Echofacts

REVERBERATION – apical four-chamber view/2D

Highly echogenic pericardium leading to reverbations

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GAIN SETTINGS – PSAX/2D

Different gain settings in the same patient. Structures are missed when gain settings are too low (upper left). Delineation of different gray scales (tissue characteristics) is impaired when the gain is set to high (lower right).

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ARTEFACT IN PROSTHETIC VALVE – apical four-chamber view/2D

Shadowing and reverberations of the left atrium caused by a me- chanical mitral valve prosthesis.

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COLOR MAPS – PSAX/2D

Different 2D color maps for individualized 2D display.

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TISSUE DOPPLER – apical four-chamber view

Tissue Doppler color display of the heart during early systole. Red indicates myocardial motion towards the transducer.

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COLOR DOPPLER ALIASING– apical four-chamber view/ Color Doppler

Patient with mitral stenosis. The color Doppler of mitral valve inflow shows the typical pattern of a high velocity jet. Red color denotes the direction of flow towards the transducer. The sud- den change from yellow to blue depicts the region where aliasing occurs.

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SIMPSON METHOD – apical four-chamber view/2D

Tracing of the endocardial bor- der in end-diastole to quantify end-diastolic volume (LVEDV). For biplane quantification, be sure that the length of the ventricle matches on the four- and two-chamber view.

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ECHOFEATURES OF DILATED CARDIOMYOPATHY – apical four-chamber view/ Color Doppler

Dilated left ventricle with reduced left ventricular function, mitral regurgitation with a central jet caused by annular dilatation.

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TAKOTSUBO CARDIOMYOPATHY – apical four-chamber view/2D

A typical feature of Takotsubo cardiomyopathy is apical bal- looning. The basal segments tend to be hyperdynamic.

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LV NON-COMPACTION – apical four-chamber view/2D

The apical portion of the left ventricle is strongly trabeculated and appears spongy. Look care- fully and visualize all portions of the myocardium to find hyper- trabe culated areas. Use contrast and color Doppler when in doubt.

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OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY –apical four-chamber view/Color Doppler

Turbulent flow in the LVOT caused by systolic anterior mo- tion of the MV. Distortion of the MV leads to regurgitation with a posteriorly directed jet. Flow acceleration is also present in the mid-ventricular portion (addi- tional mid-ventricular obstruc- tion).

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APICAL HYPERTROPHIC CARDIOMYOPATHY – apical four-chamber view/2D

Pronounced hypertrophy of the apex with a spade-shaped ventricular cavity. Atrial enlarge- ment is also a common feature of hypertrophic cardiomyopathy.

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SYSTOLIC ANTERIOR MOTION OF THE MV – apical three-cham- ber view/2D

Dynamic left ventricular out- flow tract (LVOT) obstruction is caused by anterior motion of the mitral valve during systole.

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AMYLOIDOSIS – apical four-chamber view/2D

Typical features of amyloidosis, including echogenic/hourglass appearance of the myocardium, thickened valves, and enlarged atria. This patient also received a pacemaker.

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SARCOIDOSIS – apical four-chamber view/2D

Abnormal cardiac geometry with segmental wall motion abnormal- ities, thickening, and increased echogenicity in the region of the mid- and distal anterior septum.

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FABRY’S DISEASE – apical four-chamber view/2D

Pronounced bi-ventricular hy- pertrophy and rather speckled appearance of the myocardium.

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INFERIOR WALL ANEURYSM – apical two-chamber view/2D

Inferior myocardial infarction leading to distortion of ventric- ular geometry (aneurysm) and regional wall thinning in the basal and mid inferior segments.

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APICAL ANEURYSM – apical four-chamber view/2D

Very large apical aneurysm after anterior myocardial infarction. The apical region is dilated and dys-/akinetic.

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ISCHEMIC VENTRICULAR SEPUTM DEFECT (VSD) – apical four-chamber view

Rupture of the interventricular septum is visible on the 2D image (left). Turbulent flow across the defect is seen with color Doppler (right).

