letter to the editor

Letters to the Editor

THE HEART

L355

Labelling Method for Ultrasono-Tomograms of the Heart

1. Basic Approach The labelling method outlined here is standardized by detailed identification of the

position of the probe and the plane being scanned, using the long axis of the left ventricle as the baseline. This method differs from those used in Europe and the U.S. 1)2).

A frontview of the heart is shown in Fig. 1. The structure of the basilar portion is a complex of large blood vessels and four valves, (Fig. 2); these are important in assessing congenital heart diseases. The function of the left ventricle with an ellipsoid revolution directed from the basilar to the apical part, and the function of the right ventricle,

Right common carotid artery Left common carotid artery

/-If! \-n ,Left internal jugular YeI”

Right subclavlan artery

Left pulmonary artery

Main pulmonary artery

Right ventricle’’

f”k2GY-P Antenor interventricular sulcus

Fig. 1 Heart

Superior vena cavan @

Right pulmonarv artery

WLeft heart system

ventricle

Fig. 2 Basilar Portion of Heart

a part of whose walls cover the intervenZicular septum, are important in the organ's pumping action. The heart is largely surrounded by the lungs and is enclosed within the chest cavity which includes the sternum in the front, twelve pairs of curved ribs which run from back to front, and the clavicles positioned in the upper portion(Fig. 3). The upper and posterior parts of the heart are enclosed by the trachea, and the lower part by the liver via the diaphragm. When using ultrasound to study the interior of the heart 3)4), these anatomical features which define the "acoustic windows", through which the beam can pass are of first consideration. Fig. 4 shows some of these points: the suprasternal region, the parasternal region (primarily between the third and fifth costae), the apical region and the subcostal or epigastric region. To obtain a desired tomogram accessible only from such restricted localities requires a detailed understanding of how to scan a plane by shifting, rotating, flexing and tilting the probe (Fig. 5). The most promising labelling method of ultrasono-tomograms of the heart, therefore, is one based both on the probe position selected and the skillful scanning of a plane (Fig. 6).

L356

l-l Presentation of Tomoerams

Letters to the Editor

1)

2)

3)

Presentation of tomograms should include the following information: Body position of subject: Describe the angle of the supine position, the sitting position, or the left lateral decubitus position. Probe: Describe the frequency used, the kind of probe, sector scanning angle, etc. Method of tomogram presentation a)

b) c)

d)

Present the tomogram in such a way that an echo image from a position nearer the probe is above one situated further from the probe. If the display mechanism being used produces an inverted relationship between the two echo images, correct the relationship laterally and vertically so that there is no image-inversion. State the direction pictured, such as is shown in Fig. 7. Mark the image to point out the phase of the cardiac cycle (for example, ED, ES or ECG). Provide diagrams and arrows of the localities aimed at to assure clear understanding

Fig. 3 Circumference of Heart

Fig. 5 Probe Positions and Scanning Planes

Fig. 4 Acoustic Windows

Long ax,s planes(not on the same level)

Vertebral column

Fig, 6 Combinations of Long Axis Planes and Probe Positions

Anterior

Fig. 7 An Example of Indication of Direction

of the images. Show standardized classifications of the obtained tomograms and, if possible, enter in parentheses ( ) the targeted locality.

l-2 Positions of Probe When positioned in the suprasternal region, (Fig. 4), a probe is said to be in the

suprasternal position; (when the position is concerned with a wide region, a probe is said to be in either the right or left suprasternal position). A probe position enclosed by a region whose upper part is under the left clavicle, whose lower part is above the subcostal, and which is near the left edge of the sternum, is said to be in the parasternal position. When positioned at the right edge of the sternum, the probe is in the right parasternal position. Near the center line of the subcostal (epigastric) region is the subcostal or epigastric position. A probe positioned at the apex beat or its vicinity is in the apical position. If there is an apex beat on the right side, this is referred to as the right apical position.

