Rheumatic mitral stenosis is the commonest valvular heart disease in developing countries. Other causes include congenital abnormalities and degenerative mitral valve disease. Mitral stenosis when it is due to rheumatic process, can be managed by percutaneous transvenous mitral commissurotomy. Echocardiography remains the most important investigation in diagnosing and planning the managemnt of mitral stenosis. This review highlights stepwise approach for comprehensive assessment of mitral stenosis by echocardiography.

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Regional wall motion abnormalities (RWMA) are usually described with Ischemic Heart Disease. But many other conditions also show RWMA. What are those conditions, how to recognize RWMA in them and what is it's importance is discussed.

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Hepatic vein (HV) flow pattern closely correlates with pressure changes in the right atrium. Normally, there are two forward flow waves – systolic and diastolic. Diastolic wave is slightly smaller than systolic wave. Three reversal waves can be seen – late systolic, mid-diastolic, and third during right atrial contraction. Normally, forward wave velocities increase during inspiration. Reversal waves are slightly more prominent during expiration. Systolic wave is diminished in atrial fibrillation, right ventricular systolic dysfunction, and tricuspid regurgitation. When these pathologies are severe or they coexist, systolic wave may reverse. Diastolic wave is diminished in tricuspid stenosis and impaired relaxation of the right ventricle as seen in right ventricular hypertrophy, right ventricular ischemia, or infarction. Diastolic flow reversal wave becomes prominent in restrictive cardiomyopathy and pericardial constriction. Reversal wave during right atrial contraction is absent in atrial fibrillation. It is diminished or absent when compliance of HVs is decreased due to diseases of liver parenchyma. This reversal wave is prominent in each cardiac cycle in tricuspid stenosis with sinus rhythm and in patients with right ventricular hypertrophy. It is intermittently prominent in the presence of ventricular ectopics and complete atrioventricular block.

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Global longitudinal strain imaging of the left ventricle is a simple bedside modality for objectively assessing the global and regional function of the major pumping chamber of the heart, the left ventricle. Currently available echo machines provide good quality speckle-tracking methods with good computational facilities providing standard, comparable bull's eye maps and parametric plots. This introductory chapter provides a step-by-step approach for the beginner to utilize this additional facility in day-to-day practice to precisely understand the left ventricular regional and global function for serial follow-up and prognostication. Pattern recognition is illustrated in the following article. Essentially, this article illustrates what the pictures mean and how to generate these meaningful echo pictures.

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The introduction of valve replacement surgery has dramatically improved the outcome of patients with valvular heart disease. Echocardiography plays an important role to determine the outcome of the surgery and follow up of these patients with prosthetic heart valve. Flow across the prosthesis is determined by using Doppler echocardiography. Whenever there is a high gradient across a prosthetic valve, echocardiography becomes challenging, as there are many causes, which may give rise to high prosthetic valve gradient. Some of these causes are prosthesis-related which need urgent intervention and some are non-prosthesis-related. A careful systematic echocardiographic approach, using 2D, 3D, Doppler and transesophageal echocardiography is crucial to find out the exact cause of high gradient.

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Ventricular septal defects (VSDs) are among the most common congenital heart defects. These defects may be isolated, associated with other defects, or occur as an intrinsic component of some complex heart defects. There is wide variation in size and location of VSD. Echocardiography plays an important role in evaluation of anatomy, hemodynamic significance, and planning of management of VSDs. With the emerging trends in transcatheter closure of VSD, echocardiography plays a crucial role in decision-making and intra- and postprocedure evaluation. A stepwise approach of echocardiography is necessary for accurate evaluation and management of VSDs.

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The number of coronary stent (CS) implantation has significantly increased since its introduction in 1987. CS infection is a rare but potentially fatal complication. No imaging modality is confirmatory for diagnosing CS infection. Positive blood cultures, two-dimensional-echocardiography (especially transesophageal echocardiography), transthoracic echocardiography (TTE), coronary angiography, computed tomography-scan, and magnetic resonance imaging are useful. We report a case of a 65-year-old male who presented within a month of CS implantation with high-grade fever and chest pain. TTE showed a localized collection in the right atrioventricular groove clinching the diagnosis to CS infection. The patient responded to higher doses of broad-spectrum antibiotics which were continued for 6 weeks.

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Introduction: Strain is a unitless measurement of dimensional or deformational change; speckle-tracking echocardiography is the most widely used technique to assess strain, with demonstrated clinical utility in a variety of settings. Objectives: This paper reviews the diagnostic and prognostic impact of echocardiographic assessment of left ventricle myocardial strain and what sonographers need to know in a daily practice. Methods: This paper have the most updated American society of echocardiography recommendations on a speckle tracking strain echocardiography, and included experiences of a large academic center, standardization as well as tips needed to perform a strain in a daily clinical practice. Conclusion: With good feasibility, reproducibility and evidence in support, speckle tracking strain echocardiography can be used as a standard echocardiography parameter in clinical practice.

