Role of M-mode Technique in Today’s

Echocardiography
Harvey Feigenbaum, MD, FASE, Indianapolis, Indiana

M-mode echocardiography is considered to be obsolete by many. The technique rarely is included in Amer-
ican Society of Echocardiography standards documents, except for M-mode measurements, which have
limited value. The superior temporal resolution of M-mode echocardiography is frequently overlooked. Dopp-
ler recordings reflect blood velocity, whereas M-mode motion of cardiac structures reflect volumetric blood
flow. The 2 examinations are hemodynamically complementary. In the current digital era, recording multiple
cardiac cycles of two-dimensional echocardiographic images is no longer necessary. However, there are
times when intermittent or respiratory changes occur. The M-mode technique is an effective and efficient
way to record the necessary multiple cardiac cycles. In certain situations, M-mode recordings of the valves
and interventricular septum can be particularly helpful in making a more accurate and complete echocardio-
graphic cardiac assessment, thus helping to make the examination more cost-effective. (J Am Soc Echocar-
diogr 2010;23:240-57.)

BACKGROUND trasonography. The first long-lasting diagnostic cardiac ultrasound

application, the detection of pericardial effusion, used A-mode ultra-
Echocardiography is by definition the examination of the heart using sonic signals. The B-mode (brightness-based) technique converted the
reflected ultrasound. Over the years, the examination has developed ultrasonic A-mode ‘‘spike’’ to a ‘‘dot’’ and amplitude to brightness. This
into a multitude of different ways to examine the heart ultrasonically. change left a dimension available for ‘‘time.’’ Thus, by sweeping the
These technologies are frequently described from a historical perspec- B-mode dot across the oscilloscope, we had M-mode (motion-based)
tive. I and others began using real-time A-mode (amplitude-based) ul- ultrasonography. This M-mode approach was the principle technology
available for approximately 10 years. Then a variety of two-dimensional
Accreditation Statement (2D) approaches became available. Shortly thereafter, Doppler tech-
The American Society of Echocardiography is accredited by the Accreditation Council niques for recording intracardiac blood flow were described. The
for Continuing Medical Education to provide continuing medical education for
physicians.
next development was displaying the Doppler signal as a 2D image us-
The American Society of Echocardiography designates this educational activity for ing color to denote the direction and character of the flow.
a maximum of 1 AMA PRA Category 1 CreditÔ. Physicians should only claim credit com- Because of these developments, there were 2 approaches to the
mensurate with the extent of their participation in the activity.
ARDMS and CCI recognize ASE’s certificates and have agreed to honor the credit hours ultrasonic examination of the heart. The first was a one-dimensional
toward their registry requirements for sonographers. or ‘‘ice-pick view’’ displaying the location and motion of the heart, usu-
The American Society of Echocardiography is committed to ensuring that its educa-
ally with a sampling rate of approximately 2000 frames per second.1
tional mission and all sponsored educational programs are not influenced by the special
interests of any corporation or individual, and its mandate is to retain only those authors The second was a more anatomically correct 2D or cross-sectional
whose financial interests can be effectively resolved to maintain the goals and educa- display of the heart with an initial frame rate of approximately 30
tional integrity of the activity. While a monetary or professional affiliation with a corpo-
ration does not necessarily influence an author’s presentation, the Essential Areas and
frames per second. The 2D frame rate is now up to approximately
policies of the ACCME require that any relationships that could possibly conflict with 100 frames per second. A similar approach was done with the
the educational value of the activity be resolved prior to publication and disclosed to Doppler recordings of blood flow. Initially, there was a single-
the audience. Disclosures of faculty and commercial support relationships, if any,
have been indicated. dimensional recording of the Doppler signal recorded against time
Target Audience on a strip chart recorder. This spectral display could be used with
This activity is designed for all cardiovascular physicians and cardiac sonographers with
a primary interest and knowledge base in the field of echocardiography: in addition, res-
either pulsed- or continuous-wave Doppler. Then a 2D approach
idents, researchers, clinicians, intensivists, and other medical professionals with a spe- was developed using color Doppler that was displayed as a moving
cific interest in cardiac ultrasound will find this activity beneficial. picture. In many ways, the single-dimensional or spectral Doppler
Objectives
Upon completing the reading of this article, the participants will better be able to:
recording of blood flow is essentially equivalent to the M-mode re-
cording of the valves and walls. From a historical point of view, it is
1. Describe the evolution of echocardiographic techniques.
interesting that the 1-dimensional recording of spectral Doppler has
2. Recognize clinical situations in which the sampling rate of M-mode provides specific
and precise information unavailable with the 2D sampling rate. persisted, but the 1-dimensional M-mode technique for recording tis-
3. Predict certain hemodynamic parameters from specific patterns of valve motion as sue has been considered obsolete by many. Although there are still M-
observed on M-mode.
4. Correlate M-mode patterns with spectral Doppler findings.
5. Identify specific M-mode patterns of the interventricular septum in various clinical
scenarios, especially left ventricular dysfunction and volume overload, conduction From the Indiana University Hospital, Indianapolis, Indiana.
abnormalities, and pericardial disease.
Reprint requests: Harvey Feigenbaum, MD, FASE, Krannert Institute of Cardiology,
Author Disclosure 1801 N. Senate Blvd., Indianapolis, IN 46202 (E-mail: [email protected]).
The author of this article reported no actual or potential conflicts of interest in relation
0894-7317/$36.00
to this activity.
Copyright 2010 by the American Society of Echocardiography.
Estimated Time to Complete This Activity: 1 hour
doi:10.1016/j.echo.2010.01.015
240
Journal of the American Society of Echocardiography Feigenbaum 241
Volume 23 Number 3

Figure 2 A, Mitral valve M-mode of a normal subject. B, Mitral

valve M-mode recording of a patient with a dilated left ventricle,
reduced mitral flow, reduced ejection fraction, and elevated LV
end-diastolic pressure. (From Feigenbaum H. Echocardiogra-
phy. 1st ed. Philadelphia, PA: Lea and Febiger; 1972.)