Letters to the Editor L357

l-3 Beam Scanning View The long axis view (corresponding to the longitudinal view scanned along the left

sternal border of the third to fourth intercostal space, directed from the right shoulder to the left abdomen) also includes the plane parallel to it, and the sagittal view is consid- ered an additional part. By placing the probe at approximately the midsagittal plane of the subcostal part, the area may be scanned parallel to the long axis of the body). The view at a right angle to this is called the short axis view. In some cases, from an angle other than a right angle to the long axis view, four chambers can be seen; this is called the four chamber view.

In general, a long axis view results in a tomogram that is like a view of the heart looked at longitudinally from the left side by a viewer sitting to the left of the subject. (A sagittal view may be similar depending upon the locality). The tomogram of a short axis view is as though the heart were looked at cross-sectionally from the apex. A four chamber view is that which would be seen by someone sitting just to the left of the subject and looking down upon the heart.

2. Nomenclature and Standardization of Ultrasono-Tomograms Depending on the combination of the probe position and the scanning plane, the labeling

method may be standardized in the following manner.

2-l The Left Heart System Table 1 shows the classification for the left heart system.

1) Long axis view (Fig. 8 - 11) Depending on the combination of the scanning plane and the probe position in either

the suprasternal, parasternal, apical or subcostal region, long axis views of the heart are classified as follows:

a. Suprasternal long axis view 5)-8) Keeping the frontal neck slightly extended, place the probe in the suprasternal region

and scan along a line from the right nipple to the left scapula (Fig. 8a, position 1). If no image can be obtained, turn the probe clockwise, and scan along the right side of the vertebral column to the left edge of the sternum (15'- 209 from the vertical column-sternum center line)(Fig. 8b, position 2).

While the probe is in this supraclavicular region, note whether it is on the right or left side.

In a tomogram, the ascending aorta, the aortic arch and its branch artery, the descending aorta and the right pulmonary artery are seen as shown in Fig. 9. When the subject is an adult, scanning may be difficult. Because of changes in the conditions of a disease of the aorta (aortic arch, descending aorta, etc.), an approach using various scanning views has recently been attempted. 44)-47).

b. Parasternal long axis view 8)-18),31)(Fig. 8b) With the probe at the left edge of the third to fourth intercostal sternum, scan in the

long axis cross-sectional direction. The tomogram shows the right ventricle above, the

Table 1 Left Heart System --------_-----------------~---~~--~~~_---_-~_~-~~~-~---__--~----_~-------_------______

1) Long Axis View 2) Short Axis View a. suprasternal long axis view a. parasternal short axis view b. parasternal long axis view b. subcostal short axis view c. apical long axis view c'. apical 2 chamber view 3) 4 Chamber View c". RAO equivalent view a. apical 4 chamber view cl'! LAO equivalent view b. subcostal 4 chamber view d. subcostal sagittal view

-------------------------------~---~~__--__~~~-~~_~~-------_--__---__--___-___--______

L358 Letters to the Editor

a. Suprastemal loi-tg axis view

c.Apical long axis view

Fig. 8 Long Axis Views

Position 1 Position 2

Fig. 9 Suprasternal Long Axis View ( A aorta )

aorta on the right, the apex on the left, and the posterior wall of the left ventricle and left atrium.

c. Apical long axis view d)(Fig. 8~) When the probe is in the apical pulsebeating section or its vicinity, scan in the long

axis cross-sectional direction. The tomogram shows the apex above, the aorta below, the right ventricle at the right, and the posterior wall of the left ventricle at the left.

c'. Apical 2 chamber view 24),30),31),33)-38) (Fig. 10) Left ventricular wall motion may be examined from this attitude.

c" . RAO equivalent view (Fig. 1Oa) Fixing the position of the probe for the apical 4 chamber view, turn it 30' Counter-

clockwise and scan until the structure of the right ventricle is wiped off; or scan parallel along the interventricular septum until the interventricular septum is wiped off. One report has stated that the left ventricle and left atrium as seen in the apical 4 chamber view may be fixed supinely 30' to the left and similarly treated. In a tomogram, the apex is seen above, the basilar part of the inferior - posterior walls at the right, and the anterior - lateral walls at the left.


