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Visualization of the Hepatic Veins: New Approaches for the Echocardiographer
ORIGINAL ARTICLES
Visualization of the Hepatic Veins: New Approaches for the Echocardiographer Terry Reynolds, BS, Karen Szymanski, RDMS, Kathi Langenfeld, RDMS, and Christopher P. Appleton, MD, Phoenix and Tucson, Arizona
Visualization and cardiac Doppler interrogation of the hepatic veins has become an important and integral part of the routine echocardiographic examination. The challenge lies in adequate visualization of the hepatic veins by use of the standard subcostal approach. This article proposes alternate approaches when the standard view yields unsatisfactory visual and cardiac Doppler information. (JAM Soc EcHo 1991;4:93-6.)
For cardiac sonographers, visualization and Dopp ler interrogation of the hepatic veins has become an important and routine part of the echocardiographic examination (Figure l)Y Pulsed-wave Doppler spectral displays are now being used as aids in the evaluation of tricuspid regurgitation 3 (Figure 2), re strictive cardiomyopatht (Figure 3), constrictive pericarditis 5 (Figure 3), cardiac tamponade6 (Figure 3), and in the evaluation of decreased right ventric ular compliance2 (Figure 4). Color flow Doppler ex amination of the hepatic veins is especially helpful for guiding the pulsed-wave Doppler examination of the hepatic veins/ and color flow Doppler also aids in the evaluation of tricuspid regurgitation? The standard approach most often used by the echocardiographer to visualize and obtain Doppler images of the hepatic veins is the subxiphoid ap proach. 8 With the transducer in the subxiphoid area, a four-chamber view of the heart is obtained. The transducer is then angled medially until the inferior vena cava is seen entering the right atrium. With counterclockwise rotation of the transducer and fine medial and lateral angulation, the hepatic veins are brought into view (Figure 5). We have often found the standard approach to be unrewarding for a variety ofreasons including patient
From the Arizona Heart Instimte Foundation, Humana Hospital, Phoenix, and the Veterans Administration Medical Center, Tucson. Reprint requests: Terry Reynolds, BS, Director, School ofCardiac Ultrasound, Ariwna Heart Instimte Foundation, 2632 North 20th St., Phoenix, AZ 85006. 27/l/26575
.2m/s ,
•
~epatic
.• Vein
Velocity curve of a normal hepatic vein. An regrade (negative) flow is evident during both systole (S wave) and diastole (D wave). Systolic flow is greater than diastolic flow. There is a small reversal at the time of atrial contraction (A wave) and a small reversal may be seen at end systole (V wave). (From Nishimura R, Abel M, Hade L, Tajik J. Assessment of diastolic function of the heart: background and current applications of Doppler echocar diography. Part II. Clinical studies. Mayo Clin Proc 1989;64:181-204. Reprinted with permission.)
Figure 1
body habitus and respiratory variations. Nishimura et al. 2 reported similar difficulties in acquiring Dopp ler spectral tracings of the hepatic vein. Appleton et al_9 reported that adequate pulsed-wave Doppler recordings ofthe hepatic vein were obtainable in only 30% of normal healthy adults. We propose alterna tive approaches for the adequate visualization and
93
94
Journal of the American Society of Echocardiography
Reynolds et a!.
NormaI <>~ ""76~~/\~~-----~~~--~
v
Mild-mod
Severe
A, Hepatic vein flow velocity from a patient with severe tricuspid regurgitation. Figure 2 Because of regurgitation, holosystolic reversal is present. All antegrade (forward) flow occurs during diastole. B, Diagram of spectrum of venous inflow patterns occurring with various degrees of tricuspid regurgitation. mod, moderate. (From Nishimura R, Abel M, HadeL, Tajik AJ. Assessment of diastolic function of the heart: background and current applications of Doppler echocardiography. Part II. Clinical studies. Mayo Clio Proc 1989;64:195. Reprinted with permission.)
Figure 3 This schematic figure shows electrocardiogram and the pulsed Doppler hepatic venous flow profile during different phases of respiration from a normal subject and patients of restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade. In restrictive cardiomyopathy, there is inspiratory decrease and/or flow reversal during systole (dark shaded area) and at the time of atrial contraction (AR). In constrictive pericarditis and cardiac tam ponade there is marked decrease of forward diastolic flow and marked reversal at the time of AR. D, Diastolic forward flow; S, systolic forward flow; VR, end-systolic or V wave-related reverse flow. (From Bansal RC, Chandrasekaran K. Role of echocardiography and Doppler techniques in the evaluation ofpericardial diseases. Echocardiography 1989;6:313. Reprinted with permission.)
