ECHO 1

what views do you see in parasternal?

long axis

short axis

what views do you see in apical?

4CH

5CH

2CH

3CH (long axis)

what view do you see in subcostal?

4CH

short axis (not in every protocol)

where should the probe be placed for PLAX?

between 3rd and 4th intercostal spaces, adjacent to the sternum

where is the notch pointed in PLAX? patient position?

10 o clock ; LLD

what views are obtained in the PLAX view?

LV (standard view)

RVIT

RVOT

what are the standard landmarks for PLAX?

RV
LV

aortic valve & prox asc aorta

mitral valve

LA

descending ao

what are you assessing when looking at the

• pericardium

• LV

• aorta

• ao valve

• mitral valve

• RV

pericardium : fluids

LV : wall thickness, size, function

aorta : size

ao valve : motion, openng, calcifications, hemodynamics

mitral valve : motion, opening, calcification, hemodynamics

RV : size

know this

is the apex visualized in PLAX?

no

does breathing help PLAX visualization?

yes

what end diastolic measurements are taken in PLAX?

RV outflow (optional)

LVID

IVS

LVPW

aortic root

how and where is LVID measured?

measured immediately below level of mitral valve leaflet tips

calipers placed on interface between myocardial wall and cavity & interface between wall and pericardium

how is the aortic root measured?

max diamter of sinus of valsalva

leading edge to leading edge

what measurements are taken in PLAX systole?

LVID systole

left atrium

how is LVID systole measured?

at the smallest LV dimension, place calipers on interface between myocardial wall and cavity & interface between wall and pericardium

how and where is LA measured in PLAX systole?

meaured from directly under midpoint of sinus of valsalva, perpendicular to the aortic root axis

dont measure these

what is considered a dilated LV in males? females?

males : >5.8

females : >5.2

what is considered abnormal LV thickness in males? females?

male : >1

female : >.9

how do you obtain the RVIT from standard LV PLAX view?

angle transducer infero-medially towards patient’s right hip

what can you see in PLAX RVIT view?

RV

tricuspid valve

RA

IVC/SVC

how do you obtain RVOT from standard LV PLAX?

angle transducer superiolaterally towards patient’s left shoulder

what structures do you see in RVOT view?

RV outflow tract

PV

PA

how do you obtain PSAX from PLAX? time position?

rotate notch of transducer 90 degrees CW towards the patient’s left shoulder ; 2 oclock

what are the different views to obtain in PSAX?

aortic valve

mitral valve

papillary muscle

apex

how do you obtain the PSAX at the aortic level?

tilt superior/ superiomedially from PSAX

what structures can you see in PSAX aortic level?

3 leaflets (right, left and non coronary cusps)

RVOT

RA

LA

PA (left and right)

where does the right coronary cusp lie? left? non?

right : adjacent to RVOT

non : adjacent to interatrial septum (between RA/LA)

left : adjacent to LA

when should the 3 aortic leaflets be identified and why?*

must be seen in systole when the valve is open ;

this is because a bicuspid valve may appear tri-leaflet in diastole as a result of raphe

how do you obtain the PSAX mitral (aka?) view from aortic PSAX level?

aka fishmouth

tilt inferiolaterally towards patient’s left hip

(may have to move one intercostal spaces down (no angling) or move 2 intercostal spaces down and angle superiomedially)

which leaflets are visible in PSAX mitral valve view and where are they located?

anterior and posterior mitral valve leaflet

anterior closer to LV/IVS in PSAX mitral valve view

what can be assessed on the PSAX mitral valve level?

calcification, rheumatic disease, regurg, stenosis, IVS defects

how can you obtain the PSAX view at the papillary muscle level?

tilt/slide more inferior in relation to heart (inferiolaterally)

what landmarks are seen in PSAX at level of pap muscle?

both pap muscles

LV cavity

pericardium

RV cavity

NO mitral valve

what are the pap muscles and where are they located?

posteromedial (left side of screen) and anterolateral (right side of screen) pap muscle

how do you obtain PSAX at the apical view?

tilt/slide more inferolaterally

what is visualized in PSAX apical view?

only myocardium/endocardium

what are the apical views?

4CH, 2CH, 3CH(long axis)

where should the transducer be placed to find the apical 4CH view?notch?time?

by the 5th intercostal rib on the anterior axillary line with the notch pointed towards pt’s left at around 2-3 oclock (can be pinpoint apex by feeling for apical pulse)

what structures are visualized in apical 4CH?

RV/ LV

TV / MV

RA/LA

IVS

where do the tricuspid and mitral annulus lie relative to eachother?

tricuspid annulus lies slightly higher (1cm) than mitral

how do you obtain the apical 5 chamber view?

tilt transducer superiorly from apical 4 chamber view

what is the difference between apical 4CH and 5CH?

in 5CH you now see LVOT and aorta

another view of apical 5CH

how do you obtain the apical 2CH view?

from the apical 4CH view rotate transducer 60 degrees counterclockwise

what is 2CH view mostly used to asses?

wall motion of anterior and inferior walls

what structures are visualized in apical 2CH view?*

LV

LA

(LA appendage and coronary sinus may be seen)

how do you obtain the apical 3CH view

from the 2CH view rotate the transducer an additional 60 degrees CCW

what structures are visualized in apical 3CH view?