\

b. LAO equivalent YEW

Fig. 10 Apical 2 Chamber View

Inferior wna cam

Fig. 11 Subcostal Sagittal View ( IVC )

c”’ . LAO equivalent view 21)(Fig. lob) Turning the probe fixed as in c" an additional 90' counterclockwise or fixing it to

have an apical 4 chamber view, scan by turning the probe another 60°- 90° counterclockwise. The tomogram shows the apex above, the right ventricle and the interventricular septum at the right, the posterior wall of the left ventricle at the left, and the aorta and left atrium below.

d. Subcostal sagittal view (IVC) 5),39)(Fig. 11) Placing the probe in the epigastric region, scan towards the vertebral column. The

tomogram reveals the hepatic parenchyma above, the vena cava inferior (which runa sideways and is connected to the right atrium) in the center, and also shows the hepatic vein, which enters the inferior vena cava from the liver.

2) Short axis view (Fig. 12) Depending on the combination of the scanning plane and the probe position in either the

parasternal or subcostal region, short axis views of the heart are classified as follows: a. Parasternal short axis view (Fig. 13) 8),11),12),16),19)-28),40),42)

Place the probe at the left edge of the third to fourth intercostal sternum and scan in the short axis cross-sectional direction. A short axis view will be obtained at each level along the long axis from the basilar portion to the apex. Described below are ultrasono- tomograms of short axis views at respective levels of the cardiac base, the mitral valve and the papillary muscle. i) At the basilar level, the right ventricular (RV) outflow tract is seen above, and below it the aorta having a Y-shaped trisemilunar valve; the pulmonary

Fig. 12 Combinations of Short Axis Planes and Probe Position


a. Parastemal short axis view b. Pamsternal short axis view c. Parastemal short axis view (A.V level) (MVO level) (PMM level)

Fig. 13 Parasternal Short Axis View

a. Subcostal short axis view b. Subcostai short axis view c. Subcostal short axis view (A-V level) (MVO level) (PMM level)

Fig. 14 Subcostal Short Axis View

artery is seen at the right, the right atrium at the left, and the left atrium below. ii) At the mitral valve level, the anterior wall of the left ventricle is seen above, the mitral valve orifice in the center, and the posterior wall below. iii) At the papillary muscle level, the anterior wall of the left ventricle is seen above, the antero-lateral papillary muscle at the right, the postero-medial papillary muscle at the left, and the inferior wall below. b. Subcostal short axis view (Fig.14) 11),28),31),39)

Placing the probe in the epigastric region, scan towards the respective levels seen along the long axis in the short axial cross-section. It is most desirable that the tomogram be taken when the subject's breathing is stopped and while the subject is in inspiration. i) In a tomogram at the basilar level, the right atrium is seen above, while the right ventricular outflow tract is seen below. ii) In a mitral valve orifice level tomogram, the right ventricle is seen above and the lateral wall of the left ventricle below. iii) In a tomogram at the papillary muscle level, the antero-lateral papillary muscle is seen below and to the right, while the postero-medial papillary muscle is seen at the loft.

3) 4 chamber view (Fig. 15) 5),11),12),13),31) The 4 chamber views are classified according to the combination of scanning plane and

probe position in either the apical or subcostal region. These views are often used to diagnose the heart of an elderly person with a chronic obstructive pulmonary disease or congenital heart disease, or to evaluate the function of the right heart system.

a. 4 chamber view and probe posrtmns b. Apical 4 chamber view c. Subcostal 4 chamber view

Fig. 15 4 Chamber View


a. Apical 4 chamber view (Fig. 15b) Placing the probe at the apex, scan so that a 4 chamber view may be obtained. In a

tomogram, the apical region is seen above, the left ventricle at the right, and the right ventricle at the left; the interventricular septum, the mitral valve and the tricuspid valve are seen between the two ventricles, and the atrium below them.

b. Subcostal 4 chamber view lo)-12),23)-27),29),31),32),36),38)(Fig. 15~) With the probe in the epigastric region, again scan to obtain a 4 chamber view. In the

tomogram, the right ventricle is seen above, the apex at the right and the left atrium at the left.

