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Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

Sung-AChang,MD,PhD

Associate Professor

Division of Cardiology

Departmentof Medicine

HeartVascular Stroke Institute Imaging Center

Samsung MedicalCenter

Sungkyunkwan University Schoolof Medicine

Seoul, Republic of Korea

ThaisCoutinho,MD

Chief, Division of Cardiac Prevention and Rehabilitation

Chair, Canadian Women’s HeartHealth Centre

Division of Cardiology

University of Ottawa HeartInstitute Ottawa, Ontario, Canada

Michael W.Cullen,MD

AssistantProfessor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic Rochester, Minnesota

Raúl E.Espinosa,MD

AssistantProfessor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

CovadongaFernández-Golfín,MD

Director, Cardiac Imaging Unit

Departmentof Cardiology

University HospitalRamón y Cajal Madrid, Spain

DavidA.Foley,MD

AssistantProfessor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

William K.Freeman,MD

Professor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic Scottsdale, Arizona

JeffreyB.Geske,MD

Associate Professor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic Rochester, Minnesota

ArianaGonzález,MD

Director, Valvular HeartDiseases

Departmentof Cardiology

University HospitalRamón y Cajal Madrid, Spain

DonaldJ.Hagler,MD

Professor of Medicine and Pediatrics

Consultant, Division of Pediatric Cardiology

Departmentof Cardiovascular Medicine

Mayo Clinic Rochester, Minnesota

KyleW.Klarich,MD

Professor of Medicine

Vice Chair, Departmentof Cardiovascular Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

IftikharJ.Kullo,MD

Professor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic Rochester, Minnesota

RobertoM.Lang,MD

President(Emeritus), American Society of Echocardiography

Professor of Medicine, Section of Cardiology

University of Chicago MedicalCenter Chicago, Illinois

GraceLin,MD

Associate Professor of Medicine

Director, HeartFailure Clinic

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

Lieng-H Ling,MBBS,MD

Associate Professor, Departmentof Medicine

Yong Loo Lin Schoolof Medicine

NationalUniversity of Singapore

Senior Consultant

Departmentof Cardiology

NationalUniversity HeartCentre

Singapore

JosephF.Maalouf,MD

Professor of Medicine

Director, InterventionalEchocardiography

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

JosephJ.Maleszewski,MD

Professor of Laboratory Medicine & Pathology and Medicine

Departments of Laboratory Medicine & Pathology, Cardiovascular Medicine, and Clinical

Genomics

Mayo Clinic

Rochester, Minnesota

Sunil V.Mankad,MD

Associate Professor of Medicine

Consultant, DepartmentCardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

Robert B.McCully,MD

Professor of Medicine

Director (Emeritus), Stress Echocardiography

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

HectorI.Michelena,MD

Professor of Medicine

Director, Intraoperative Echocardiography

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

FletcherA.Miller,MD

Professor of Medicine

Director (Emeritus), Echocardiography Laboratory

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

William R.Miranda,MD

AssistantProfessor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic Rochester, Minnesota