ventricular septum, move very quickly. There are circumstances in

Figure 1 Normal M-mode recording of the mitral valve. (From which temporal resolution or sampling rate can be critical in detecting
Feigenbaum H. Echocardiography. 1st ed. Philadelphia, PA: very rapid or subtle motions. Even with the fastest 2D imaging device,
Lea and Febiger; 1972.) it is unusual to record more than 100 frames per second. The original
stand-alone M-mode instruments recorded at a sampling rate of 2000
mode questions on the echocardiography board examinations, and per second. Even with the 2D-guided M-mode recording of today, the
they are sometimes a part of ‘‘quiz shows’’ at meetings, M-mode find- sampling rate is still at least 1000 samples per second. The introduc-
ings are rarely a part of official echocardiography standards docu- tion of 2D or color Doppler certainly did not make the spectral dis-
ments except for M-mode dimensions, which now only have play of Doppler obsolete. The same should have been true with
limited applications because M-mode measurements are heavily tissue imaging. The introduction of 2D tissue imaging does not
influenced by the location of the available acoustic windows. Thus, make M-mode tissue imaging irrelevant.
the M-mode left ventricular (LV) diameter is rarely the true minor di- This review of what M-mode echocardiography can provide in to-
mension and varies depending on the location of the acoustic win- day’s echocardiographic examination will hopefully reintroduce
dow. In addition, the M-mode beam is stationary while the heart is some of the unique advantages of recording cardiac valves and walls
moving, that is, the diastolic measurement is at a slightly different with a temporal resolution of 1000 samples per second. This discus-
location than the systolic measurement. Direct measurements made sion is by no means intended to be an exhaustive review of all the pos-
from 2D echocardiograms overcome these problems. sible uses of M-mode techniques in today’s echocardiography. I will
The exact reason for the clinical disappearance of M-mode record- only review what I consider to be some of the more relevant uses
ings of valves and walls is difficult to explain. Admittedly, many of the of the historically older technique.
applications that were done with the M-mode technique became ob-
solete when 2D echocardiography was developed. The single dimen-
sions that one would record and measure with M-mode were no M-MODE RECORDING OF THE MITRAL VALVE
longer necessary once 2D echocardiography became available. The
more correct anatomic shape and size of cardiac structures were The fastest moving structure within the heart is probably the mitral
now available with the 2D technique. Some M-mode diagnoses, valve. Figure 1 describes an M-mode recording of a normal mitral
such as fluttering of the mitral valve for the diagnosis of aortic regur- valve. This is an old recording that was taken at a sampling rate of
gitation, were no longer relevant with the availability of Doppler tech- 2000 samples per second. The various labels that were placed on
niques. However, the almost complete abandonment of M-mode the valve are indicated. This particular normal valve was selected par-
echocardiography ignored the fact that we are still examining a mov- tially because it exhibits a finding that is distinctly different from a sim-
ing object. Some of these structures, especially the valves and inter- ilar recording of mitral Doppler flow. In this normal subject, there is
242 Feigenbaum Journal of the American Society of Echocardiography
March 2010

Figure 3 An old 2000 samples per second mitral valve M-mode recording (A) and a recent 1000 samples per second M-mode mitral
valve recording (B) in patients with elevated LV end-diastolic pressure. (A, From Feigenbaum H. Echocardiography. 1st ed. Philadel-
phia, PA: Lea and Febiger; 1972.)

Figure 4 Relationship between LV and left atrial diastolic pres-

sure and mitral valve motion (From Feigenbaum H. Echocardi- Figure 5 Mitral valve recording in a patient with acute severe
ography. 1st ed. Philadelphia, PA: Lea and Febiger; 1972.) aortic regurgitation and elevated LV diastolic pressure. There
is a timeline right after the C-point. By following that timeline
to the electrocardiogram, one can appreciate that the C-point
occurs before the electrical QRS and therefore before ventricu-
a mid-diastolic reopening of the mitral valve. This simulates a Doppler lar contraction. (From Feigenbaum H. Echocardiography. 1st ed.
signal in mid-diastole called the ‘‘L-wave.’’ The L-wave, which reflects Philadelphia, PA: Lea and Febiger; 1972.)
flow velocity, is usually considered to be an abnormal sign indicative
of diastolic dysfunction or abnormal LV filling. However, the mid- it is usually a normal finding. A detailed discussion as to the mecha-
diastolic reopening of the mitral valve in the M-mode recording in nism for the L-wave and mitral valve mid-diastolic reopening might
Figure 1 represents volumetric blood flow rather than velocity. help to explain the differences in these 2 echocardiographic findings;
Although this may also appear in patients with diastolic dysfunction, however, the main point is to illustrate that an M-mode recording may
Journal of the American Society of Echocardiography Feigenbaum 243
Volume 23 Number 3

Figure 6 M-mode mitral valve recordings of patients with mitral valve systolic anterior mitral valve motion. A, The mitral valve touches
the interventricular septum in mid-systole. B, The mitral valve touches the septum only briefly in late systole. C, The mitral valve strikes
the septum in early systole and stays in contact with the septum almost throughout systole in this patient with hypertrophic cardio-
myopathy and severe LV outflow tract obstruction.

Figure 7 Mitral valve recording in patients with mitral valve prolapse. A, The posterior motion of the posterior leaflet begins in early
diastole as it separates from the anterior leaflet. In mid-systole both leaflets move abruptly posteriorly. This mid to late displacement
of the mitral valve is the characteristic M-mode sign of mitral valve prolapsed (arrow). B, Mitral valve recording of another patient with
mitral valve prolapse. In this case the posterior motion of the leaflets is limited to late systole (arrow).
244 Feigenbaum Journal of the American Society of Echocardiography
March 2010

Figure 8 M-mode recordings of the aortic valve in a patient with a normal valve (A) and a patient with valvular aortic stenosis (B). Both
valves produce a parallelogram on the M-mode tracing; however, the stenotic valve is more echogenic and the separation of the leaf-
lets is reduced. Although this recording provides no quantitative information, it does confirm that if there is LV outflow obstruction,
then the aortic valve is at least a contributor of, if not the sole reason for, the obstruction. (From Feigenbaum H. Echocardiography. 1st
ed. Philadelphia, PA: Lea and Febiger; 1972.)

