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Dedication
To the Washington University Cardiology Fellowship Program and
Barnes Jewish Hospital Cardiac Diagnostic Laboratory.
Contributors

Suzanne V. Arnold, MD, MHA

Assistant Professor
Department of Internal Medicine
Saint Luke’s Mid America Heart Institute
University of Missouri—Kansas City
Kansas City, Missouri
Mirnela Byku, MD, PhD
Fellow, Cardiovascular Disease
Washington University School of Medicine
St. Louis, Missouri
Pedro M. Calderón-Artero, MD, MS
Cardiology Fellow
Barnes-Jewish Hospital
Washington University School of Medicine
St. Louis, Missouri
Daniel H. Cooper, MD
Assistant Professor of Medicine
Associate Program Director for Electrophysiology
Cardiovascular Division, Department of Medicine
Clinical Cardiac Electrophysiologist
Barnes-Jewish Hospital
Washington University School of Medicine
St. Louis, Missouri
Sharon Cresci, MD
Assistant Professor
Departments of Medicine and Genetics
Washington University School of Medicine
St. Louis, Missouri
Rafael S. Garcia-Cortes, MD
Cardiology Fellow
Barnes-Jewish Hospital
Washington University School of Medicine
St. Louis, Missouri
Jacob S. Goldstein, MD
Cardiology Fellow
Barnes-Jewish Hospital
Washington University School of Medicine
St. Louis, Missouri
Justin Hartupee, MD, PhD
Cardiology Fellow
Department of Medicine
Washington University School of Medicine
St. Louis, Missouri
Christopher L. Holley, MD, PhD
Instructor of Medicine
Cardiovascular Division
Department of Internal Medicine
Washington University School of Medicine
St. Louis, Missouri
Kathryn J. Lindley, MD
Assistant Professor of Medicine
Cardiovascular Division
Washington University School of Medicine
St. Louis, Missouri
Brian R. Lindman, MD, MSCI
Assistant Professor of Medicine
Cardiovascular Division
Washington University School of Medicine
St. Louis, Missouri
Jose A. Madrazo, MD, FASE
Assistant Professor of Medicine
Johns Hopkins School of Medicine
Baltimore, Maryland
Majesh Makan, MD, FACC, FASE
Associate Professor of Medicine
Associate Director of Echocardiography
Division of Cardiology
Washington University School of Medicine
St. Louis, Missouri
Deana Mikhalkova, MD
Fellow
Department of Cardiology
Barnes-Jewish Hospital
Washington University School of Medicine
St. Louis, Missouri
Michael E. Nassif, MD
Fellow
Division of Cardiology
Washington University School of Medicine
St. Louis, Missouri
Olusegun Olusesi, MD
Cardiac Electrophysiology Fellow
Division of Cardiology
Washington University School of Medicine
St. Louis, Missouri
Julio E. Pérez, MD, FACC, FASE, FACP, FAHA
Professor of Medicine
Director of Echocardiography
Cardiovascular Division
Barnes-Jewish Hospital
Washington University School of Medicine
St. Louis, Missouri
Nishath Quader, MD, FACC, FASE
Assistant Professor of Medicine
Cardiovascular Division
Washington University School of Medicine
St. Louis, Missouri
Praveen K. Rao, MD
Cardiology Fellow
Barnes-Jewish Hospital
Washington University School of Medicine
St. Louis, Missouri
David S. Raymer, MD
Cardiology Fellow
Barnes-Jewish Hospital
Washington University School of Medicine
St. Louis, Missouri
Justin S. Sadhu, MD, MPHS, FACC
Instructor of Medicine
Cardiovascular Division
Department of Internal Medicine
Washington University School of Medicine
St. Louis, Missouri
Marc Sintek, MD
Interventional Fellow
Cardiovascular Division
Washington University School of Medicine
St. Louis, Missouri
Nishtha Sodhi, MD
Interventional Fellow
Cardiovascular Division
Washington University School of Medicine
St. Louis, Missouri
Tyson E. Turner, MD, MPH
Fellow
Cardiovascular Division
Washington University School of Medicine
St. Louis, Missouri
Justin M. Vader, MD
Assistant Professor of Medicine
Cardiovascular Division
Washington University School of Medicine
St. Louis, Missouri
Michael Yeung, MD
Assistant Professor
Department of Cardiology
University of North Carolina
Chapel Hill, North Carolina
Foreword
It is a pleasure to be able to write the forward for the second edition
of the Washington Manual of Echocardiography. The second edition
hues closely to the same guiding principles that formed the basis for
the first edition: namely, to provide a handheld, easy-to-use manual
that serves as a quick reference for physicians on call, in the
emergency room, on the wards, or in the intensive care unit.
Certainly there are a number of excellent, comprehensive textbooks
on echocardiography that are available; however, these books are
too big to fit into your pocket and take with you, and hence are less
useful in the middle of the night when one is faced with diagnosing
a critically ill patient rapidly. Increasingly cardiology fellows,
intensive care physicians, and emergency room physicians are being
placed in the situation of having to perform and interpret
echocardiograms, and to utilize this diagnostic information in real
time, in order to make split-second management decisions that have
life or death consequences. This book was written for you!
Dr. Nishath Quader, who is the new lead editor for the book, and
Drs. Makan and Perez have done a masterful job in updating the
second edition of the Washington Manual of Echocardiography. The
second edition is more than an update, it is re-envisioning of the
excellent first edition. For example, the second edition has been
completely reformatted in an “easy-to-read” layout with many new
and updated figures. The second edition has also been modernized
and includes a new chapter on imaging cardiac circulatory assist
devices, which is playing an increasingly important role in
managing critically ill patients. The second edition also features
extensive updates in the section on transesophageal
echocardiography, including new information on three-dimensional
imaging of mitral and aortic valves. Finally, the second edition is
written to reflect the latest American College of
Cardiology/American Heart Association (ACC/AHA) and American
Society of Echocardiography (ASE) guidelines, so that it serves as a
useful resource for trainees who are interested in board certification.
I am quite certain that the second edition of the Washington
Manual of Echocardiography will prove to be a useful and reliable
source of information for physicians and sonographers who provide
care for patients afflicted with cardiovascular disease. I am proud to
endorse this book, which I believe will not only prove to be a
worthy successor of the first edition, but will also be of great help to
health care providers who are on the front lines of cardiovascular
care.
Douglas L. Mann, MD
Preface
You are a first year cardiology fellow and the pager goes off; it’s the
ICU asking for a “stat” echo for assessment of a pericardial effusion
and possible tamponade. You have only been a cardiology fellow for
a short amount of time, so you want to quickly review the echo
findings of tamponade before making your way up to the ICU with
the echo machine. The only problem is, you didn’t bring your 785-
page echo textbook with you while you are on call!
The above scenario, in which cardiology fellows have to make
complex decisions at night, which are based, at least in part, on
echo images is becoming increasingly more common. Fellows are
faced with the daunting task of not only performing a quality
diagnostic echo but also interpreting it accurately. Even though
there are several excellent, comprehensive textbooks on
echocardiography available, our fellows have frequently commented
that they need a “handheld,” easy-to-carry book, that they can use
as a quick reference when important questions came up while on
call or on different cardiology rotations.
The goal of this book is to provide an introduction to
echocardiography, as well as highlight some of the critical
echocardiographic findings in the normal heart and in different
disease states. Thus, not only will cardiology fellows find this book
helpful, but so will anesthesia fellows and cardiac sonographers who
utilize echocardiography on a daily basis. In addition, intensive care
and emergency department physicians who also have been
increasingly utilizing hand-held ultrasound will find that this book
provides a succinct overview of disease states frequently
encountered by them.
After the wonderful feedback that we received from the first
edition of this book, it was clear that a second edition was needed in
order to keep pace with the rapid changes in the field. In keeping
with the purpose of the first edition (i.e., to provide a succinct
overview of various topics in echocardiography), the second edition
again focuses on critical aspects of interpreting echocardiograms in
different disease states. Although some of the sections retain the
same structure, each of the chapters has been revised extensively.
Moreover, this second edition is completely re-formatted in an
“easy-to-read” layout with multiple updated and additional figures.
This edition also features brand new chapters on hypertrophic
cardiomyopathy and cardiac devices (LVAD, IABP, Impella). These
chapters are designed with the latest American College of
Cardiology/American Heart Association (ACC/AHA) and American
Society of Echocardiography (ASE) guidelines in mind. In addition,
the chapter on LV systolic and diastolic function now has integrated
the updated chamber quantification guidelines by the ASE. The
chapters on valve assessment have incorporated the recent valvular
heart disease guidelines published by the ACC/AHA. This edition
also features several updates to the TEE section with a special focus
on the mitral valve and three-dimensional echocardiography.
The editors of this book would like to thank all the authors who
made the production of this book possible. We would also like to
thank our cardiology fellows who conceived the original idea for
this book. Without their relentless efforts to learn, provide great
clinical care to patients with complex diseases, and to provide a
unique perspective from a trainee’s standpoint, this book would not
have become a reality. Finally, we would like to thank our cardiac
sonographers who constantly strive to learn and improve their
echocardiographic skills and knowledge, and who provided the
spectacular images used in this book.
Nishath Quader
Majesh Makan
Julio Pérez
Contents
Contributors
Foreword
Preface

