Visual troubleshooting library
Acquisition, caliper placement, waveform selection, common errors and artifacts. Items without a cleared image use an honest description rather than a placeholder clip.
Native valves
- LVOT diameter and sample position — Zoomed parasternal long axis showing the centre axis of the LVOT and the aortic cusp insertion points.
- LVOT velocity and VTI sample position — Apical long-axis or five-chamber view, pulsed-wave Doppler.
- Aortic jet velocity: CW envelope selection — Continuous-wave Doppler with the dedicated (nonimaging) transducer from multiple windows: apical, right parasternal, suprasternal.
- MR, LVOT and AV signal differentiation — Apical CW and PW recordings; colour Doppler occasionally helps avoid an eccentric MR jet.
- PISA geometry — Zoomed colour Doppler of the regurgitant orifice, variance mapping off, baseline shifted in the direction of the jet.
- Mobile valvular structures — Zoomed parasternal and apical views of the valve, multiple planes; grayscale map with enough shades to show low-amplitude structures; TEE when shadowed.
Visual troubleshooting library
- CW envelope selection and Doppler gain — Any spectral Doppler recording (PW or CW), beam as parallel to flow as possible.
- Reverberation and comet-tail artifacts — Any 2D view; common behind the LAA ridge, in the ascending aorta, and distal to mechanical prostheses, leads and catheters.
- Mirror image artifact — Parasternal long axis beyond the pericardium; suprasternal aorta; subcostal IVC.
- Acoustic shadowing — Any view with calcification, prosthetic material, device leads or dense contrast between the transducer and the region of interest.
- Side lobe artifact — Near highly reflective structures: calcified sinotubular junction, pericardium in PLAX, far field of the apical four-chamber (atria).
- Beam width, slice thickness and refraction artifacts — Lateral artifacts in any view; ghost echoes mostly in echo-free cavities; duplicated structures lateral to the true one (e.g. aortic valve in short axis).
- Aliasing and range ambiguity — Pulsed-wave and colour Doppler; CW and HPRF as alternatives.
- Spectral Doppler artifacts: mirroring, double envelope, tiger stripes — PW and CW recordings, especially near the pleura or pericardium, across prosthetic or calcified valves, and over oscillating structures.
Left ventricle
- Foreshortening — Apical four- and two-chamber views at reduced depth focused on the LV cavity; dedicated atrial views separately.
- Strain tracking — Three apical views at reduced sector width including only the ventricles, true apex visualized, speckle tracking of the full wall.
- Regional wall thickening — Parasternal short axis at the papillary-muscle level (circular ventricle, papillary muscles not wobbling) plus apical views with the sector reduced to the ventricles; each segment in more than one view.
- Apical densities — Apical views with the focus and depth set for the near field; PSAX at the apical third (transducer down an interspace and lateral); colour Doppler with a low scale; UEA when uncertain.
- LV internal dimension: caliper placement — Parasternal long axis along the centre axis of the ventricle (papillary muscles not visible); biplane imaging can confirm perpendicular alignment.
Atria and diastolic function
- Atrial tracing — Dedicated apical four- and two-chamber views repositioned to maximize the base width and long axis of the left atrium.
- Mitral inflow E velocity sampling — Apical four-chamber, pulsed-wave Doppler.
- Tissue Doppler e′ sampling (septal and lateral annulus) — Apical four-chamber, pulsed tissue Doppler at the septal (medial) and lateral mitral annulus, beam as parallel as possible to annular motion.
Right heart and pulmonary pressures
- RV-focused acquisition — RV-focused apical four-chamber: from the A4C, rotate slightly counterclockwise at the apex to maximize RV area, keeping the LV apex centred and avoiding anterior tilt into a five-chamber view.
- Septal motion — PSAX at the papillary-muscle level for septal position and LVEI; A4C observed during respiration for interdependence; M-mode for timing.
- IVC measurement site — Subcostal long axis showing the IVC for several centimetres as it enters the right atrium, with the hepatic vein; patient supine.
- TR peak velocity signal selection — CW Doppler of the TR jet from multiple windows (apical, parasternal RV inflow, subcostal), colour-guided to align with the jet.