look similar to a Doppler recording and the 2 findings may occur in stroke volume, which are the 2 components of ejection fraction.
the same patient, but in reality they are not the same but rather com- The EPSS is not valid in some patients with primary valvular abnor-
plementary. One represents blood velocity, and the other reflects vol- malities. Mitral valve motion in patients with mitral stenosis and pa-
umetric flow. tients with aortic regurgitation is distorted by factors other than
Figure 2 shows some of the obvious diagnostic value of an M-mode flow passing through the valve and cannot be used to measure EPSS.
mitral valve recording. Figure 2A again exhibits a normal M-mode mi- Another observation in Figure 2 is that the A-wave of the mitral
tral valve. The excursions of the anterior and posterior leaflets virtually valve looks decidedly different between Figure 2A and B. In
fill the LV cavity. The mitral anterior leaflet reaches its peak at the Figure 2B the amplitude of the A-wave is reduced and the slope of
E-wave that almost touches the interventricular septum. The posterior the mitral motion after the peak of the A-wave is much different
leaflet moves in an opposite direction as the 2 leaflets separate from than the slope in the normal recording. In Figure 2B there is a more
each other. The M-mode recording in Figure 2B, which has the same gradual closure of the mitral valve after the peak of the A-wave.
calibration as Figure 2A, is grossly different. The LV cavity is much There is also a slight interruption of mitral closure. Clearer examples
larger with the location of the posterior ventricular wall being much of interrupted mitral valve closure are illustrated in Figure 3. This find-
further from the transducer. The size and shape of the mitral valve ing is helpful in identifying patients with an elevated LV end-diastolic
in Figure 2B are strikingly different from that in Figure 2A. The dis- pressure.
tance between the anterior and posterior leaflets is substantially less Figure 4 shows how mitral valve closure is related to LV and left
than in Figure 2A. This finding is indicative of decreased blood flow atrial pressures.6,7 Normally, mitral valve closure begins with atrial
passing through the mitral orifice, or at least reduced flow relative relaxation and then is completed with LV contraction. This process
to the size of the ventricle. The increased distance or separation be- is usually smooth and uninterrupted. The corresponding pressure
tween the peak of the mitral valve opening or E-point and the septum between the left atrium and the left ventricle is characterized by
is obvious. This E-point septum separation (EPSS) has been used for a gradual increase in left atrial pressure after atrial contraction,
years as an indicator of global LV function.2-5 Any EPSS greater which in turn produces a gradual increase in LV pressure. When
than 1 cm is considered to be abnormal.4 There is a good theoretic there is an elevated LV end-diastolic pressure as a result of the left
reason why EPSS correlates with ejection fraction. Ejection fraction atrium contracting against a stiff or already fully dilated left ventricle,
is stroke volume divided by diastolic volume. The flow going through there is a rapid increase in the LV pressure to a point that it exceeds
the mitral valve is related to stroke volume. Therefore, the E-point is the left atrial pressure earlier than is normal.8 This earlier reversal in
reduced because of the small amount of blood flowing through the the pressures causes the peak of the mitral valve A-wave to be earlier.
mitral orifice. As the left ventricle dilates, the mitral valve apparatus, Then there is a more prolonged closure of the mitral valve before ven-
which is more closely aligned to the posterior ventricular wall, moves tricular contraction with a frequent interruption or plateau caused by
away from the interventricular septum. Thus, the E-point septal sepa- equalization of the pressures. This interruption is called a ‘‘B-bump,’’
ration is related to the LV end-diastolic volume and the transmitral
Journal of the American Society of Echocardiography Feigenbaum 245
Volume 23 Number 3

Figure 9 A, Mid-systolic closure of the aortic valve caused by dynamic obstruction of the LV outflow tract in a patient with hypertro-
phic obstructive cardiomyopathy. B, M-mode aortic valve recording in a patient with discreet membranous subaortic stenosis. The
valve initially opens fully and then abruptly closes. (Courtesy of Alan S. Pearlman, MD.)

or ‘‘notch’’ or ‘‘shoulder,’’ between the A and C points of the mitral Figure 5 shows another mitral valve M-mode recording indica-
valve. tive of an elevated LV diastolic pressure. This older recording
In current discussions of diastolic function and LV pressure, the shows premature closure (C) of the mitral valve before electric de-
M-mode mitral valve ‘‘B-bump’’ is almost never mentioned. It is not polarization. This finding is indicative of a patient with severe aor-
a strictly quantitative assessment; however, it almost never occurs un- tic regurgitation in whom the LV diastolic pressure increases
less the LV end-diastolic pressure is more than 20 mm Hg.6 Figure 3A dramatically to the point that it closes the mitral valve before ven-
shows a distinct plateau between the A and C points of the mitral tricular contraction.1
valve. This recording was made with the older technique using Several well-recognized findings on an M-mode recording of the mi-
2000 samples per second. Figure 3B shows a more recent study tral valve are also seen with 2D echocardiography, and the hemody-
with standard 2D-guided M-mode echocardiography again showing namic consequences are recorded with Doppler techniques. One of
the interrupted closure of the mitral valve after the A-wave. This these is systolic anterior motion (SAM) of the mitral valve, which is indic-
M-mode finding is still relevant today. It may be one of the easier ative of a dynamic obstruction of the LVoutflow tract.9,10 Historically, the
ways to help identify mitral flow Doppler ‘‘pseudo-normalization’’ M-mode technique was the first to describe this phenomenon. Figure 6
and an elevated LVend-diastolic pressure. A ‘‘B-bump’’ is not a normal shows 3 different varieties of SAM. Figure 6A shows a recording in a pa-
finding and should not occur if the LV diastolic pressure is normal and tient with known hypertrophic cardiomyopathy where the SAM gradu-
the mitral flow is truly normal. This M-mode finding can also be useful ally approaches the interventricular septum and then falls away before
in differentiating patients who have a mitral Doppler E/A ratio less the onset of diastole. Figure 6B shows another patient with SAM
than 1 because of abnormal LV relaxation from those in whom the whereby the mitral valve apparatus only briefly touches the interventric-
abnormal ratio is caused by low LV filling pressures. Patients with di- ular septum late in systole. Figure 6C shows yet a more severe form of
astolic dysfunction frequently may have elevated diastolic pressures SAM that is almost undoubtedly caused by hypertrophic cardiomyopa-
and an M-mode B-bump, which will not be present with low LV thy and fairly significant LV outflow tract obstruction. There is early ap-
filling pressures. This situation is another example of how M-mode position of the mitral valve to the interventricular septum, and the
and Doppler recordings can provide complementary hemodynamic valve stays in contact with the septum almost throughout systole. The
information. duration of contact between the mitral valve and the septum is one
246 Feigenbaum Journal of the American Society of Echocardiography
March 2010

Figure 11 Aortic valve M-mode recording demonstrating varia-

tions in systolic valve motion reflecting changes in volume of
blood passing through the valve. In this patient with atrial fibril-
lation and very poor cardiac function, there is also diminished
amplitude of motion of the posterior aortic wall reflecting poor
overall cardiac function and changes in left atrial volume. PA,
pulmonary artery; RV, right ventricular.

