2. Four standard
cardiac views
1.Parasternal long
axis view (PLAX)
2.Parasternal short
axis view (SAX)
3.Apical four
chamber view
(A4C)
4.Subcostal view
(SUB)
• Technique and probe placement
• Echocardiographic plane
• Normal anatomy
• Good view features
• What to look for
3. PLAX
Probe placement:
1.Just left of sternum, 3rd or 4th
intercostal space
2.Probe’s dot mark towards
patient’s R shoulder
Dot
mark
Cardiac
apex
4. PLAX
What to look for:
1.LV contractility, size and wall
thickness
2.LA size = Aortic root
3.Pericardial effusion
4.AV and MV
LV
LA
DAo
Ao
LVOT
IVS
RVOT
Good view:
1.IVS as horizontal as possible
2.Apex should not be seen
3.Should see AV and MV
5. SAX
Probe placement:
1.From PLAX view, turn probe
90 degrees clockwise
2.Probe’s dot mark towards
patient’s L shoulder
Dot
mark
R side of
patient
L side of
patient
6. SAX – mitral valve level
What to look for:
1.LV contractility and wall
thickness
2.LV and RV size, IVS
3.Pericardial effusion
4.MV
Good view:
1.LV round shaped and
symmetric
2.LV in middle of screen
LV
RV
AMVL
PMVL
7. SAX – papillary muscle level
What to look for:
1.LV contractility and wall
thickness (RWMA)
2.Pericardial effusion
8. SAX – aortic valve level
What to look for:
1.LV contractility and wall
thickness
2.AV, PV, TV
RVOT
PA
RA
LA
TV PV
9. A4C
Probe placement:
1.At the cardiac apex
2.Probe’s dot mark towards
patient’s L side
3.Probe angle to ’look’ at
patient’s R shoulder
Dot
mark
10. A4C
What to look for:
1.Contractility and wall
thickness
2.RV should not be >2/3rd LV
width
3. Pericardial effusion
Good view:
1.Four chambers must be
visualised
2.IVS and IAS draw a cross
between the four chambers
3.Both TV and MV seen
TV
RV
LA
RA
RVFW
MV
LV
12. SUB
What to look for:
1.Contractility and wall
thickness
2.RV should not be >2/3rd LV
width
3. Pericardial effusion
TV
RV
LA
RA MV
LV
Good view:
1.Four chambers must be
visualised
2.IVS and IAS draw a cross
between the four chambers
3.Both TV and MV seen
15. Ejection fraction
Hypotensive patients and
patients with chest pain or
SOB can benefit from
focused cardiac US as an
adjunct method to assess
contractility
EF = % of end diastolic LV
blood volume ejected out
during systole
Normal EF >50%
Methods (common): eye-
balling, M-mode, Simpson
16. Eye-balling method
Inward motion of endocardium
Thickening of myocardium
Longitudinal motion of mitral annulus
Geometry of ventricle
25. Pericardial
cavity
Pericardium: fibrous and serous
layers
Serous pericardium : inner visceral
(part of epicardium) and outer
parietal (fused to fibrous
pericardium)
Pericardial cavity = potential
space between visceral and
parietal layers
Normally contains 15 – 50 ml of
serous fluid as lubrication
Anatomy
28. Pericardial
effusion
The pericardium cannot be stretched
When pericardial space is filled by
effusion, cardiac chambers expansion
is limited during diastole
Cardiac tamponade happens when
intrapericardial pressure >
intracardiac pressure
Intrapericardial pressure > RA
diastolic pressure = late diastolic RA
inversion
Intrapericardial pressure > RV
diastolic pressure = early diastolic RV
collapse
Quantity of pericardial fluid is not as
clinically important as the rate of
accummulation of pericardial
effusion
Pathophysiology
31. Pericardial effusion vs. pericardial fat
Fat = same echo intensity
as blood
Presence and size of fat
pad is related to presence
of abdominal fat
Fat pads are usually
localised, located anteriorly
to the RVOT and RV free
wall
32. Pericardial effusion vs. pleural effusion
From PLAX view
localisation of the effusion
compared to the
descending aorta
Pericardial effusion =
anterior to descending
aorta (ends as a tail as LA
not covered by
pericardium)
Pleural effusion = posterior
to descending aorta
36. Direct signs
o Free floating thrombus
in right heart or
pulmonary artery
Indirect signs
o RV dilatation
o Flattening/bowing of
IV septum into LV
o McConnell sign
o RV dysfunction
o IVC dilatation without
inspiratory collapse
o Lower limb DVT
44. RV dysfunction
RV dysfunction with TAPSE
(tricuspid annular plane systolic
excursion)
Normal >1.6 cmTAPSE <1.6 cm is
significant predictor of acute PE-related 30
day mortality (Paczynska 2016).
45. RWMA
Evaluation for
RWMA when high
concern for UA or
NSTEMI by history
and physical
examination with
equivocal ECG for
cardiac ischaemia
46. RWMA
For simplicity, 17-wall motion
segment condensed into 3-area
evaluation
Corresponds to major coronary
artery perfusion areas
ASE guidelines
Described as hypokinesia,
dyskinesia or akinesia of a
segment when compared to the
other contracting segments