TEE - views

The sequence of the following views is based on the position of the transesophageal echocardiography (TEE) probe in the esophagus and/or stomach. The course of the examination depends on the specific clinical questions and will be influenced by the patient tolerance. The views shown here should only serve as orientation, since anatomy and anatomic relationships may differ from patient to patient, an on the other hand, omniplane transesophageal examination allows all possible views between 0 and 180.

Upper position - view of the great vessels, 0: the ascending aorta (Ao), the main pulmonary artery (MPA) and the right pulmo- nary artery (RPA) can be displayed.

Upper position - view of the aortic valve and the pulmona- ry artery, 40-50: the aortic valve (AV), the main pulmonary artery (MPA), the right ventricular outflow tract (RVOT) and the left atrium (LA) can be displayed.

Upper position - view of the aortic valve, 40-50: the aortic valve (AV), the left atrial appendage (LAA) and the left atrium (LA) can be displayed.

Mid-position views, 0: the left (LV) and the right ventricle (RV), as well as the left (LA) and right atrium (RA) can be displayed. This view is similar to the four-chamber view in TTE. It is possible to get a two-chamber view (60) and three-chamber view (120) from this position.

Mid-position views, 90 left: the left ventricle (LV), the left atrium (LA), the left atrial appendage (LAA) and the left upper pulmonary vein (LUPV) can be displayed.

Mid-position views, 90 right: the left (LA) and right atrium (RA), as well as the right atrial appendage (RAA), the superior vena cava (VCS), the right pulmonary artery (RPA), the interatrial septum and the inferior vena cava (VCI) can be displayed.

Mid-position views, 90 further right: the left atrium (LA), the right upper pulmonary vein (RUPV) and the right pulmonary artery (RPA) can be displayed.

Mid-position views, 120: the ascending aorta (Ao), the left atrium (LA), the left ventricular outflow tract (LVOT) and part of the right ventricular outflow tract (RVOT) can be displayed.

Transgastric view - short axis, 0: the left (LV) and the right ventricle (RV), as well as the liver can be displayed.

Transgastric view - long axis, 90: the left ventricle (LV) and the mitral valve apparatus (*) can be displayed.

Dorsal view - during pullback, 0: the descending aorta (AD) can be displayed.

Exit view, 0: last view before TEE probe pullback is completed. At the upper part of the ascending aorta turn the probe to the right, to display the aortic arch (AB) completely.

Transthoracic examination
[Standard measurements] [Normal values]

Two-dimensional views

Parasternal long axis: place the transducer on the 3rd intercostal space left parasternal. The trans- ducer's index mark is directed towards the patient's right shoulder. The right (RV) and the left ventricle (LV), as well as the aortic bulb (Ao) and the left atrium (LA) can be displayed.

Parasternal short axis (papil- lary muscle level): turn the transducer 90 clockwise from the previous position. The left ventri- cle (LV) at the level of the papil- lary muscles and the right ventricle (RV) can be displayed.

Parasternal short axis (mitral valve level): tilt transducer a little from the same position down to the right. A cross section of the left ventricle (LV) at the level of the mitral valve and the right ventricle (RV) can be displayed.

Parasternal short axis (aortic valve level): tilt transducer a little more from the same position down to the right. The aortic valve (AV), the pulmonary valve (PV), the left atrium (LA) and the right atrium (RA), as well as the tricuspid valve (TV) and the right ventricular outflow track (RVOT) can be displayed.

Apical four-chamber view: place transducer on the 5th inter- costal space, aprox. left midclavi- cular. The transducer's index mark is directed towards the patient's left side. The left (LV) and the right ventricle (RV), as well as the left (LA) and the right atrium (RA) can be displayed.

Apical two-chamber view: turn the transducer aprox. 60 counterclockwise from the previous position. The left ventricle (LV) and the left atrium (LA) can be displayed.

Apical three-chamber view: turn the transducer further, aprox. 60 counter-clockwise from the previous position and side tilt slightly. The left ventricle (LV), the left atrium (LA) and the aortic bulb (Ao) can be displayed.

Apical five-chamber view: show a four-chamber view and then tilt the transducer slightly down. The aortic valve (AV) can be seen in the middle, between chambers. Tilting the transducer to the opposite direction, the coronary sinus can be displayed.

Subcostal view: place the transducer on the subxyphoid region. The transducer's index mark is directed towards the patient's head. The inferior vena cava (VCI) can be displayed. Turn the transducer clockwise slightly to diplay the right and left ventricle, as well as the right (RA) and left atrium.

Suprasternal view: place the transducer on the suprasternal region. The transducer's index mark is directed towards the patient's head and turned aprox. 45 to the right. The aortic arch (*), the neck arteries (TB, CL, SL) and the right pulmonary artery (RPA) as well as the left atrium (LA) can be displayed.

[overview]

Standard measurements - parasternal view

(1)

Aortic bulb

(2) Left atrium (3) Interventricular septum (4) LV-EDD (end diastolic diameter, LV) (5) Posterior wall (6) LV-ESD (end systolic diameter, LV)
Measurements must always be done perpendicular to the main axis of a vessel, a chamber or atria. The aortic bulb should be measured at the beginning, the left atrium at the end of the ventricular systole. Perpendicular "cuts" from the parasternal view in adults are often not possible, short axis can be taken instead for a better orientation. A global impression from all views is necessary in order to avoid under- or overestimation of dimensions. Therefore, traditional measurements with M-Mode from parasternal can not be recommended anymore.
[overview]

Normal values
Diameters Aortic bulb Asce aorta Aortic arch Descendinaorta Left atrium Right atrium Right ventricle Inferior vena cava Interventricular septum Posterior wall Lelft ventricle - end diastolic Left ventricle - end systolic < 40 mm < 40 mm < 30 mm < 20 mm < 40 mm < 35 mm < 30 mm < 20 mm 6-10 mm 6-10 mm 40-55 mm variable

Doppler velocities Aortic valve Mitral valve Pulmonary valve Tricuspid valve 1.35 (1.0 - 1.7) m/s 0.90 (0.6 - 1.3) m/s 0.75 (0.6 - 0.9) m/s 0.50 (0.3 - 0.7) m/s

The American Society of Echocardiography has published new recommendations for chamber quantification. This document can be downloaded directly from the ASE: Recommendations for Chamber Quantification, 2005.