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PAPILLARY MUSCLE RUPTURE – apical four-chamber view/2D

The head of the papillary muscle is detached from its body and swings freely between the left ventricle and the atrium attached to the mitral valve.

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APICAL THROMBUS – zoomed apical four-chamber view/2D

The thrombus has a slightly different echogenicity than the myocardium. Older thrombi ap- pear more echodense.

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TRICUSPID AORTIC VALVE – zoomed PSAX AV

Calcified aortic valve with re- duced opening (aortic valve area= AVA) in a patient with severe aortic stenose.

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BICUSPUD AORTIC VALVE – zoomed PSAX AV

Calcified bicuspid aortic valve with severe stenosis. Only 2 cusps are visible. It may be difficult to determine whether a valve is bicuspid when it is heavily calcified.

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LVOT DIAMETER – PLAX/2D

The LVOT diameter is measured on a parasternal long-axis view, closely below the aortic valve. It is advisable to slightly over- measure the LVOT diameter and thus compensate the oval shape of the LVOT.

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SUBVALVULAR AORTIC STENOSIS – PLAX/2D

A muscular ridge with a mem- brane causing obstruction is seen in the LVOT. In some patients you will need to scan through the entire LVOT to detect the membrane.

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TRANSCATHETER AORTIC VALVE – PLAX/2D

The steel frame and the bovine pericardial tissue leaflets of an Edwards-Sapien valve are visible in the aortic annulus.

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RETROGRADE FLOW IN AR – suprasternal view/Color Doppler

Severe retrograde flow during diastole. The red color Doppler signal denotes flow towards the transducer from the descending aorta towards the the arch. Color Doppler may be used to guide positioning of the PW Doppler spectrum.

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VENA CONTRACTA – apical three-chamber view

Severe aortic regurgitation with a large flow convergence zone, a vena contracta >6 mm, and a jet width of 70% of the LVOT.

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MITRAL STENOSIS – PLAX/2D

Typical features of mitral ste- nosis: Doming of the anterior leaflet, thickening of leaflet tips, thickened aortic valve (aortic valve involvement), and enlarged left atrium.

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THROMBUS IN MITRAL STENOSIS – PLAX/2D

Severe mitral stenosis with large left atrial thrombus (partly shadowed by the calcified aortic valve).

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MITRAL VALVE PLANIMETRY – PSAX MV/2D

The mitral valve was investigated at the tip of the leaflets, where the mitral valve opening is smallest. The image is frozen in diastole at the time when mitral valve opening is largest. Tracing may be difficult when the valve is calcified.

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BALLOONVALVULOPLASTY IN MITRAL STENOSIS – TEE long-axis view

The balloon is positioned within the mitral valve and expanded to enlarge the mitral valve orifice.

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QUANTIFICATION OF MITRAL REGURGITATION – Apical four-chamber view/ Color Doppler

Typical color Doppler features of mitral regurgitation with a prominent flow convergence zone (PISA), a vena contracta ≥ 7mm, and a jet area > 40% of LA area.

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PMVL PROLAPS – Apical four- chamber view / 2D

Severe prolapse of the posterior mitral valve leaflet (medial scal- lop – P2). The valve is thickened (myxomatous) and the left atri- um/ventricle are enlarged.

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PMVL PROLAPSE – Apical four- chamber view / Color Doppler

The jet direction is typically anterior and medial (towards the interatrial septum).

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PMVL FLAIL – Apical four- chamber view / 2D

Flail posterior leaflet; the pos- terior leaflet protrudes behind the anterior leaflet into the left atrium. Small chordal structures are seen attached to the tip of the posterior leaflet.

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PMVL FLAIL – Apical four- chamber view / Color Doppler

Chordal ruputure of the posteri- or leaflet directs the jet towards the interatrial septal and anterior (seen best on an apical long-axis view).

