(8) Parasternal Long Axis View

What are the five echo techniques listed in the study guide protocol?

TTE, TEE, Stress Echo, Contrast Echo, and 3D/4D Echo.

Why must the EKG signal have good R and T waves in TTE?

These signals trigger the video clip acquisition.

What can occur if the EKG signals are of poor quality?

Incorrect triggering or inaccurate recording.

Where should the WHITE electrode be placed in a standard three-lead EKG?

Under the right clavicle at the mid-clavicular line and within the rib cage frame.

Where should the BLACK electrode be placed in a standard three-lead EKG?

Under the left clavicle at the mid-clavicular line and within the rib cage frame.

Where should the RED electrode be placed in a standard three-lead EKG?

On the lower left abdomen within the rib cage frame.

How should lead placement be adjusted for a patient with a pacemaker?

Move the black lead $3-5\,inches$ away from the device to avoid artifact.

What skin preparation is required before applying EKG electrodes?

Clean the skin with alcohol and remove hair if needed.

Why is it important to confirm the electrode gel is still moist?

Dried gel will not conduct a signal.

What areas should be avoided when placing EKG electrodes?

Large muscles or bony structures.

List four ways to address a weak or fluctuating EKG signal.

Shift the electrode slightly, clean the skin and apply a new electrode, use skin-prep tape to abrade the skin, or open a fresh pack of electrodes.

What is the definition of 'Tilt' in transducer movement?

The transducer maintains the same axis orientation but moves to a different imaging plane.

What is the definition of 'Sweep' in transducer movement?

Multiple movements used to record a long video clip showing multiple anatomic structures.

What is the definition of 'Rotate' in transducer movement?

The transducer stays in one position while the index marker is moved to a new position.

What is the definition of 'Slide' in transducer movement?

The transducer moves across the patient's skin to a new position.

What is the definition of 'Rock' in transducer movement?

The transducer changes orientation toward or away from the marker in the same plane to center a structure.

What is the definition of 'Angle' in transducer movement?

The transducer stays at the same location while the beam is directed to show a new structure.

Where does the ASE recommend making 2D and 3D measurements of the left ventricle?

At the interface between compacted myocardium and noncompacted myocardium (trabeculated).

What are the characteristics of compacted myocardium?

It is the solid, homogeneous wall separate from trabeculations and papillary muscles.

What interface should be used for measurement if the myocardium interface cannot be determined?

The blood-tissue interface.

What are the physiological effects of the straining phase of the Valsalva maneuver?

Decreases venous return, increases heart rate and ventricular contractility, and decreases systemic blood pressure.

How does straining during Valsalva affect venous return flow?

Flow toward the heart should stop in the venous system and resume with release.

For which conditions is straining during Valsalva particularly helpful?

Suspected MVP and hypertrophic cardiomyopathy.

When is the release phase of the Valsalva maneuver helpful?

When evaluating a suspected PFO during a saline contrast exam.

What is the immediate effect of squatting on hemodynamics?

Immediately increases venous return.

How does moving from supine to standing affect the left atrium?

Immediately decreases venous return and reduces left atrial volume.

Which maneuver enhances the visualization of Mitral Valve Prolapse (MVP)?

Supine to standing.

What happens to venous return when moving from standing to supine?

It immediately increases.

How does inspiration affect venous return from below the diaphragm?

It slows or stops it.

How does inspiration affect flow into the right atrium?

It increases flow from the vena cava.

What specific maneuver is used to assess IVC collapse?

A quick inspiration or a 'sniff'.

How does inspiration affect right-sided murmurs?

They increase.

How does expiration affect left-sided murmurs?

They increase.

What are three effects of the handgrip exercise?

Increases blood pressure, cardiac output, and total peripheral resistance.

Which murmurs are increased by handgrip exercise?

Murmurs associated with aortic/pulmonic stenosis, mitral/aortic regurgitation, and VSD.

What is the most common patient position for the Parasternal Window?

Left lateral decubitus (LLD).

In PLAX, where is the transducer usually positioned?

The third or fourth intercostal space just to the left of the sternum.

How should the transducer notch be oriented for the PLAX view?

Toward the patient's right shoulder.

Describe the orientation of the heart in a PLAX image.

Apex toward the left and base toward the right of the image display.

How should the left ventricular walls be positioned relative to the ultrasound beam in PLAX?

Perpendicular to the beam.

What characterizes a 'proper' PLAX view regarding the septum and aortic root?

They should appear as a continuous structure with minimal angle of intersection.

What is the consequence of a large angle between the septum and aortic root in PLAX?

The heart appears vertical, negatively affecting measurements and wall-motion assessment.

What should be done if the LV is not horizontal across the screen in PLAX?

Move to a higher parasternal window or turn the patient to a steeper LLD position.

Is the apex well visualized in the PLAX view?

No, it is not well visualized.

What does a 'false apex' indicate in a PLAX view?

Foreshortening.

Should papillary muscles be visible in a standard PLAX view?

No, they should not be visible.

What is the purpose of the initial 'scout view' in PLAX?

To exclude pericardial and pleural effusion using increased depth.

What structure should be at the most posterior aspect of the image after decreasing depth in PLAX?

The descending aorta.

Which is the most anterior chamber in the PLAX view?

The Right Ventricle (RV).