Prosthetic valves - normal values Velocities depend not only from the diameter and type of the prosthesis, but also from the degree of hyperdynamia (pregnant women, hyperthyoidism, anemia), significant prosthetic valve regurgitation, and the "too-small-to-fit" phenomenon, caused by too small prosthetic valves for the native anatomic architecture.

Maximal velocity (Vmax) in m/s, peak pressure gradient (PPG) and mean pressure gradient (MPG) in mmHg. AVP = prosthetic aortic valve, MVP = prosthetic mitral valve.

Stress echocardiography
[Dobutamine SE] [Dipyridamole SE]

Echocardiographic examinations under dynamic or pharmacological stress are conducted with strict, and continuous monitoring and documentation of systemic arterial pressures and ECG. Image documentation and archiving are carried out by means of digital softwares, which allow a posterior evaluation of the examination in quad screen format. Standard protocols are used for the different stress modalities.

Dynamic stress echocardiogram

Pharmacological stress echocardiogram: Dobutamine

Pharmacological stress echocardiogram: Dipyridamole

Cardiac asynchrony

The different electromechanical delays are measured from QRS start to contraction start,but some times they will be measured in a time-to-peak manner (QRS to maximal velocity), in cases of difficult TDI profiles. Excellent reviews on cardiac asynchrony (dyssynchrony) and resynchronisation therapy were published recently in the Journal of the American Society of Echocardiography.

Assessment of RV and LV delays: (using TDI, RV-free wall, LV septal basal, LV lateral basal, LV posterior basal) Intraventricular asynchrony: LVsep - LVlat or LVsept - LVpost > 55 ms Interventricular asynchrony: RVfw - LVsep > 70 ms or RVfw - LVlat > 55ms Summ of asynchrony: LVas + RVas > 100 ms Assessment of PET: (pre-ejection time, PW-Doppler, RVOT and LVOT) Intraventricular asynchrony: LVpet > 140 ms Interventricular asynchrony: RVpet - LVpet > 40 ms

CRT optimization: Definite echocardiographic parameters for DRT optimization are still not available. VTI assessment at the level of the LVOT, right underneath the aortic valve e.g., can give hints to acute changes in left ventricular function, that may happen during manipulations in AV- and/or LV-RV-Delays and help in the decision to optimal CRT setting.

Strain Strain rate

Strain: myocardial deformation (strain) can be assessed with this tool. It can be obtained based on Tissue Doppler Imaging (TDI) or on bidimensional images (speckle tracking). TDI allows better time definition and can be also used in case of poor echocardiographic windows. Analyses from bidimensional images allow assessment of radial and circumferencial strain, the latter needed to calculate ventricular torsion. Normal values of longitudinal LV deformation are between - 20 to - 25 %. Strain rate: rate of myocardial deformation in time. Units are expressed in number/second or %/second. Diastolic myocardial deformation can be assessed more clearly in this way. Normal values of longitudinal LV deformation are 1 - 1.5/s or higher. Here an extensive tutorial on this topic by Dr. Asbjrn Stylen - NTNU Trondheim, Norway.

Normal strain: values of myo- cardial deformation at systole lie here around - 25 % on the lateral segments of the left ventricle. Color encoded dynamic bidimen- sional image helps to visualize strain, red stands here for - 20 %.

Pathological strain: values of myocardial deformation at systole lie here around - 7 %, being consequently very reduced. This case is a proven myocardial invol- vement in systemic amyloidosis.

Normal strain rate: values of diastolic myocardial deformation in this normal heart lie between 1.3 and 1.7/s.

Pathological strain rate: this former amyloidosis case shows also a severe impairment of longitudinal diastolic myocardial deformation, with values around 0.6/

Indications for echocardiographic examination

[Transesophageal examination] [Stress echocardiography]

Transthoracic echocardiography is an examination with not known side effects, has a widespread availability, represents a low-cost high-effective approach and can be used in a large variety of clinical questions. However, even if the possibility of becoming a wide range screening method exists, echocardiography examinations should be rationalized to meet criteria of incremental clinical value. The following lists of indications are based in recent publications regarding appropriateness and clinical application of echocardiography, as well as appropriateness criteria for stress echocardiography. Indications displayed below represent only class I indications, i.e. conditions for which there is evidence and/or general agreement that a given procedure is useful and effective. Newest publications classify these indications as grouped in score 7 to 9, i.e. appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication). Only some indications grouped under score 9 are listed below. For extensive content please refer to: Douglas PS et al. J Am Coll Cardiol 2007;50:187204 and Douglas PS et al. Circulation 2008;117:1478-1497. These guidelines provide an estimate of the reasonableness of the use of echocardiography in different settings. However, clinical judgment will still be playing the most important role in determining whether to order an specific imaging modality for an individual patient. New Appropriate Use Criteria for Echocardiography (PDF) published ahead for 2011.

Indications for transthoracic examination (selected main indications)

Symptoms potentially due to suspected cardiac etiology. Assessment of known or suspected adult congenital heart disease. Evaluation of suspected complication of myocardial ischemia/infarction. Initial evaluation of murmur in patients for whom there is a reasonable suspicion of valvular or structural heart disease. Initial evaluation of prosthetic valve for establishment of baseline after placement. Initial evaluation of suspected infective endocarditis with positive blood cultures or a new murmur. Evaluation of cardiac mass (suspected tumor or thrombus). Evaluation of pericardial conditions: i.e. pericardial effusion, constrictive pericarditis. Known or suspected Marfan disease for evaluation of proximal aortic root and/or mitral valve. Initial evaluation of known or suspected cardiomyopathy.

Indications for transesophageal examination

Evaluation of suspected acute aortic pathology including dissection/transsection. To determine mechanism of regurgitation and determine suitability of valve repair. To diagnose/manage endocarditis with a moderate or high pre-test probability (e.g., bacteremia, especially staph bacteremia or fungemia). Persistent fever in patient with intracardiac device. Evaluation of patient with atrial fibrillation/flutter to facilitate clinical decision-making with regards to anticoagulation and/or cardioversion and/or radiofrequency ablation.

Indications for stress echocardiographic examination (some score 8 indications also included here)

Initial evaluation of chest pain syndrome or anginal equivalent Intermediate pre-test probability of CAD, ECG uninterpretable OR unable to exercise.

Worsening symptoms: abnormal catheterization OR abnormal prior stress imaging study Re-evaluation of medically managed patients.