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Pulmonary hypertension (PH) is the end result of nearly all cardiac and some noncardiac conditions. It is an important marker of mortality and morbidity. It is also the deciding factor in the management of the etiological conditions, such as the timing of surgery in valvular heart disease, follow-up of pulmonary arterial hypertension, diuretic therapy for diastolic dysfunction, and so on. To add to the problems, early signs and symptoms are nonspecific, and so the diagnosis is attained at a later and advanced stage. Although clinical evaluation is always essential, echocardiography is now the main tool for the evaluation of PH. The aims of echocardiography in PH are: (1) to identify the etiology, (2) assess the effects of PH on the right ventricle, (3) estimation of the severity of the PH, (4) monitoring the progression and therapeutic response in PH, and finally (5) predicting the prognosis. It is hence very important that one measures the pulmonary pressures accurately for proper patient management. The aim of this article is to provide a detailed information of the different parameters of PH in the different echocardiographic views and the technique of measuring these parameters.

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Double outlet ventricle is a type of conoventricular anomaly. The great arteries arise predominantly (more than 50%) from one of the ventricle. The aortomitral discontinuity varies from minimum discontinuity to complete bilateral conal tissue. Both right and left ventricles can have double outlet though double outlet right ventricle (DORV) is the most common anomaly in this group of abnormalities. Double outlet left ventricle (DOLV) is relatively rare. There are multiple types of DORV based on the site of ventricular septal defect and great artery relationship and presence or absence of ventricular outflow obstruction. The correct anatomical diagnosis requires a detail segmental approach in echocardiography. The echocardiographic features of DORV reviewed in detail followed by a brief discussion on DOLV.

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Physicians and sonographers performing echocardiographic scans place themselves at risk of developing work-related musculoskeletal disorders (WRMSDs) owing to faulty posture and repetitive hand and arm movements. Poor ultrasound ergonomics plays a pivotal role in the development of WRMSD and can result in injury and sickness absence, impacting efficiency and work productivity. The aim of this article is to draw the attention to common considerations and corrective measures to reduce the risk of WRMSD among professionals actively performing echocardiographic scans.

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Congenital heart disease (CHD) is the most common birth defect worldwide. The optimal timing for performance of a comprehensive transabdominal fetal echocardiogram is 18–22 weeks gestation. All radiologists should perform screening of the heart during all obstetrical ultrasound studies beyond 18 weeks of gestation. Detailed fetal echocardiography can be performed only with the help of a technically well-quipped ultrasound machine. Skilled expertise and appropriate knowledge are required to perform detailed fetal echocardiography. Despite of limitations, fetal echocardiography can identify most of the CHDs which have major pre- and post-natal implications. This is necessary to delineate the high-risk group of fetuses who are suffering from complex cardiac defects and would require tertiary hospital setup for delivery. This further aids in appropriate postnatal medical as well as surgical management, antenatal parent counseling, and explaining risk factors as well as postnatal outcome.

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The sequential segmental approach is essential for better understanding of cardiac anatomy in normal and malformed hearts. It is based on a detailed analysis of the three main cardiac segments, namely atria, ventricles, and great vessels, and the two connecting segments, namely atrioventricular and ventriculoarterial connections. Each segment is systematically defined based purely on its morphological characteristics. In most cases, echocardiography is sufficient, but some cases necessitate the use of other imaging modalities. Systematic identification of different segments, connections, and their abnormalities helps in making an accurate diagnosis of congenital heart disease (CHD). This review provides a brief description of the sequential segmental approach for detecting CHD on echocardiography.

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Stress echocardiography is one of the most useful non-invasive diagnostic modalities for detection and evaluation of coronary artery disease (CAD). It is also very useful for assessment of cardiac response to hemodynamic stress in a variety of other cardiac and non-cardiac disorders. Given its cost-effectiveness, stress echocardiography is particularly suited for Indian scenario where the incidence of CAD is rising at an alarming rate and the astronomical expenditure required for its management is borne largely by the patients themselves. However, despite its unequivocal diagnostic value, stress echocardiography remains underutilized, particularly in India, due to the lack of adequate exposure and training in this modality. Unfortunately, while there is extensive literature available to document diagnostic accuracy of stress echocardiography, there are very few texts that actually describe how to perform stress echocardiography in real life. This Indian Academy of Echocardiography guideline document aims to fill this very void. This is a comprehensive 'how to do' document prepared with the objective of providing detailed description of the steps involved in performance and interpretation of stress echocardiography so that there is increased adoption of this important and clinically useful diagnostic modality in daily clinical practice. However, while stress echocardiography has several clinical applications, the present document is restricted to its main application, which is evaluation of CAD.

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Congenital pulmonary stenosis (PS) is a common term for lesions causing right ventricular outflow obstruction. It can be further classified as the valvar, supravalvar, and infundibular PS. The PS may often present with other congenital heart diseases. In this article, echo imaging of isolated PS has been discussed. It is imperative to know that the guideline for intervention in isolated PS is totally based on echocardiography. Echocardiographic guidance is required for the selection of procedure, hardwares, evaluation of the outcome of the procedure, and long-term prognosis.

