Embedded Files
Learning Objectives
Cardiac Views: acquire the ability to obtain the five core views of the heart
Parasternal long-axis (PLAX)
EPSS (E-point septal separation)
Parasternal short-axis (PSAX, at mid-ventricular level)
Apical 4-chamber (A4C)
Subcostal (subxiphoid) 4-chamber (S4C)
Subcostal inferior vena cava (IVC)
Use the cardiac views to assess:
LV size and function (normal, reduced, or hyperdynamic)
RV size and function
Pericardial effusion
IVC collapsibility
Key Points
Cardiac POCUS is a quick and efficient way to evaluate heart chamber size and function, the presence (or absence) of a pericardial effusion, and overall volume status.
Obtain the standard 4 + 1 views: PLAX, PSAX, A4C, S4C, and IVC
Introduction to Cardiac Views
Bedside cardiac echocardiography evaluates the various aspects of the heart utilizing five main viewpoints (with patient positioning in the left lateral decubitus position often helpful for image optimization) discussed below.
With ideal bedside images, the following can be evaluated/interpreted:
LV size and function
RV size and function
Presence of a pericardial effusion
IVC Size/Collapsibility (volume status)
Parasternal Long-Axis (PLAX)
Placement: Just lateral to the left sternal border, with the probe marker pointed to the right shoulder. Optimal view is typically around the 4th/5th intercostal space.
From this viewpoint, the right ventricle is the most anterior heart structure, with a longitudinal view of the left ventricle directly below. The LV apex is not often fully seen
Normal EF with ideal view
Key: right ventricular outflow tract (RVOT), left ventricle (LV), left atrium (LA), anterior/posterior mitral valve leaflets (AML/PML), aortic valve (AV), descending aorta (DA)
Clinical: The PLAX view can be used to evaluate mitral valve (MV) movement, assess left ventricular (LV) function, and evaluate for pericardial effusions.
Normal LV Function: Notice substanial thickening of the LV walls and ~30-50% reduction in LV cavity size. The anterior leaflet of the mitral valve comes close to touching the interventricular septum (expanded upon below)
Reduced LV Function: There is minimal thickening of the LV walls and little change in LV cavity size during the cardiac cycle. The anterior leaflet of the mitral valve does not even go halfway towards the interventricular septum.
Hyperdynamic LV Function: There is almost complete obliteration of the LV cavity as well as significant thickening of the LV walls during contraction. The anterior MV leaflet appears to touch the interventricular septum. There likely also is LV hypertrophy.
Mitral Valve movement as a proxy for Left Ventricular Function: E-point septal separation (EPSS) is an advanced bedside technique that can provide additional information when evaluating LV function. Using M-mode, align the line with tip of the anterior leaflet of the mitral valve, and measure the minimum distance between the anterior MV leaflet and the interventricular septum (see below)
< 7mm = normal or hyperdynamic LV function
7-10mm = indeterminate
> 10mm = reduced LV function (vs. mitral valve disease)
Parasternal Short-Axis (PSAX)
Placement: From the PLAX view (in the same location just lateral to the left sternal border and around the 4th/5th intercostal space), rotate the transducer 90 degrees clockwise so that the probe marker is now pointing to the left shoulder.
Key: RVOT - right ventricular outflow tract, PV - pulmonic valve, TV - tricuspid valve, PA - pulmonary artery, RA - right atrium, LA - left atrium, AV - aortic valve, AML - anterior mitral leaflet, PML - posterior mitral leaflet, ALPM - anterolateral papillary muscle, PMPM - posteromedial papillary muscle, RV - right ventricle, LV - left ventricle {another great image).
The ideal PSAX view evaluates LV function at the level of the papillary muscles (shown above), which reflects the mid-ventricle. Movement of the LV walls inward by a third or more during the cardiac cycle suggests normal LV function. With normal RV pressures, the LV appears donut-shaped in this view. With RV pressure overload, the IV septum can bow into the LV, creating a D-shaped appearance.
Normal LV Function: All walls of the LV seem to be contracting symmetrically, with inward movement of the walls and change in LV diameter by more than one third.
Reduced LV Function: PSAX from a patient with non-ischemic cardiomyopathy and a severely reduced EF. Note the minimal inward movement of the LV walls.
Hyperdynamic LV Function: Almost complete obliteration of the LV cavity is seen.
Apical 4-chamber (A4C)
Placement: Place transduce near the point of maximal impulse (PMI) with indicator at 3 o’clock.
Multiple views are possible depending on the plane, but should focus on the mitral valve level by tilting the probe up towards the patient's head. Ideal image includes all four chambers of the heart (with an oblong appearance), as well as the mitral and tricuspid valves. Important view for assessing RV size, as well as presence of a pericardial effusion.
Normal Apical Four Chamber View: RV should be thinner than the LV, and excursion of RV wall and apex should be appreciable.
Depressed LV function: Note LV dilation and poor excursion of walls
RV dilation (right heart dysfunction/pulmonary HTN): Note dilation of RV, lateral bowing of interventricular septum into LV and small size of LV.
Subcostal 4-chamber (S4C)
Placement: Easiest to obtain while patient is fully supine. Grab the ultrasound probe from above, and push immediately below the sternum/ribs and angle up towards the patient's heart. Probe marker should be pointed to the patient's left (three o'clock). This serves as a bonus four-chamber view.
Subcostal inferior vena cava (IVC)
Placement: From the subcostal four chamber view, maintain the right atrium in the center of the screen, and gradually rotate the probe counterclockwise 90 degrees (probe marker in the end should be cephalad), with ultrasound point of entry now perpendicular to the skin surface. In contrast to the IVC (which will usually be just right of midline, collapsible, and have hepatic veins draining into it), the aorta will be thick-walled, pulsatile, deep, and approach the left side of the heart.
Images / information from: https://www.pocus101.com/cardiac-ultrasound-echocardiography-made-easy-step-by-step-guide/ ; https://www.echocardiographer.org/tte-plax https://www.thepocusatlas.com/ https://www.showmethepocus.com/
This site was created for educational purposes only. No copyright is claimed in the images and videos presented here and to the extent that material may appear to be infringed, we assert that such alleged infringement is permissible under fair use principles in U.S. copyright laws.
If you believe material has been used in an unauthorized manner, please contact the poster at slwpocus@gmail.com
Page updated
Google Sites
Report abuse