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RESTRICTED PMVL – Apical three-chamber view/ 2D

Inferior infarction and change of LV geometry restricts the motion of the PMVL. The leaflet is drawn towards the apex. This results in incomplete closure of the mitral valve.

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RESTRICTED PMVL – Apical three-chamber view/ Color Doppler

The jet in restricted posterior leaflet motion is typically direc ted posteriorly. It aligns with the position of the posterior leaflet.

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AMVL Perforation – apical four-chamber view/2D

The anterior leaflet is thickened and destroyed. A small gap can be seen in the anterior leaflet. This patient has a perforated mitral valve after endocarditis.

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AMVL PERFORATION – apical four-chamber view/color Doppler.

The color jet clearly traverses the basal anterior leaflet through the perforation. The most frequent site of perforation is the anterior leaflet.

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MITRAL VALVE PROLAPSE – TEE 3D surgical view

A myxomatous mitral valve with a prolapse of the posterior leaflet (P3/P2). Chordal rupture is also present. 3D may be helpful in localizing a prolapse or defect.

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PARALLEL SIGN – zoomed apical four-chamber view/2D

The ruptured leaflet always extends behind the non-ruptured leaflet to which it frequently lies parallel (as seen in the example with a ruptured AMVL). This sign may be helpful in cases of subtle chordal rupture.

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MITRACLIP – TEE 3D surgical view

3D echo is used to monitor the MitraClip procedure. A central clip was placed, resulting in two incongruent mitral valve orifices.

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EBSTEIN’S ANOMALY – apical four-chamber view/2D

Ebstein’s anomaly is character- ized by elongated leaflets and displacement of the tricuspid valve. This leads to partial atrial- ization of the right ventricle.

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SEVERE TRICUSPID REGURGITA- TION – apical four-chamber view RV optimized/color Doppler

Tricuspid regurgitation with a large flow convergence zone and a wide vena contracta. The right ventricle and atrium are severely dilated (volume overload).

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FEATURES OF SEVERE TR – PSAX/2D

D-shaped ventricle with a flattened interventricular septum, both in systole and diastole – in severe TR and pulmonary hypertension.

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BIOLOGICAL MITRAL VALVE – apical four-chamber view/2D

The struts (2 of 3 visible) protrude into the left ventricle. The tissue component of the valve cusps are seen between the struts.

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FLOW PATTERN IN MECHANICAL VALVE PROSTHESIS – zoomed apical five-chamber view

Typical flow pattern of a mecha nical bileaflet aortic prosthesis. The regurtitant jets originate within the frame of the prosthesis (central) and the jet direction is ”V-shaped”.

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MECHANICAL MITRAL VALVE – apical four-chamber view/2D

The two mechanical leaflets are almost parallel during diastole. The prosthesis causes shadowing of the left atrium.

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PROSTHETIC VALVE ENDOCAR- DITIS – TEE short-axis view/2D

Staphylococcal infection of the valve, resulting in paravalvular abscess. Infectious material and echo-free cavities suround the prosthesis. Always look for partial dehiscence and paravalvular regurgitation.

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THROMBUS OF MITRAL PROS- THESIS – TEE/2D

Mechanical obstruction of a bileaflet prosthesis caused by thrombus. Thrombi are difficult to see with transthoracic echo. They are usually located at the atrial side of the prosthesis, which is shadowed in the trans- thoracic exam.

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PARAVAVULAR LEAK – TEE/3D surgical view

Paravavular leak in a patient with a bileaflet mechanical mitral valve.

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MITRAL VALVE REPAIR – apical four-chamber view/2D

Artifical chords and annuloplasty ring after mitral valve repair.

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TRICUSPID VALVE ENDOCARDITIS – apical four- chamber view RV optimized/2D

Endocarditis with a large vegetation attached to the native tricuspid valve.

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MITRAL VALVE ENDOCARDITIS – PLAX zoomed/2D

A vegetation is attached to the tip of the anterior mitral valve leaflet.

