<p begin="00:00:11.177" end="00:00:13.140" style="s2">- Hello, my name is Phil Perera</p>
<p begin="00:00:13.140" end="00:00:15.016" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:15.016" end="00:00:17.935" style="s2">at the New York Presbyterian<br />Hospital in New York City</p>
<p begin="00:00:17.935" end="00:00:20.602" style="s2">and welcome to Soundbytes Cases.</p>
<p begin="00:00:21.664" end="00:00:23.207" style="s2">In this module we'll continue our journey</p>
<p begin="00:00:23.207" end="00:00:26.643" style="s2">down the path of the four<br />cardiac examination views.</p>
<p begin="00:00:26.643" end="00:00:28.233" style="s2">Specifically in this module</p>
<p begin="00:00:28.233" end="00:00:30.275" style="s2">we're going to look at probe position C,</p>
<p begin="00:00:30.275" end="00:00:32.752" style="s2">known as the apical view of the heart.</p>
<p begin="00:00:32.752" end="00:00:34.040" style="s2">I hope you've been able to join me prior</p>
<p begin="00:00:34.040" end="00:00:37.314" style="s2">looking at probe position<br />A, the parasternal views,</p>
<p begin="00:00:37.314" end="00:00:41.331" style="s2">and probe position B the<br />subxiphoid views of the heart.</p>
<p begin="00:00:41.331" end="00:00:43.908" style="s2">So the apical view of the<br />heart is an excellent view</p>
<p begin="00:00:43.908" end="00:00:45.693" style="s2">and gives a great deal of information</p>
<p begin="00:00:45.693" end="00:00:47.101" style="s2">about our patient's heart</p>
<p begin="00:00:47.101" end="00:00:49.087" style="s2">as it shows all four chambers of the heart</p>
<p begin="00:00:49.087" end="00:00:50.769" style="s2">in relation to one another.</p>
<p begin="00:00:50.769" end="00:00:52.612" style="s2">Therefore, the apical view of the heart</p>
<p begin="00:00:52.612" end="00:00:55.154" style="s2">is preferred by cardiologists<br />as it shows the synergy</p>
<p begin="00:00:55.154" end="00:00:58.599" style="s2">of all of the chambers of<br />the heart to one another.</p>
<p begin="00:00:58.599" end="00:01:00.386" style="s2">Now let's take a look at a pictorial</p>
<p begin="00:01:00.386" end="00:01:03.571" style="s2">showing how to perform the<br />apical view of the heart.</p>
<p begin="00:01:03.571" end="00:01:05.650" style="s2">Preferably, you're going to<br />be using a small footprint</p>
<p begin="00:01:05.650" end="00:01:07.263" style="s2">phased array type probe</p>
<p begin="00:01:07.263" end="00:01:09.139" style="s2">that can easily get in between the ribs.</p>
<p begin="00:01:09.139" end="00:01:11.667" style="s2">Position the probe directly<br />underneath the left nipple</p>
<p begin="00:01:11.667" end="00:01:14.690" style="s2">at about the point of<br />maximal impulse of the heart</p>
<p begin="00:01:14.690" end="00:01:15.895" style="s2">with the probe indicator</p>
<p begin="00:01:15.895" end="00:01:17.915" style="s2">over towards the patient's right side.</p>
<p begin="00:01:17.915" end="00:01:19.059" style="s2">Now that's with the caveat</p>
<p begin="00:01:19.059" end="00:01:21.312" style="s2">that the ultrasound's screen<br />indicator is positioned</p>
<p begin="00:01:21.312" end="00:01:23.338" style="s2">toward the left of the screen.</p>
<p begin="00:01:23.338" end="00:01:24.419" style="s2">Now moving the patient</p>
<p begin="00:01:24.419" end="00:01:26.503" style="s2">into the left lateral decubitus position</p>
<p begin="00:01:26.503" end="00:01:28.997" style="s2">can improve imaging from<br />the apical view of the heart</p>
<p begin="00:01:28.997" end="00:01:31.166" style="s2">as it moves the heart closer to the probe</p>
