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Basic Transthoracic Echocardiography (Cardiac Ultrasound) - TTE Made Simple — Transcript

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0:00hi my name is Mike avula and today we
0:02will be talking about basic trans
0:04thoracic echocardiography including the
0:06Imaging windows and various pathologies
0:08at the end we will also talk about IVC
0:11measurements the probe of choice for
0:13this examination is the cardiac probe
0:16aka the phased array probe this probe is
0:19great for fitting in between the rib
0:20spaces if your machine does not have
0:22this probe the curval linear probe can
0:24be used but really the preferred probe
0:27is the phase array probe first we need
0:29to talk about probe positioning you will
0:31use a standard mode where the indicator
0:33is on the left of the screen for most
0:35scans that are non-cardiac in this
0:37convention the probe marker will either
0:39be to the patient's right side or to the
0:42patient's
0:43head to get a cross-section of the heart
0:45however you need to imagine the heart as
0:47an upside down cone in standard mode a
0:50cross-sectional view or short AIS view
0:53of the heart will have the probe marker
0:55pointing to the patient's right hip and
0:57in Long AIS view to the patient's left
1:00hip as an example this is a parisal long
1:03AIS view of the heart we are in standard
1:05mode shown by the red arrow on the left
1:08of the screen the probe marker on the
1:09body is facing to the patient's left hip
1:12contrast standard mode with cardiac mode
1:14notice the indicator is on the right of
1:17the screen shown by the red arrow in
1:19this view again Imagining the heart as
1:21an upside down cone the long axis view
1:24will have the probe indicator pointing
1:25to the patient's right shoulder and in
1:28short AIS orientation to the patient's
1:30left shoulder this is opposite of
1:32standard mode but so is the indicator on
1:34the screen opposite of standard mode
1:36therefore the image acquired will be the
1:38same basically if you flip the indicator
1:41then you need to also flip the probe
1:43this is a parisal long AIS view of the
1:45heart probe marker is facing to the
1:47patient's right shoulder and we are in
1:49cardiac mode because the indicator on
1:51the screen is on the right side remember
1:53that the left ventricle should always be
1:56on the left of the screen for parason
1:58long axis we will talk about that again
2:01so here the image looks different it is
2:03actually flipped remember when I said
2:04that the LV should be on the left of the
2:06screen well here it's on the right why
2:09is this image flipped first see that the
2:10indicator on the screen is on the right
2:12which tells you that you are in cardiac
2:14mode then see where the probe marker is
2:16facing and in this case it is facing
2:19down to the patient's left hip the
2:21orientation in standard mode not cardiac
2:23mode remember in cardiac mode for
2:26parison long axis probe indicator should
2:29point to the right shoulder this image
2:31also looks different again it is flipped
2:34why is it flipped first see that the
2:36indicator on the screen is on the left
2:38which tells you that you are in standard
2:39mode then see where the probe marker is
2:42facing and in this case it is facing to
2:44the patient's right shoulder the
2:46orientation in cardiac mode not standard
2:48mode remember in standard mode probe
2:51indicator should point to the left hip
2:54so to summarize in cardiac mode the
2:56indicator on the screen should be on the
2:57right side and the probe marker should
2:59be be facing the right shoulder the LV
3:02should be on the left of the screen
3:04don't worry there's an easy way to
3:05remember that which we'll get to in a
3:07moment in case you got lost here's
3:09another summary when troubleshooting
3:11your image first check the screen for
3:13the indicator position for personal long
3:16axis make sure the probe is either
3:18pointing to the right shoulder in
3:19cardiac mode or left hip standard mode
3:22also make sure the LV is on the left of
3:25the screen for par long AIS if you do
3:27the previous two and are still
3:28unsatisfied with the image it may help
3:30to ask the patient to assume a left
3:33lateral decubitus position this brings
3:35the heart forward and closer to the
3:37chest surface which could help in
3:39acquiring your image have them lay on
3:41their left side it may help to ask the
3:43patient to place his or her arm above
3:45the head now we will talk about
3:47obtaining the cardiac views you can
3:50practice your Echo skills by developing
3:52a systematic protocol a suggested
3:54approach can begin with the parasal long
3:56axis view rotate the probe 90° for short
4:00axxis move on down to the apical four
4:02chamber and then finish up with the
4:04subid window let's start with the
4:06parisal long AIS view start out in
4:09cardiac mode the indicator should be on
4:11the right of the screen and then the
4:12probe indicator on the patient's body
4:15should be facing the right shoulder
4:17start by placing the probe at the nipple