Doppler interrogation of the hepatic veins. In the first alternative approach, the patient is placed on his or her left side. The transducer, with the index mark pointed toward the patient's feet, is placed in a lo-
cation that is obtained by drawing an imaginary line from the xiphoid process laterally to the right mid axillary area. With the transducer in the right mid axillary area at the level of the xiphoid process, the
Volume 4 Number 2 March-Aprill99l
Visualization of hepatic veins
95
.
•
•
v
syst
-•
-
I
--
•
•
.2m/s
·
••
•
.2m/s1 .
Figure 4 Hepatic vein velocity curve of a normal patient (A), showing characteristic systolic (syst) and diastolic (diast) patterns, and of a patient with right ventricular hypertrophy (B) in whom all forward flow is during systole, and diastolic flow is completely absent (vertical arrowhead). This indicated decreased right ventricular compliance. Flow reversal is increased (horizontal arrowhead) with the onset of atrial contraction (a). (From Nishimura R, Abel M, Hade L, Tajik J. Assessment of diastolic ftmction of the heart: background and current ap plications ofDoppler echocardiography. Part II. Clinical studies. Mayo Clin Proc 1989;64: 198. Reprinted with permission.)
Figure 5 Real-time image acquired by the standard ap proach. HV, Hepatic vein; IVC, inferior vena cava; RA, right atrium.
Figure 6 Real-time image obtained with the transducer in the right midaxillary area at the level of the xiphoid process. HV, Hepatic vein; IVC, inferior vena cava; RA, right atrium; AO, aorta.
liver is used as an ultrasonic "window," and the he patic veins will be effectively visualized (Figure 6). Fine angulation of the transducer anteriorly or pos teriorly may be necessary to enhance the real-time image. Having the patient sitting up or lying supine may also help to enhance the visualization of the
hepatic veins from this transducer position. The second alternative approach that we have found very useful is acquired by having the patient lay in the supine position and sliding the transducer from the subxiphoid area used in the standard ap proach laterally toward the patient's right side along
96
Journal ofthe American Society of Echocardiography
Reynolds et a!.
With such great interest currently in the visualiza tion and Doppler interrogation of the hepatic veins in echocardiography, new approaches have been sug gested. These approaches should be used whenever the standard approach fails to adequately provide the necessary visualization and Doppler information on the hepatic veins. REFERENCES
Figure 7 Real-time image obtained with the transducer placed subcostally in line with the patient's right midcla vicular area. HV, Hepatic vein; PV, portal vein.
the costal margin until the transducer is in line with the right midclavicular area. With the transducer in this subcostal position in line with the patient's right midclavicular area, the liver may be used as an ultra sonic ''window," and the hepatic veins will be ade quately visualized (Figure 7). The transducer index mark will be pointed toward the patient's left shoul der. Anterior or posterior angulation of the trans ducer may be necessary to enhance the real-time lffiage.
l. Feigenbaum H. Echocardiography. 4th ed. Philadelphia: Lea and Febiger, 1986:108-9. 2. Nishimura R, Abel M, Hade L, Tajik J. Assessment ofdiastolic function of the heart: background and current applications of Doppler echocardiography. Part II. Clinical studies. Mayo Clin Proc 1989;64:181-204. 3. Nanda N. Doppler Echocardiography. New York: Igaku Shoin, 1985:136. 4. Appleton C, Hade L, Popp R. Demonstration of restrictive ventricular physiology by Doppler echocardiography. J Am Coil Cardia! 1988;11:757-68. 5. Bibra H, Schober K, Jenni R, Busch R, Sebening H, Blamer H. Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography of the hepatic vein. Am J Cardia! 1989; 63:483-8. 6. Bansal RC, Chandrasekaran K. Role of echocardiography and Doppler techniques in the evaluation of pericardia! diseases. Echocardiography 1989;6:293-315. 7. Kisslo J, Adams D, Belkin R. Doppler color flow imaging. New York: Churchill Livingston, 1988:105-12. 8. Weyman A. Cross-sectional echocardiography. 1st ed. Phila delphia: Lea and Febiger, 1981:129. 9. Appleton C, HadeL, Popp R. Superior vena cava and hepatic vein Doppler echocardiography in healthy adults. J Am Coil Cardia! 1987;10:1032-9.
