Intro to Echocardiography

What can be learned from an echocardiogram regarding heart location?

We assume that the human heart lies in the chest, left of the sternum; however, some could have variations such as Dextrocardia (heart is on the right)

What can be learned from an echocardiogram regarding heart anatomy?

We can evaluate whether or not the anatomy is congenitally correct and describe it

What can be learned from an echocardiogram regarding heart function?

assesses how effectively the heart pumps and fills with blood by evaluating ventricular function, ejection fraction, and overall cardiac performance

What can be learned from an echocardiogram regarding heart pathology?

helps identify structural and functional abnormalities of the heart by assessing its anatomy, motion, and blood flow to detect potential pathologies

Nomenclature

Terminology used by medical professionals to improve their ability to communicate with each other

What 4 things should an echo nomenclature include?

1. WINDOW (parasternal, apical, subcostal, suprasternal)

2. IMAGING PLANE (long/short axis, 4 chamber, etc.)

3. AREA/STRUCTURE OF INTEREST (MV, LVOT, etc)

4. ABBREVIATIONS (PLAX, PSAX, A4, AP 4, SSN)

What should you do when the apex is palpated on the right side of the chest?

specify right parasternal and right apical, otherwise it is assumed to be left-sided

What are cardiac planes based on?

based on how the ultrasound beam transects the heart

Name the following plane:

plane transects the heart perpendicular to the anterior and posterior surfaces of the body and parallel to the long axis of the heart

long-axis

Name the following plane:

plane transects the heart perpendicular to the anterior and posterior surfaces of the body and perpendicular to the long axis of the heart

short-axis

Name the following plane:

plane that transects the heart approximately parallel to the anterior and posterior surfaces of the body

four chamber

What is the echocardiographic appearance of chambers and vessels?

should be anechoic since they are fluid-filled; may have posterior enhancement

What is the echocardiographic appearance of valve leaflets/cusps?

hyperechoic and should be mobile; thickness will vary

What is the echocardiographic appearance of chamber walls?

thickness will vary depending upon whether atria or ventricles and pathology; usually a medium level gray

The parasternal window is bounded superiorly by the _____, medially by the _____, and inferiorly by _____ ______.

clavicle

sternum

apical region

What is the patient position for the PLAX (LVOT and LVIT) view?

in LLD w/ left arm extended over head

Where should the transducer be placed and oriented for the PLAX (LVOT and LVIT) view?

Tx in 3rd-5th intercostal space near the sternum, with the index mark toward the head/patient's right shoulder (~11:00).

What is the sector image orientation for the PLAX (LVOT and LVIT) view?

Image display shows chest wall and RV at top, LV inferior wall at bottom, aorta and LA at right, and portion of LV apex at left.

What anatomical structures can be identified in the PLAX (LVOT and LVIT) view?

• RVAW, RV

• Anteroseptum, LV, LV inferior wall, LVIT, MVLs

• LVOT, AVLs (RCC & NCC), Ao Root

• LA, Descending thoracic aorta, coronary sinus

What is the transducer tilt and movement for the PLAX (RVIT) view?

Starting with Tx orientation for PLAX LVOT & LVIT, tilt the Tx inferiorly with medial angulation with the faceplate towards the patient's right hip

What is the image display orientation for the PLAX (RVIT) view?

Chest wall at top, RA at bottom right, and RV apex at top left

What anatomical structures can be identified in the PLAX (RVIT) view?

• RVIT, RV, TVLs, RA

• IVC is often seen at bottom left; coronary sinus

What 2 normal variants might you see in the PLAX-RVIT view?

1. Eustachian valve

2. Chiari network

Eustachian valve

a remnant of the embryonic valve for fetal circulation; appears as a horizontal linear

structure from the entrance of the IVC to the inferior border of the RA below TV annulus

Chiari network

a redundant eustachian valve; appears as a thin, web-like, fenestrated membrane; may exhibit chaotic, random motion and is highly reflective in RA

How should the transducer be adjusted for the PLAX (RVOT) view?