4:18line or fourth interner Cal space or in
4:21women the infr memory line right next to
4:24the sternum keep the probe perpendicular
4:26to the skin and hug the sternum as you
4:28go up and down the chest searching for
4:30the best window so I told you I would
4:32give you an easy way to remember the
4:33paral long AIS view you can remember it
4:36by the 3 L's to success the personal
4:38long axis should have the left ventricle
4:41on the left side of the screen so for a
4:43visual here's what we're looking at for
4:45the personal long AIS view make sure the
4:47left ventricle is on the left of the
4:49screen before we go identifying what we
4:51see on the image it may be helpful to
4:53see a schematic representation on the
4:55ultrasound image toward the top of the
4:58screen we will see the right ventricle
5:00with the left ventricle beneath or
5:02deeper to it and the interventricular
5:03septum in between in the left ventricle
5:05you can see the mitro valve and
5:07sometimes the papillary muscles to the
5:09right of the mitro valves you will see
5:10the left atrium in this image you can
5:13also see the aortic Valves and the
5:15aortic outflow track going back to the
5:17ultrasound image if we again imagine the
5:18heart as a cone the Apex is at the upper
5:22left of the screen with the base towards
5:24lower right anteriorly is at the top of
5:26the screen which makes sense because
5:28that is where you physically have the
5:30Probe on the chest and deeper or towards
5:32the bottom of the image is the posterior
5:34portion of the heart the items to
5:36identify in the parasal Long exis View
5:38are the left ventricle the right
5:40ventricle the aortic valve and the mitro
5:42valve the left atrium the
5:44interventricular septum the descending
5:47aorta which will be important for
5:48distinguishing between a pericardial
5:50fusion and a plural Fusion we'll talk
5:52about that later the aortic outflow
5:54tract and the pericardium the parisal
5:57long AIS view is great for estimating e
5:59ection fraction there are a few studies
6:01that show that eyeballing the ejection
6:03fraction by looking at the squeeze of
6:05the heart and how closely the anterior
6:07mitro valve leaflet gets to the
6:08interventricular septum is a good
6:11estimate of the gold standard Cardiology
6:13method of evaluating the EF additionally
6:17it is much faster and can easily be done
6:19in the emergency setting in this
6:21ultrasound image you can see that the
6:23anterior mitro valve leaflet is slapping
6:25up against the interventricular septum
6:27you can also see that there is good
6:28squeeze of the ventricle and that the
6:30ventricular walls are almost touching
6:32with each contraction this is indicative
6:34of a normal ejection fraction of greater
6:36than 50% in this ultrasound image the
6:39anterior mitro valve leaflet does not
6:41quite make it to the inter ventricular
6:42septum Additionally the squeeze of the
6:44ventricles just isn't as good as the
6:46last image this EF is consistent with
6:49moderately depressed at 30 to 50% how do
6:52we know it is not severely depressed
6:54look at the next image in this image
6:56there's very little motion of the mitro
6:58valve leaflets and hardly any squeeze of
7:00the ventricles at all this is a sick
7:02heart with an ejection fraction of
7:03probably less than
7:0530 if you want to quantitatively measure
7:08the ejection fraction and not exactly
7:10eyeball it you can do so using epss or E
7:14Point sepal
7:16separation this is a heart in the
7:18parasal long AIS view if we want to use
7:22epss we just throw down an M mode Spike
7:25at the tip of the anterior mitro valve
7:27leaflet you can freeze the image and
7:28this is what you will see the thicker
7:30white line represents the
7:32interventricular septum and the squiggly
7:34wavy lines beneath that represents the
7:36motion of the anterior mitro valve
7:38leaflet I don't know if you noticed but
7:40the anterior mitro valve leaflet slaps
7:42twice on the interventricular septum in
7:43A Normal Heart the E represents the
7:46passive filling of the ventricles and a
7:49represents the atrial contraction the
7:51distance between the IVs and the
7:52squiggly lines show just how close the
7:55anterior mitro valve leaflet gets to the
7:58interventricular septum a distance of
8:00less than 7 mm is considered normal and
8:03greater than 10 is considered LV
8:05dysfunction or reduced EF 7 to 10 is
8:08sort of a gray area and needs to be
8:10taken into context notice this distance
8:12is greater than 10 mm and is consistent
8:15with CHF this is another example of
8:17reduced ejection fraction CHF is not the
8:19only way that your patient can end up
8:21with a reduced EF if your patient has
8:24atic regurgitation the back flow of
8:26blood will inhibit the anterior mitro
8:28valve leaflet from opening fully this
8:30will make your epss larger even though
8:33there is no CHF or if your patient has
8:35mitro stenosis the poor Excursion of the
8:38mitro valve leaflets will give you a
8:39large epss falsely predicting cardiac
8:43ejection fraction now I mentioned
