary. Pulmonic valve or pulmonary artery, you want the gate just 1/3 before the pulmonic valve, and then 2/3 beyond the valve, the width of the, the pulmonary artery. And the reason is, is you want to close down that, that colour flow sector to just the minimal amount that you need, because that will give you cleaner images, it's concentrating the signal into that space to give you cleaner images, OK?
So, then, when you're looking for PDAs, you want the deep pulmonary artery right at the bifurcation, then that's where the PDAs live, and at the ventricular septum for VSDs, OK? Duplex Doppler. So, colour flow first, then spectral Doppler.
So, it's earn the right for the colour flow with a clean B mode, then once you have a clean colour flow, you earn the right for the spectral Doppler, the PW and then the CW. P pulse wave to identify. Continuous wave for the higher velocities and to quantify them, right?
And those are gonna be over 2 metres per second, right? If you have an A-listing spectral PW Doppler, you're gonna maximise your PRF. If that's not gonna be able to capture the signal, then you're gonna move to CW, all right?
Does the velocity make sense? If it doesn't lower your frequency. If that doesn't work, lower your probe frequency.
So, or lower the change, probes, so you have an even further lower frequency to be able to assess. If that doesn't help, then consider upgrading your machine because it doesn't have the acoustic power, no matter what you do with the probes, no matter how low your frequency, lower, how far you lower the frequency. It just doesn't have the signal, which comes with the hardware, and that's a whole another discussion.
I have a whole image optimisation talk that you can download at SonopPath.com, and that talks about how you optimise your general images, and it talks about what goes into making the signal, and why you need to have a solid machine to start that, right? So, it's all about, you're not gonna win a Ferrari race with a Fiat 500, it's just not gonna happen, no matter.
How good of a driver you are, right? OK, so this is your typical colour flow of the mitral valve and tricuspid. Our PRFs at 80 to 90 for dogs, 70 for cats, right?
And here's our colour flow sector, 1/3 to the left of the valve, 2/3 into the AA into the into the left atrium. Same thing with the tricuspid valve. This is where you want your sector.
So you can see the direction of flow, these are normal flows, blues and reds, no turbulence. Nothing to worry about, no murmurs here, at least nothing clinically significant. Now, this is a trivial MR.
You can see this little MR dropping in there. I'm gonna stop this here and run it on back. Red's normal.
Blues normal. And then you have this little tiny regurg jet in here somewhere, haven't gotten to it yet. It's just a flash.
There, OK. So, when you have a really low grade murmur, that's what you can have. Right there, OK?
And that's a centralised trivial MR. It's not really filling anything. You pick it up, you may hear it, you may not.
I wouldn't worry about it. It's not clinically significant, OK? So mitral valve Doppler or spectral Doppler, you usually do it in apical, but this one was done in, in five chamber, where you have an E wave and A wave.
The E-wave velocity normally is under 1. When you get into left-sided heart failure, it starts to get up into 1.3, 1.4, just another parameter we use to see if they're gonna fail or not.
But typically you want to do that in apical position, right? So here's what's wrong with this position. Here's an MR case, right?
Mushy envelope, don't want that. Mushy envelope, mushy envelope. OK.
So this is about 4 metres per second and mushy, doesn't make sense. The reason is, is we're offline because this You want to be within 15 degrees the of that regurg jet. If it's centralised, your S deposition one isn't gonna work, you gotta do it, take it in the apical, right?
If you, if you have a, an MR jet like this, that's coming through the, into the, Left atrial free wall, you may get it with this angle here that you're within 15 degrees theta. But why this spectral, when you get the spectral Doppler envelopes that are mushy like this, you're either offline with the regurgitant jet, right? So, you wanna get in line with that jet.
Here's a typical eccentric jet. I can drop the cursor right down here. I'm gonna be within 15 degrees theta, therefore, I should have a clean envelope, and it should be the velocity that I'm looking for.
Or I just moved to apical, like this. So this is the apical where we have A nice, solid jet that's completely filling the left atrium, and therefore, I, I have severe MR doesn't mean that that's, he has a left atrial enlargement, but he has severe MR. Therefore, I should have a nice solid envelope here around 5.56 metres per second.
This is a lesser envelope, I'm gonna ignore that. This is clean, this is clean, this is clean. I can take any of these three, OK?
So here, we have a position, an MR, this is just spectral, no colour on there, or the colour isn't showing up on this. But we have an envelope here on the MR that's 4.5 metres per second.
Let's say they're lined up correctly within 15 degrees theta. How do you change that to make it over 5 metres per second, or 5.5 metres per second, which is physiologically makes sense, right?