Chest pain syndrome or anginal equivalent, prior test result Coronary artery stenosis of unclear significance (cardiac catheterization or CT angiography).

Preoperative evaluation for noncardiac surgery, high-risk nonemergent surgery Poor exercise tolerance (< 4 METs, < 75 Watts at bicycle exercise).

Risk assessment post-revascularization (PCI or CABG), symptomatic Evaluation of chest pain syndrome, not in the early post-procedure period.

Ischemic cardiomyopathy, assessment of viability/ischemia Known CAD on catheterization, patient eligible for revascularization.

Valvular stenosis Evaluation of equivocal aortic stenosis, evidence of low cardiac output, use of dobutamine.

Use of contrast with stress echo Selective use of contrast, 2 or more contiguous segments are NOT seen on noncontrast images.
Training in echocardiography

The following section is short summary from the report: American College of Cardiology/American Heart Association Clinical Competence Statement on Echocardiography, Quiones MA et al. Circulation 2003;107:1068-1089. For extense depiction of cognitive and technical skills required for competence in TEE, stress echo, as well as documentation and maintenance of competence in each of those examination modalities, please refer to this unique publication.

Basic requirements for competence in echocardiography Knowledge of physical principles of echocardiographic image formation and blood flow velocity measurements. Knowledge of instrument settings required to obtain an optimal image. Knowledge of normal cardiac anatomy. Knowledge of pathologic changes in cardiac anatomy due to acquired and congenital heart disease. Knowledge of fluid dynamics of normal blood flow. Knowledge of pathological changes in blood flow due to acquired heart disease and congenital heart disease.

Requierements for competence in adult transthoracic echocardiography Basic knowledge outlined in above. Knowledge of appropriate indications for echocardiography. Knowledge of the differential diagnostic problem in each case and the echocardiographic techniques required to investigate these possibilities. Knowledge of appropriate transducer manipulation. Knowledge of cardiac auscultation and electrocardiography for correlation with results of the echocardiogram. Ability to distinguish an adequate from an inadequate echocardiographic examination.

 Knowledge of appropriate semi-quantitative and quantitative measurement techniques and ability to distinguish adequate from inadequate quantitation. Ability to communicate results of the examination to the patient, medical record, and other physicians. Knowledge of alternatives to echocardiography.

Training requirements for performance and interpretation of adult transthoracic echocardiography

Systolic LV function
[Regional wall motion] [18 segment model] [Examples]

Assessment and description of left ventricular function comprises usually its systolic or diastolic, global or regional aspects. Myocardial function during the whole cardiac cycle is more complex, due to myocardial architecture. Radial left ventricular function predominates certainly, but longitudinal and torsional function also play a role. Global strain (e.g. 2D-strain), as well as other parameters, can give an insight in the longitudinal left ventricular function. Radial LV function can be assessed with the methods presented below.

Qualitative assessment of systolic LV function multiple cross-sectional views endocardial movement and myocardial thinckening Assessment: "descriptive" normal mild impairment moderate impairment severe impairment | | | | | Ejection fraction, %* 55 % 45 - 54 % 30 - 44 % < 30 %

*Current reference limits after the new recommendations of American Society of Echocardiography (ASE), 2005.

Quantitative assessment of systolic LV function Calculation of left ventricular ejection fraction, LV-EF Formula: [(EDV - ESV) / EDV] x 100 = EF (%) Assessment of LV volumina with the method of discs (modified Simpson's rule, biplane)

Regional wall motion assessment

18-segment model: left ventricular wall segments There are several models to depict left ventricular wall segments, and correspondingly, some confusion. The 16-segment model, suggested by the American Society of Echocardiography in 1989 has proven its practicability in clinical work. Three-chamber view, used regularly in echocardiography examinations in Europe since decades introduced two more apical segments: anteroseptal apical and posterior apical. In American models, apical segments remained only 4: apical anterior, apical lateral, apical inferior and apical septal. A new model was recently proposed, in order to equalize standards in echocardiographic, thallium-scintigraphy, NMR and PET examinations. The document can be downloaded directly from the ASE: Recommendations for Chamber Quantification, 2005.

Typical distribution of coronary perfusion and the new 17-segment model from the ASE shown here as an overlay to the old model onMouseover (enable JavaScript in your browser).

Examples of wall motion abnormalities Left: normokinesia of all wall segments in four-chamber view. Notice the slight lesser movement of septal compared to lateral segments. This is a physiological phenomenon. Right: lateral hypokinesia. A light increase of wall thinkness during systole can still be seen. Notice the clear septal hyperdynamia as a compensatory reaction.

Left: inferior basal akynesia, inferior medial hypokinesia in the two-chamber view. Notice the absence of myocardial thickening in the akinetic segment. Right: dyskinesia of the LV apex. Notice die excentric movement of the corresponding LV segments during the systole.

Diastolic LV function

[Mitral annular velocities] [Pulmonary veins] [Vp] [Parameters to assess diastolic LV function] [Algorithm]
A prerequisite to assessment of diastolic LV function is the capability of the method to measure pressures, and Doppler echocardiography is only able to measure velocities. Only through application of formulas, as the modified Bernoulli equation (V 4 = P) it is possible to estimate pressure gradients. Different alternative possibilities to assess diastolic LV function were developed in the last decades. However, these tools made diagnosis of global diastolic LV dysfunction not always easy and clear. Sometimes different parameters just do not match to each other, or can not be correctly interpreted in case of atrial fibrillation or flutter. A new equation enables non-invasive assessment of PCWP, the Nagueh-Formula: 1,9 + (1,24 E/E') = PCWP, that could make estimation of diastolic function in some way easier, since PCPW mLAP LVEDP. Here an online calculator from the Canadian Society of Echocardiography, to calculate PCWP. Classic parameters are still in current use and will be presented below. Current guidelines of the American Society of Echocardiography concerning diastolic function can be found here.

Mitral inflow velocities examination Pulsed wave Doppler (PW-Doppler) allows the measurement of velocities at the level of the sample volume. Two flow velocity envelopes can be seen during diastole in persons with sinus rhythm: the E-wave, representing the early, passive filling of the left ventricle, and the A-wave, that happens late in diastole, representing the active filling, the atrial contraction.

Left: PW-Doppler sample volume is placed at the tips of the mitral valve in the left ventricle. Right: normal mitral velocities, inflow coming from the left atrium in the left ventricle during diastole, shown here with color Doppler.