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MITRAL VALVE ENDOCARDITIS – TEE surgical view/3D

Large vegetation on the posterior leaflet prolapsing into the left atrium.

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PSEUDOANEURYSM IN AV ENDOCARDITIS – TEE long-axis view/2D

A pulsating cavity surounds the aortic valve (pseudoaneurysm). Numerous vegetations are pre- sent at the aortic cusps.

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PERIANNULAR PROSTHETIC VALVE ABSCESS – TEE short- axis/2D

The echodense area surounding the prosthesis corresponds to a periannular abscess. Additionally, a large vegetation is seen on the rim of the cusps.

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CENTRAL LINE ENDOCARDITIS – apical four-chamber view/2D &TEE bicaval view/2D

Central line with its tip in the right atrium. Mobile vegeta- tion attached to the catheter (thickened tip) on transthoracic echo (this) and the adjacent wall (bottom) seen in TEE.

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CENTRAL LINE ENDOCARDITIS – apical four-chamber view/2D &TEE bicaval view/2D

Central line with its tip in the right atrium. Mobile vegeta- tion attached to the catheter (thickened tip) on transthoracic echo (top) and the adjacent wall (this) seen in TEE.

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LIBMAN-SACKS ENDOCARDITIS – apical three-chamber view/2D

Patient with lupus and antiphos- pholipid syndrome. Several small vegetations are seen on the mitral valve.

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DILATED INFERIOR VENA CAVA – subcostal IVC view/2D

Severely dilated inferior vena cava without respiratory fluctu- ations in diameter and dilated hepatic veins in a patient with pulmonary hypertension. These findings suggest right atrial pres- sures > 20 mmHg.

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ECHO FINDINGS IN PULMONARY HYPERTENSION – PSAX/2D

Echo features of severe pulmo- nary hypertension: D-shaped left ventricle with a flattened interventricular septum in systo- le, a dilated right ventricle, right ventricular hypertrophy, and peri- cardial effusion.

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CARCINOID HEART DISEASE – apical four-chamber view RV optimized/2D

Restricted motion/position of the tricuspid leaflets, leaving a wide coaptation defect. The leaflets are thickened (from the base) and rigid. The endocardium is bright. These findings are high- ly indicative of carcinoid heart disease.

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VISUALIZATION OF THE ASCENDING AORTA – modified PLAX/2D

The more cranial portions of the ascending aorta can be better vi- sualized by moving the transduc- er up one intercostal space and more laterally.

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ANEURYSM OF THE ASCENDING AORTA – PLAX/2D

Patient with bicuspid valve, aortic stenosis and aneurysm of the aortic root and the ascending aorta. There is no narrowing at the sinotubular junction.

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DISSECTION OF THE ASCENDING AORTA – PLAX/2D

Highly mobile intimal flap in the ascending aorta, denoting aortic dissection. This flap is almost cir- cumferential and thus visualized both anteriorly and posteriorly.

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AORTIC COARCTATION – suprasternal view/Color and CW Doppler

Turbulent flow in the descending aorta (left) denotes the location of coarctation. The Doppler spectrum (right) shows a systolic and diastolic gradient (>4 m/s), suggesting severe coarctation.

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PERICARDIAL EFFUSION – subcostal four-chamber view/2D

Large circumferential pericardial effusion with fibrin strands. The image loop shows swinging heart motion.

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EPICARDIAL FAT – subcostal four-chamber view/2D

A patient with a small pericardial effusion and pronounced epicar- dial fat. Epicardial fat is promi- nent in the AV groove and absent in the region of the right atrium.

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SEQUENTIAL IMAGES OF PERI- CARDIAL EFFUSION – PSAX/2D

Changes in the size of a peri- cardial effusion can be best appreciated by recording similar images and displaying them in split-screen format. The effusion in this patient clearly diminishes over time.

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PERICARDIAL CYST – apical four- chamber view/2D

Incidental finding of a large peri- cardial cyst located in the right cardiophrenic angle.

