introduction to cardiac ultrasound€¦ · structures visible in each view parasternal long:...
TRANSCRIPT
Intro to Bedside Ultrasound
Cardiac Ultrasound
University of California-Irvine School of Medicine
Nathan Molina [email protected] Trevor Plescia [email protected] Jack Silva [email protected]
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