Left: pulsed wave (PW) Doppler spectral display shows an E-wave with higher velocities, as well as an enddiatolic A-wave with lower velocities. Right: an A-wave twice as large as the E-wave indicates impaired LV relaxation.
[overview]

Mitral annular velocities examination

Slow wall velocities can be assessed with Tissue Doppler Imaging (TDI). The sample volume, when placed at the medial mitral annulus, shows slower velocities as when placed at the lateral annulus. The E/E' relationship will be different according to each case, making more difficult the interpretation of results.

Left: PW-TDI sample volume is place at the level of the lateral mitral annulus. Right: normal LV wall velocities during cardiac cycle, here a color coded display.

Left: spectral tissue Doppler (TDI) display shows an antegrade sys- tolic, and two retrograde waves, E' (passive LV filling) and A'-wave (atrial contraction). Right: E' and A' waves show here a reversed relationship. In com- bination with other parameters this could indicate an impairment of relaxation or a pseudonormal pattern.

[overview]

Pulmonary venous flow examination

Pulmonary venous flow velocities can be assessed with PW-Doppler. Localization of pulmonary veins with color Doppler is relatively easy, and allows to place sample volume at the right position. Usefulness of the examination of pulmonary venous for estimation of left atrial pressure was shown by Kuecherer H et al. Circulation 1990;82:1127-1139.

Left: pulmonary venous flow can be assessed with PW-Doppler from the apical four-chamber view. Right: normal pulmonary vein velocities into the left atrium during cardiac cycle, here shown with color Doppler.

Left: PW Doppler spectral display shows a larger systolic (S), a diastolic (D) and a smaller end- diastolic wave (AR), the atrial contraction. Right: the shift towards diastole, with a predominant diastolic wave (D) speak for an increase of LA pressure. This can be documented in a case of impairment of LV compliance (restrictive pattern).
[overview]

Velocity of flow progression (Vp)

Velocity of flow progression (Vp) during diastole can be assessed with color Doppler M-mode. A Vp > 50 cm/s can be considered as normal. A E/Vp 2.5 in a patient with impaired systolic left ventricular can predict a PCWP > 15 mmHg. Left: a narrow color Doppler sector is placed between mitral valve and LV apex. The M-mode examination line is place through the center of the LV entrance flow. Right: here a normal case. The Nyquist-limit should be reduced if no spontaneous aliasing is ob- served. The first aliasing velocity front should be measured.

Left: higher velocities at the A- wave can be seen at impairment of LV relaxation, even without changing the Nyquist-limit. Right: here an example of a restrictive pattern. The Vp is 27 cm/s and hence clearly under the limit of 45 cm/s.

[overview]

Echocardiographic parameters to assess diastolic LV function The concept of Rosetta Stone for diastole was presented first by Rick A. Nishimura und A. Jamil Tajik, J Am Coll Cardiol 1997;30:8-18. It is very important to understand, that the diagnosis of diastolic LV dysfunction can not be made with one parameter alone. A patient with dyspnea, preserved systolic LV function, dilated left atrium and elevated pulmonary artery systolic pressure, without any significant mitral valve disease that could explain these findings, is the patient that requires an intensified search for diastolic LV dysfunction.

I: impaired relaxation, II: moderate diastolic dysfunction (pseudonormal), III: restrictive left ventricular filling (impaired LV compliance), ECG: electrocardiogram, MI: mitral inflow, MA: mitral annular velocities, PVF: pulmonary venous flow, Vp: velocity of flow progression, LA: left atrium, PASP: pulmonary artery systolic pressure. A very good dynamic presentation of diastolic LV dysfunction ca be found here: Dr. Guido Giordano - Catania, Italia.
[overview]

Algorithm for practical assessment of diastolic LV function

NYHA: New York Heart Association classification to stages of heart failure, LV-EF: left ventricular ejection fraction, E/E': relationship between maximal values of passive mitral inflow (E, PW-Doppler) and lateral early diastolic mitral annular velocities (E', TDI), LV-EDP: end-diastolic LV pressure, PASP: pulmonary artery systolic pressure.

Longitudinal ventricular function [Quantitative assessment] [Torsional function] Leonardo da Vinci described as early as 1478, that contracting hearts showed a movement from the base to the apex during each cardiac systole. Ventricular torsion was first described by William Harvey in 1628. Recently, a new dissection technique developed by Francisco Torrent Guasp and published in 1980, could show the complexity of myocardial architecture, explaining all types of cardiac movement during the heart function.

The picture left shows a very simplified scheme of the helical ventricular myocardial band. To the right, a superposition with the apical four-chamber view. (1) band insertion at the pulmonary artery, (2) free RV wall, (3) basal loop, (4) apical loop and (5) insertion at the aorta. From this architectonic structure of the heart can be perceived, that the right ventricle will have a predominantly longitudinal and torsional, and the left ventricle a preponderant radial function.

Quantitative assessment of longitudinal venticular function Longitudinal LV function can be quantitatively assessed with different methods. The degree of movement of the atrioventricular plane can be determined with M-mode, its velocity with tissue Doppler imaging (TDI). Longitudinal deformation examined with strain/strain rate can be also very helpful. The following values reflect the lower normal limits of longitudinal LV and RV function:

MAPSE (mitral annular plane systolic excursion) MASV (mitral annular systolic velocity) LV-LSS (left venticular longitudinal systolic strain)

1 cm 10 cm/s 20 %

TAPSE (tricuspid annular plane systolic excursion) TASV (tricuspid annular systolic velocity) RV-LSS (right ventricular longitudinal systolic strain)

2 cm 20 cm/s 30 %

Obtained values can be influenced by at least 4 factors: age, angulation of examination beam (M-mode, TDI), respiration and method-dependent (PW-TDI versus color TDI, the latter shows significant lower values). Studies that define normal values in larger populations are still lacking.

Left: MAPSE is assessed with M-mode in apical four-chamber view, placing the examination beam on the lateral mitral annulus. Right: measurement take place from the end of diastole, until maximal expansion in systole.

Left: pulsed TDI sample volume is placed on the lateral mitral annulus to assess systolic velocities. Possible oscillation due to respiration, as well as by MAPSE, should also be avoided here. Right: here an example of TDI velocities of mitral annulus, with a important wave of isovolumetric contraction. This wave should not be taken for the systolic wave.