Visualization of the Hepatic Veins: New Approaches for the Echocardiographer Terry Reynolds, BS, Karen Szymanski, RDMS, Kathi Langenfeld, RDMS, and Christopher P. Appleton, MD, Phoenix and Tucson, Arizona
Visualization and cardiac Doppler interrogation of the hepatic veins has become an important and integral part of the routine echocardiographic examination. The challenge lies in adequate visualization of the hepatic veins by use of the standard subcostal approach. This article proposes alternate approaches when the standard view yields unsatisfactory visual and cardiac Doppler information. (JAM Soc EcHo 1991;4:93-6.)
For cardiac sonographers, visualization and Dopp ler interrogation of the hepatic veins has become an important and routine part of the echocardiographic examination (Figure l)Y Pulsed-wave Doppler spectral displays are now being used as aids in the evaluation of tricuspid regurgitation 3 (Figure 2), re strictive cardiomyopatht (Figure 3), constrictive pericarditis 5 (Figure 3), cardiac tamponade6 (Figure 3), and in the evaluation of decreased right ventric ular compliance2 (Figure 4). Color flow Doppler ex amination of the hepatic veins is especially helpful for guiding the pulsed-wave Doppler examination of the hepatic veins/ and color flow Doppler also aids in the evaluation of tricuspid regurgitation? The standard approach most often used by the echocardiographer to visualize and obtain Doppler images of the hepatic veins is the subxiphoid ap proach. 8 With the transducer in the subxiphoid area, a four-chamber view of the heart is obtained. The transducer is then angled medially until the inferior vena cava is seen entering the right atrium. With counterclockwise rotation of the transducer and fine medial and lateral angulation, the hepatic veins are brought into view (Figure 5). We have often found the standard approach to be unrewarding for a variety ofreasons including patient
From the Arizona Heart Instimte Foundation, Humana Hospital, Phoenix, and the Veterans Administration Medical Center, Tucson. Reprint requests: Terry Reynolds, BS, Director, School ofCardiac Ultrasound, Ariwna Heart Instimte Foundation, 2632 North 20th St., Phoenix, AZ 85006. 27/l/26575
.2m/s ,
•
~epatic
.• Vein
Velocity curve of a normal hepatic vein. An regrade (negative) flow is evident during both systole (S wave) and diastole (D wave). Systolic flow is greater than diastolic flow. There is a small reversal at the time of atrial contraction (A wave) and a small reversal may be seen at end systole (V wave). (From Nishimura R, Abel M, Hade L, Tajik J. Assessment of diastolic function of the heart: background and current applications of Doppler echocar diography. Part II. Clinical studies. Mayo Clin Proc 1989;64:181-204. Reprinted with permission.)
Figure 1
body habitus and respiratory variations. Nishimura et al. 2 reported similar difficulties in acquiring Dopp ler spectral tracings of the hepatic vein. Appleton et al_9 reported that adequate pulsed-wave Doppler recordings ofthe hepatic vein were obtainable in only 30% of normal healthy adults. We propose alterna tive approaches for the adequate visualization and
93
94
Journal of the American Society of Echocardiography
Reynolds et a!.
NormaI <>~ ""76~~/\~~-----~~~--~
v
Mild-mod
Severe
A, Hepatic vein flow velocity from a patient with severe tricuspid regurgitation. Figure 2 Because of regurgitation, holosystolic reversal is present. All antegrade (forward) flow occurs during diastole. B, Diagram of spectrum of venous inflow patterns occurring with various degrees of tricuspid regurgitation. mod, moderate. (From Nishimura R, Abel M, HadeL, Tajik AJ. Assessment of diastolic function of the heart: background and current applications of Doppler echocardiography. Part II. Clinical studies. Mayo Clio Proc 1989;64:195. Reprinted with permission.)
Figure 3 This schematic figure shows electrocardiogram and the pulsed Doppler hepatic venous flow profile during different phases of respiration from a normal subject and patients of restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade. In restrictive cardiomyopathy, there is inspiratory decrease and/or flow reversal during systole (dark shaded area) and at the time of atrial contraction (AR). In constrictive pericarditis and cardiac tam ponade there is marked decrease of forward diastolic flow and marked reversal at the time of AR. D, Diastolic forward flow; S, systolic forward flow; VR, end-systolic or V wave-related reverse flow. (From Bansal RC, Chandrasekaran K. Role of echocardiography and Doppler techniques in the evaluation ofpericardial diseases. Echocardiography 1989;6:313. Reprinted with permission.)
