Parasternal Short Axis View (PSAX)

Transducer position: left sternal edge; 2nd – 4th intercostal spaceMarker dot direction: points towards left shoulder(900 clockwise from PLAX view)By tilting transducer on an axis between the left hip and right shoulder, short axis views are obtained at different levels, from the aorta to the LV apex.Many structures seen

Papillary Muscle (PM)levelPSAX at the level of the papillary muscles showing how the respective LV segments are identified, usually for the purposes of describing abnormal LV wall motion LV wall thickness can also be assessed

Apical 4-Chamber View (AP4CH)Transducer position: apex of heartMarker dot direction: points towards left shoulderThe AP5CH view is obtained from this view by slight anterior angulation of the transducer towards the chest wall. The LVOT can then be visualised

Apical 2-Chamber View (AP2CH)

Transducer position: apex of the heartMarker dot direction: points towards left side of neck (450 anticlockwise from AP4CH view)Good for assessment ofLV anterior wallLV inferior wall

Sub–Costal 4 Chamber View(SC4CH)

Transducer position: under the xiphisternumMarker dot position: points towards left shoulderThe subject lies supine with head slightly low (no pillow). With feet on the bed, the knees are slightly elevatedBetter images are obtained with the abdomen relaxed and during inspirationInteratrial septum, pericardial effusion, desc abdominal aorta

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• Normal• Hypovolemia• Vasodilatation• Systolic failure• Diastolic failure• Systolic and diastolic failure• RV failure

Hemodynamic states

• 75yr male for hip surgery• Starting BP 140/90 down to 85/50 after 10 mins of

anesthesia• HR unaltered lil bit improvement with aramine fall

back to 80/50• CVL inserted RA pressures 17 mm hg• PA Catheter: CI 1.8l/min/m2 & PCWP of 18• What next?????????• TTE

Case discussion?

• Estimate volume• Estimate systolic function• Estimate filling pressures• Final assessment (Put all together)

Hemodynamic assessment

• Estimate LV end diastolic vol ( preload) M mode; Simpsons biplane etc

• Estimate LV systolic function Eye balling; FS; FAC; EF

• RV systolic function mostly qualitative• Estimate LA pressures: Intra atrial septum; LA

size; surrogate from RA pressures• Estimate RA pressures : IVC

• Normal : LVEDA; EF & LAP normal• Hypovolemia : LVEDA & LAP ; EF = or • Diastolic failure : LVEDA ; LAP ; EF =• Systolic failure : LVEDA ; LAP =; EF • Systolic & diastolic: LVEDA & LAP ; EF • RV failure : RV vol; LAP • Vasodilatation : LVEDA & LAP =; EF

Final Assessment

Normal Echo Dimensions • LV Diastolic Dimension: 3.7-5.5 cm• LV Systolic Dimension: 2.0-4.0 cm• Interventricular septum* (Diastole): 0.6-1.1cm• LV Posterior Wall* (Diastole): 0.6-1.1cm• LVOT diameter (Systole): 1.8-2.2 cm • Aortic Root** (Diastole): 2.0-3.7 cm• Left Atrium (Systole): 2.0-4.0 cm• Left Atrial Area (4 chamber): <20cm2• Left Atrial Volume/m2 BSA: 16-28 ml• RV Diastolic Dimension: 0.9-2.5 cm

Thank You