VictorMor-Avi,PhD

Research Professor Departmentof Medicine, Section of Cardiology

University of Chicago MedicalCenter

Chicago, Illinois

SharonL.Mulvagh,MD

Professor of Medicine

Dalhousie University

Halifax, Nova Scotia, Canada

Professor (Emeritus), Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

VuyisileT.Nkomo,MD,MPH

Professor of Medicine

Director, Valvular HeartDiseases Clinic

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

PatrickO’Leary,MD

Professor of Pediatrics

Division of Pediatric Cardiology

Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

Sungji Park,MD,PhD

Professor

Director, Imaging Center

HeartVascular Stroke Institute

Samsung MedicalCenter

Sungkyunkwan University Schoolof Medicine

Seoul, Republic of Korea

PatriciaA.Pellikka,MD

President(Emeritus), American Society of Echocardiography

Professor of Medicine

Director, Echocardiography Laboratory

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

SorinV.Pisralu,MD,PhD

Professor of Medicine

Vice Chair, Division of Cardiovascular Ultrasound

Consultant, Departmentof Cardiovascular medicine

Mayo Clinic

Rochester, Minnesota

DavidPlayford,MBBS,PhD

Professor

University of Notre Dame

Fremantle, Australia

MountHospital, Western Australia

PeterM.Pollak,MD

Director of StructuralIntervention

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Jacksonville, Florida

GuyS.Reeder,MD

Professor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

Charanjit S.Rihal,MD

William S. and Ann Atherton Professor of Cardiology

Chair (Emeritus), Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

Hartzell V.Schaff,MD

StuartW. Harrington Professor of Surgery

Consultant, Departmentof Cardiovascular Surgery

Mayo Clinic

Rochester, Minnesota

PeterC.Spittell,MD

AssistantProfessor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

Geoff Strange,BN,PhD

Professor

University of Notre Dame, Fremantle

Western Australia, Australia

RoyalPrince Alfred Hospital

Sydney, New South Wales, Australia

RakeshM.Suri,MD,DPhil

Professor of Surgery

Cleveland Clinic Foundation and Cleveland Clinic Abu Dhabi

JeremyJ.Thaden,MD

AssistantProfessor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

YanTopilsky,MD

Associate Professor

Sackler University of medicine TelAviv, Israel

Director of Echo and Non Invasive Cardiology

TelAviv MedicalCenter

HectorR.Villarraga,MD

Associate Professor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic

Rochester, Minnesota

BrandonM.Wiley,MD,MS

AssistantProfessor of Medicine

Consultant, Departmentof Cardiovascular Medicine

Mayo Clinic Rochester, Minnesota

José

LuisZamorano,MD

Vice President, European Society of Cardiology

Head of Cardiology

University HospitalRamón y Cajal Madrid, Spain

Preface

The first edition of the Echo Manual was originally written in early 1990s asaninternal manual at MayoClinictostandardizetheacquisitionandthe interpretationof echocardiography,whichwas rapidlydeveloping.Whenit was published, we were thrilled by readers’ encouraging response, which has motivated us to update this Manual few times to the current fourth edition. The first edition took 4 years to complete. At that time, all echocardiography images were stored in video tapes. We created a list of educationally valuable illustrative images, which were later retrieved and photographed using 38-roll film per each image. When each roll-film was developed, the best image was selected to be labeled and cropped. The revised images were photographed again to create figures shown in the first edition of the Manual. When echocardiography images were acquired and stored digitally, it became much easier to locate and create images. But, it is remarkable that images created by photography were frequently better than digitized images, some of which are still shown in this edition. The Echo Manual has lived through remarkable growing periods of echocardiography with development of Doppler hemodynamics, color flow imaging, transesophageal imaging, stress echocardiography, contrast (ultrasound enhancing) agent, tissue Doppler, strain imaging, 3D echocardiography and hand-held ultrasound imaging. Echocardiography has matured to have become the most practical and the most widely available imaging and hemodynamic diagnostic tool for the entire field of cardiovascular diseases. Consequently, the utilization of echocardiography is nowin the hands of not only cardiologists, but any physicians who have a need to assess cardiac structure, function, and hemodynamics in their outpatient office, bedside, emergency department, critical care unit, interventional suite, and operating room. The bedside ultrasound imaging

by a hand-held device was recommended to be the fifth pillar to bed-side physical examination in addition to inspection, palpation, percussion, and auscultation (1). There is, however, a large gap between what echocardiography can do and how it is used in clinical practice. Optimal utilization of echocardiography requires dedicated training and it is our sincere hope that this fourth edition of the Echo Manual can help to close the gap for all physicians and sonographers who perform and interpret echocardiography to provide the best care for their patients. Echocardiography has become an amazing tool not only for diagnosis but also guiding many innovative device therapies and procedures. We hope that the Manual also helps interventionalists and cardiac surgeons to use echocardiographyfor obtainingthebest result for their procedures.

As the field of echocardiography has expanded tremendously since the last edition, several new chapters (3D echocardiography, interventional echocardiography, echocardiography for heart failure and LVAD, handcarried ultrasound, and artificial intelligence in echocardiography) were added. Previous chapters were updated with new information, recent references, and new images with corresponding real-time images. We thank all contributing authors for their passion and expertise for echocardiography and for their sacrifice in precious time. We continued to emphasize the interpretation of echocardiography information in clinical context since our ultimate goal of performing echocardiography is to providethebest carefor our patients.

A creation of this fourth edition of the Echo Manual would not have been possible without support and understanding from our families. Most of echocardiography cases and images in this manual came from the extensive clinical materials at Mayo Clinic. We thank Mayo Clinic Echocardiography Laboratory and the Department of Cardiovascular Medicine for providing an amazing environment for practice, education, and research as well as collegiality and friendship. Mark A. Zang, Jeffrey R. Stelley, and Jeffrey W. Gansen of our Echocardiography Laboratory visual section helped creating still and video images used for the Manual. Paul W. Honerman of Illustration and Design revised and created all illustrative figures. Tessa Flies helped me with administrative duties and made sure that I dohave a time tocomplete this Manual intime.We could not thank enough the Wolters Kluwer for their support and patience for

having this fourth edition of the Echo Manual published almost 10 years after thethirdedition.