M-MODE RECORDING OF THE AORTIC VALVE

Although the motion of the aortic valve is not as complex as the mitral
Figure 10 M-mode aortic valve recording showing gradual clo- valve, an M-mode recording of this structure also can provide useful
sure of the valve throughout systole. This finding indicates that clinical information even in today’s practice of echocardiography.
blood flow through the valve is constantly decreasing during Figure 8A shows a normal recording of the aortic valve. The aortic
systole either because a left ventricle is too weak to maintain valve produces a characteristic parallelogram whereby 2 of the 3
constant flow or the blood is leaving the left ventricle via a regur- leaflets are seen moving parallel to each other throughout systole.
gitant mitral valve rather than via the aorta. (From Feigenbaum Figure 8B shows an M-mode recording of a thickened, somewhat ste-
H. Echocardiography. 1st ed. Philadelphia, PA: Lea and Febiger; notic aortic valve. Originally, we thought we could judge the severity
1972.)
of the aortic stenosis by seeing the separation of the 2 leaflets; how-
ever, this proved to be unreliable, especially with congenital aortic ste-
nosis. The real value in looking at the valve in Figure 8B is the
way of judging the severity of obstruction.10 However, now we rely on observation that the leaflets are thickened and, more important, mov-
Doppler recordings for making this assessment. ing parallel to each other. In the setting of LV outflow obstruction, this
SAM can be recorded with 2D echocardiography; however, the finding clearly denotes that at least part if not all of the obstruction is at
timing of the SAM in 2D echocardiography does not come close to the aortic valve level because the leaflets are separated to the maxi-
appreciating the timing and duration of contact between the valve mum degree throughout systole.
and the interventricular septum. The M-mode recording of SAM Figure 9 shows different types of aortic valve patterns. In Figure 9A,
may not be considered critical in today’s management of patients there is an abrupt closure of the valve in the latter half of systole. This
with hypertrophic cardiomyopathy, but it does add to our under- finding represents a dynamic obstruction of flow, usually as a result of
standing of the mechanism underlying any LV outflow obstruction subaortic obstruction. This obstruction could be dynamic or due to
and is confirmatory or complementary to the Doppler recording of a fixed abnormality. Although valve closure in early systole occasion-
dynamic LV outflow obstruction, especially if there is any question ally occurs with dynamic obstruction,1 the lateness of this valve
about the Doppler recording. closure in mid-systole indicates that this obstruction is dynamic. The
Figure 7 represents another M-mode recording that many would Doppler flow velocity will usually make a more definitive diagnosis
think has only historical value. These recordings are of patients with mi- as to whether or not it is dynamic with late systolic peaking of the
tral valve prolapse.11-14 The M-mode criteria are rarely used today as Doppler flow velocity. However, with severe obstructive cardiomyop-
a definitive way to make the diagnosis. The only real value is that the athy, one can get a fairly holosystolic Doppler flow and the dynamic
timing of the prolapse is better appreciated with the M-mode nature might be more difficult to identify without seeing this M-mode
technique. For example, in Figure 7A the posterior displacement of phenomenon of the aortic valve.
the posterior leaflet seems to begin fairly early in systole and peaks in A fixed form of subaortic obstruction is noted in Figure 9B. This
the latter half of systole. This leaflet motion produces essentially holosys- aortic valve recording is from a patient with a fixed membranous sub-
tolic separation and regurgitation with late systolic accentuation. In con- aortic stenosis. There is a brief full opening of the valve followed by an
trast, Figure 7B shows separation of the leaflets to occur only in the latter abrupt closure of the anterior leaflet. Contrary to a dynamic obstruc-
half of systole, resulting in a shorter duration of the separation and regur- tion, this type of outflow obstruction almost always has early systolic
gitation, and becomes a factor in quantifying the degree of regurgitation. closure of the valve. An M-mode recording in a patient with
Journal of the American Society of Echocardiography Feigenbaum 247
Volume 23 Number 3

Figure 12 Relationship between the M-mode recording of the pulmonic valve and the pressures in the right ventricle and pulmonary
artery. (From Feigenbaum H. Echocardiography. 1st ed. Philadelphia, PA: Lea and Febiger; 1972.)

Figure 13 A, M-mode examination of a normal pulmonic valve. Only 1 of the leaflets is usually recorded. B, M-mode pulmonic valve
recording from a patient with pulmonary hypertension. The ‘‘a’’ wave is absent, and there is mid-systolic closure (n) in mid-systole.
This finding has been called the ‘‘flying W’’ sign. (From Feigenbaum H. Echocardiography. 1st ed. Philadelphia, PA: Lea and Febiger;
1972.)

a membranous discrete subaortic stenosis is particularly useful be- (Figure 8A). Figure 9 shows the effects of subvalvular obstruction.
cause the differentiation between valvular and subvalvular aortic ste- Figure 10 demonstrates another form of non-parallel aortic valve leaf-
nosis is not always perfectly obvious. The membrane can be very thin let motion. In this situation the leaflets gradually close throughout sys-
and may not be recorded well echocardiographically or even angio- tole. This gradual closure of the valve indicates that the blood flowing
graphically. Furthermore, the early or mid-systolic closure of the aortic through the aortic valve is not being sustained but gradually diminishes
valve rules out significant valvular obstruction. throughout systole.15 This finding may occur in patients with mitral re-
Finding non-parallel aortic valve leaflets can be critical in making gurgitation who have a significant degree of regurgitation. The initial
the proper diagnosis in many situations. Normally, aortic valve flow LV stroke volume may pass into the aorta, fully opening the aortic
is constant throughout systole so that the leaflets remain parallel valve. As systole progresses, more of the blood is moving into the
248 Feigenbaum Journal of the American Society of Echocardiography
March 2010

findings of an M-mode recording of the pulmonic valve.19 Because

of the orientation of the valve to the M-mode beam, only the motion
of one of the leaflets is usually recorded. The normal valve has a small
‘‘a’’-wave secondary to atrial contraction. The valve then opens and
stays open throughout systole. Figure 13A illustrates an M-mode re-
cording of a normal pulmonic valve.
The most important use of the M-mode recording of the pulmonic
valve today is for those few patients who have pulmonary hyperten-
sion and may not have a good enough tricuspid regurgitation jet to
fully appreciate the severity of the pulmonary hypertension. In these
patients, the pulmonary artery is frequently dilated and the recording
of the pulmonic valve is technically easier. With pulmonary hyperten-
sion one will see an absence of the ‘‘a’’ wave.19-22 However, the ‘‘a’’
wave might reappear if the right ventricular (RV) diastolic pressure
becomes elevated. The more striking finding is that in systole there
is mid-systolic closure and then reopening of the valve before diastole
(Figure 13B). This pattern is sometimes referred to as the ‘‘flying W’’
sign. It is a fairly specific finding of severe pulmonary hypertension
and usually elevated pulmonary vascular resistance.
The M-mode pulmonic valve finding of pulmonic stenosis with its
exaggerated ‘‘a’’ wave (Figure 12) is hardly used anymore. We rely
almost entirely on a Doppler gradient for that diagnosis.