8:45earlier that the descending aorta is
8:47important for distinguishing between a
8:49pericardial fusion and a plural effusion
8:52you can see in this image that this
8:53patient has a paracardial fusion because
8:55the fluid is within the pericardium
8:57anterior to the descending a y shown by
9:00the bottom arrow in this Echo you can
9:02see that the effusion is posterior to
9:04the pericardium and posterior to the
9:06descending aorta this is actually a
9:08plural affusion we can't talk about
9:11paracardial Fusion without talking about
9:13paracardial tanod traditionally the
9:15diagnosis of tamponade is made when you
9:17have diastolic collapse of the ventricle
9:20with clinical symptoms of hypo profusion
9:22such as hypotension tachicardia Syncopy
9:25shortness of breath chest pain Etc
9:28what's happening is the pressure of the
9:30fusion is great enough to impair filling
9:32of the RV blood in equals blood out so
9:35there will also be impaired filling of
9:37the LV you can tell that there is
9:39diastolic collapse of the RV because it
9:41happens when the mitro valves are open
9:43right ventricular strain can be assessed
9:45in this view as well strain can be due
9:48to any acute event usually a PE that
9:51causes sudden pulmonary hypertension
9:53causing resistance to the outward flow
9:55of the RV this can cause the RV to
9:57enlarge now we're going going to talk
9:59about the parisal short axis from the
10:02parisal long axis view rotate the probe
10:0490° clockwise towards the patient's left
10:07shoulder then fan towards the Apex and
10:11up towards the base Fanning up towards
10:13the base of the heart to the patient's
10:15head will get you more of the mitro
10:17valve even the aortic valve in view in
10:19this image we are more inferior or
10:21towards the Apex in the mid papillary
10:24view the circle in the middle is a left
10:25ventricle on the other side of the IVs
10:28is the right ventricle
10:30the arrows are pointing to the papillary
10:31muscles and the mitro valve Fanning
10:34superior to the patient's head you can
10:36see the mitro valve leaflets and the
10:38fish mouth view Fanning even more
10:40superiorly and you can see the aidic
10:42valve called the Mercedes-Benz sign
10:44here's a schematic that will help
10:46identify the images in the parach long
10:48AIS view with the atic valve in view
10:51most anteriorly is the right ventricle
10:54with the ra feeding through the
10:56tricuspid valve the tricuspid aortic
10:58valve is right in the middle the left
11:00atrium is the deepest structure feeding
11:02down into the screen out of plane of the
11:04probe the LA is the deepest structure so
11:08in review more inferiorly or towards the
11:10Apex is the mid papillary view fing up
11:14towards the head you can see the
11:15fishmouth mitro
11:17valve most superiorly you can begin to
11:20see the atic valve you can also assess
11:23for right ventricular strain in the
11:25peristal short axis view here we see an
11:29enlarged RV and sepal Boe showing
11:31something called the D sign where the
11:34pressure of the right ventricle is great
11:36enough during cyly to actually cause the
11:38IVs to bend in towards the LV here's
11:41another image demonstrating the D sign
11:44now we will talk about the apical four
11:46chamber view make sure the probe
11:48indicator is pointing towards the
11:49patient's left axila and from the
11:51parasal short axis view slide down
11:54towards the Apex until you see the
11:56chamber size getting smaller and smaller
11:58then when you get to the Apex or when
12:01you see the chamber size getting smaller
12:03fan up towards the patient's head the
12:07probe at this point should be at the
12:09point of maximal impulse the bottom
12:10right image displays the LA and the LV
12:13on the right of the screen and the RV
12:16and the RA are on the left of the screen
12:18as a general rule taking the ventricles
12:19as one the LV should take up about 2/3
12:23of the total and the RV 1/3 of the total
12:26consider PE or another acute event
12:28causing pulmonary hypertension if the RV
12:31is greater than the size of the LV you
12:33can also assess for pericardial Fusion
12:35in this view as shown in the image at
12:37the top left the fourth and final window
12:39of trans thoracic echocardiography is
12:41the subho view with the patient's knees
12:44bent place the probe in the subid region
12:47make sure the indicator on the probe
12:48still points with the patient's left
12:50side assume an overhand grip on the
12:52probe this will help you get more level
12:54and parallel with the skin and will
12:56allow you to visualize the heart start
12:58on on the patient's right locate the
13:00liver and sweep to the patient's left
13:03using the liver as an acoustic window
13:05basically acoustic window just means
13:07using an organ that doesn't contain gas
13:09and allows sound waves to travel through
13:11in the subid region bowel gas can
13:14sometimes mess up your image so using
13:15the liver as an acoustic window will
13:17help avoid this you can have the patient
13:19take a deep breath to help bring the
13:21heart into view so here the liver is