Finally, we are grateful to echocardiography and numerous pioneers in this field for making our professional life filled with new discoveries, better diagnostic methods, many memorable trips, wonderful meetings, international cousins, mentoring fellows, making friends all around the world, and the most importantly, opportunities to improve the care for our patients.

Jae K. Oh

Onbehalf of all authors

REFERENCE

1. Narula J, Chandrashekhar Y, Braunwald E. Time to add a fifth pillar to bedside physical examination:Inspection, palpation, percussion, auscultation, and insonation. JAMA Cardiology, 2018;3(4):346–350.

List of Contributors

Preface

Abbreviations

1 Transthoracic M-mode and Two-Dimensional Echocardiography

Jae K Oh and Joseph J. Maleszewski

2 Transthoracic Three-Dimensional Echocardiography

Karima Addetia, Victor Mor-Avi, and Roberto M. Lang

3 Transesophageal Echocardiography

Jeremy J. Thaden, Joseph F. Maalouf, and Jae K. Oh

4 Doppler Echocardiography and Color Flow Imaging: Comprehensive Noninvasive Hemodynamic Assessment

Jae K. Oh and William R. Miranda

5 Tissue Doppler and Strain Imaging

Hector R. Villarraga, Garvan C. Kane, and Jae K. Oh

6 Contrast Echocardiography

Sahar S. Abdelmoneim and Sharon L. Mulvagh

7 Quantification of Left-sided Cardiac Chambers: Mass, Volumes, and Ejection Fraction

Garvan C. Kane

8 Assessment of Diastolic Function

Jae K. Oh

9 Right Heart Assessment and Pulmonary Hypertension

Garvan C. Kane and Sung-A Chang

10 Cardiomyopathies

Jeffrey B. Geske and Jae K. Oh

11 Heart Failure, LVAD, and Transplantation

Yan Topilsky, Grace Lin, and Jae K. Oh

12 Pericardial Diseases

Jae K. Oh, Raúl E. Espinosa, and Lieng-H Ling

13 Native Valvular Heart Disease

Jae K Oh, Sungji Park, Sorin V Pisralu, and Vuyisile T Nkomo

14 Prosthetic Valve Evaluation

Lori A. Blauwet, Fletcher A. Miller, and Jae K. Oh

15 Infective Endocarditis

William K. Freeman

16 Stress Echocardiography

Robert B. McCully, Patricia A. Pellikka, and Jae K. Oh

17 Coronary Artery Disease, Acute Myocardial Infarction, Takotsubo Syndrome

Sunil V. Mankad and Jae K. Oh

18 Cardiac Diseases Due to Systemic Illness, Genetics, or Medication

Garvan C. Kane

19 Cardiac Tumors and Masses

Kyle W. Klarich, Jae K. Oh, and Joseph J. Maleszewski

20 Diseases of the Aorta

Peter C. Spittell

21 Congenital Heart Disease

Patrick O’Leary, Naser Ammash, and Frank Cetta

22 Interventional Echocardiography

Jeremy J. Thaden, Brandon M Wiley, Peter M Pollak, and Charanjit S. Rihal

23 Adult Intraoperative Echocardiography

Hector I. Michelena, Rakesh M. Suri, and Hartzell V. Schaff

24 Intracardiac and Intravascular Ultrasound

Donald J. Hagler, Allison K. Cabalka, and Guy S. Reeder

25 Vascular Tonometry and Imaging for Cardiovascular Risk Assessment

Thais Coutinho and Iftikhar J. Kullo

26 Handheld Cardiac and Point-of-Care Ultrasound

Michael W. Cullen and Brandon M. Wiley

27 Physics of Ultrasound

David A. Foley

28 The Future of Echocardiography

José Luis Zamorano, Ariana González, and Covadonga

Fernández-Golfín

29 Artificial Intelligence and Echocardiography: Current Status and Future Directions

David Playford and Geoff Strange

Appendix

Index

Abbreviations

A latediastolicfillingduetoatrial contraction

a′ latediastolicvelocityof themitral anulus

Aa (sameasa′)

ACTorAT Accelerationtime

Ao aorta

AS aorticstenosis

AVP aorticprostheticvalve

AVR aorticvalvereplacement

CHF congestiveheart failure

CI cardiacindex

CO cardiacoutput

CSA crosssectional area

CW continuouswave

D diastolicforwardflowvelocity

DT decelerationtime

E peakvelocityof earlydiastolicfillingof mitral inflow

e′ peakearlydiastolicvelocityof themitral anulus

Ea mitral anulusearlydiastolicvelocity(samease′)