Figure 14 M-mode recording through the body of the left ventri-

cle illustrating the motion of the interventricular septum and the OTHER VALVULAR M-MODE RECORDINGS
posterior LV wall. There is a slight pause between the onset of
electrical depolarization (vertical line) and opposing motion of The M-mode recording of the tricuspid valve has a few isolated uses;
the 2 walls. The peak downward motion of the interventricular
however, it is not nearly as relevant in today’s practice of echocardi-
septum slightly precedes the peak upward motion of the poste-
rior wall. In early diastole, there is a small downward motion of ography and is not going to be discussed in this article.
the septum (arrow, diastolic ‘‘dip’’) as the result of early RV filling There also are some useful M-mode signs for prosthetic valves.
preceding filling of the left ventricle. They again are rarely being used. However, there are a couple of
situations in which they can be useful, especially with some older
mechanical valves. The tilting disk valve, especially the Bjork-Shiley
valve (Pfizer, New York, NY), was a popular valve for a long time.
left atrium and less is going through the aortic valve. In some patients One of the first signs of malfunction was that the peak opening of
with significant mitral regurgitation, the gradual aortic valve closure the valve was rounded rather than producing a sharp E point. That
may occur later in systole. Gradual aortic valve closure may also occur finding indicated that there was something (ie, fibrosis or clot) impair-
with low cardiac output because of a poorly contracting left ventricle. ing the full opening of the valve. The other valve that was commonly
Under these circumstances even the initial opening may be reduced as used in the early days was the Starr-Edwards (Edwards Lifesciences,
well. Figure 11 is an aortic valve M-mode recording from a patient with Irvine, CA) ball-in-cage valve. This valve would intermittently stick
very poor cardiac function, atrial fibrillation, and ventricular ectopy. at times, and a long recording of this valve might show intermittent
There is marked variation in aortic valve opening according to the partial or incomplete opening of the valve. Because both valves are
amount of blood passing through the valve with each cardiac cycle. rarely used today, the M-mode techniques are rarely used for looking
Figure 11 also shows another indicator of cardiac function, that is, at prosthetic valves. If, however, a patient has one of these older
motion of the posterior aortic wall, which is also the anterior wall of valves and even one of the newer disk valves, then an M-mode re-
the left atrium. In this patient the amplitude of motion of the left atrial cording should be seriously considered to document the timing and
wall is markedly reduced, which is another indicator of poor overall pattern of prosthetic leaflet motion.
cardiac function.16,17 A fairly recent study found that the diastolic
slope of the M-mode aortic motion could help identify pseudo-
normalization of mitral Doppler recordings.18 M-MODE RECORDING OF THE INTERVENTRICULAR
SEPTUM

M-MODE RECORDING OF THE PULMONIC VALVE In my judgment, probably the most important use of the M-mode
technique today is using it to record the interventricular septum.
The pulmonic valve is sometimes considered to be the forgotten Although the septum by and large does not move with the same ra-
valve. It is not the easiest valve to record with M-mode or 2D echo- pidity as the valves, it is amazing how rapidly the septum can move in
cardiography, especially in adults. We frequently merely rely on the certain situations. This septal motion can provide important clinical in-
easier to record Doppler pulmonic valve velocity for the valve evalu- formation, especially in today’s practice. Figure 14 shows an M-mode
ation. Even in those laboratories where M-mode echocardiography is recording of a patient with normal septal motion. The relationship of
still a part of the examination, the pulmonic valve is frequently not in- septal motion to the onset of the electrocardiographic QRS is shown
terrogated. The diagram in Figure 12 shows some of the diagnostic with the vertical line. The septum essentially functions as one of the
Journal of the American Society of Echocardiography Feigenbaum 249
Volume 23 Number 3

Figure 15 A, M-mode recording showing an exaggerated septal diastolic ‘‘dip’’ (arrow) in a patient with mitral stenosis. This finding
highlights the fact the RV filling is unimpeded while the stenotic mitral valve restricts LV filling. B, This recording is taken from a patient
with severe pulmonary hypertension and severe tricuspid regurgitation. The RV volume overload produces an upward motion of the
septum immediately after ventricular depolarization (vertical line), because the septum is flattened toward the left ventricle in diastole
and ‘‘pops out’’ with onset of systole. The second finding is a very exaggerated diastolic ‘‘dip’’ (arrow).