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EUSTACHIAN VALVE – zoomed apical four-chamber view/2D

Very prominent and long Eusta- chiian valve in the right atrium. The Eustachian valve typically arises from the inferior vena cava.

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LIPOMATOUS INTERATRIAL SEPTUM – TEE bicaval view/2D

A lipomatous interatrial septum is best seen with TEE. The fossa ovalis is typically spared, resulting in a ”dumbbell”.

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ABBERANT CHORD – apical four- chamber view/2D

Abberant chord that traverses the left ventricle from the septum to the lateral wall.

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THROMBUS IN LEFT ATRIAL APPENDAGE/atypical api- cal four-/two-chamber view/2D

This rare example shows that it may be possible to detect left atrial appendage thrombi with transthoracic echo, especially when using atypical views.

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MYXOMA – zoomed apical four- chamber view/2D

A typical myxoma originating from the interatrial septum. Its surface is rather smooth, it has a very short stalk and is homogeneous. Myxomas may be much larger, filiform, and more inhomogeneous.

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FIBROELASTOMA (AORTIC VALVE) – apical three-chamber view/2D

Small mass on the ventricular aspect of the aortic valve, which was histologically proven to be a fibroelastoma. Fibroelastomas may also appear as pedunculated or berry-like structures.

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MALIGNANT MASS (RHABDOMYOSARCOMA) – atypical apical four-chamber view/2D

Tumor masses in the left atrium. The structure of the tumor is inhomogeneous and it is causing inflow obstruction into the left ventricle.

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COMPLETE ATRIOVENTRICULAR CANAL DEFECT – apical four- chamber view/2D

Improperly formed atrioventricu- lar valve (shared atrioventricular valve). Both an ASD (primum type) and a VSD are present.

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SECUNDUM ATRIAL SEPTAL DEFECT – slanted apical four- chamber view/color Doppler

Moving the transducer medially allows more parallel alignment to the Doppler and therefore better visualization of the ASD jet.

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ASD OCCLUDER – subcostal four-chamber view/2D

The left and the right atrial disks of an Amplatzer occluder are visible. The interatrial septum is captured in between.

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PATENT FORAMEN OVALE – TEE bicaval view/2D

Separation between the primum and the secundum septum form- ing a patent foramen ovale (PFO). The primum septum overlaps the secundum septum and the PFO is a channel rather than a hole.

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PERIMEMBRANOUS VENTRIC- ULAR SEPTAL DEFECT – PSAX/ color Doppler

Typical jet origin and direction of a perimembranous VSD. The defect is located below the aortic valve. The jet is directed more towards right ventricular inflow.

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PATENT DUCTUS ARTERIOSUS – PSAX/Color Doppler

Shunt (color jet) between the aorta and the pulmonary artery at its bifurcation. The jet is present during systole as well as diastole.

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TETRALOGY OF FALLOT – PLAX/2D

A patient with a tetralogy of Fallot, a large VSD and an overriding aorta.

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L-TGA – Apical four-chamber view/2D

Since the tricuspid valve and the mitral valve are in opposite positions, the valve on the left side of the screen is more apical (lower in the screen) than the valve on the right. This is one of the key features that help to identify L-TGA. The right ventricle is in the position of the left ventricle. It can be identified because it is heavily trabeculated.

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L-TGA – Atypical long-axis view, subpulmonic ventricle/2D

The subpulmonic ventricle, which is anatomically the left ventricle, ensures pulmonary circulation.

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STRESS REACTION – PSAX Quad view/2D

Quad view comparing four different levels of dobutamine stress from baseline (left upper corner) to 40 mcg/kg/min (right lower corner). The global contractility of the left ventricle is increased (see moving image).

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VIABILITY TESTING – Apical four-chamber view/2D & PW Doppler

Patient with akinesia of the septum (top left) with low LVOT velocity at rest (top right), There is no change in the contractility of the septum during dobutamine stress (bottom left). The segment is not viable. The residual myo- cardium increases its contrac- tility (non-ischemic). This is also reflected by the increase in LVOT velocity (bottom right).