E/A ratioof EandAvelocities

ECG electrocardiogram (-graphy)

ERO effectiveregurgitant orifice

IVC inferior venacava

IVCT isovolumiccontractiontime

IVRT isovolumicrelaxationtime

LA left atrium (-ial)

LV left ventricle(-icular)

LVEF left ventricular ejectionfraction

LVOT left ventricular outflowtract

MR mitral regurgitation

MS mitral stenosis

MV mitral valve

MVP mitral valveprosthesis

PFO patent foramenovale

PHT pressurehalf-time

PISA proximal isovelocitysurfacearea

PVR pulmonaryvascular resistance

PW posterior wall or pulsedwave

Qp pulmonarystrokevolume

Qs systemicstrokevolume

RA right atrium (-ial)

RV right ventricle(-icular)

S systolicforwardflowvelocity

S′ systolicvelocityof themitral anulus

SV strokevolume

SVC superior venacava

SVR systemicvascular resistance

TAVR transcatheter AVR

TEE transesophageal echocardiography

TR tricuspidregurgitation

TTE transthoracicechocardiography

TVI timevelocityintegral

TVP tricuspidvalveprosthesis

2D two-dimensional

3D three-dimensional

VS ventricular septum

CHAPTER 1

Transthoracic M-mode and Two-Dimensional Echocardiography

Jae K. Oh and Joseph J. Maleszewski

TWO-DIMENSIONAL ECHOCARDIOGRAPHY

Even with a great advance in three-dimensional (3D) echocardiography, two-dimensional (2D) transthoracic echocardiography, currently, remains as the main tool for a comprehensive echocardiography study. Hence, an echocardiography examination begins with transthoracic 2D scanning from four standard transducer positions: the parasternal, apical, subcostal, and suprasternal windows. The parasternal and apical views usually are obtained with the patient in the left lateral decubitus position (Fig. 1-1A), and the subcostal and suprasternal notch views are obtained with the patient in the supine position (Fig. 1-1B). A patient may need to flex or bend the knee to relax the abdomen during the subcostal examination. An examiner may sit at the left or right side of a patient and scan with the right or left hand, respectively. From each transducer position, multiple long- and short-axis tomographic images of the heart are obtained by manually rotating and angulating the transducer (Table 1-1); hence, a multiplaneexaminationisperformed(Fig.1-2) (1–4).

The long-axis view represents a sagittal section of the heart, bisecting theheart from thebasetotheapex.Theshort-axisviewisperpendicular to the long-axis view and is equivalent to sectioning the heart like a loaf of bread. Real-time 2Dechocardiography provides high-resolution images of cardiac structures and their movements so that detailed anatomic and functional information about the heart can be obtained. Quantitative

measurements of cardiac dimensions, area, and volume are derived from 2D images or 2D-derived M-mode (see below). In addition, 2D echocardiography provides the framework for Doppler and color flow imaging. These standard long and short tomographic imaging planes are acquired as described in the following sections. Newer matrix transducers allowvisualizationof multiple tomographic views from a single 3Dimage of the heart (see Chapter 2). Biplane or X-plane imaging allows visualization of two tomographic views, which are orthogonal to each other, from the same acquisition. This shortens the duration of the examination and minimizes variation in the acquisition of cardiovascular images. With more advances and clinical experiences in 3D or multidimensional echocardiographic imaging, visualization and quantitation of cardiovascular structure, function, and hemodynamics will improve. While ultrasound technology is able to provide 3D and 4D imaging of the heart, echocardiography unit is being miniaturized to be held in a hand to provide a point-of-care imaging in various clinical situations including physician’s office, critical care unit, emergency department, and medical school education (5). Comprehensive knowledge about cardiovascular anatomy provided by multiple tomographic images from 2D transthoracic echocardiography is essential for medical staff utilizingtheminiaturizedechocardiographyunit (seeChapter 26).

ParasternalPosition

The examination is begun by placing the transducer in the left parasternal region, usually in the third or fourth left intercostal space, with the patient in the left lateral decubitus position (Fig.1-1A). From this position, sector imagescanbeobtainedof theheart alongitslongandshort axes.

