Enddiastole

Interventricular septum

Septal leaflets-TRICUSPID VALVE \ Anterior leaflets

LV apex

^ Endocardial border m

Interatrial septum \ I (drop out)

Right superior-^ pulmonary vein

LV free wall

Anterior leaflet / MITRAL VALVE ^ Posterior leaflet lateral annulus MITRAL VALVE medial annulus

^^Left superior pulmonary vein

Fig. 33. Annotated apical four-chamber view (A4C).

Septal leaflet (TV)

Coarse trabecu-lations with -Septo-marginal Moderator bj^nd

Pulmonary Vein Confluence Chamber

Morphoioc Right Ventricle

Anterior leaflet (mitral valve)

_, Smoother apical

Cardiac Crux trabeculations showing leaflet^. insertion levels ?- ' Papillary muscle

Morphologic Left Ventricle

Fig. 34. Defining morphological left and right ventricles on two-dimensional (2D) echocardiography (A4C). The confluence of the interventricular and interatrial septa and the septal insertions of the tricuspid and mitral valve leaflets constitute the internal cardiac crux (cross). The normal cross-like configuration on 2D echocardiography is not symmetrical. The septal leaflet of the tricuspid valve is inserted more apically, i.e., toward the cardiac apex. This relationship becomes important in evaluating certain congenital heart lesions, e.g., atrioventricular canal defects. Another distinguishing echocardiographic feature of the morphological right ventricle is its coarser trabeculated endocardial surface (including the moderator band), the presence of a tricuspid valve, and the absence of two distinct papillary muscles. These characteristics are important in segmental sequential analysis of congenital heart disease. (See companion DVD.)

Echocardiography Images

Fig. 35. Apical four-chamber view (A4C). Zooming on (reduce depth) the left ventricle (A) provides better definition of the left ventricular endocardium and apex. Further improved definition can be achieved by use of a higher frequency transducer and/or contrast agent. Diastolic A4C frame with superimposed color flow Doppler (B) shows flow extending from the right and left upper pulmonary veins through the mitral valve toward the left ventricle. Pulmonary vein flow (C) is phasic, with normal systolic (S) and diastolic (D) peaks (D). This pattern varies with age and disease states, e.g., diastolic heart failure and restrictive cardiomyopathy. (See companion DVD.)

Fig. 35. Apical four-chamber view (A4C). Zooming on (reduce depth) the left ventricle (A) provides better definition of the left ventricular endocardium and apex. Further improved definition can be achieved by use of a higher frequency transducer and/or contrast agent. Diastolic A4C frame with superimposed color flow Doppler (B) shows flow extending from the right and left upper pulmonary veins through the mitral valve toward the left ventricle. Pulmonary vein flow (C) is phasic, with normal systolic (S) and diastolic (D) peaks (D). This pattern varies with age and disease states, e.g., diastolic heart failure and restrictive cardiomyopathy. (See companion DVD.)

Echocardiography Images

Fig. 36. Apical four-chamber view (A4C). Pulsed Doppler evaluation of normal mitral inflow shows early rapid filling (E) velocities and lower A velocities owing to atrial contraction (A). The normal E:a ratio is >1. Loss of A velocities is seen in atrial fibrillation. Clear identification of mitral annulus (B) is necessary for optimal tissue Doppler imaging (TDI or DTI). Mitral annular movement assessed on TDI normally shows three waveforms (C,D): systolic velocities toward the apex (Sm) and diastolic velocities (Em and Am) away from the apex. These lower velocities normally exceed 8-10 cm/s. The lateral annulus is the preferred site. (A,B, see companion DVD.)

Fig. 36. Apical four-chamber view (A4C). Pulsed Doppler evaluation of normal mitral inflow shows early rapid filling (E) velocities and lower A velocities owing to atrial contraction (A). The normal E:a ratio is >1. Loss of A velocities is seen in atrial fibrillation. Clear identification of mitral annulus (B) is necessary for optimal tissue Doppler imaging (TDI or DTI). Mitral annular movement assessed on TDI normally shows three waveforms (C,D): systolic velocities toward the apex (Sm) and diastolic velocities (Em and Am) away from the apex. These lower velocities normally exceed 8-10 cm/s. The lateral annulus is the preferred site. (A,B, see companion DVD.)

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