<p begin="00:01:31.166" end="00:01:33.539" style="s2">and moves the lung out of the way.</p>
<p begin="00:01:33.539" end="00:01:35.851" style="s2">Thus, it's important to<br />consider moving the patient</p>
<p begin="00:01:35.851" end="00:01:37.040" style="s2">into this position</p>
<p begin="00:01:37.040" end="00:01:40.097" style="s2">when performing the<br />apical view of the heart.</p>
<p begin="00:01:40.097" end="00:01:42.009" style="s2">Now let's learn how to<br />interpret the images</p>
<p begin="00:01:42.009" end="00:01:43.284" style="s2">that we'll obtain.</p>
<p begin="00:01:43.284" end="00:01:45.033" style="s2">We see here a pictorial to the left</p>
<p begin="00:01:45.033" end="00:01:46.962" style="s2">and an ultrasound image to the right.</p>
<p begin="00:01:46.962" end="00:01:49.543" style="s2">As we're imaging from the<br />apical view of the heart,</p>
<p begin="00:01:49.543" end="00:01:51.009" style="s2">we're closest to the ventricles</p>
<p begin="00:01:51.009" end="00:01:52.654" style="s2">and in this image we<br />see the left ventricle</p>
<p begin="00:01:52.654" end="00:01:55.486" style="s2">to the right of the screen and<br />the right ventricle adjacent.</p>
<p begin="00:01:55.486" end="00:01:58.346" style="s2">The atria from the<br />apical view of the heart</p>
<p begin="00:01:58.346" end="00:02:01.831" style="s2">will be further away, thus<br />posterior to the ventricles</p>
<p begin="00:02:01.831" end="00:02:03.499" style="s2">and we see here the left atrium</p>
<p begin="00:02:03.499" end="00:02:05.104" style="s2">just below the left ventricle</p>
<p begin="00:02:05.104" end="00:02:08.321" style="s2">and the right atrium<br />below the right ventricle.</p>
<p begin="00:02:08.321" end="00:02:11.325" style="s2">We also see the valves, the<br />tricuspid valve to the left</p>
<p begin="00:02:11.325" end="00:02:13.252" style="s2">and the mitral valve to the right</p>
<p begin="00:02:13.252" end="00:02:15.888" style="s2">in between the left atrium<br />and the left ventricle.</p>
<p begin="00:02:15.888" end="00:02:17.729" style="s2">We can also appreciate the white lines</p>
<p begin="00:02:17.729" end="00:02:20.608" style="s2">surrounding the heart,<br />which is the pericardium.</p>
<p begin="00:02:20.608" end="00:02:22.202" style="s2">Now let's take a look at a video clip</p>
<p begin="00:02:22.202" end="00:02:24.960" style="s2">showing the apical view<br />of the heart in action.</p>
<p begin="00:02:24.960" end="00:02:26.815" style="s2">This is taken from a<br />medical student triathlete,</p>
<p begin="00:02:26.815" end="00:02:29.167" style="s2">so let's take a look<br />at that left ventricle.</p>
<p begin="00:02:29.167" end="00:02:32.312" style="s2">We see the left ventricle in<br />its more superficial location</p>
<p begin="00:02:32.312" end="00:02:34.173" style="s2">to the right of the screen.</p>
<p begin="00:02:34.173" end="00:02:37.441" style="s2">Notice the percentage change<br />from diastole to systole.</p>
<p begin="00:02:37.441" end="00:02:39.918" style="s2">Note the walls almost<br />touch with each heartbeat,</p>
<p begin="00:02:39.918" end="00:02:42.198" style="s2">indicating a good contractility.</p>
<p begin="00:02:42.198" end="00:02:44.781" style="s2">We see the right ventricle to<br />the side of the left ventricle</p>
<p begin="00:02:44.781" end="00:02:48.247" style="s2">and the two atria posterior<br />to the ventricles.</p>
<p begin="00:02:48.247" end="00:02:50.848" style="s2">Notice the mitral valve<br />in between the left atrium</p>
<p begin="00:02:50.848" end="00:02:52.928" style="s2">and left ventricle and the tricuspid valve</p>
<p begin="00:02:52.928" end="00:02:54.242" style="s2">to the right side.</p>
