Heart

Using the apical view and a phased array probe during bedside cardiac ultrasound examinations can enable clinicians to evaluate cardiac health, structures, & ventricular contractility. This view is ideal for identifying cardiomyopathy, pericardial effusion, and cardiac tamponade.

Applications

Cardiology

Media Library Type

Case Study Videos

Subtitles

- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City
and welcome to Soundbytes Cases.
In this module we'll continue our journey
down the path of the four cardiac examination views.
Specifically in this module
we're going to look at probe position C,
known as the apical view of the heart.
I hope you've been able to join me prior
looking at probe position A, the parasternal views,
and probe position B the subxiphoid views of the heart.
So the apical view of the heart is an excellent view
and gives a great deal of information
about our patient's heart
as it shows all four chambers of the heart
in relation to one another.
Therefore, the apical view of the heart
is preferred by cardiologists as it shows the synergy
of all of the chambers of the heart to one another.
Now let's take a look at a pictorial
showing how to perform the apical view of the heart.
Preferably, you're going to be using a small footprint
phased array type probe
that can easily get in between the ribs.
Position the probe directly underneath the left nipple
at about the point of maximal impulse of the heart
with the probe indicator
over towards the patient's right side.
Now that's with the caveat
that the ultrasound's screen indicator is positioned
toward the left of the screen.
Now moving the patient
into the left lateral decubitus position
can improve imaging from the apical view of the heart
as it moves the heart closer to the probe
and moves the lung out of the way.
Thus, it's important to consider moving the patient
into this position
when performing the apical view of the heart.
Now let's learn how to interpret the images
that we'll obtain.
We see here a pictorial to the left
and an ultrasound image to the right.
As we're imaging from the apical view of the heart,
we're closest to the ventricles
and in this image we see the left ventricle
to the right of the screen and the right ventricle adjacent.
The atria from the apical view of the heart
will be further away, thus posterior to the ventricles
and we see here the left atrium
just below the left ventricle
and the right atrium below the right ventricle.
We also see the valves, the tricuspid valve to the left
and the mitral valve to the right
in between the left atrium and the left ventricle.
We can also appreciate the white lines
surrounding the heart, which is the pericardium.
Now let's take a look at a video clip
showing the apical view of the heart in action.
This is taken from a medical student triathlete,
so let's take a look at that left ventricle.
We see the left ventricle in its more superficial location
to the right of the screen.
Notice the percentage change from diastole to systole.
Note the walls almost touch with each heartbeat,
indicating a good contractility.
We see the right ventricle to the side of the left ventricle
and the two atria posterior to the ventricles.
Notice the mitral valve in between the left atrium
and left ventricle and the tricuspid valve
to the right side.
Notice here the absence
of any significant pericardial effusion.
Let's contrast that last clip from this patient
who has a dilated cardiomyopathy,
and as we look at that left ventricle
from the apical view of the heart
we see a very poor percentage change
from diastole through systole.
This is indicative of a very poor contractility
of this heart.
We see the right ventricle to the side of the left ventricle
and the two atria posterior.
Notice the sluggish movement of both the mitral value
and the tricuspid valve.
We see a little bit of pericardial effusion,
that little black rim around the heart,
also going together
with this patient's cardiomyopathy status.
Here's an interesting video clip
of a patient who presented with acute shortness of breath.
What we notice here is the right ventricle
and the left ventricle closest to the screen,
but we see here a very large pericardial effusion
circumferentially surrounding the heart.
And notice the heart swinging back and forth
in all the pericardial effusion.
This gives rise to the phenomenon
known as electrical alternans
or different sizes QRSs on the EKG.
Here's a patient who was in bad shape
and presented with acute shortness of breath.
We see a very large pericardial effusion
and let's look specifically at the right ventricle.
Notice that it caves in from diastole
due to the high pressure in the pericardial sac.
Thus this is indicative of advanced cardiac tamponade.
This patient will need a stat pericardiocentesis procedure.
So in conclusion I'm glad I could share with you
this Soundbytes module
going over the apical views of the heart.
This is an often neglected view
but one that gives a great deal of information
about your patients heart
and really should be routinely integrated
into the cardiac echo examination.
It's best to move the patient
into the left lateral decutibus position
to optimize imaging from the apical view of the heart
to see all four chambers of the heart
in relation to one another.
So I hope to see you back as Soundbytes continues.

Brightcove ID

5752159405001

https://youtube.com/watch?v=4vBJoWP-zBM

Body

How to: Focused Echo: Apical View

Read more about How to: Focused Echo: Apical View

/sites/default/files/14_Focused_Echo_Apical_View_Scanning_Technique.jpg

Learn to examine the heart using the apical window and four chamber plane.

Applications

Cardiology

Media Library Type

How To Videos

Subtitles

- The other view that you wanna do
as part of the focused echo examination
is the apical four chamber view,
and the orientation marker for this view
is gonna be to the patent's left.
So it actually matches the orientation marker on the screen.
To identify where you need to go, palpate for the PMI,
and then place the transducer at this point.
This is the apical four chamber view.
On this view, we have an overall assessment of the heart.
We can see all chambers of the heart in one view.
On the left side of the screen,
we're gonna see the right side of the heart.
So this is gonna be the right atrium, tricuspid valve,
right ventricle, intraventricular septum,
left ventricle, mitral valve, and left atrium.
And what we're really looking for here is a comparison
of right to left side, size of the left ventricle
to the right ventricle, left atrium to the right atrium.
If you've determined that you need
to do a pericardiocentesis, this is a good view to evaluate
if you can get good access from this point,
because if you can get access from this point,
instead of going through the subxiphoid approach,
you avoid the liver altogether,
and at this point, you're very close to the heart
and can quickly identify where the fluid is
and draw it out.