Doppler interrogation of the hepatic veins. In the first alternative approach, the patient is placed on his or her left side. The transducer, with the index mark pointed toward the patient's feet, is placed in a lo-
cation that is obtained by drawing an imaginary line from the xiphoid process laterally to the right mid axillary area. With the transducer in the right mid axillary area at the level of the xiphoid process, the
Volume 4 Number 2 March-Aprill99l
Visualization of hepatic veins
95
.
•
•
v
syst
-•
-
I
--
•
•
.2m/s
·
••
•
.2m/s1 .
Figure 4 Hepatic vein velocity curve of a normal patient (A), showing characteristic systolic (syst) and diastolic (diast) patterns, and of a patient with right ventricular hypertrophy (B) in whom all forward flow is during systole, and diastolic flow is completely absent (vertical arrowhead). This indicated decreased right ventricular compliance. Flow reversal is increased (horizontal arrowhead) with the onset of atrial contraction (a). (From Nishimura R, Abel M, Hade L, Tajik J. Assessment of diastolic ftmction of the heart: background and current ap plications ofDoppler echocardiography. Part II. Clinical studies. Mayo Clin Proc 1989;64: 198. Reprinted with permission.)
Figure 5 Real-time image acquired by the standard ap proach. HV, Hepatic vein; IVC, inferior vena cava; RA, right atrium.
Figure 6 Real-time image obtained with the transducer in the right midaxillary area at the level of the xiphoid process. HV, Hepatic vein; IVC, inferior vena cava; RA, right atrium; AO, aorta.
liver is used as an ultrasonic "window," and the he patic veins will be effectively visualized (Figure 6). Fine angulation of the transducer anteriorly or pos teriorly may be necessary to enhance the real-time image. Having the patient sitting up or lying supine may also help to enhance the visualization of the
hepatic veins from this transducer position. The second alternative approach that we have found very useful is acquired by having the patient lay in the supine position and sliding the transducer from the subxiphoid area used in the standard ap proach laterally toward the patient's right side along
96
Journal ofthe American Society of Echocardiography
Reynolds et a!.
With such great interest currently in the visualiza tion and Doppler interrogation of the hepatic veins in echocardiography, new approaches have been sug gested. These approaches should be used whenever the standard approach fails to adequately provide the necessary visualization and Doppler information on the hepatic veins. REFERENCES
Figure 7 Real-time image obtained with the transducer placed subcostally in line with the patient's right midcla vicular area. HV, Hepatic vein; PV, portal vein.
the costal margin until the transducer is in line with the right midclavicular area. With the transducer in this subcostal position in line with the patient's right midclavicular area, the liver may be used as an ultra sonic ''window," and the hepatic veins will be ade quately visualized (Figure 7). The transducer index mark will be pointed toward the patient's left shoul der. Anterior or posterior angulation of the trans ducer may be necessary to enhance the real-time lffiage.
l. Feigenbaum H. Echocardiography. 4th ed. Philadelphia: Lea and Febiger, 1986:108-9. 2. Nishimura R, Abel M, Hade L, Tajik J. Assessment ofdiastolic function of the heart: background and current applications of Doppler echocardiography. Part II. Clinical studies. Mayo Clin Proc 1989;64:181-204. 3. Nanda N. Doppler Echocardiography. New York: Igaku Shoin, 1985:136. 4. Appleton C, Hade L, Popp R. Demonstration of restrictive ventricular physiology by Doppler echocardiography. J Am Coil Cardia! 1988;11:757-68. 5. Bibra H, Schober K, Jenni R, Busch R, Sebening H, Blamer H. Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography of the hepatic vein. Am J Cardia! 1989; 63:483-8. 6. Bansal RC, Chandrasekaran K. Role of echocardiography and Doppler techniques in the evaluation of pericardia! diseases. Echocardiography 1989;6:293-315. 7. Kisslo J, Adams D, Belkin R. Doppler color flow imaging. New York: Churchill Livingston, 1988:105-12. 8. Weyman A. Cross-sectional echocardiography. 1st ed. Phila delphia: Lea and Febiger, 1981:129. 9. Appleton C, HadeL, Popp R. Superior vena cava and hepatic vein Doppler echocardiography in healthy adults. J Am Coil Cardia! 1987;10:1032-9.