1 Introduction to Echocardiographic Principles

Jose A. Madrazo and Suzanne V. Arnold

2 The Comprehensive Transthoracic Echocardiographic

Examination
David S. Raymer

3 The Role of Contrast in Echocardiography

Majesh Makan

4 Quantification of Left Ventricular Systolic and

Diastolic Function
Praveen K. Rao and Christopher L. Holley

5 Right Ventricular Function and Pulmonary

Hemodynamics
Deana Mikhalkova and Nishath Quader

6 Stress Testing for Ischemia and Viability

Pedro M. Calderón-Artero and Daniel H. Cooper

7 Ischemic Heart Disease and Complications of

Myocardial Infarction
 Olusegun Olusesi and Michael Yeung

8 Cardiomyopathies
Mirnela Byku, Praveen K. Rao, and Christopher L. Holley

9 Hypertrophic Cardiomyopathy
Sharon Cresci

10 Aortic Valve Disease

Brian R. Lindman and Jacob S. Goldstein

11 Mitral Valve Disease

Brian R. Lindman and Nishath Quader

12 Pulmonic Valve
Tyson E. Turner, Kathryn J. Lindley, and Julio E. Pérez

13 Tricuspid Valve Disorders

Nishtha Sodhi and Julio E. Pérez

14 Evaluation of Prosthetic Valves

Jose A. Madrazo

15 Infective Endocarditis
Mirnela Byku, Majesh Makan, and Nishath Quader

16 Pericardial Disease and Cardiac Tamponade

Marc Sintek and Michael Yeung

17 Diseases of the Great Vessels: Aorta and Pulmonary

Artery
Praveen K. Rao and Nishath Quader

18 Congenital Heart Disease

Tyson E. Turner, Kathryn J. Lindley, and Majesh Makan
19 Cardiac Masses
Justin S. Sadhu

20 Cardiac Manifestations of Systemic Illness

Justin Hartupee and Justin M. Vader

21 Transesophageal Echocardiography
Rafael S. Garcia-Cortes, Praveen K. Rao, and Nishath Quader

22 Cardiac Devices in Heart Failure

Michael E. Nassif and Justin M. Vader

Index