Z-2 The Right Heart System In contrast to the shape of the left ventricle, the shape of the right ventricle is

pyramidal, with the long axial dimension expressed by the distance from the right ventricular apex to the mid-point between the apex and the medial side of Atrio-ventricular SUlCUS, and the short axial diameter by the maximum distance from the right ventricular septal wall to the free wall which is perpendicular to the septum (48). Thus, the long axis is determined by the interventricular septum, and since this latter is a constituent part of the left ventricle, a scanning cross-sectional view of the left ventricle can roughly be accepted as a standard scanning view of the right ventricle. However, since the right ventricle inflow and outflow tract intersect each other at a wide angle, the scanning plane used for the left ventricle alone is not enough. A variety of combinations of scanning views are therefore believed needed. For this reason, a classification of views according to probe position (as shown in Table 2) may be more appropriate than classification according to the scanning view of the left ventricle.

1) Scanning view obtained when the probe is in the parasternal region (Fig. 16) a. Parasternal long axis RV inflow view 42) (Fig. 16a)

Place the probe at the left edge of the third to fourth intercostal sternum and scan at the innermost side of the parasternal long axial cross-section so that the probe is inclined to run parallel with the ventricular septum. In the tomogram, the right ventricle is then seen above, the anterior and posterior leaflets of the tricuspid valve are in the center, and the right atrium and inferior vena cava below.

Table 2 Right Heart System

1) Scanning Planes when Probe is in the Parasternal Region a. parasternal long axis RV inflow view b. parasternal long axis RV outflow view

2) Scanning Plane Obtained when Probe is at the Apex a. apical inferobasal view b. apical R heart 2 chamber view

3) Scanning Plane Obtained when Probe is in the Subcostal Region a. subcostal short axis RV outflow view b. subcostal RV inflow-apex-outflow view

A. Parasternal long axis RV inflow view b. Parasternal long axis RV outflow view

Fig. 16 Scanning Planes when Probe is in the Parasternal Region (Right Heart System)


eft ventricle

iv3

a. Apical inferobasal view

b. Apical R heart 2 chamber vwv

Fig. 17 Scanning View Obtained When the Probe Is at the Apex (Right Heart System)

a. Sukostal short axis RV outflow view b. Subcostal RV inflowapex-outflow view

Fig. 18 Scanning View Obtained When the Probe Is in the Subcostal Region (Right Heart System)

b. Paras'cernal long axis RV outflow view 40),42) (Fig. 16b) When scanning this cross section, with the probe in the same position as in a. above,

turn it so that it runs parallel with the sternum or slightly clockwise, then turn it inside and tilt it towards the head. The right ventricular outflow tract and the pulmonary valve are seen at the top of the tomogram, while the left ventricular outflow tract and the left atrium are seen below.

2) Scanning view obtained when the probe is at the apex (Fig. 17) a. Apical inferobasal view 40) (Fig. 17a)

Fixing the probe position in the apical 4 chamber cross section, flex it downward and scan the basilar area of the heart after scanning the region where the basilar part of the right ventricular free wall joins the right ventricular diaphragmmatic wall. In a tomogram, the apex of the heart is seen above, the right ventricle at the left, and the left ventricle at the right.

b. Apical right heart 2 chamber view 40) (Fig. 17b) With the probe positioned in the apical 4 chamber cross section, scan by turning the

probe until the left ventricle is wiped off. In a tomogram, the right ventricular apex is seen above and the right atrium below.

3) Scanning view obtained when the probe is in the subcostal region 43) (Fig. 18) a. Subcostal short axis RV outflow view 43) (Fig. 18a)

Placing the probe in the subcostal region, scan in the short axial direction by turning it towards the basilar part of the heart. In a tomogram, the right ventricle and its


outflow tract are seen above, the left ventricle is at the lower left, and the pulmonary valve at the lower right.

b. Subcostal RV inflow-apex-outflow view 40),41) (Fig. 18b) After press-fixing the probe in the subcostal region, tilt it and scan through the

diaphragmmatic wall of the right ventricle; the tricuspid valve, the right ventricular apex a.nd the pulmonary artery are visible in the resulting tomogram. The diaphragmmatic wall of the right ventricle is seen above, the right atrium at the left, the right ventricular apex at the right, and below are seen the aortic valve orifice, the pulmonary valve and the right ventricular outflow tract from the apex of the heart.