Torsional ventricular function

Torsional ventricular LV function can be calculated with the formula: LVtor (degree/cm) = (apical LV rotation basal LV rotation)/longitudinal diastolic LV dimension. Normal value = 3/cm; it shows no variation with age (Kim HK et al. J Am Soc Echocardiogr 2007;20:45-53).

Left: a counterclockwise rotation of the apex and a clockwise rotation of the base can be determined in normal physiology. Right: assessment of ventricular rotation is not easy, especially at the ventricular base. It can be conducted with B-mode strain, as in this example.

RV function

[Parameters] [Algorithm] [3D volumetry] The assessment of the right ventricle (RV) is in a continuos state of "work in progress". Parameters, values and algorithm presented here may be interpreted differently in the future. Due to complex RV morphology, a quantitative assessment of systolic RV function is not possible with established methods, since a required cylindrical form is not available. Therefore, systolic RV function is assessed only qualitatively. A regional or global RV dilatation must be documented, as well as the diameter and respiratory behavior of the inferior vena cava. It is not known if available parameters to assess diastolic LV function would have the same value when assessing diastolic RV function. However, other have found its place, e.g. parameters for assessment of global function (Tei-index) or longitudinal systolic function (TAPSE, TASV, RV-strain). A review can be found at Advances in Pulmonary Hypertension. First Guidelines for the Echocardiographic Assessment of the Right Heart in Adults (PDF) published in 2010.

Parameters for quantitative assessment: TAPSE, TASV, Tei-Index, Lei Following values can provide support in the diagnosis of a right ventricular dysfunction:

TAPSE (tricuspid annular plane systolic excursion) TASV (tricuspid annular systolic velocity) Tei-Index (myocardial performance index) Lei (LV eccentricity index)

< 2 cm < 20 cm/s > 0,50 >1

The assessment of RV function starts with the measurement of RV dimentions and the qualitative evaluation of its function. Left: the right ventricle appears normal in size and systolic function. Notice the smaller RV surface compared to the LV (aprox. 1:2 to 1:3). Right: massive dilated RV with severely reduced systolic function.

Left: TAPSE can be assessed with M-mode, measuring the distance of tricuspid annular movement between end-diastole to end- systole. Right: the velocity of this move- ment can be measured with TDI.

Left: color encoded tissue Doppler imaging (TDI). Right: Tei-index, also known as "myocardial performance index" (MPI) can be assessed with PWDoppler in RVOT and RV inflow, and also with TDI, with the formula (a-b)/b.

Left: ventricular interdependence can be clearly recognize here. The LV is impaired in its function through a significant septal inden- tation. Right: eccentricity index (Lei), systolic and diastolic, is an im- portant parameter that can be determined with the formula: Lei = D1/D2. Normal value = 1.

Algorithm for assessment of RV function

This proposition for estimation of right ventricular function begins with the assessment of RV morphology. It is very important to examine and document the RV from all its 9 different echocardiographic views. Be careful: the RV appears larger than normal when examined too medially, or projections with apical foreshortening. Other aspects that must be taken into account when assessing RV function are: physiology of the inferior vena cava, pulmonary pressures, severe tricuspid regurgitation, impaired left ventricular function, suspicion of atrial shunt.

Assessment of RV function with 3D-echo

RV function can accurately be assessed with three-dimensional echocardiography. Requirements are: a matrix-array ultrasound probe and a current software for offline analysis of 3D data. Here some examples of examinations with 2D and 3D echocardiography. Abbreviations: EDV, end-diastolic volumen; ESV, end-systolic volumen; EF, ejection fraction. Left: dilated RV with 3D volu- metry, here seen from the front. Red represents the apex, green the inflow and yellow the outflow track. Right: the same RV, here seen from behind. Grey surfaces repre- sent tricuspid and

pulmonary valves.

Left: here the 2D examination of the same case, from the apical four-chamber view. Qualitative assessment show a severe impairment of RV function. Right: here the quantitative results of 3D volumetry.

Left: the RV only mildly dilated and its function is slightly im- paired, here seen from the front. Right: same case seen from behind.

Left: 2D examination of the same case, from the apica four-chamber view. Qualitative assessment show a mildly impaired RV function. Right: quantitative results of 3D volumetry confirm the qualitative estimation of RV function.

Assessment of pulmonary artery pressure (PA-pressure)

The systolic PA-pressure (PASP) is an indicator of cardiac hemodynamic status and can be quiet

accurately non-invasively assessed with echocardiography. There are several pitfalls that may produce over- and underestimation. The PASP at rest is also an independent predictor of prognosis and an indicator for elevated left ventricular filling pressures [Lam CS et al. 2009]. During exercise, and already at low stages (through 125 Watt), it can raise over 40 mmHg in 10 % of healthy persons under the age of 60 years. In 30 % of healthy family members with genetic predisposition to pulmonary arterial hypertension (I/FPAH), it can also rise over 40 mmHg at the same conditions [Grnig E et al. 2009]. Following animations show pathophysiological aspects of PA-pressure behavior.

Assessment of PA-pressure is an important part of a correctly and comprehensive conducted echocardiographic examination. Assessment of pulmonary artery systolic pressure (PASP) can be carried out by measuring maximal tricuspid regurgitation velocity, and applying the modified Bernoulli equation to convert this value into pressure values. Estimated right atrial pressure (RAP) must be added to this obtained value. Mean (PAMP) and diastolic PA-pressures (PADP) can be estimated by assessment of the pulmonary regurgitation.

Systolic PA-pressure (PASP) PASP = tricuspid regurgitation gradient + RApressure (RAP) PASP = (Vmax x 4) + RAP Normal values: rest up to 30 mmHg, during exercise up to 40 mmHg.

Mean PA-pressure (PAMP) PAMP = pulmonary regurgitation gradient (M) Normal values: rest up to 25 mmHg, during exercise up to 30 mmHg. Diastolic PA-pressure (PADP) PADP = pulmonary regurgitation gradient (D) + RAP

Left: estimated RA-pressure is up to 5 mmHg, when inferior vena cava collapses completely in ins- piration. Right: estimated RA-pressure can be 10, 20, 30 mmHg in case of absence of inferior vena cava collapse or presence of a severe tricuspid regurgitation. Tricuspid velocities are slower in this case, comparison to PAMP can be help- ful.

Valvular heart disease [Mitral valve stenosis] [Valvular regurgitation] The EAE/ASE have published new recommendations for the evaluation of valvular stenosis. The document (PDF) can be downloaded directly from the ASE: Echocardiographic assessment of valve stenosis, 2009.