When is the RV outflow tract diameter measured in PLAX?

In end diastole.

What are the three segments of the aorta seen in PLAX?

Aortic root, sinotubular junction, and ascending portion.

What edge-to-edge convention is used for measuring aortic segments?

Leading edge to leading edge.

Where is the LVOT diameter measured in PLAX?

Inner edge to inner edge just proximal to the leaflet insertion points.

How is the AP dimension of the left atrium measured in PLAX?

From the inside posterior wall of the aortic root to the inner wall of the atrium, perpendicular to the chamber axis.

Which LV walls are visualized in PLAX for motion assessment?

The interventricular septum (IVS) and the inferolateral (posterior) wall.

What are the four basal/mid LV wall segments associated with the LAD in PLAX?

Basal anteroseptal, mid anterior, apical anteroseptal, and apical cap.

Which wall segments can be supplied by either the LCX or RCA in PLAX?

Mid inferolateral and basal inferolateral.

Which Doppler technique is used to assess regurgitation in the AV and MV in PLAX?

Color Doppler.

Where is the coronary sinus located in the PLAX view?

Posterior to the left atrium, adjacent to the posterior mitral leaflet.

Can left-heart valves be accurately evaluated with spectral Doppler in PLAX?

No, they cannot be accurately evaluated.

How should the cursor be placed for Aortic Valve M-mode?

Perpendicular to the aortic root at the level of the aortic valve leaflets (aortic sinus).

How does the aortic root appear and move on M-mode during the cardiac cycle?

Two parallel lines moving anteriorly during contraction and posteriorly during relaxation.

What identifies the right coronary cusp in Aortic Valve M-mode during systole?

It moves anteriorly.

What identifies the noncoronary cusp in Aortic Valve M-mode during systole?

It moves posteriorly.

What does the height and width of the 'box-like structure' in AV M-mode represent?

Aortic valve opening and motion.

When is the maximum internal AP dimension of the AV box measured?

At the onset of systole.

What does the length of the AV box on M-mode indicate?

Aortic ejection time or Left Ventricular Ejection Time (LVET).

What effect does increasing aortic stenosis have on LVET?

It increases LVET.

How does an increased heart rate affect LVET?

It can decrease LVET.

What does an irregular, more triangular closure pattern on AV M-mode suggest?

Poor systolic function.

When is the leading-edge to leading-edge measurement of the aortic root made?

During end diastole.

When is the left atrial measurement made on M-mode?

At its greatest dimension during end systole.

Where is the cursor placed for Mitral Valve M-mode?

Perpendicular to the leaflet tips.

What creates the 'M' shape in Mitral Valve M-mode?

The anterior leaflet.

What creates the 'W' shape in Mitral Valve M-mode?

The posterior leaflet.

In MV M-mode, what does the D-E-F segment represent?

The rapid filling phase.

In MV M-mode, what does the A-C segment represent?

The atrial kick.

What does an increased distance between E and A peaks in MV M-mode indicate?

A slow heart rate.

What does an increased duration of the A-C segment in MV M-mode indicate?

Increased LV diastolic pressure.

When is the E-F slope measured in MV M-mode?

When evaluating mitral stenosis.

What is EPSS and why is it measured?

E-point septal separation; it evaluates LV dilatation (CHF, DCM, CAD).

What technical error can create a false-positive MVP diagnosis on M-mode?

Positioning the transducer too high on the chest.

Where is the cursor placed for Left Ventricle M-mode?

Perpendicular to the septum and posterior wall between the papillary muscle head and mitral annulus.

How do the IVS and LVPW move during systole in M-mode?

They thicken and move toward each other.

How do the IVS and LVPW move during diastole in M-mode?

They thin and move away from each other.

What measurements are needed to calculate FS% and EF% on M-mode?

Wall thickness and chamber size in both systole and diastole.

What is the purpose of Vena contracta measurement in PLAX?

To evaluate Mitral Regurgitation (MR) and Aortic Insufficiency (AI).

What is the recommended color scale setting for Vena contracta measurement?

$50-60\,cm/s$.

How is the diameter of Vena contracta measured?

Perpendicular to the direction of the jet at the area of flow convergence.

Where is the RV diameter measured in PLAX?

At its greatest capacity during end diastole.

What is the normal limit for RV diameter in PLAX?

Less than $3.0\,cm$.

What has largely replaced the PLAX measurement for RV size?

RV-focused apical 4-chamber measurements.

What type of measurements are preferred over linear measurements for EF% calculations?

Volume measurements (2D or 3D).

Why are linear measurements from 2D preferred over M-mode?

To avoid oblique measurements.

Where specifically are LV linear measurements obtained relative to the LV long axis?

Perpendicular to the axis and immediately below the mitral valve leaflet tips.

Define 'End diastole' for LV dimension measurements.

The first frame after mitral valve closure or the peak R wave, when volume is largest.

Define 'End systole' for LV dimension measurements.

The frame just before the mitral valve opens, when volume is smallest.

What borders are used to measure LV systole and diastole?

Inner border of compacted myocardium to inner border of compacted myocardium.

How are calipers placed to measure IVS thickness?

One where the RV cavity meets the IVS and the second where the IVS meets the LV cavity.

Where should calipers be placed for IVS thickness in a patient with a sigmoid septum?

Just apical to the bulge.