walls of the left ventricle. Of special note, however, there is a small thus there is an increased diastolic ‘‘dip.’’ Figure 15B shows an even
notch in the septal motion at the onset of diastole (arrow). This motion greater exaggerated diastolic ‘‘dip.’’ This recording is of a patient
is sometimes referred to as the diastolic ‘‘dip.’’ The explanation for this with pulmonary hypertension, severe tricuspid regurgitation, and
phenomenon is that aside from essentially being one of the walls of RV failure. Under these circumstances the filling of the right ventricle
the left ventricle, the septum also reflects the relative volume flow was significantly greater than that of the left ventricle and the diastolic
in the 2 ventricles. Because the right ventricle is a more compliant ven- ‘‘dip’’ was more striking in depth and duration.
tricle with a larger tricuspid orifice, the right ventricle fills slightly be- Figure 16 demonstrates probably one of the most important uses
fore the left ventricle, and this filling of the right ventricle produces of M-mode echocardiography in today’s practice of cardiology. This
a brief displacement of the interventricular septum toward the left M-mode examination of the interventricular septum shows the classic
ventricle. The left ventricle then fills, and the septum then moves findings in a patient with left bundle branch block (LBBB). There is
back toward the neutral zone. One can frequently see relatively flat a typical brief downward dip or ‘‘beak’’ followed by upward motion
or slightly upward motion of the septum throughout diastole with an- of the septum shortly after the onset of electrical depolarization (left
other slight upward motion of the septum with atrial contraction. It arrow).23 This ‘‘beak’’ is presumably a result of the abnormal depolar-
should be noted that the peak downward motion of the septum, ization of the septum inherent in an LBBB abnormality and occurs
which precedes the diastolic ‘‘dip,’’ also slightly precedes the peak during the isovolumic contraction period. Because this ‘‘beak’’ septal
upward motion of the posterior LV wall. motion occurs during isovolumic contraction, it has no effect on the
Figure 15 demonstrates that the diastolic ‘‘dip’’ may be exaggerated ejection of blood from the left ventricle.
in some situations, especially with mitral stenosis (Figure 15A). With The critical septal motion in the patient in Figure 16 is that during
the mechanism for the diastolic ‘‘dip’’ being that it reflects relative the ejection of blood from the left ventricle the septum is moving par-
early filling of the ventricles, the exaggerated diastolic ‘‘dip’’ with mitral adoxically or toward the right ventricle.24-26 With the onset of diastole
stenosis should not come as a surprise. With mitral stenosis, there is there is a somewhat exaggerated early diastolic ‘‘dip’’ (right arrow).
impeded diastolic flow into the left ventricle; therefore, the unim- One can appreciate that this septum is not contributing to the LV
peded early RV filling is even relatively greater than normal and function of ejecting blood.27 Septal motion toward the left ventricle
250 Feigenbaum Journal of the American Society of Echocardiography
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(Figure 18B). Now the septum is moving toward the left ventricle dur-
ing the ejection of blood, and the ventricle has shrunken to a normal
size. The patient also obviously improved clinically.
Figure 19 shows the more frequent consequence of today’s man-
agement of patients with cardiomyopathy and LBBB. Figure 19A
shows a somewhat broadened systolic ‘‘beak’’ of the left bundle pat-
tern. Again the septal systolic motion is akinetic and the left ventricle
is dilated (6.6 cm). After resynchronization therapy (Figure 19B),
there is dramatic improvement with the absence of any left bundle
‘‘beak’’ and normal septal motion during ejection of blood. The LV
end-diastolic diameter now decreased to 5.4 cm. The patient was
obviously clinically improved.
This patient can be compared with the patient seen in Figure 20,
who had a dilated cardiomyopathy and met the usual criteria for re-
synchronization therapy with a wide QRS but no LBBB. The echocar-
diograms before and after resynchronization are shown. There was no
echocardiographic evidence of LBBB, and there was no improvement
after resynchronization therapy.
Those who currently use M-mode echocardiography to evaluate
patients for resynchronization therapy frequently use the ‘‘shortest in-
terval between the maximal posterior displacement of the septum
and the maximal displacement of the posterior wall using a mono-
Figure 16 Septal motion in a patient with LBBB. The character- dimensional short-axis view at the papillary muscle level.’’28 In the
istic M-mode finding with LBBB is a downward and then upward
M-mode recording illustrated in that article (Figure 21), the interval
motion of the septum (first arrow, ‘‘early systolic beak’’) shortly
after electrical depolarization. The septum moves paradoxically demonstrated is from the septal ‘‘beak’’ to the peak upward posterior
or toward the right ventricle during ventricular ejection of blood. wall motion.28 The theory behind resynchronization is that the walls
The diastolic ‘‘dip’’ (second arrow) is frequently exaggerated. of the left ventricle are not contracting synchronously for the efficient
There is also delayed upward motion of the posterior wall. ejection of blood. The septal ‘‘beak’’ is not involved in the ejection of
blood. On the basis of my own experience when selecting patients for
resynchronization therapy, the pattern of septal motion is an impor-
is only during isovolumic contraction (left arrow) and early diastole tant factor and may be more important than the recommended
(right arrow). Thus, LBBB with paradoxical septal motion during sys- M-mode time interval measurements. The M-mode pattern of septal
tole is a negative inotropic event. It is the equivalent to having an aki- motion should be included as one of the criteria in future studies eval-
netic or dyskinetic septum with a myocardial infarction. One can uating echocardiography’s role in identifying patients for resynchroni-
easily appreciate how an LBBB with paradoxical septal motion is a sig- zation therapy.
nificant negative inotropic phenomenon for LBBB. In this particular One of the most difficult diagnoses to make in echocardiography is
patient, the ventricle is also dilated. the diagnosis of constrictive pericarditis. Multiple echocardiographic cri-
Figure 17 presents M-mode septal recordings from other patients teria have been used. Many of these criteria include a variety of Doppler
with LBBB. The early systolic ‘‘beak’’ (left arrow) is again seen in all 3 techniques. There are several 2D echocardiographic findings for mak-
examples, although it may not be as prominent as in the previous ing the diagnosis. One of these findings is a ‘‘septal bounce.’’ The ‘‘septal
illustration. In Figure 17A the septal motion during ejection of blood bounce’’ is fairly nonspecific because there are several different reasons
is flat and followed by the diastolic ‘‘dip’’ (second arrow). In for the septum to move abnormally. In my judgment, any abnormal sep-
Figure 17B, one again sees the early systolic ‘‘beak’’ (left arrow) tal motion on a 2D echocardiogram is a clear indication for an M-mode
and the diastolic ‘‘dip’’ (right arrow). However, in this patient, during recording of the septum to identify the cause of the apparent septal
systole the septum is moving toward the left ventricle and contrib- ‘‘bounce.’’ Figure 22A is a recording from a patient with constrictive
uting to LV function. This is a so-called benign or nonparadoxical pericarditis. This M-mode echocardiogram demonstrates the reason
LBBB. The LV cavity is not dilated, and this type of LBBB does for the septal bounce with constrictive pericarditis.29,30 First, there are
not cause significant deterioration in global LV function. Another ex- several different downward motions of the septum, each of which
ample of a nonparadoxical LBB is shown in Figure 17C. Again, the could produce a ‘‘bounce.’’ There is normal systolic motion that is not
classic left bundle ‘‘beak’’ is visible (left arrow). However, during sys- indicated by an arrow in this recording. There is then an exaggerated
tolic ejection of blood the septum is moving normally. In this partic- diastolic ‘‘dip’’ (left arrow). The finding that is characteristic of
ular patient, the normal systolic motion is combined with the constrictive pericarditis is the additional diastolic ‘‘dip’’ that occurs in
diastolic dip so that it is somewhat difficult to know exactly when early or mid-diastole (right arrow). The explanation for these 2 diastolic
systole ends. Again, the left ventricle is not dilated and global LV ‘‘dips’’ is that the thickened pericardium encases the 2 ventricles and
function is intact. limits their ability to expand and fill normally. As a result, the septum
Figure 18A shows a patient with a dilated cardiomyopathy, suppos- has to facilitate alternate filling of the 2 chambers. Motion of the septum
edly caused by chemotherapy. There is a paradoxical LBBB pattern downward toward the left ventricle represents RV filling, and upward
with the ‘‘beak’’ and diastolic ‘‘dip’’ separated by a totally akinetic sep- motion toward the right ventricle indicates LV filling. This phenomenon
tum and dilatation of the left ventricle (5.5 cm). There was recovery of has also been called ‘‘ventricular interdependence.’’ The diastolic ‘‘dips’’
the myopathic process as the chemotherapy was removed, and the disappear, and the oscillating septum returns to normal after surgical re-
patient reverted to a more benign or nonparadoxical form of LBBB moval of the constricting pericardium (Figure 22B).
Journal of the American Society of Echocardiography Feigenbaum 251
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Figure 17 A, Another M-mode recording of septal motion in a patient with LBBB. Septal motion during LV systole, that is, between the
septal ‘‘beak’’ (first arrow) and the diastolic ‘‘dip’’ (second arrow), is flat. B, In this patient with nonparadoxical LBBB, septal motion
during systole (between the 2 arrows) is normal, moving downward toward the left ventricle. C, This patient also has LBBB as noted by
the classic septal ‘‘beak’’ (first arrow). However, septal motion during the ejection of blood is completely normal. The peak downward
motion of the septum is actually a prominent diastolic ‘‘dip’’ (second arrow).