References

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2) Lange L, et al : Standardsierungsempfehlungen

tir abbildungen und nomenklatur in der zweidi-

mensionalen echokardiographie. Z Kardiof 70 : 476, 1981.

3) Bommer W, et al: Determinstion of R.A and R. V size by 2DE. Circ 60: 91, 1979.

4) H&k JW, et al: 2DE imaging of the LV; Com-

parison of mechanical and phased army systems in vitro. am J Cardiol 48: 728, 1981.

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6) Duncan WJ, et nl: Noninvasive diagnosis of

neonatnl coarctntion and associated onomnlies

using 2DE. Am Heart J 106: 63, 1983. 7) C&no V, et al: 2DE recognition of the r. nortic

arch. Am J Cardiol 51: 1507, 1983. 8) Brandenburg RO, et al: Accuracy of 2DE ding-

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VSD by 2DE. Am J Cardiol 51: 1474, 1983.

10) Chentham JP, et al : VSD in infancy : Detection

with 2DE. Am J Cardiol 74: 86, 1981.

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diogrnphic nbnormnlities in oortic regurgitation : An experimental study. Circ 67: 860, 1983.

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prolapse syndrome by 2DE. Circ 65: 174, 1982.

16) Ciro E, et al: Heterogenous morphologic ex- pression of geneticnlly transmitted hypertrophic

cardiomyopathy. 2DE nnalysis. Circ 67: 1227,

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October lOth, 1984 Dr. Masao Ide, Chairman The Committee for the Standards on Ultrasonic Medical Equipment, Japan Society of Ultrasonics in Medicine.

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idiopathic hypereosinophilic syndrome. Circ 67 : 572, 1983.

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graphic detection of aortic valve prolapse. Am Hcnrt J 100: 295, 1980.

19) Friedman MJ, et al: High predictive nccurncy

for detection of 1 mnin coronary artery disease

by antilog signal processing of 2DE image. Am Heart J 103: 194, 1982.

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in patients with coronary artery disease. Am J Cardiol 48: 711, 1981.

21) Mercier JC, et al : 2DE assesment of LV volume

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26) DeMaria AN, et al: Valve and limitations of

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valve in the diagnosis and qunntification of valvu-

lar aortic stenosis. Circ 62: 304, 1980.

27) Cannle JM, et al: Accurncy of 2DE in the dc-

tcction of aneurysm of the ventricular septum. Am Ifeart J 101: 255, 1981.

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truncus arteriosus. Am Heart J 105: 281, 1983. 29) Acquatella H, et al: Valve of 2DE in endomyo-

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Smuckler AL, et al: Echocardiographic diag-

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RV body: 2DE features. Am J Cardiol 51: 1498, 1983. Duncan WJ, et al: 2DE identification of hemi-

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A PROCEDURE FOR CUTTING SOFT TISSUE SPECIMENS OF REGULAR

SHAPE

Sir:

The majority of experiments concerned with measurement of the

ultrasonic propagation characteristics (i.e. velocity and attenuation or scattering)

of soft tissues require the use of specimens of regular geometry. The most

common geometries used are parallel-sided slabs or cylinders. The size of the

specimen depends primarily on the organ being used and considerations of

availability. The flexibility of soft tissue, and the difficulty of cutting it -

particularly if it is fresh - makes the isolation of specimens of regular geometry

a skilled procedure. The use of long bladed knives is common for trying to

achieve flat surfaces, while core samples are used for cylindrical specimens. The

main deficiency of the latter is that the bevel is usually on the outside of the

cylinder thus tending to produce a core that is smaller than the internal diameter

(and often non-uniform lengthwise).

letter to the editor

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