FIGURE 1-1 Four standard transthoracic transducer positions A: The parasternal(1) andapical (2) views usually areobtainedwiththepatient intheleft lateral decubitus position The parasternal view usually is obtained by placing the transducer at the left parasternal area in the third or fourth intercostal space The apical view is obtainedwiththetransducer at themaximal apical impulse(usually slightly lateral and inferior to the nipple, but it may be substantially displaced laterally and inferiorly because of cardiac enlargement or rotation or both). These views may beimagedbest duringheldexpiration, especially inpatients whohave chronic obstructivelungdisease.Theapicalview canbedifficulttoobtaininathin young person, and the transducer may need to be tilted superiorly. B: The subcostal(3) andsuprasternalnotch(4) views are obtained with the patient in the supineposition.For subcostalimaging,relaxingtheabdominalmuscles by flexing the patient’s knees and forced inspiration frequently improve the views. For suprasternal notch imaging, the patient’s head needs to be extended and turned leftward so the transducer can be placed comfortably in the suprasternal notch withoutrubbingthepatient’s neck

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Video1-1A

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Video1-1B

Long-Axis View of the Left Ventricle

The long-axis view of the left ventricle (LV) is recorded with the transducer groove facing toward the patient’s right flank and the transducer positioned in the third or fourth left intercostal interspace so that the ultrasound beam is parallel with a line joining the right shoulder to the left flank. The image obtained represents a section through the long axis of the LV(Fig.1-3A). The image is oriented so the aorta is displayed on the right, the cardiac apex on the left, the chest wall and right ventricle

(RV) anteriorly,andposterior structures posteriorly(Fig.1-3B).Therefore, the long-axis view of the LV is displayed as a sagittal section of the heart viewedfrom theleft sideof asupinepatient.

TABLE 1-1

Transducer Positions and Cardiac Views

Parasternalposition

Long-axis view

LV insagittalsection

RV inflow

LV outflow

Short-axis view

LV apex

Papillary muscles (midlevel)

Mitralvalve(basallevel)

Aortic valve–RV outflow

Pulmonary trunk bifurcation

Apicalposition

Four-chamber view

Five-chamber (or long-axis) view

Two-chamber view

Subcostalposition

Inferior venacavaandhepatic vein

RV andLV inflow

LV-aorta

RV outflow

Suprasternalnotchposition

Long-axis aorta–short-axis pulmonary artery

Short-axis aorta–long-axis pulmonary artery

Long-axis aortaandsuperior venacava

LV,leftventricle;RV,rightventricle

The long-axis viewof the LVallows visualization of the aortic root and aortic valve cusps. The chamber behind the aortic root is the left atrial (LA) cavity.Usually,theleft inferior pulmonaryvein,appearingasaround structure, also can be seen immediately posterior to the lower part of the LA. The long-axis view allows good visualization of the anterior and posterior leaflets of the mitral valve and their chordal and papillary muscleattachments(Fig.1-4A).

The coronary sinus appears as a small, circular echo-free structure and usually can be recorded in the region of the posterior atrioventricular groove (Fig. 1-3A). If the coronary sinus is enlarged, a persistent leftsided superior vena cava, increased right atrial (RA) pressure, or rarely coronary sinus atrial septal defect should be suspected (Fig. 1-4B). The left-sided superior vena cava can be confirmed by opacification of the coronary sinus with the administration of agitated saline through a vein in the left arm (see Chapter 6).The LVoutflowtract (LVOT),boundedbythe ventricular septum anteriorly and the anterior leaflet of the mitral valve posteriorly, is well seen and normally is widely patent during systole. Subaortic membrane may be seen as a subtle bulge near the junction between the LVOT and the ventricular septum and can be suspected by turbulent flow before the aortic valve (see Chapter 21). The LVOT diameter, which is used to calculate systemic stroke volume, is measured from this view. However, the measurement of actual LVOT area by 3D echocardiography is more accurate for calculation of stroke volume. In this view, the descending thoracic aorta appears as a circular structure behind the LA(Fig.1-4A) and LV posterior wall true- or pseudoaneurysm may be seen well from the parasternal long-axis view (Fig. 1-4C). RV enlargement or RV pressure overload as well as asymmetric ventricular septal hypertrophy in hypertrophic cardiomyopathy can be assessed in this view (Fig. 1-4D and E). With this view, color flow imaging is useful for screening for aortic and mitral valve regurgitation as well as subaortic obstruction.

FIGURE 1-2 A: Drawings of the longitudinal views from the four standard transthoracic transducer positions Shown are the parasternal long-axis view (1), parasternal right ventricular inflow view (2), apical four-chamber view (3), apical five-chamber view (4), apical two-chamber view (5), subcostal four-chamber view (6), subcostal long-axis (five-chamber) view (7), and suprasternal notch view (8). B: Drawings of short-axis views. These views are obtained by rotating the transducer 90 degrees clockwise from the longitudinal position. Drawings 1 to 6 show parasternal short-axis views at different levels by angulating the transducer from a superomedial position (for imaging the aortic and pulmonary valves) to an inferolateral position, tilting toward the apex (from level 1 to level 6