You have to lower the velocity or lower the frequency first on the probe. If that doesn't work, you change probes to a lower frequency. If you're still getting this kind of value, and it's not kicking up to 5.56 metres per second, which makes sense for an MR jet, then you need to change machines.
It's, it just is what it is. It's not a proper cardiac machine. Now, same thing here, what's going on, I got this regurgit jet coming through here.
This is a variance map, so it's gonna come out, the regurgitate, flow is gonna come out green, and I have a weak signal here. Same thing. Either I'm offline, but I look fairly online.
This, or I don't have a low enough frequency going on, or my machine is inadequate to be able to capture that velocity, right? This is the MR jet that should happen, right? So, 6.39, fairly clean envelope, not the best, one of these 31 of these two, I would.
This is a mushy offline envelope, so we don't wanna pay attention to these. This is what we're shooting for, right? And that number makes sense.
I'd be worried about systemic hypertension with that kind of velocity, right? So, check your alignment, check your position, check your frequency, keep lowering it to make sure that the velocity keeps increasing. And If that doesn't work, you're an acoustic power deficit, which means you may need to downgrade that machine to just a fast scanning machine or an abdomen machine and upgrade to a cardiac machine or a machine that does abdomen and cardiac.
Same thing here, we're in apical position. Am I offline? Am I low frequent if my frequency is too high, or my acoustic power is inadequate.
So, don't forget the VSD views, right? And you may come onto a VSD that's clinically the animal's been carrying around and not clinical for it. A small VSD may not be clinical, and this is where you catch them, catch them in 5 chamber long axis, your colour flow is 1/3 into the right ventricle, and then you can catch the aorta and maybe some, the mitral valve as well with it, and we see this crossover turbulence happening left to right.
There's your VSD. You put the spectral Doppler over the top of it, and you get a velocity that fits with, that should fit with systolic flow, or you can do it from the short axis as well. And some tricuspid Doppler.
OK. So this one, the sector's too wide. I would close it down a little bit, so I'm not wasting my signal.
Something more like this. And I wanna look at the direction of the jet. This one's septal, this one's central.
I need to get within 15 degrees stated there with my Spectral Doppler. So I'm gonna earn the right to use the spectral, and then I'm gonna be within 15 degrees theta. I'm gonna check my, my, my frequency to see if I can lower it enough to maximise that TR jet, and then maybe I'm gonna switch probes, and if that doesn't work, I need a new machine.
So TR velocities, again, if we're gonna talk pulmonary hypertension, 3.4 metres per second is what you need. You're gonna have typically septal flattening or right ventricular hypertrophy, like we have in this guy.
You're gonna map it out, that's a variance map, so the turbulence is green, it's fairly centralised. So I need to get my, get this in a position to where my cursor is gonna come down through that at 15 degrees. Data, and therefore, I'm gonna get a clean envelope with a pulmonary hypertension velocity that makes sense.
With a 4.89, which is approaching left-sided velocities, I would expect a lot of right-sided change. Right ventricular hypertrophy, septal flattening, right atrial enlargement, and, vena cava dilation, hepatic vein dilation, plus or minus ascites.
Make sure this number. Fits everything. If you're getting a velocity that's too high, what might be happening here is you get a summation effect, sometimes your angle is going into the left atrium here.
So you're actually measuring left-sided flows along with the right-sided flows. When that happens, you typically get a wave form that is kind of staggered in its echocture. So it kind of stops and then continues.
So make sure that you're not getting In the left-sided flow. This one's kind of going through, a little bit, to the side of the pulmonary artery here, and the left atrium is out of view from my sector here, right? So, I know that that is a clean envelope.
There's no double, double flow look to it. So I know that this is probably real, especially if I have all the other parameters that go with it. But just make sure that you have have a velocity that makes sense, and you have the structural changes that make sense.
You can get the TR Doppler from the heart-base view as well. Here's your Mercedes-Benz sign, your pulmonary artery, your right ventricle, your tricuspid, and I see that turbulence, so I'm gonna drop that cursor right at the valve gate closure in the middle. Of the turbulence right in that position.
I'm not gonna be over here, I'm not gonna be over here. I wanna be right here at the gate closure. I get clean envelopes.
I'm gonna get a velocity that makes sense. And if I have a right atrial enlargement like that, I would expect a high TR velocity, unless I have myocardial failure, right? So, when you have right-sided volume overload, remember on left-sided volume overload, you slide up towards the spine to flatten the brick.
When you have right-sided volume overload, you're gonna slide towards the sternum to flatten the brick, right? And so, that you have to adjust to the volume overloads to be able to flatten your brick. Here's the left atrium, mitral valve, left ventricle.