Starting with Tx orientation for PLAX LVOT & LVIT, tilt the Tx superiorly and angle laterally so that the faceplate is towards patient's left shoulder

What is the image display orientation for the PLAX (RVOT) view?

RVOT at top, pulmonary valve (PV) and main pulmonary artery (MPA) on right, and LV on left

What is the patient position for PSAX view?

90 degrees clockwise from PLAX with notch towards patients left shoulder

What are the levels of PSAX from superior to inferior?

• Pulmonary artery bifurcation

• Ao, AV, LA

• LVOT

• MV

• LV papillary muscle

• Apex

What is the Tx placement for the Pulmonary Artery Bifurcation PSAX view?

move Tx superiorly or an intercostal space higher from PSAX

What is the Tx placement for the Apex PSAX view?

move Tx laterally & an intercostal space inferior

What is the patient and Tx position for apical window?

LLD with left arm extended

Tx is at 5th intercostal space in mid-axillary

Notch at 3:00

The Tx beam in the apical window is directed in what direction? How does it transect the heart

superiorly towards head and transects heart from apex through atria

A drop out of the IAS in the 4th chamber of apical view should not be mistaken for what?

ASD because the drop out is due to depth and parallel sound beam

What is apical 4 foreshortened and how can this be fix?

when the Tx is aimed too high and makes the ventricles look rounded. Move down a rib space or two

Tx placement for the Apical 5th chamber

Modification of 4th chamber so no movement of Tx is needed, just tilt Tx anteriorly until LVOT and Prox. asc. Ao are seen

What is the Tx and patient position for apical 3rd/long axis chamber?

Rotate Tx 60-90 degrees counterclockwise from apical 4 chamber view and tilt anteriorly to bring in Ao

Notch is at patient's head (12-1:00)

What is the Tx and patient position for apical 2nd chamber?

Rotate Tx 45 degrees clockwise from long (3rd) axis chamber or 45 degrees counterclockwise from apical 4 chamber

Patient position for subcostal window

supine w/ knees bent

inspiration to increase the volume of lungs to bring heart closer to Tx

Tx placement for subcostal 4 chamber view

Tx in subxiphoid at about midline

notch at 3:00 (like apical 4 chamber)

tilt Tx anteriorly

Tx placement for subcostal short axis

Tx rotated 90 degrees counterclockwise from subcostal 4 chamber with notch at 12-1:00

sweep as with PSAX from superior to inferior

What are the levels of subcostal SAX from superior to inferior?

• LV at level of apex

• LV at level of papillary muscles

• LV at level of MV

• Abdominal aorta (LAX)

• RVOT level

• IVC and SVC level

Tx placement for subcostal SAX at LV apex

angle Tx towards patients left with scan plane toward patients

Tx placement for subcostal SAX at Papillary MM

Sweep from subcostal SAX LV apex slightly towards midline

Image display for subcostal SAX at Papillary MM

ALPM at 6:00 and IMPM at 11:00

same as PSAX but slightly rotated

Tx placement for subcostal SAX at MV

Sweep from subcostal SAX papillary level slightly towards midline

Image display for subcostal SAX at MV

MVLs in center (AMVL to right; PMVL to left)

same as PSAX

Tx placement for subcostal SAX at RVOT

Scan plane towards left midclavicular line from left shoulder

Tx placement for subcostal SAX at IVC and SVC

Notch towards right midclavicular line with slight counterclockwise rotation

Patient should not hold breath in order to evaluate normal respiratory variation of IVC

Subcostal SAX IVC collapse. What information does this give use?

• IVC should collapse with inspiration

• Provides information about RA pressures

Patient and Tx position for suprasternal LAX

Patient is supine with neck/shoulders extended over pillow

Tx in suprasternal notch with notch at 1:00 and tilted inferiorly and angled anteriorly

Patient and Tx position for suprasternal SAX

Tx rotated 90 degrees clockwise from suprasternal LAX with notch at 3-4:00