Aortic valve stenosis 1. ACC/AHA 1998 guidelines for grading an aortic valve stenosis

* information not available (Bonow et al. Circulation 1998;98:1949-1984) PPG = peak pressure gradient, MPG = mean pressure gradient

2. Continuity equation: standard method to calculate valvular opening area. Systolic velocities in left ventricular outflow track (LVOT) and on the aortic valve, as well as LVOT area must be assessed.

A2 = aortic stenosis area, V2 = aortic stenosis velocity time integral (VTI, obtained with CW-Doppler), A1 = LVOT area and V1 = LVOT VTI (obtained with PW-Doppler). Calculation of the continuity equation can be usually made in every echomachine, but in case this is not possible, hier an online calculator of the Canadian Society of Echocardiography.
Left: assessment of valvular morphology ist the first step to a correct diagnosis of valvular heart disease. Here a cross sectional view of the aortic valve from the parasternal short axis view. Right: the aortic valve is thickened, calcified and with severely reduced leaflet separa- tion, as seen from the apical five-chamber view.

Left: color Doppler helps to CW-Doppler beam positioning. Pin hole stenoses are very difficult to examine, fact that can lead to important underestimation of velocities. Right: maximal velocities from 4.5 m/s or above (peak pressure gradient aprox. 80 mmHg) can be considered as a thumb rule for severe aortic stenosis.

[overview]

Mitral valve stenosis

Correct assessment of the pressure half time (PHT) is decisive for calculating mitral valvular opening area, correspondingly its stenosis degree. This can be difficult in case of atrial fibrillation, since Doppler profile inclination varies with the duration of diastole.

Left: a dilated left atrium is a common occurrence to a signi- ficant mitral stenosis. Right: the degree of thickness, calcification and movement limitation of the whole mitral valve apparatus are important parame- ters for decision to a percutaneous valvuloplasty (Wilkins-Score, online calculator from the Canadian Society of Echocardiography).

Left: a concurrent mitral valve regurgitation must be included in the evaluation before valvulo- plasty. Right: different values of PHT can be obtained in case of atrial fibrillation, according to diastole length. It is importante to find a mean value, that correlate to measured values of transmitral gradients.

Valvular regurgitation
1. Overview

All valvular regurgitations have three components: PISA (proximal isovelocity surface area), vena contracta and regurgitation jet. PISA can be spontaneously seen when regurgitation is already significant. Vena contracta plays a more important role for assessment of degree of regurgitation than regurgitation jet.

A vena contracta with an area larger than 50 % of LVOT, with a regurgitation jet deceleration >3 m/s and a diastolic retrograde flow in the descendant aorta can be consistent with the diagnosis of a severe aortic regurgitation.

A wide vena contracta with a v-shaped regurgitation jet (CW-Doppler), PISA and systolic retrograde flow into the pulmonary veins can be consistent with the diagnosis of a severe mitral regurgitation. A TEE examination to exclude e.g. partial ruptured chordae tendineae can be necessary in this case, especially in presence of an eccentric mitral regurgitation. A retrograde flow into the hepatic veins together with the afore mentioned parameters lead to the diagnosis of a severe tricuspid regurgitation. 2. Parameters for quantitative assessment: EROA, regurgitation volumen, regurgitation fraction New "high-end" echomachines simplify the assessment of the effective regurgitation orifice area (EROA), regurgitation volume and fraction. Assessment of EROA can be carried out with the continuity equation, where A1 (PISA area), V1 (PISA Nyquist-limit) and V2 (regurgitation VTI) are the known variables, and A2 (EROA) the variable to be calculated. EROA = (PISA area x PISA Nyquist-limit) / regurgitation VTI Regurgitation volume = SVreg - SVnorm
SVreg: Stroke volume measured at the regurgitating valve SVnorm: Stroke volume measured at a valve without regurgitation

Regurgitation fraction = Regurgitation volume / SVreg

SV (Stroke volume) = CSA (cross sectional area, valve annulus) x VTI

3. Aortic valve regurgitation

4. Mitral valve regurgitation

Calculations with the PISA method can usually be made directly in the echomachine, alternatively here an online calculator from the Canadian Society of Echocardiography. Excentric regurgitations may produce inaccurate results. A complete description of all criteria for the assessment of valvular regurgitation can be downloaded from the American Society of Echocardiography: Recommendations for Evaluation of the Severity of Native Valvular Regurgitation, 2003.
Left: color Doppler settings must be correctly adjusted for the PISA method. The Nyquist-limit should be placed around 50-60 cm/s. Right: afterwards, base line should be shifted in the direction of the regurgitation jet, until a welldefined hemisphere appears.

Left: to calculate VTI of regurgi- tation jet, CWDoppler profile area should be delineated. Right: by measuring PISA radius it is important to hit correctly the limit ot the hemisphere. Small errors can produce important variations.

Left: furthermore, it is very im- portant to define the cause of the valvular regurgitation. Here a TEE examination of partial ruptured chordae tendineae of the posterior mitral leaflet. Right: a severe, excentric mitral regurgitation can be verified with color Doppler.

Intracardiac masses
[Tumors] [Other intracardiac masses]

Thrombi
Two examples of thrombi in the left atrial appendix (LAA) seen at a TEE examination. Left: this thrombus has a wide attachment in the LAA, but also an extreme mobile part, that prolapses in part as far as the mitral valve. Right: large wall-adherent throm- bus in LAA.

Two examples of thrombi in the left atrium at the TEE examination. Left: a large, in part wall-adherent thrombus at the LA roof can be seen in a severe mitral stenosis case. Right: a large free-floating throm- bus bounces at irregular intervals against a mitral valve prosthesis.

Two other examples of thrombi in the LA. Left: the TEE examination of a thrombosed mitral prosthesis shows a large wall-adherent LA thrombus that reaches to the prosthesis. Right: mitral stenosis TTE examination. A large mobile thrombus in LA mimics an atrial mymoma.

Two examples of LV thrombi at the TTE examination. Left: wall-adherent thrombus in LV apex aneurysm. Right: wall-adherent, echolucent thrombus in LV apex in a dilatative cardiomyopathy.

Two further examples of thrombi in the LV apex at the TTE examination. Left: wall-adherent thrombus, but with a narrow attachment. Right: here a similar case. Echolu- cent aspect and myxoma-like movement speak for a relative recently formed thrombus.

