introduction to cardiac ultrasound€¦ · structures visible in each view parasternal long:...

Intro to Bedside Ultrasound

Cardiac Ultrasound

University of California-Irvine School of Medicine

Nathan Molina nathan.d.molina@gmail.com Trevor Plescia taplescia90@gmail.com Jack Silva jpsilva42@gmail.com

TEACHERS

Left ventricle

Right ventricle

Pulmonary trunk Aorta

Pericardium

PARASTERNAL LONG PARASTERNAL SHORT APICAL 4-CHAMBER

SUBXIPHOID (SUBCOSTAL)

The 4 Views of Cardiac Ultrasound

Right Subxiphoid

Apical 4-Chamber

Parasternal Long Parasternal Short

CARDIAC ULTRASOUND TRANSDUCERS

Phased Array (P21) Convex (C60)

• The best transducer for viewing the heart is the phased array P21

• The convex C60 can also be used

- Start with the probe just to the left of the sternum (parasternal), in the 2nd intercostal space

- The indicator should be pointed to the  patient ’s  left  hip

- This will give a view of the heart along its long axis

PARASTERNAL LONG

What is the arrow pointing to?

Left Ventricle

What is the arrow pointing to?

Right Ventricle

What is the arrow pointing to?

Interventricular septum

What is the arrow pointing to?

Pericardium

What is the arrow pointing to?

Aortic Outflow Tract

What is the arrow pointing to?

Mitral Valve

17

Left Atrium

Mitral Valve (Anterior Leaflet)

Mitral Valve (Anterior Leaflet)

- In parasternal long axis, observe movement of mitral valve

- Anterior leaflet should slap interventricular septum

- Observe left ventricular contraction during systole

- Deficiencies indicate poor left ventricular function

- Avoid fluid overload

LEFT VENTRICULAR FUNCTION

HYPERTROPHIC CARDIOMYOPATHY

- Normal septum thickness: 0.8 – 1.2 cm

- >1.2 cm – HCM - Each tick mark = 1 cm

- Useful for estimation - Use calipers to make exact

measurement

ATHLETE’S  HEART  VS  HCM Athlete’s  Heart

(Benign Enlargement) HCM

Septum Thickness <15 mm >15 mm

Symmetry Yes (for septum and LV wall)

No (septum much thicker)

Deconditioning Reduction within 3 months None

- Start in the parasternal long axis (indicator pointed to patient ’s  left hip)

- Then rotate the probe 90° clockwise so that the indicator is pointed  to  the  patient ’s  right hip

PARASTERNAL SHORT

- Once positioned, use the fanning technique to view different structures:

- Initially you will see the mitral valve, which resembles a “fish  mouth”

- Fan inferiorly to see the papillary muscles and the apex

- You may also see the chordae tendineae - Fan superiorly, to see the aortic valve, which

resembles  the  “Mercedes-Benz”  logo

PARASTERNAL SHORT

Mitral Valve: “Fish  Mouth”

Fan inferiorly to see papillary muscles

Fan superiorly to see the aortic valve

Aortic  Valve:  “Mercedes-Benz”

From the parasternal short view, how would you manipulate the transducer

to visualize the aortic valve?

QUESTION

Fan superiorly

- Start with the  transducer  over  the  patient ’s  Point  of  Maximal Impulse or PMI (4th or 5th intercostal space, midclavicular or anterior axillary)

- Point  the  indicator  to  the  patient ’s  right

APICAL 4-CHAMBER

- Fan the probe superiorly toward the base of the heart

- Assess the size of the ventricles. The right ventricle should be approximately 2/3 the size of the left ventricle.

- The apical 4-chamber view can be hard to find on patients in a supine position

- Try the left lateral decubitus position, as it brings the heart closer to the thoracic cage

APICAL 4-CHAMBER

LV

LA

RV

RA

Mitral valve

Tricuspid valve

APICAL 4-CHAMBER

- Indicator pointed  to  patient ’s  right

SUBXIPHOID

SUBXIPHOID VIEW

The subxiphoid view is useful clinically for:

• Diagnosing pericardial effusion

• The pericardium is a high attenuating structure, and will appear hyperechoic. Fluid will be hypoechoic.

• Diagnosing cardiac arrest

• FAST scan

Start at liver edge and follow subcostal margin until heart is seen

Aim beam at chin

SUBXIPHOID TRICK

LV RV

LA

RA

Mitral Valve

Tricuspid Valve Pericardium

Subxiphoid

- Fluid in the pericardial sac - Increased intrapericardial pressure can disrupt

cardiac rhythm and efficiency - Cardiac tamponade

PERICARDIAL EFFUSION

Cardiac ultrasound utilizes 4 different views: 1) Parasternal long 2) Parasternal short 3) Apical 4-chamber 4) Subxiphoid

The indicator is pointed to the patient ’s  right  in  all  views  except for parasternal long, where it is pointed to the patient ’s  left  hip

SUMMARY

Structures visible in each view Parasternal long: interventricular septum, left ventricle,

mitral valve, aortic valve, aortic outflow tract, and right ventricle In  a  normal  heart,  the  mitral  valve’s  anterior leaflet will

make contact with the interventricular septum Parasternal short: aortic valve, mitral valve, and papillary

muscles Apical 4-chamber: all 4 chambers of the heart Subxiphoid is good for assessing pericardial effusion

SUMMARY

Atlas of Anatomy, Second Edition, By Gilroy, MacPherson, Ross, Schuenke, Schulte, Schumacher. Thieme Medical Publishers, 2012.

Select images from the UCISOM Ultrasound in Education Department

REFERENCES