Flattening of the ventricular septum, volume overload of the right atrium, gonna have a high tricuspid insufficiency going on, it's gonna fill that left atrium. I would expect to see a lot of filling of that left atrium, otherwise, my, I have to go back to my frequency discussion that I had. I keep lowering the frequency until the numbers and the Doppler makes sense.
Now we go to the pulmonary artery here, you can take the pulmonary artery from short axis, or you can take it from S step position 2. Bottom line is you need a clean pipe from, to pass that signal through that right ventricle into that pulmonary artery, and you want to measure the outflow velocity just after the valve. And then get a clean envelope.
Again, 0.5 to 1.6 metres per second is typically normal.
You want to put the colour flow before the valve and after the valve, this is position two. You can see how clean that is, there's less in the way with a position two pulmonary artery view, that's why I like it so much. This is a short axis view, that's fine as well.
And then you get your pulmonary, pulmonic regurg here. You should get a regurg flow if the if the gate is before the valve, you're checking your regurgitate flow. After the valve, you're checking your outflow velocity.
Down the deep pulmonary artery at this bifurcation, this is where PDAs live, right? So same thing here. Colour flow over the PDA and map it out like this, right?
Here's the, here's the PDA right there. It's right at the bifurcation, and you put the colour flow over the, or the spectral Doppler over the top, and you're gonna get a whole systolic jet on CW. OK?
Now, apical position, flatten the probe, under the xiphoid, running through the liver, through the diaphragm, lower your frequency here, because you have a lot more territory to go through. But it gives you a nice, clean. Assessment of the left ventricular outflow and the mitral valve.
This is a centralised MR jet. Therefore, I'm gonna take my CW right here, right down the pipe, and because I wasn't able to, I wasn't gonna be able to get it at 15 degrees theta before, when I was in S step one position. So I'm in S step 4 in apical.
Same thing on this cat with HCM has this jet, this MR jet going on. Here in the left ventricular outflow. I'm gonna run my cursor right here.
I inspect a higher velocity on the left ventricular outflow. You want to make sure that your gate is after the valve to get the outflow velocity and before the valve to get the insufficiency jet. This is PW after the valve, this is CW after the valve, and make sure the numbers make sense.
We're just under 2 metres per second, and that makes sense. OK? Same thing here, same animal, different, different setting.
This is PW and this is CW 1.74, and this is 1.74 as well.
So, same values, just different settings. The, the PW gives you this PRF, that allows you to, be up in the 67 metres per second. OK.
And here's your regurgitant jet. If the gate is before the valve, You're gonna get a regurg jet, it should be over 5 metres per second. And then this jet doesn't mean anything if your gate is before the valve.
If it's after the valve, then your outflow velocity is valid, and this is subaortic stenosis case, it's over, over 3 metres per second anyway. But if I get an outflow velocity, that's 0.95.
And my gait is after the valve, there's something wrong here. So, in this case, I'm at 10 megahertz. I just need to lower the frequency, right?
In this case, I would lower the frequency to 6 megahertz and maybe I put on a low frequency probe to make sure my aortic velocity is up in the range that it should be in 1 to 2 metres per second. And I'm gonna try to maximise that. OK?
And here's your apical views, here's your MR jet that's a bit eccentric, but I can still get it from apical, nice clean envelope, and centralised jet. I gotta drop that spectral Doppler gate right behind the valve and get a nice clean envelope. So, just seek for clean envelope.
Now, this is a, to take a screenshot of this, and we're running out of time here, but take a screenshot of this. These are just good rules of thumb from Peter Modler on how to interpret your, volume, and volume overload and pressure overload of the heart. And these are mine as well.
These are quick tips all the way around on how to get a clean echo, print this out, put it next to your, put it, put it on a wall in front of your machine, make sure you're following these, and you will make a clean echo every time. Some quick outflow or some quick numbers to remember when you're talking about subaortic stenosis. So your left ventricular outflow velocity is too high, it's gonna be mild from 2.25 to 3.5, unless it's a boxer, they can have 2.5 and still be normal.
Moderate is 3.5 to 4.5 metres per second, severe, and this is where they start having clinical signs and extreme at 5.
0.5 metres per second. So from over 4.5 metres per second, with proper low frequency, correct 15 degrees state of lineup, and left ventricular hypertrophy, this sort of number makes sense.
And they start having clinical signs, like this, right? And you, and the sub- Erikson knows, you're almost, you're always gonna get an AI jet as well, you know, so make sure you get that, and this is what it's gonna look like on colour flow. Nice to and fro.
Pulmonic stenosis, outflow velocities are gonna be high, same numbers to remember. But remember, when you get to this area, you should see right ventricular hypertrophy because it's a pressure overload issue. So make sure your envelopes are clean, you lower your frequency to maximise those envelo.
