becoming a better Clinician
Cardiac imaging Planes
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ECHO imaging planes are defined in relation to the position of the heart not the anatomical planes of the body
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heart axis is rotated in relation to the body axis (not the mean QRS axis)
![](https://static.wixstatic.com/media/668574_ef993b77ed0b48ceb2a99989c118eeab~mv2.png/v1/crop/x_250,y_0,w_508,h_396/fill/w_100,h_78,al_c,q_85,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_ef993b77ed0b48ceb2a99989c118eeab~mv2.png)
![](https://static.wixstatic.com/media/668574_f091d3556ac64a8e835b98cd3117146a~mv2.jpg/v1/crop/x_82,y_0,w_288,h_259/fill/w_69,h_62,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_f091d3556ac64a8e835b98cd3117146a~mv2.jpg)
![](https://static.wixstatic.com/media/668574_fc4a39d721a34f4a9b81af7ef8a5836e~mv2.jpg/v1/fill/w_59,h_59,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_fc4a39d721a34f4a9b81af7ef8a5836e~mv2.jpg)
Transducer
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small footprint transducer (eg. phased array or microconvex-array) is desired to obtain images in between and around ribs
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lower frequency allows better penetration (2-5 MHz) because takes longer for attenuation to occur
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curvilinear probe may be used but only in the subxiphoid or subcostal position
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selecting the cardiac modality on the point-of-care ultrasound machine will optimize image acquisition; note that the probe indicator marker is now to the right of the ultrasound screen
![](https://static.wixstatic.com/media/668574_40cf829b748d4e9aa15b10025ae10f11~mv2.jpg/v1/crop/x_4,y_9,w_186,h_207/fill/w_124,h_138,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_40cf829b748d4e9aa15b10025ae10f11~mv2.jpg)
![](https://static.wixstatic.com/media/668574_e9e03096d40f4756be6f0868a6545944~mv2.jpg/v1/crop/x_8,y_10,w_283,h_271/fill/w_130,h_124,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_e9e03096d40f4756be6f0868a6545944~mv2.jpg)
Transducer Movements
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moving
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sliding
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probe moves parrallel to indicator
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sweeping
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probe moves perpendicular to indicator
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rocking (heel-toeing)
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rocking the probe parrallel to the indicator
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tilting (fanning)
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rocking the probe perpendicular to indicator
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rotating
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turing the probe clockwise or counterclockwise
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compression
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applying axial pressure along the long axis of the transducer
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![](https://static.wixstatic.com/media/668574_e812646e0b0c491a80479ff446fe51a7~mv2.jpg/v1/crop/x_127,y_6,w_506,h_523/fill/w_60,h_62,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_e812646e0b0c491a80479ff446fe51a7~mv2.jpg)
Transducer pointer
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as long as the indicator on the screen and probe are on the same side, your image should be anatomically correct
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historically, cardiologist established the probe indicator to be placed on the right side of the screen from the viewer's presepective
![](https://static.wixstatic.com/media/668574_32fc4d76c14f4560b7b70779fde9566a~mv2.jpg/v1/fill/w_75,h_38,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_32fc4d76c14f4560b7b70779fde9566a~mv2.jpg)
Windows and Views
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parasternal long-axis
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parasternal short-axis (mid-ventricle)
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parasternal short axis (base)
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apical four-chamber
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subcostal
![](https://static.wixstatic.com/media/668574_7226242c25784b1d8547708bb8ced1cb~mv2.jpg/v1/fill/w_52,h_52,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_7226242c25784b1d8547708bb8ced1cb~mv2.jpg)
![](https://static.wixstatic.com/media/668574_6864ac091ecb4ad4b1797b2c1c416375~mv2.jpg/v1/fill/w_170,h_170,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_6864ac091ecb4ad4b1797b2c1c416375~mv2.jpg)
Parasternal Long-Axis View
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3rd to 5th intercostal space
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30 to 45 degrees toward left lateral
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assessment of left ventricular systolic function
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view aortic and mitral valve
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assessment of pericardial effusion
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not suited for right ventricle size evaluation because it varies greatly