M-MODE RECORDINGS OF THE RIGHT VENTRICULAR FREE alternans that is seen with a large pericardial effusion.37 This recording
WALL WITH PERICARDIAL EFFUSION also shows one of the advantages of M-mode echocardiography, es-
pecially in the era of digital echocardiography. One feature of digital
The one M-mode recording that is probably still being used is RV wall echocardiography is that one no longer needs to record numerous
diastolic collapse as an indicator of hemodynamic compromise sec- cardiac cycles as with videotape. The ability to record only 1 digital
ondary to pericardial effusion.31-34 Figure 23 shows the usual cardiac cycle offers several advantages. However, there are certain sit-
M-mode finding of RV diastolic collapse with pericardial effusion. uations, such as with intermittent or respiratory changes or a swinging
One can make the same assessment using 2D echocardiography. In heart, when one clearly needs more than 1 cardiac cycle to appreciate
fact, the small 2D echocardiogram in Figure 23 shows an indentation what is taking place. One may only need to record 3 cardiac cycles,
of the RV wall. However, the M-mode recording can help determine but frequently one might need more. M-mode echocardiography is
that the collapse is truly in diastole. In addition to the electrocardio- a convenient and efficient way to record multiple cardiac cycles.
gram, one also has either the mitral valve or the aortic valve to help Figures 26 and 27 illustrate another common use of M-mode
with more precise timing of wall motion. RV collapse is not always echocardiography based on the ease with which multiple cardiac
dramatic. Figure 24A shows a very subtle RV collapse that is clearly cycles can be displayed. In this case, the issue is whether or not the
in diastole as judged by the aortic valve recording. This type of col- inferior vena cava collapses with inspiration.
lapse can easily be missed by using just 2D echocardiography.
There are also other varieties of RV collapse. Figure 24B illustrates
holodiastolic collapse of the right ventricle whereby the RV cavity is CONCLUSIONS
virtually obliterated with severe hemodynamic compromise.
Figure 25 shows 2 phenomena that make the M-mode technique It is hoped that this article will not merely be considered by many to
still relevant. There is not only collapse of the RV wall (arrow) but be a historical review of an obsolete technique. I have tried to present
also a pattern of cardiac motion that covers 2 cardiac cycles, so that enough evidence, without describing every possible use of M-mode
every other electrical depolarization finds the heart in a different echocardiography, to indicate that this technique should be taken se-
location.35-37 This alternating cardiac displacement affects the riously. Because of its superior temporal resolution, its complemen-
electrocardiogram and is the mechanism for the classic electrical tary relationship to Doppler recordings, and its ability to record
252 Feigenbaum Journal of the American Society of Echocardiography
March 2010

Figure 18 A, M-mode recording of a patient undergoing chemotherapy who developed LBBB, with a classic ‘‘beak’’ (first arrow), flat
septal motion during systole, and dilated LV cavity. The second arrow indicates a relatively flat diastolic ‘‘dip.’’ B, M-mode recording
of the same patient after cessation of the chemotherapy. There is still a septal ‘‘beak’’ caused by the LBBB that is still present, but the
LBBB is now non-paradoxical with the septum moving normally during systole. The left ventricle is no longer dilated. The left arrow is
the LBBB ‘‘beak,’’ and the right arrow is the diastolic ‘‘dip.’’

Figure 19 A, This patient has a dilated left ventricle with a broad septal LBBB ‘‘beak’’ and flat systolic septal motion. B, Same patient
as in 28A after resynchronization therapy. Septal motion is now normal, the LV cavity is smaller, and the posterior wall is moving better.
Journal of the American Society of Echocardiography Feigenbaum 253
Volume 23 Number 3

Figure 20 M-mode recordings before (A) and after (B) resynchronization of a patient with a dilated, poorly functioning left ventricle
and no echocardiographic findings of LBBB. There is no improvement.

Figure 21 M-mode recording taken from the literature describing the time interval to be measured for identifying a patient suitable for
resynchronization therapy. The time interval is from the early systolic ‘‘beak’’ to the peak upward motion of the posterior wall in this
patient with LBBB. (From Pitzalis MV, Iacoviello M, Romito R, Massari F, Rizzon B, Luzzi G, et al. Cardiac resynchronization therapy
tailored by echocardiographic evaluation of ventricular asynchrony. J Am Coll Cardiol 2002;40:1615-22.).
254 Feigenbaum Journal of the American Society of Echocardiography
March 2010

Figure 22 A, Interventricular septal motion in a patient with constrictive pericardititis. There is a prominent early diastolic ‘‘dip’’ (left
arrow). Now there is also a second diastolic ‘‘dip’’ (right arrow). This illustrates how septal motion reflects filling of the 2 ventricles.
Because the free walls of the ventricles are not free to expand properly, the chambers appear to fill alternately through changes in
septal motion. B, M-mode recording of the same patient after pericardial stripping and relief of the constriction. Septal motion is
now normal.

