Introduction to Cardiac Ultrasound€¦ · Structures visible in each view Parasternal long:...
Transcript of Introduction to Cardiac Ultrasound€¦ · Structures visible in each view Parasternal long:...
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Intro to Bedside Ultrasound
Cardiac Ultrasound
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University of California-Irvine School of Medicine
Nathan Molina [email protected] Trevor Plescia [email protected] Jack Silva [email protected]
TEACHERS
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Left ventricle
Right ventricle
Pulmonary trunk Aorta
Pericardium
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PARASTERNAL LONG PARASTERNAL SHORT APICAL 4-CHAMBER
SUBXIPHOID (SUBCOSTAL)
The 4 Views of Cardiac Ultrasound
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Right Subxiphoid
Apical 4-Chamber
Parasternal Long Parasternal Short
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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
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- 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
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What is the arrow pointing to?
Left Ventricle
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What is the arrow pointing to?
Right Ventricle
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What is the arrow pointing to?
Interventricular septum
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What is the arrow pointing to?
Pericardium
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What is the arrow pointing to?
Aortic Outflow Tract
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What is the arrow pointing to?
Mitral Valve
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17
Left Atrium
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Mitral Valve (Anterior Leaflet)
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Mitral Valve (Anterior Leaflet)
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- 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
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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
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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
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- 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
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- 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
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Mitral Valve: “Fish Mouth”
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Fan inferiorly to see papillary muscles
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Fan superiorly to see the aortic valve
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Aortic Valve: “Mercedes-Benz”
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From the parasternal short view, how would you manipulate the transducer
to visualize the aortic valve?
QUESTION
Fan superiorly
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- 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
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- 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
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LV
LA
RV
RA
Mitral valve
Tricuspid valve
APICAL 4-CHAMBER
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- Indicator pointed to patient ’s right
SUBXIPHOID
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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
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Start at liver edge and follow subcostal margin until heart is seen
Aim beam at chin
SUBXIPHOID TRICK
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LV RV
LA
RA
Mitral Valve
Tricuspid Valve Pericardium
Subxiphoid
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- Fluid in the pericardial sac - Increased intrapericardial pressure can disrupt
cardiac rhythm and efficiency - Cardiac tamponade
PERICARDIAL EFFUSION
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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
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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
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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