![](https://static.wixstatic.com/media/668574_c384e5e01dc14d10975a6429a3cc98c4~mv2.jpg/v1/fill/w_170,h_170,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_c384e5e01dc14d10975a6429a3cc98c4~mv2.jpg)
![](https://static.wixstatic.com/media/668574_1407f22a840842ad9860e7faeeb252c2~mv2.jpg/v1/fill/w_57,h_43,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_1407f22a840842ad9860e7faeeb252c2~mv2.jpg)
Parasternal Short-Axis View: mid ventricular view
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30 to 45 degree left lateral decubitus
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assessment of left ventricular size and function
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assessment of right ventricular size and function
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assessment of pericardial effusion
![](https://static.wixstatic.com/media/668574_5c0a0960f707452a97d610e56accb860~mv2.jpg/v1/fill/w_170,h_170,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_5c0a0960f707452a97d610e56accb860~mv2.jpg)
![](https://static.wixstatic.com/media/668574_060a79166e87483c811f371a064cacaf~mv2.jpg/v1/fill/w_171,h_171,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_060a79166e87483c811f371a064cacaf~mv2.jpg)
![](https://static.wixstatic.com/media/668574_8df045804dde4db0acfea032f4285f00~mv2.jpg/v1/fill/w_57,h_43,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_8df045804dde4db0acfea032f4285f00~mv2.jpg)
Parasternal Short-Axis View: Base
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tilt the back of the transducer toward the patients left hip
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assessment of aortic valve morphology and function
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assessment left atrial size & interatrial septum
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assessment of tricuspid and pulmonic valve morphology and function
![](https://static.wixstatic.com/media/668574_fa36f5003c864f99874483208a703cdd~mv2.jpg/v1/fill/w_170,h_170,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_fa36f5003c864f99874483208a703cdd~mv2.jpg)
![](https://static.wixstatic.com/media/668574_239d905a0d084547a940d49be9eeed05~mv2.jpg/v1/fill/w_57,h_43,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_239d905a0d084547a940d49be9eeed05~mv2.jpg)
Apical Four-Chamber View
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30-45 degree left lateral decubitus
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near apical impulse
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point the probe toward the patients back
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tricuspid annulus is closer to the apex than the mitral valve annulus
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Assess left ventricular size and function
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Assess right ventricular size and function
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Assess tricuspid and mitral valve morphology and function
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Assess right and left atrial size
![](https://static.wixstatic.com/media/668574_1a3979e5b87748238bfa37419d5a38a4~mv2.jpg/v1/fill/w_169,h_169,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_1a3979e5b87748238bfa37419d5a38a4~mv2.jpg)
![](https://static.wixstatic.com/media/668574_4c175f2f1c3345d0a61331b3e1ecfd3b~mv2.jpg/v1/fill/w_171,h_171,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_4c175f2f1c3345d0a61331b3e1ecfd3b~mv2.jpg)
![](https://static.wixstatic.com/media/668574_1fa3e1201061423ca4b9ee96cf6b70d1~mv2.jpg/v1/fill/w_45,h_45,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_1fa3e1201061423ca4b9ee96cf6b70d1~mv2.jpg)
Subcostal Four-Chamber View
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supine and bend knees; deeper breathing helps
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transducer indicator pointing toward left flank and the US beam aimed toward left shoulder
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compression is often required
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Assess right and left ventricular systolic function
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Assess interatrial septum
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Assess pericardial effusion
![](https://static.wixstatic.com/media/668574_a9139234ee32467a8799939d098f432d~mv2.jpg/v1/fill/w_168,h_168,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_a9139234ee32467a8799939d098f432d~mv2.jpg)
![](https://static.wixstatic.com/media/668574_8e6c4af993fe4298bde0e6ba51eaae55~mv2.jpg/v1/fill/w_56,h_42,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_8e6c4af993fe4298bde0e6ba51eaae55~mv2.jpg)
![](https://static.wixstatic.com/media/668574_45795fa8ffb146a3b4f788e1928573d6~mv2.jpg/v1/fill/w_168,h_168,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_45795fa8ffb146a3b4f788e1928573d6~mv2.jpg)
IVC Evaluation
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use low frequency transducer (eg. curved or phased array)
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starting from subcostal view, rotate counterclockwise and tilted perpendicular to the long axis of the body
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right atrial pressure determined by the degree of collapse of the IVC upon inspiration (more predictive than diameter alone)
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diameter measured at the junction of hepatic veins draining into IVC
![](https://static.wixstatic.com/media/668574_f9be00963f694796be86c555cd091422~mv2.jpg/v1/fill/w_169,h_130,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_f9be00963f694796be86c555cd091422~mv2.jpg)
