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BASIC CARDIAC US.pptx
- 1. CARDIAC ULTRASOUND DR ROSLANUDDIN MOHD SALEHUDDIN EMERGENCY PHYSICIAN HOSPITAL SULTANAH BAHIYAH, ALOR SETAR
- 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
- 11. SUB Probe placement: 1.At subxiphoid 2.Probe’s dot mark towards patient’s L side 3.Flatten the probe left Dot mark
- 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
- 14. Contractility
- 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
- 17. Hyperdynamic LV function (EF >65%)
- 18. Normal LV function (EF 55-65%)
- 19. Mild LV dysfunction (EF 45-54%)
- 20. Moderate LV dysfunction (EF 30-44%)
- 21. Severe LV dysfunction (EF <30%)
- 22. M-mode linear internal dimension measurements (Teichholz method) IVSd LVIDd LVPWd IVSs LVIDs LVPWs
- 23. Volume measurements (Biplane Simpson’s method)
- 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
- 26. Pericardium appearance on ultrasound
- 27. Pericardium appearance on ultrasound
- 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
- 33. Pericardial effusion vs pleural effusion
- 35. Pulmonary embolism Thrombus lodged in pulmonary artery of lobar branches Increased pulmonary vascular resistance Increased RV afterload Increased RV pressure (RV dilatation) RV dysfunction Pathophysiology
- 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
- 37. Free floating thrombus in RV
- 38. RV dilatation (> 1:1 R/LV ratio) Dilated RV Normal
- 39. RV dilatation (> 1:1 R/LV ratio) Dilated RV Normal
- 40. RV dilatation (> 1:1 R/LV ratio) Dilated RV Normal
- 41. Bowing of IV septum into LV
- 42. IVC dilatation without inspiratory collapse
- 43. McConnell sign
- 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
- 49. Normal RWMA