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Three-dimensional echocardiography (3DE) is a new echocardiographic tool that enables echocardiographers visualization of cardiac structures from any anatomical view. Furthermore, the recent development of new transducer technology and software allows the easy acquisition and analysis of datasets for sonographers. A few common applications of 3DE consist of the left and right ventricle for chamber quantification, mitral valve stenosis and regurgitation assessment, and the guidance of catheter placement during interventional procedures. Despite current literature illustrating the importance of 3DE, it fails to demonstrate how to acquire 3D datasets from the sonographer's perspective. Understanding 3DE data acquisition technique and applications are paramount to implement it as standard of care. Acquisition of 3DE should be accomplished in three steps (1) optimization, (2) acquisition, and (3) cropping of 3D images.

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The stepwise approach in evaluation of left ventricular (LV) diastolic function is essential in any patients with dyspnea on exertion or heart failure. Many of them have normal to near-normal ejection fractions (EFs). These subsets of patients are labeled as diastolic heart failure or heart failure with preserved EF. It is important to differentiate diastolic dysfunction from dyspnea of pulmonary origin for further management and future prognosis. LV filling pressures is usually synonymous with pulmonary capillary wedge pressure (PCWP), mean left atrial pressure (LAP), mean LV diastolic pressure, and LV end-diastolic pressure (LVEDP). PCWP on the other hand is also an indirect estimate of LV diastolic pressures. LVEDP is often elevated in early diastolic dysfunction because of a large atrial pressure wave, while mean PCWP and LAP remain normal. While mean PCWP and LAP increased during tachycardia and where there is increased LV afterload which is the basis for the diastolic stress test. It is essential that certain Doppler variables correlate well with an increase in LVEDP only and not reflecting the increase in either LAP or LVEDP. Therefore, early evaluation of LV filling pressures and LVEDP are more important than mean LA pressure which is elevated later. Echocardiography is the best evaluation tool to evaluate LV diastolic function. The purpose of this article is to provide the simplest stepwise approach of different diastolic parameters which are used as routine protocol with minimal use of the newer modalities at various clinical settings.

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The hallmark of corrected transposition is discordance at atrio-ventricular and ventriculo-arterial level and that is defined as “double discordance”. This can occur as an isolated anomaly but more commonly has associated defects; most common being ventricular septal defect followed by tricuspid valve abnormalities. Other associated defects are pulmonary stenosis, systemic and pulmonary venous anomalies, univentricular physiology, ventricular dysfunction (morphological right ventricle facing systemic circulation) and association of conduction abnormalities. Echocardiography plays a pivotal role in defining the anatomy and planning the management. In this article we are discussing about role of echocardiography in evaluation of corrected transposition, diagnosing the lesion, role in immediate post-operative period and on follow up.

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Tissue Doppler imaging (TDI) records velocities of myocardial tissue. Routinely longitudinal velocities of medial and lateral mitral annulus and lateral tricuspid annulus are evaluated in apical four chamber view. Commonly recorded waves include isovolumic contraction wave, systolic wave, isovolumic relaxation wave, early diastolic wave, and late diastolic wave. TDI is useful in detection of subclinical systolic dysfunction and early diastolic dysfunction. It is useful in differentiating athlete's heart from hypertrophic cardiomyopathy and pericardial constriction from restrictive cardiomyopathy.

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Ischemic stroke remains a major cause of morbidity and mortality. Cardiac sources of embolism account for almost up to 40% of all the ischemic strokes. Accordingly, echocardiography is an important investigation in the evaluation of clinically suspected cardioembolic stroke or cryptogenic stroke. Both transthoracic echocardiography and transesophageal echocardiography (TEE) are complementary to each other for this purpose. However, because of its superior resolution and the ability to image structures that are the most likely sources of cardioembolism (e.g., left atrial appendage), TEE is the preferred imaging modality in the cardiac evaluation of stroke. This document describes the systematic TEE evaluation of the patients referred with a clinical diagnosis of either cryptogenic stroke or cardioembolic stroke.

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Cardiac muscle dysfunction resulting in heart failure can be reversed with appropriate diagnosis and therapy in nearly 25%8211;50% of all nonischemic cardiomyopathies. Diverse etiologies such as congenital, metabolic, toxic, infective, inflammatory, infiltrative, stress induced, and arrhythmia induced can cause myocardial dysfunction which can be restored to normal. All morphologic types including dilated, hypertrophic, and restrictive cardiomyopathies can have an underlying reversible cause. Imaging modalities such as echocardiography, cardiac computed tomography (CT), positron-emission tomography-CT, and cardiac magnetic resonance along with appropriate biochemical tests can help diagnose these varied etiologies. Recognizing reversible myocardial dysfunction at an early stage of the disease helps avoid inappropriate prolonged therapy for heart failure and repeated hospital admissions and may result in a cure in a significant number of cases.

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Atrial septal defect accounts for 8-10% of all congenital heart defects. Echocardiography is method of choice for assessment of patient with a known or suspected atrial septal defect. A Thorough knowledge and understanding of all echocardiographic view is essential for complete assessment of atrial septal defect , associated physiological status and assessment of neighbouring intracardiac structures. Complete evaluation is crucial for planning the modality of treatment whether it is suitable for catheter intervention or needs surgical intervention.

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Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.

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