Brightcove ID

5752153080001

https://youtube.com/watch?v=Ze0s5XRv2gQ

How to: Focused Echo: Parasternal View

Read more about How to: Focused Echo: Parasternal View

/sites/default/files/13_Focused_Echo_Parasternal_View_Scanning_Technique.jpg

Learn to examine the heart using the parasternal window and the long axis plane.

Applications

Cardiology

Media Library Type

How To Videos

Subtitles

- Okay, I'm going to walk you through the steps of
doing a focused echo exam.
And, there's a couple of different views that you do
as part of the focused echo exam.
I'm going to concentrate first on the parasternal
long axis, and then we'll walk you through the
apical four-chamber view as well.
The parasternal long axis, you can also use as part
of your FAST examination if you're having trouble
doing the subcostal or subxiphoid view.
The parasternal long axis is a great alternative to
get an overall estimation of function of the left ventricle,
as part of the FAST exam, and also
evaluate for pericardial effusion.
Okay, so the first thing you're going to do with this,
if you can, is have the patient
turn over to their left side.
The reason we like to do this is as you have the patient
turned to their left, the heart's going to fall forward in
the chest cavity and bring it a little bit closer to the
window that you're trying to access, through the ribs.
So in this case, if we're doing a cardiac examination, with
a cardiac exam type, we want the orientation marker facing
up to the patient's right shoulder.
So once we have the orientation figured out, we're going to
put a little bit of gel on the transducer.
And we're going to find where the sternum is, and just move,
just a little bit left of the sternum, looking for the
fourth to sixth intercostal space.
And that should put you at least in the ballpark area for
where you're going to find the parasternal long axis
view of the heart.
So remembering that the heart sits in the body
at a slight angle, this is going to be the
long axis view of the heart itself.
Not long axis of the body, but we'll look at the long
axis of the heart.
When we look at the ultrasound image, we should quickly
be able to identify the left ventricle, which we see here.
And what we're evaluating for is a squeeze
of this left ventricle.
So on this image, we have the right ventricle,
left ventricle, left atrium, and the aorta.
Mitral valve, and aortic valve.
Typically, we are doing this examination to
evaluate for pericardial effusion.
So we want to identify the pericardium.
This is going to be this bright, white line
around the heart.
What's important in this view is that
you have it deep enough so that you can identify
where the descending aorta is.
The descending aorta is going to appear posterior
to the left atrium.
And we're going to see it as a round circle.
If the fluid is in the pericardium,
it's going to be above this descending aorta.
If it's a plural effusion, it's going to be
behind the descending aorta.
So this is a very important landmark that you need to
identify, so you can clearly establish
where the fluid is present.
Another important area you have to identify to determine
exactly where the pericardial effusion is, is the
anterior aspect of the heart.
You have to be careful when you evaluate this area,
because there could be a fat pad in this area
that appears hypoechoic.
So for it to be a true pericardial effusion, we want to
see the fluid wrapping all the way around the heart,
to the posterior aspect.
If it's just here, in the anterior aspect,
it's probably just a fat pad.

Brightcove ID

5752164354001

https://youtube.com/watch?v=ZzizANi2bJQ

How to: Focused Echo: Subcostal View

Read more about How to: Focused Echo: Subcostal View

/sites/default/files/07_FAST_Exam_Subcostal_View_Scanning_Technique.jpg

Learn to examine the heart using the subcostal window and four chamber plane. This view is commonly taught as part of the cardiac evaluation during the trauma FAST exam.

Applications

Cardiology

Media Library Type

How To Videos

Media Library Tag

Subtitles

- The next view I'm gonna take you through
in the FAST exam is the subcoastal view
of the heart in a four-chamber plane.
For this, we're gonna put our transducer
to phased array
to the subxiphoid area,
aiming towards the patient's left shoulder.
Here is the probe marker here,
which I'm going to angle towards
the patient's right.
When I do this exam, I wanna make sure this transducer is
along the frontal plane
and aiming toward the chest.
A common mistake is to go too
inferior into the abdomen,
so you want to go deep into the chest.
When you're in this location,
the other thing you're gonna need to do
is increase your depth.
I'm gonna use my depth key right here
and I'm gonna increase,
so I can see the full heart in view
and now you can see we're at 21 centimeters.
Some common landmarks that you need to identify,
the first thing you see is that we see liver
at the top of the screen.
That liver is our coustic window into the heart.
The beating thing in the center is obviously the heart
and we can identify the entire heart
and the perimeter of the heart with the pericardium.
The pericardium is the white line that I'm seeing,
you can see that's surrounding the full heart.
Then we can identify the chambers.
The chambers are relatively easy to identify
in this view.
The chambers on the right side
of the heart are over here
and the easy way to identify those,
remember the liver's on the right side of the body,
so these chambers that are adjacent to the liver would be
right-sided chambers.
The large chamber, which is adjacent to the liver
is the right ventricle,
on the other side we see the left ventricle
and we see the two atria.
Again, our focus
on this exam is to identify the pericardium
and to look for free fluid within it.
What we're gonna look for
is an anechoic area within that pericardium
which would be signs of a hemopericadium.
Now if you can't get this view,
a great alternate view is the parasternal view
of the heart in a long axis plane.
We're gonna take you through that in the
echocardiography section.

Brightcove ID

5794989675001

https://youtube.com/watch?v=Mkc6tUVRgKo