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3D RECONSTRUCTION– short-axis views/3D

Live 3D Reconstruction of short-axis views for the analy- sis of contractility during stress echocardiography (see moving image)

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CONTRAST IN PFO – TEE bicaval view/2D & contrast

Large PFO and hypermobile interatrial septum; the separation between the primum and secundum septum is visible in 2D (left side). Pronounced contrast opacification of the left atrium occurs after the injection of oxypolygelatine (right side).

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CONTRAST IN PFO – TEE bicaval view/2D & contrast

Large PFO and hypermobile interatrial septum; the separation between the primum and secundum septum is visible in 2D (left side). Pronounced contrast opacification of the left atrium occurs after the injection of oxypolygelatine (right side).

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COLOR DOPPLER in PFO – slant- ed apical four-chamber view/ color Doppler

A small jet (PFO) is passing through the interatrial septum

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POSITIVE TRANSTHORACIC CONTRAST STUDY – apical four-chamber view/2D contrast

Positive contrast study with Oxypolygelatine (Gelifusin®) used as contrast agent. A small “cloud” of contrast enters the left atrium via the interatrial septum.

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PERIMEMBRANOUS VENTRIC- ULAR SEPTAL DEFECT – PSAX/ color Doppler

Typical jet origin and direction of a perimembranous VSD. The defect is located below the aortic valve. The jet is directed more towards right ventricular inflow.

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PERSISTENT LEFT SUPERIOR VENA CAVA – apical four-chamber view/2D & contrast

Patient with a dilated coronary sinus (bottom); contrast (Oxypolygelatine - Gelifusin®) injected via a left cubital vein demonstrates contrasting of the right atrium via the coronary sinus, suggestive of a persistent left superior vena cava.

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IMPROVEMENT OF IMAGE QUALITY USING CONTRAST – apical four-chamber view/2D & contrast

Difficult assessment of global and regional left ventricular function in a patient with very poor image quality (this). The contrast study greatly improves image quality (bottom).

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IMPROVEMENT OF IMAGE QUALITY USING CONTRAST – apical four-chamber view/2D & contrast

Difficult assessment of global and regional left ventricular function in a patient with very poor image quality (top). The contrast study greatly improves image quality (this).

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CONTRAST AND WALL MOTION – apical four-chamber view/2D & contrast

Contrast study to assess regional wall motion. Akinesia of the anteroseptal region is clearly visible with contrast

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CONTRAST AND WALL MOTION – apical four-chamber view/2D & contrast

Contrast study to assess regional wall motion. Akinesia of the anteroseptal region is clearly visible with contrast

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3D CONTRAST STUDY – apical multiplane image acquisition/3D

Contrast study with multiplane 3D, four- (upper left) two- (up- per right) and three-chamber views (lower left). The lower right image shows the corresponding cut planes.

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CONTRAST AND APICAL THROM- BUS – apical four-chamber view/2D & contrast

Patient with suspected apical thrombus (left). Contrast injec- tion demonstrates a filling defect at the apex of the left ventricle, denoting a thrombus (right).

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CONTRAST AND SEPTAL ABLATION – apical four-chamber view/coronary contrast.

A contrast agent (Optison) is in- jected into the first septal branch of the LAD during an alcohol septal ablation procedure, result- ing in opacification of the basal septum.

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SURFACE AND VOLUME REN- DERING – apical four-chamber view/3D

Combination of left ventricular surface and volume rendering with segmental analysis (com- parison of two regional volumes). The curves in the right lower quadrant represent the regional volume curves during the cardiac cycle. The bull’s eye shows the selected segments (mid lateral segment= green, mid septal seg- ment= orange) in the left lower quadrant.

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MULTIPLANAR REPRESENTATION – apical views/3D

Simultaneous display of four- (upper right), two- (upper left), and three-chamber views (lower left). The right lower corner shows the corresponding cut planes.