Figure 23 RV diastolic collapse (arrow) in a patient with pericardial effusion.

Journal of the American Society of Echocardiography Feigenbaum 255
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Figure 24 A, Mild RV early diastolic collapse in a patient with pericardial effusion. B, Extreme form of holodiastolic RV collapse
(arrows) in a patient with a large pericardial effusion.

Figure 25 M-mode recording of a patient with a larger pericar- Figure 26 Respiratory change in size of the inferior vena cava in
dial effusion and a ‘‘swinging’’ heart. RV diastolic collapse a patient with normal central venous pressure.
(arrow) is shown, and the heart is moving excessively so that it
takes 2 cardiac cycles before the heart returns to its baseline
position. The resulting alternating position of the heart produces
electrical alternans on the electrocardiogram.
256 Feigenbaum Journal of the American Society of Echocardiography
March 2010

5. D’Cruz IA, Lalmalani GG, Sambasivan V, Cohen HC, Glick G. The

superiority of mitral E point ventricular septum separation to other echo-
cardiographic indicators of left ventricular performance. Clin Cardiol
1979;2:140.
6. Konecke LL, Feigenbaum H, Chang S, Corya BC, Fischer JC. Abnormal
mitral valve motion in patients with elevated left ventricular diastolic pres-
sures. Circulation 1973;47:989-96.
7. Lewis JR, Parker JO, Burggraf GW. Mitral valve motion and changes in left
ventricular end-diastolic pressure: a correlative study of the PR-AC inter-
val. Am J Cardiol 1978;42:383.
8. Ambrose JA, Teichholz LE, Meller J, Weintraub W, Pichard AD, Smith H Jr,
et al. The influence of left ventricular late diastolic filling on the A wave of
the left ventricular pressure trace. Circulation 1979;60:510.
9. Henry WL, Clark CE, Griffith JM, Epstein SE. Mechanism of left ventricular
outflow obstruction in patients with obstructive asymmetric septal hypertro-
phy (idiopathic hypertrophic subaortic stenosis). Am J Cardiol 1975;35:337.
10. Pollick C, Rakowski H, Wigle ED. Muscular subaortic stenosis: the quanti-
tative relationship between systolic anterior motion and the pressure gra-
dient. Circulation 1984;69:43.
11. Dillon JC, Haisse CL, Chang S, Feigenbaum H. Use of echocardiography in
Figure 27 M-mode recording of an inferior vena cava that is
patients with prolapsed mitral valve. Circulation 1971;43:503-7.
dilated and does not vary in size with respiration in a patient
12. Kerber RE, Isaeff DM, Hancock EW. Echocardiographic patterns in
with elevated central venous pressure.
patients with the syndrome of systolic click and late systolic murmur.
N Engl J Med 1971;284:691.
13. Popp RE, Brown OR, Silverman JF, Harrison DC. Echocardiographic abnor-
multiple cardiac cycles efficiently and conveniently especially in the malities in the mitral valve prolapsed syndrome. Circulation 1974;49:428.
digital echocardiography era, M-mode echocardiography is alive 14. DeMaria AM, King JF, Bogreu HG, Lies JE, Masow DT. The variable spec-
and well. It should be a part of every routine transthoracic echocardio- trum of echocardiographic manifestations of the mitral valve prolapsed
gram. M-mode recordings usually can be limited to the valves, espe- syndrome. Circulation 1974;50:33.
15. Corya BC, Rasmussen S, Phillips JF, Black MJ. Forward stroke calculated
cially the mitral and aortic, the interventricular septum, and the
from aortic valve echograms in normal subjects and patients with mitral
inferior vena cava. Situations where M-mode recordings are particu- regurgitation secondary to left ventricular dysfunction. Am J Cardiol
larly useful are when the 2D echocardiogram exhibits abnormal inter- 1981;47:1215.
ventricular septal motion or the Doppler tracings show abnormal 16. Strunk BL, Fitzgerald JW, Lipton M, Popp RL, Barry WH. The posterior
hemodynamics. In these patients, ancillary M-mode information is aortic wall echocardiogram: its relationship to left atrial volume change.
frequently helpful. For example, it is likely that a careful analysis of Circulation 1976;54:744.
septal motion with M-mode echocardiography should be a part of ev- 17. Akgun G, Layton C. Aortic root and left atrial wall motion: an echocardio-
ery patient being evaluated for cardiac resynchronization therapy. graphic study. Br Heart J 1977;39:1082.
We are entering a new era in the practice of medicine. Ordering 18. Hung MJ, Cherng WJ, Kuo LT, Wang CH, Cher MS. Analysis of left atrial
multiple ‘‘complementary’’ tests will no longer be consistent with volume change rate during left ventricular diastolic phase with M-mode
echocardiography for differentiation between normal and pseudonormal
the necessity of being ‘‘cost-effective.’’ Every test has to provide as
mitral inflow. Am J Cardiol 2002;89:552-6.
much accurate information as possible while using time and equip- 19. Weyman AE, Dillon JC, Feigenbaum H, Chang S. Echocardiographic pat-
ment efficiently. M-mode recordings meet this criterion. No extra terns of pulmonic valve motion with pulmonary hypertension. Circulation
equipment is required. The recordings take very little time, and the 1974;50:905-10.
interpretation is basically ‘‘pattern recognition’’ without any required 20. Nanda NC, Gramiak R, Robinson TI, Shah PM. Echocardiographic evalu-
time-consuming measurements. We need to remember that the ation of pulmonary hypertension. Circulation 1974;50:575.
most expensive test is one that produces wrong information. The sec- 21. Shiina A, Yaginuma T, Matsumoto Y, Kawasaki K, Tsuchiya M, Miyuata K,
ond most expensive test is one that gives incomplete or nondiagnostic et al. Echocardiographic analysis of pulmonic and aortic valve motion by
information. The addition of M-mode recordings should help make simultaneous recordings of flow velocity and intravascular pressure: gene-
a routine transthoracic echocardiographic study more accurate, com- sis of mid-systolic semi-closure of the pulmonic valve in patients with pul-
monary hypertension. J Cardiogr 1977;7:599.
plete, and potentially more cost-effective.
22. Marin-Garcia J, Moller JH, Mirvis DM. The pulmonic valve echogram in
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