(A) Inferior vena caval (IVC) size and degree of collapse yields a range of right atrial pressure (RAP): <1.2 cm with full collapse = RAP 0 mm Hg; 1.2 to 1.7 cm with >50% collapse = RAP 0 to 5 mm Hg; >1.7 cm with >50% collapse = RAP 6 to 10 mm Hg; <50% collapse = RAP 10 to 15 mm Hg; and >1.7 cm with 0% collapse = RAP >15 mm Hg (51). (B) The tricuspid regurgitant velocity (TR Vel) is used to estimate the systolic right ventricle—right atrium gradient (and the pulmonary artery systolic pressure, in the absence of pulmonic stenosis). (C) The maximal pulmonic valve regurgitant velocity is used to estimate the mean pulmonary artery pressure (PAPm). The end diastolic pulmonic regurgitant velocity is used to estimate diastolic pulmonary artery pressure (PAPd). (D) The early mitral inflow (E-wave)/early diastolic mitral valve annular motion (E'-wave) ratio <8 or >15 is calculated to assess PCWP <15 mm Hg or >15 mm Hg, respectively. E/E' = ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral valve annulus; IVCCI = inferior vena cava collapsibility index; PCWP = pulmonary capillary wedge pressure; PR Vel. = pulmonic valve regurgitant velocity; RVSP = right ventricular systolic pressure.

(A) Prediction of normal versus elevated filling pressure. In patients with preserved and reduced left ventricular ejection fraction (LVEF), normal filling pressures are predicted by normal mitral inflow E-wave to tissue Doppler E'-wave ratio (E/E') and mitral inflow E-wave to flow propagation ratio (E/Vp) values or intermediate values with normal left atrium (LA) size, normal pulmonary vein atrial reversal duration minus mitral inflow A-wave duration (ARdur – Adur), and a minimal change in the E/A wave ratio with Valsalva. Elevated filling pressures are predicted by elevated E/E' and E/Vp values or intermediate values with elevated LA size, prolonged ARdur – Adur, a substantial change in the E to A valve with Valsalva, or a prolonged pulmonary vein D-wave deceleration time (DDT). (B) Degree of diastolic dysfunction. In patients with reduced LVEF, mitral inflow E/A, mitral inflow E-wave deceleration time (EDT), and isovolumic relaxation time (IVRT) parameters, confirmed by pulmonary vein S to D ratio (S/D), systolic fraction of pulmonary venous forward flow (SF), and DDT can further define filling dynamics by stratifying diastolic function into "abnormal relaxation" (normal filling pressures), "pseudonormal" (elevated filling pressures), and "restrictive" (very high filling pressures) categories. Valsalva E/A = change in mitral inflow E to A-wave ratio with Valsalva maneuver. (Modified from Nagueh SF, Zoghbi WA. Clinical Assessment of LV Diastolic Filling by Doppler Echocardiography. ACC Current Journal Review. 2001; July/Aug: 49).

(A) Apical 4-chamber views with poor endocardial definition. (B) The same view with improved endocardial definition after echocardiographic contrast administration.

(A) Transesophageal echocardiogram in the mid-esophageal 4-chamber view demonstrating inflow cannula of a left ventricular assist device (arrow). (B) Transgastric short-axis view demonstrates inflow cannula proximity to an area of hypertrabeculation that is consistent with non-compaction of the left ventricular myocardium (arrows). (C) Close-up view in the mid-esophageal 4-chamber view demonstrates an area of hypertrabeculation being pulled into the inflow cannula (arrow). (D) Continuous wave Doppler imaging demonstrates high velocities into the inflow cannula, consistent with partial obstruction.

Apical 4-chamber view with tissue Doppler imaging showing regional analysis of the contraction patterns of the septal and lateral walls in a patient with dilated cardiomyopathy. Regions of interest (ROI) are drawn at the mid portions of the septal and lateral walls, and the contraction velocities within each ROI in the vertical plane are graphically displayed over time.

The upper panels display radial and rotational mechanics of the left ventricle (LV) by Velocity Vector Imaging (VVI). (A) Depiction of radial velocity vectors (yellow arrows) in end-systole with the direction of the arrows pointing to a counter-clockwise rotation of the apex. Velocities that are orthogonal to these radial velocities are rotational velocities (red arrows). These velocities are automatically calculated at each location of the arrows around the LV circumference. (B and C) Depiction of visual representation of the rotational motion at the base (B) of the LV and at the apex (C). The lower panels show the magnitude of the rotational motion at the apex and base (degrees of rotation). The apical rotation in this example is –7°, the minus sign depicting counterclockwise rotation. The basal rotation in the clockwise direction is 4°. Thus, the LV twist is 11°, and LV torsion is derived by dividing LV twist by the distance between the base and the apex in centimeters.

(A) A real time 3-dimensional full volume image is acquired in the apical 4-chamber view. (B) The image can be cropped and rotated along multiple planes (red, green, and blue lines) to isolate the left ventricle (LV) for analysis. (C) Application of an automated border detection algorithm yields a cast of the endocardium. (D) From the cast, LV cavity volumes can be calculated and tracked over the cardiac cycle. Stroke volume, end systolic and end diastolic volumes, ejection fraction, and filling dynamics can be measured. (E) The cast can also be automatically divided into wall segments. (F) Regional/segmental volume changes can be tracked over the cardiac cycle, enabling regional wall motion and dyssynchrony analyses.