![](https://static.wixstatic.com/media/668574_3c529327e903495197606241f8d68d2a~mv2.jpg/v1/fill/w_181,h_139,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_3c529327e903495197606241f8d68d2a~mv2.jpg)
![](https://static.wixstatic.com/media/668574_cd5ab97878cb4a879046997676358d90~mv2.jpg/v1/fill/w_187,h_140,al_c,q_80,usm_0.66_1.00_0.01,blur_3,enc_auto/668574_cd5ab97878cb4a879046997676358d90~mv2.jpg)
Dilated Right Ventricle
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pulmonary embolism
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ASD
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VSD
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tricuspid regurgitation
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pulmonary regurgitation
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pulmonary hypertension
![](https://static.wixstatic.com/media/668574_9fb047435b8d450d93350e05feb6bf44~mv2.gif)
![](https://static.wixstatic.com/media/668574_ddc85e95ccd1440aa8d3e8bafab28005~mv2.gif)
Interventricular flattening timing and right heart disease (volume vs pressure overload)
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systolic flattening
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pulmonary HTN
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diastolic flattening
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volume overload
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RV volume overload (hyperdynamic & dilated):
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ASD
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tricuspid regurgitation
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pulmonary regurgitation
Acute Pulmonary Embolism
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McConnell's sign (hypokinesis RV base with preserved hyperdynamic contraction of apex) suggests acute pressure overload
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"D" shaped ventricle
Pericardial Effusion
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swinging heart, usually circumferential
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hyperdymanic
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early diastolic collapse of right ventricular free wall
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IVC dilated and does not collapse
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epicardial fat pad
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usually only found anteriorly
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heterechoic appearance
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usualy < 1cm
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to and from movement in concert with cardiac contractions
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Cardiac Tamponade
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dilation of intrahepatic IVC (most sensitive)
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early diastolic collapse (highly specific) of right or left ventricle
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mitral inflow velocity during pulse Doppler > 25% decline during inspiration (pulses paradoxus) or exaggerated drop in systolic blood pressure during inspiration
Left Ventricular Ejection Fraction Estimation
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normal 55-70%
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SV = EDV - ESV
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EF = Stroke volume / EDV
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Simpson's rule calculator with automated border detection to aid in estimating the ejection fraction
Pleural Effusion
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parasternal long axis
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coronary sinus (intra-cardiac)
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descending aorta (extra-cardiac)
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Right Ventricle Dimensions
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best estimated at end-diastole
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use a right-ventrcle focused apical 4 chamber view
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make sure the crux and the apex are in view
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>42 mm at the base and >35 mm at mid level indicates RV dilatation
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>86 mm longitudinal indicates RV dilatation
![](https://static.wixstatic.com/media/668574_b7731950c2104f8a897f82c09990e5eb.png/v1/fill/w_54,h_52,al_c,q_85,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_b7731950c2104f8a897f82c09990e5eb.png)
RV Systolic Function
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evaluated using several parameters
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TAPSE (tricuspid annular plane systolic excursion)
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measures RV longitudinal function
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<16 mm indicates RV systolic dysfunction
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place M-mode cursor through the tricuspid annulus and measure the amount of longitudinal motion of the annulus at peak systole
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![](https://static.wixstatic.com/media/668574_c96108b1c86b4d4c8dd16c667b976b64.png/v1/fill/w_100,h_52,al_c,q_85,usm_0.66_1.00_0.01,blur_2,enc_auto/668574_c96108b1c86b4d4c8dd16c667b976b64.png)