13:23being used as an acoustic window
13:25remember the RV is closest thing to the
13:27liver in this View you can see the LV
13:30the LA the RV the ra mitro valve and
13:33tricuspid valve and the pericardium this
13:36is a video clip of the same thing up
13:38here you can see the liver and right
13:40next to the liver you see the RV the
13:42subai foot view is pretty good for
13:43seeing a paracardial
13:45affusion here's another image of
13:47it remember that the traditional
13:50definition of pericardial tamponade is
13:52RV collapse with symptoms of hypo
13:54profusion here in these images we see a
13:57paracardial affusion and in the the
13:58image to the right we see RV compression
14:01and collapse this is a clip of cardiac
14:04standstill seems obvious like why do we
14:06need to Ultrasound that but if you have
14:08a patient without a pulse it helps to
14:10know that this isn't because of an
14:11arhythmia but instead because the heart
14:13isn't actually pumping if it was an
14:15arhythmia you would see motion of the
14:18heart even though we talked about the
14:20four views of the heart it would be
14:22prudent to also talk about the IBC as
14:24this can help you gather more
14:25information that is very important about
14:27the patient's fluid stat St in a
14:29nutshell IVC measurements are important
14:31because they help guide fluid
14:34management the respiratory Cycles
14:37correlate with changes in IVC diameter
14:39in someone that can receive fluid giving
14:41estimates of CVP during deep inspiration
14:44the diameter gets smaller and during
14:46expiration the diameter gets larger we
14:49will get into this a little bit more in
14:50a few slides but if the diameter does
14:52not change and remains open remains
14:55dilated this is a suspicion that the
14:57patient is pretty Prett overfilled with
14:59fluid the cable index is the percent
15:03collapsibility of the IVC throughout the
15:05respiratory cycle and is considered a
15:07predictor of preload Reserve or in other
15:09words a predictor of how much fluid the
15:11patient can receive before you run the
15:13risk of plural edema or a fusion let's
15:15talk about how to obtain the correct
15:17image of the IBC start in the subcostal
15:20region the collapsibility is measured by
15:23obtaining a long AIS view of the IVC aim
15:26towards the head which would be over
15:28here until you see the IVC entering the
15:30ra right here changes in size throughout
15:33the respiratory cycle are identified
15:35with the machine and M mode measure the
15:38diameter 2 to 3 cm distal to the
15:40Confluence of the hepatic vein and the
15:42IVC so here's the hepatic vein and
15:44here's the IVC the cable index is
15:47measured by taking the maximum IVC
15:49diameter during expiration and
15:51subtracting the minimum diameter of the
15:53IVC during inspiration from that then
15:56dividing all of that by the maximum IVC
15:59diameter this table was taken from
16:01asap.org and shows the correlations
16:03between the IVC size and the CVP small
16:06diameters with greater than 50% cable
16:09index correlates with a relatively low
16:11CVP compared to a dilated IVC with
16:14little to no change in the cable index
16:17which correlates with a high CVP in the
16:19first case probably the patient can
16:21receive fluid whereas the second case
16:23probably should not receive as much
16:25fluid all right so that was a lot we
16:28talked about the cardiac views forming a
16:30protocol that you go through each time
16:32so that you don't miss anything start in
16:33the parisal long AIS view rotate 90° to
16:36the parasal short AIS view go down to
16:39the Apex for the apical four chamber
16:41view then assuming an overhand approach
16:44go to the subid view we talked about
16:46troubleshooting your image first check
16:48the screen indicator then check the
16:50probe positioning then if that doesn't
16:52work put the patient in a left lateral
16:54decubitus if the patient is able to do
16:56so to remember the paral long axis view
16:59remember the three L is Success the
17:01paral long axis view should have the LV
17:04on the left side of the screen we talked
17:07about ejection fraction and how that can
17:09be a predictor of the patient's cardiac
17:12status whether it's a strong functioning
17:15heart or whether it's a poor functioning
17:16heart you can do that qualitatively by
17:19just looking at it which takes little to
17:21no time or you can quantitatively do it
17:23by using epss we talked about
17:25pericardial fusion and how that's
17:27different from paric cardial tanod we
17:30talked about right ventricular strain
17:32and how a pulmonary embolism or other
17:34cause of acute pulmonary hypertension
17:36can cause the right ventricle to enlarge
17:39and we also talked about IVC
17:40measurements we talked about the caveal
17:42index and how that can be a predictor of
17:44the fluid status of the patient here are
17:47the references that I used and that is
17:50it I hope you enjoyed that I hope you
17:52learn something have a great day

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