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3D COLOR DOPPLER – apical full-volume acquisition/3D

The color jet is seen in various cut planes, including a short-axis view (left lower corner), and additionally visualized in 3D (right lower corner).

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THROMBUS IN THE RIGHT UPPER PULMONARY VEIN – cropped image/3D TEE

Patient after lung transplantation. Cropped image techniques were used to cut away the left atrium and permit visualization of the right upper pulmonary vein, in which a highly mobile thrombus is seen.

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APICAL THROMBUS – apical multiplanar image acquisi- tion/3D TTE

3D echocardiography showing a highly mobile apical thrombus.

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LEFT ATRIAL APPENDAGE OC- CLUDER – 3D TEE

An Amplatzer Cardio Plug System is deployed in the left atrial appendage.

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ENDOCARDIAL SURFACE RENDERING – apical full volume acquisition/3D

Surface rendering is performed in accordance with semi-automated endocardial tracing on apical and short-axis views. The resulting volume (bag) is seen in the right lower corner.

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TIMING OF CONTRACTION – apical full-volume acquisition/3D

Timing of contraction in a normal patient. All segments reach their lowest volume (end systole) at (almost) the same time.

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3D RIGHT VENTRICULAR VOL- UMES – apical RV full-volume acquisition/3D

Regional volumes are divided into outlet (yellow), inlet (green) and apical (red) parts, which allows regional volume computations (curves in the right lower corner)

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3D RECONSTRUCTION OF THE MITRAL VALVE – apical full-volume acquisition/3D

The mitral valve is viewed from the left ventricle.

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3D MITRAL VALVE PROLAPSE – 3D TEE

Visualization of mitral valve prolapse in the medial posterior leaflet (P2) using 3D TEE.

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LEFT ATRIAL MASSES – 3D TEE

Two large masses originating from the left atrial appendage, which extend towards the mitral valve.

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FUSION IMAGING – CT and 3D echocardiography

Fusion of cardiac CT data (showing coronary arteries) with a left ventricular Beutel generated by 3D echo. The LV “Beutel“ shows the area of latest contraction in a color coded way (red is the area of late contraction).

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TISSUE VELOCITY TRACINGS – apical four-chamber view/TDI

Color tissue Doppler imaging of a normal patient with velocity tracings of the basal septal and basal lateral segments

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GLOBAL LEFT VENTRICULAR LONGITUDINAL STRAIN – apical views/2D STE

Global left ventricular longitudinal strain is calculated using two-, three-, and four-chamber views. Bull’s eye representation (lower right corner) shows normal longitudinal contraction, indicated in red.

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SUBENDOCARDIAL TRACKING – apical four-chamber view/STE

Selective quantification of longitudinal strain of the subendocardial (inner) layers of the myocardium.

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CIRCUMFERENTIAL STRAIN – PSAX apical/2D STE

Circumferential strain of the apical part of the left ventricle in a normal patient. Peak systolic segmental circumferential strain values are shown in the lower left corner.

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RADIAL STRAIN – PSAX mid-ventricle/2D STE

Radial strain of the apical part of the left ventricle in a normal patient. Peak segmental radial strain values are shown in the lower left corner.

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RIGHT VENTRICULAR LONGI- TUDINAL STRAIN – optimized four-chamber view/2D STE

Longitudinal strain of the right ventricle in a normal patient with a mean longitudinal strain of -24.8%. Peak systolic longitudinal strain values are shown in the lower left corner.

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APICAL HYPERTROPHIC CARDIOMYOPATHY – apical views/2D STE

Typical strain pattern in a patient with apical hypertrophic cardiomyopathy. Strain is reduced at the apex in the region of hypertrophy.

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AMYLOIDOSIS – apical views/ 2D STE

Typical longitudinal strain pattern in a patient with amyloidosis. Longitudinal strain is preserved at the apex and severely reduced in (most of) the mid and basal segments.

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