[overview]

Tumors

Two examples of LA myxomas at the TEE examination. Left: large characteristic left atrial myxoma with attachment at the atrial septum. The myxoma prolapses in the LV through the mitral valve during diastole. Right: mid-size, round myxoma with attachment in the superior portion of the atrial septum.

Two further examples of masses at the TTE examination. Left: large metastasis of a renal cell carcinoma in the RV. Right: large mediastinal mass at the level of the great vessels.

Other intracardiac masses

Two examples of valvular vege- tations at the TEE examination. Left: large vegetation attached to a bioprosthesis in aortic position. Right: large vegetation on a native mitral valve.

Left: large round vegetation on a native tricuspid valve at the TEE examination. Right: Chiari network in RA at the TTE examination. Notice a hyper- mobile atrial septum and the clear ultrasound shade due to mitral annular calcificacion.

Left: pronounced spontaneous echo contrast in LAA at the TEE examination. Right: cardiac involvement of hypereosinophilic syndrome. Well defined masses fill completely the apical regions of both ventricles.

Pericardial disease
[Constrictive pericarditis]

Pericardial effusion
Pericardial effusion estimation is usually done cualitatively. Measurements of systolic and diastolic dimensions from parasternal in M-

mode is important, in order to allow follow-up controls. Hemodynamic severity can be assessed through evidence of atrial or ventricular wall compression, interventricular septum displacement during inspiration and inferior vena cava plethora with blunted respiratory response. Left: small pericardial effusion with inferior basal localization. Right: small pericardial effusion with posterior basal localization.

Left: circular, mid-size pericardial effusion, with posterior und lateral accentuation. Right: mid-size pericardial effu- sion, as well as large pleural effusion clear delimitated through parietal pericardial line.

Left: mid-size to large pericardial effusion with important hemody- namic severity, as evidenced through RV compression. Right: large, circular pericardial effusion. RV and LV filling show respiratory dependent compromise.

Left: this same case from the parasternal short axis. Aspirated volumen was 1.5 liters. Right: inferior vena cava is plethoric and without respiratory collapse, a sign of hemodynamic severity.

Constrictive pericarditis Following images show charac- teristics of pericardial compres- sion. Left: contraction of the free RV wall is impeded through the organized pericardial effusion. RV expands during filling at the beginning of each inspiration, only through a septal shift toward the LV (septal bounce). Right: E-wave shows a clear (> 25 %) increase in inspiration (1).

Left: tricuspid regurgitation is also more evident during inspiration, here more accentuated as in physiologic status. Right: tricuspid regurgitation maximal velocity becomes lower as EROA increases.

Left: inferior vena cava is plethoric and show no inspiratory collapse. Right: antegrade velocities in suprahepatic vein also show clear respiratory accentuacion.

Cadiomyopathies

Left: dilatative cardiomyopathy (DCM) form the parasternal long axis view. The LV and LA are dilated. Right: same case from the short axis view. Systolic LV function is severely reduced.

Left: dilated cardiomyopathy with severly reduced systolic LV function as seen from the four- chamber view. Right: here a DCM with severe mitral regurgitation.

Left: a severe myocadial hypertrophy can point to a hypertrophic cardiomyopathy, but also as in this case, to a myocardial involvement by amyloidosis. Right: hypertrophic nonobstruc- tive cardiomyopathy (HNCM) with normal systolic LV function. Atrial arrhythmia makes difficult the interpretation of diastolic function.

Left: apical form of a hypertrophic cardiomyopathy. Right: lung-crossing ultrasound contrast agent in a case of isolated left ventricular noncompaction car- diomyopathy (LVNC). Notice deep trabeculations in LV, especially the apical region. Aortic dissection

Classification of aortic dissection

Standford A Left: dissection membrane starts approx. 2 cm above the aortic valve, the ascendant aorta is aneurysmatic. Right: view of the ascendant aorta, so far it can be seen in the TEE examination. The left main bronchus hinders usually visuali- zation of intersection of ascendant aorta to the aortic arch.

Left: cross-section of the ascen- dant aorta in the same case. Notice the intramural hematoma previous to start of dissection membrane. Right: further away of the aortic valve, intramural hematoma and start of dissection membrane.

Standford B Left: descendant aorta short after intersection from the aortic arch. Flat, wall-adherent plaques. Right: same case, further distal from in the descendant aorta, a large intramural hematoma can be seen.

Left: more distal, a dissection membrane with entrance tear can be seen. False lumen at the bottom of the image. Right: dissection membrane with entrance tear and color Doppler flow display.

Left: dissection membrane with entrance tear and PW-Doppler flow display. Right: further distal in the descen- dant aorta, pronounced spontane- ous echo contrast in false lumen.

Congenital heart disease [Complex congenital heart disease] [More examples of congenital heart disease] Interatrial shunt Cross section of the right atrium as seen from the right side. At the top the superior vena cava (VCS), at the bottom the inferior vena cava (VCI), to the right the tricuspid valve (TV). 1: Patent foramen ovale 2: ASD II = ostium secundum atrial septal defect 3: ASD I = ostium primum atrial septal defect 4: Sinus venosus defect 5: Anomalous drainage of one or more pulmonary veins 6: Sinus coronarius defect An interatrial shunt may be suspected in the presence of following findings in transthoracic echocardiography (TTE): dilated right ventricle with preserved systolic function, dilated right atrium, as well as increased velocities over the pulmonary valve. To define localisation and morphology, as well as depiction of the shunt, a multiplane transesophageal echocardiography (TEE) should be performed. Non-invasive assessment of shunt magnitude (Qp:Qs) can be made with the following formula: (CSARVOT x VTIRVOT)/(CSALVOT x VTILVOT). Cross sectional area (CSA) calculated from the

diameter of the right (RVOT) and left ventricular outflow tract (LVOT) with B-mode and velocity time integral (VTI) with PW-Doppler at the same place during passive end expiration. Next 4 animations apply to an ostium secundum atrial septal defect (ASD II). Left: TEE examination at 0 shows a large ASD II in the upper part of the fossa ovalis. Right: ASD II at 90.

Left: demonstration of a large left-to-right shunt with color Doppler. Right: negative contrast effect showed with an nontranspul- monary ultrasound contrast agent, with partial crossing from RA to LA.

Next 7 animations apply to ano- ther ASD II case. Left: Four chamber view. The RV is dilated with not severely decreased systolic function. The RA is severely dilated. An atrial shunt is suspected. A TEE exami- nation should follow. Right: short axis view shows a dilated RV.