Envelopes, you have a machine that is gonna drive the signal far enough to make sure you maximise those velocities. Because if you give it a lower than normal subnormal velocity, it says 4 metres per second, that's not when they're gonna typically intervene, right? With a balloon or surgery or what have you.
So, if you have, you don't lower the frequency and you find out that, oh no, that's 5 metres per second, that's treatable range. That's a crucial error, right? So always double-check your velocities with the lower frequency, and make sure your machine is powerful enough to do it.
And that's why cardiologists use expensive machines. Cardiologists are usually using machines in the 500 and higher range, or 40, 40, a good solid mobile 40K machine and higher, right? Because you don't wanna underestimate those velocities, especially if they're intervening, you know, they're, they're using 800,000 to $90,000 dollar machines that have all the power, they don't have to worry about it, right?
There's no power issue. But when you're doing echocardiograms with a lower power, you run into this issue of underestimating velocities and underestimating Doppler flows. And that's where you get stung, right?
Because you can, you can downplay the importance of a stenotic lesion, for example, or an MR lesion. So, valve disease classification, this is a Soopath protocol, that Peter and I came up with that kind of modifies a little bit from the consensus statement in 2019. So this is not verbatim from the consensus statement.
This is using the consensus statement as a point of reference based on new information. An Experience that Peter and I have run into over the last number of years, that go beyond this consensus statement. B1, B1 valvular disease, no left atrial enlargement.
We typically recheck in 6 to 12 months unless there's really bad valve morphology, like a prolapse, or if the murmur grade increases or clinical signs start, we're gonna recheck earlier. B2, you're gonna have mild left atrial enlargement, that's fair game for Pimal Bendon. This is all assuming that you've followed all of the recommendations here, and your measurements are appropriate, and they're, they're correct, right?
Always double-check your blood pressure, recheck in 6 to 9 months earlier if these scenarios are in play. B2+ is not in the consensus statement in 2019, but we're sure it's going to be in the next one. B2+, you have severe left atrial enlargement and left ventricular enlargement, but no wet lung yet.
So there's this whole, what is truly heart failure or not, and your E wave in the apical position is gonna be 1.5 metres per second or higher. That's B2+.
So that is, that you're gonna use yobbendin plus or minus Lasix. In the States, we tend to use ACE inhibitors more. There's a thought of a yobbendin spironolactone combination.
Anyway, something a little more than pobbendin would be valid for B2+. C valvular disease, C category is gonna be left-sided CHF. You have wet lung, even a little bit of wet lung, pimobendin, Lasix, plus or minus ACE inhibitor, plus or minus spironolactone.
Your survival time is about 14 to 17 months, depending on how they respond. And then if they're refractive to this, and your Lasix dose is over 8 mgs per kg per day, to control the CHF, then, then you're pulling out all the stops, torsemide, amlodipine, other, whatever else you can. You've pretty much used up everything.
This is not a good scenario. So, the, the, but these are nice categories to go along with. You can take a picture of this.
Again, this is derived from a basis of the 2019 statement adjusted by Doctor Peter Madler and myself. Oh, and, quick, this is a typical B1, atrial septum isn't deviated. This is a typical B2, where the atrial septum is deviated.
If I don't have wet lung, this might be a B2+. It's kind of B2+, B2, B2+. If I have wet lung, and I have all of this, this is a C1, and if this is a D1 that's starting to form pericardial effusion as well, and it's res not responsive to this category.
So these are examples that we'd see. On echocardiogram. So, special thanks also to Doctor Peter Modler, and my partner in crime here as far as playing around with hearts here at Sonopath, along with many of our, our talented cardiologists.
We have full cardiology services at Sonopath, for remote help, reading echocardiograms, radiographs, Holter monitors, EKG, Sonopath.com. We are here for you.
And, any questions at all, feel free to email, Info at Soopath.com. It'll get to me and be happy to answer any of your questions.
And, thanks for hanging out with me, and I'll leave you with a nice pretty PDA and don't forget about that second edition curbside guide. We're really proud of that. It's everything after the probe.
You find whatever pathology it is, even a tetrology flow to a pheochromocytoma. What do you do with it? What's the latest on it?
Lots of pretty pictures to show pathology and interactive QR codes. Where Peter and I go through cases by cases that are represented in each chapter, and a link also to the Sonopath archive. If you're a member of Sonopath.com, you can access our archive.
We have hundreds of thousands of cases in there for you to peruse. So, anyway, thank you so much for joining me today, and, we appreciate you. Come join the community, community at Sonopath.com if you haven't already.
We're here to support your excellence and foster your art of veterinary medicine. Have a great day.