LV

IVS

MV (anterior and posterior leaflet)

LA

Ao

right coronary cusp

3Ch view is aka?

apical long axis view (PLAX from apex)

how does apical 3CH compare to PLAX?

in apical 3CH you can see the LV apex

however, aortic and mitral valve are at greater depth → poorer resolution

how do you obtain the subcostal view? time? notch?

place transducer directly below the xiphoid process with notch towards pt’s left at 3 oclock (opposite of scanning abdomen)

what is the best pt position for optimizing subcostal view?

pt supine with legs bent (deep breaths help lower heart for better optimization)

what structures do you see in subcostal view?

RV/LV

RA/LA

IVS

interatrial septum

what view is best for assessing ASD? why

subcostal because interatrial septum is perpendicule to ultrasound beam

how do you assess IVC from subcostal view?

rotate notch to 12 oclock to see IVC entering RA

what is the normal change of the IVC from rest and respiration?

IVC should collapse at least 50% with respiration

subcostal view is a good view to assess

pericardial effusion. septal defects, venous return

when is subcostal SAX used and how does it compare to PSAX from parasternal window?

short axis view from the subcostal area

looks the same as PSAX but includes liver

subcostal SAX has decreased frame rate because of increased depth

what position should the pt be in for SSN view?

pt should be supine with neck extended

what structures are seen in SSN?

aortic arch / ascending / descending

RPA

SSN is used for

aortic stenosis

aortic dissection

aortic aneurysm

measure the aorta

aortic regurg

what is the right parasternal view used for?

demonstrate flow in the ascending aorta

review Qs

name all the windows used in echo

parasternal

apical

subcostal

suprasternal

review Q

in what views do we see the pulm art?

PSAX (aortic level)

parasternal RVOT

suprasternal

review Q

what views do we see the RA?

parasternal RVIT

PSAX aortic level

apical 4ch, 5ch

subcostal 4ch

review Q

what position should notch be in to obtain apical 2CH?

60 degrees counterclockwise from 4ch (notch towards 12 o clock)

review Q

what view do we measure the wall thickness of LV? what about aortic root?

measure LV wall thickness : PLAX, (potentially PSAX at pap muscle level)

aortic root : PLAX

**know which phases of cardiac cycle you measure all plax structures**

review

review

review

what does the x and y axis of m mode depict?

x axis : time

y axis : depth

review

m mode has superior - resolution which makes identification of what more accurate and reproducible?

temporal resolution; thin moving structures such as LV endocardium

m mode guided by 2d imaging is most helpful and used for

• assessing fast moving structures

• very rapid motions

• precide measurements of cardiac dimensions

• aids in diagnosing conditions such as cardiac tamponade, MVP, paradoxical septal motion

what do the two peaks represent?

what does this show?

not normal m mode

what is anatomical m mode?

cursor placement must always be perpendicular to structure; anatomical m mode is a post processing function circumvents limitation → but reduces temporal resolution

review

review

what structures are visualized in m mode aortic root diameter/LA/cusp separation

RV free wall

aortic root

RCC

NCC

left atrium

fibrous pericardium

**all measurements in m mode should be

leading edge to leading edge (outer to inner)

what are the three measurements taken in m mode:aortic root diameter/LA/cusp separation

ao root diameter

acs (aortic cusp separation)

LA

when is the aortic root measured?

at the onset of ventricular systole or end diastole

when is the ACS (aortic cusp sep) measured?

onset of ventricular ejection when cusps first open

when is LA measured?

closure of ACS (end of systole) - t wave

what structures are visualized in m mode through LV?

RV anterior wall

RV

IVS

LV (LVIDd & LVIDs)

LV posterior wall

fibrous pericardium

how do you calc ejection fraction?

measure LV in end diastole (QRS) and systole (T wave)

IVS and PW greater than what indicates LVH?

1.1cm

what is measured in end diastole?

RV

IVS

LV

PW

PW

Aortic root

if your PLAX image is not perpendicular what can you do?

use anatomical m mode

why is EF% produced via m mode only reliable with symmetric left ventricular systolic function?

it is only showing the movement through the one like on the cursor and therefore may not show abnormalities not on the line

in M mode mitral valve, what does D represent?

end of isovolumetric relaxation (shortly after t wave)

in M mode mitral valve, what does E represent?

early ventricular diastole (mitral valve opens)

in M mode mitral valve, what does F represent?

mid diastolic partial closure

in M mode mitral valve, what does A represent?

late ventricular diastole (atrial kick) - mitral valve opens again

• seen after P wave or on QRS

in M mode mitral valve, what does C represent?

onset of isovolumetric contraction

• normally appears near R wave

ventricular filling is described as

biphasic (e and a wave)