Left: TEE view at 100 shows an ASD II at the superior portion of the foramen ovale. Right: Shunt depiction with color Doppler. The Nyquist limit lies at 60-70 cm/s, slow velocities speak for a moderate to severe shunt.

Left: ASD II depiction with "real- time 3D echocardiography" (RT3D-TEE). Right: The ASD II as seen from the LA (arrow), superior vena cava (VCS) confluence and right atrial appendage (RAA) are labeled here.

Left: ASD II as seen from the right atrium (RA). Depiction with RT3D-TEE uses colors to give the impression of deepness: light blue lies on a deeper level than light brown. Right: Shunt depiction with color 3D echocardiography, as seen from the RA.

Next 4 animations apply to diffe- rent cases of patent foramen ovale (PFO) and/or atrial septal aneurysm (ASA). Left: several small left-to-right shunts depicted with color Doppler (PFO fenestrations). Right: ASA and PFO with massive right-to-left ultrasound contrast agent passage at the end of a Valsalva maneuver.

Left: spontaneous right-to-left shunt can be depicted with color Doppler in cases of large PFO. Right: this can cause a reduction in oxygen saturation and dyspnea during changes in body position (platypnea-orthodeoxia).

Left: here a case of a complete atrioventricular (AV) canal defect, with ASD I and a large superior located VSD. Septal insertion of AV valves (mitral and tricuspid) lies at the same level.

Right: a malformation of the AV valves, especially of the mitral valve (cleft) cannot be seen in this case.
[overview]

Complex congenital heart disease Approach to echocardiographic diagnosis

1. Anatomic orientation - Situs solitus - Situs inversus - Dextrocardia - Dextroposition 2. Atrioventricular relationship - Concordant - Discordant 3. Great vessels - 2 or 1 - Parallel course - Ventricular-arterial concordance or discordance 4. Shunts - Atrial - Ventricular - Great vessels: aortopulmonic window, Ductus arteriosus

5. Valves - Pulmonic stenosis - Tetracuspid valve (truncus arteriosus) - Aortic stenosis: valvular, subvalvular - Bicuspid aortic valve/aortic isthmus stenosis - Ebstein's anomaly

Extensive and excellent Flash-animations from congenital heart disease can be seen at the Health Center Encyclopedia from the Cincinnati Children's Hospital Medical Center.

Next 4 animations apply to a Dtransposition of the great vessels (D-TGA). Left: parallel course of the great vessels. The aorta lies ventral and the pulmonary artery dorsal. Right: short axis of the aortic (above) and pulmonary valve (below).

Left: four-chamber view, there is an atrioventricular concordance. However, the RV is the systemic ventricle. Mustard baffle can be seen right below at the RA.

Right: pulmonary vein flow can be seen in and at the intersection of the Mustard baffle to the RA.

Next 4 animations apply to a Fallot's tetralogy. Left: 50 to 60 % riding aorta and large outlet VSD as seen from the parasternal long axis. Right: pulmonary stenosis as seen from the parasternal short axis.

Left: apical five-chamber view of the riding aorta and the VSD. Right: RV hypertrophy can be clearly seen from the four-chamber view.

Next 4 animations apply to a truncus arteriosus. Left: from the parasternal long axis view it looks like a Fallot's tetralogy. Right: VSD shunt can be seen with color Doppler.

Left: the truncus can be followed in a modified parasternal view. Pulmonary artery originates dorsal from the truncus (below in the image), approx. 4 cm distal to the truncus valve. Right: truncus valve is in this case bicuspid, and not tetracuspid as expected.
More examples of congenital heart disease Next 4 animations apply to an univentricular heart. Left: four-chamber view, a rudimentary RV and a large VSD can be seen. Right: examination with an ultra- sound contrast agent. Anatomic and rheologic characteristics of a double inlet LV (DILV), but without transposition of the great vessels or ventricular inversion.

Left: modified parasternal long axis view. Right: with an ultrasound contrast agent can be seen, that blood flow from the caval veins fill the rudimentary RV and the LV.

Next 4 animations apply to an aortopulmonic window. Left: parasternal long axis view. Right: severe RV and LV hyper- trophy can be seen from the short axis view.

Left: short axis view of the aortic and pulmonary valves shows a severe pulmonary artery dilatation. Right: a modified view above this level shows an approx. 2 cm large window between aorta and pulmonary artery.

Ductus arteriosus Botalli apertus. Left: retrograde flow in the pulmonary artery as seen with color Doppler. Right: typical, systolic-diastolic flow with high velocities as depicted with CW-Doppler.

Membranous subvalvular aortic stenosis. Left: subvalvular membrane can be clearly seen in five-chamber view. Right: turbulence with color Doppler shows stenotic effect of the membrane.

echo|case

echo|case is an echocardiographic "showcase", intended to present pregnant, visual impressive echocardiographic findings with high didactical value, seen from the point of view and experience of different echocardiographists. This is not a section for case reports, namely, it is not destined for unusual echocardiographic cases or cases of excepcional occurrence.

Mobile left atrial mass

A 59-year-old male patient with a history of systemic arterial hypertension and type 2 diabetes, both under therapy, comes to the outpatient clinic with dyspnea on effort, which was getting worse in the last two weeks. The electrocardiogram showed sinus rhythm with frequent supraventricular extrasystolia, heart rate was 75/min, signs of left ventricular hypertrohpy were present. Transthoracic echocardiography showed a hypertrophic left ventricle, dilated with an impairment of systolic function. Calculated ejection fraction is 40%. A complementary finding complicated non-invasive diagnosis in this patient.

Left: B-mode, parasternal long axis projection. The left ventricle is hypertrophic, with impareid contractility. Right: an echogenic, mobile mass with inhomogeneous density can be seen in the dilated left atrium, dimensions 25 x 20 x 30 mm (arrow), with insertion on the interauricular septum.

Left: apical four-chamber view, here inverted following a Mayo Clinic tradition. The mobile mass in the left atrium causes a partial mitral valve obstruction during diastole. Right: echocardiographic diagno- sis suggest an ischemic cardiomyopathy with a concomitant left atrial myxoma.

A differential diagnosis can be proposed: mobile thrombus in the left atrium. However, sinus rhythm make this option more distant. The diagnosis of atrial myxoma was histologically confirmed after surgery.