<p begin="00:02:54.242" end="00:02:55.459" style="s2">Notice here the absence</p>
<p begin="00:02:55.459" end="00:02:58.792" style="s2">of any significant pericardial effusion.</p>
<p begin="00:03:00.251" end="00:03:02.942" style="s2">Let's contrast that last<br />clip from this patient</p>
<p begin="00:03:02.942" end="00:03:05.753" style="s2">who has a dilated cardiomyopathy,</p>
<p begin="00:03:05.753" end="00:03:07.113" style="s2">and as we look at that left ventricle</p>
<p begin="00:03:07.113" end="00:03:09.111" style="s2">from the apical view of the heart</p>
<p begin="00:03:09.111" end="00:03:10.826" style="s2">we see a very poor percentage change</p>
<p begin="00:03:10.826" end="00:03:13.001" style="s2">from diastole through systole.</p>
<p begin="00:03:13.001" end="00:03:15.653" style="s2">This is indicative of a<br />very poor contractility</p>
<p begin="00:03:15.653" end="00:03:17.093" style="s2">of this heart.</p>
<p begin="00:03:17.093" end="00:03:19.773" style="s2">We see the right ventricle to<br />the side of the left ventricle</p>
<p begin="00:03:19.773" end="00:03:21.909" style="s2">and the two atria posterior.</p>
<p begin="00:03:21.909" end="00:03:24.244" style="s2">Notice the sluggish movement<br />of both the mitral value</p>
<p begin="00:03:24.244" end="00:03:26.987" style="s2">and the tricuspid valve.</p>
<p begin="00:03:26.987" end="00:03:29.091" style="s2">We see a little bit of<br />pericardial effusion,</p>
<p begin="00:03:29.091" end="00:03:31.418" style="s2">that little black rim around the heart,</p>
<p begin="00:03:31.418" end="00:03:32.785" style="s2">also going together</p>
<p begin="00:03:32.785" end="00:03:35.774" style="s2">with this patient's cardiomyopathy status.</p>
<p begin="00:03:35.774" end="00:03:37.137" style="s2">Here's an interesting video clip</p>
<p begin="00:03:37.137" end="00:03:39.516" style="s2">of a patient who presented<br />with acute shortness of breath.</p>
<p begin="00:03:39.516" end="00:03:41.328" style="s2">What we notice here is the right ventricle</p>
<p begin="00:03:41.328" end="00:03:44.311" style="s2">and the left ventricle<br />closest to the screen,</p>
<p begin="00:03:44.311" end="00:03:47.199" style="s2">but we see here a very<br />large pericardial effusion</p>
<p begin="00:03:47.199" end="00:03:49.426" style="s2">circumferentially surrounding the heart.</p>
<p begin="00:03:49.426" end="00:03:51.444" style="s2">And notice the heart<br />swinging back and forth</p>
<p begin="00:03:51.444" end="00:03:53.151" style="s2">in all the pericardial effusion.</p>
<p begin="00:03:53.151" end="00:03:55.029" style="s2">This gives rise to the phenomenon</p>
<p begin="00:03:55.029" end="00:03:56.569" style="s2">known as electrical alternans</p>
<p begin="00:03:56.569" end="00:04:00.298" style="s2">or different sizes QRSs on the EKG.</p>
<p begin="00:04:00.298" end="00:04:02.505" style="s2">Here's a patient who was in bad shape</p>
<p begin="00:04:02.505" end="00:04:04.682" style="s2">and presented with acute<br />shortness of breath.</p>
<p begin="00:04:04.682" end="00:04:07.056" style="s2">We see a very large pericardial effusion</p>
<p begin="00:04:07.056" end="00:04:09.578" style="s2">and let's look specifically<br />at the right ventricle.</p>
<p begin="00:04:09.578" end="00:04:12.535" style="s2">Notice that it caves in from diastole</p>
<p begin="00:04:12.535" end="00:04:15.382" style="s2">due to the high pressure<br />in the pericardial sac.</p>
<p begin="00:04:15.382" end="00:04:18.592" style="s2">Thus this is indicative of<br />advanced cardiac tamponade.</p>
<p begin="00:04:18.592" end="00:04:22.759" style="s2">This patient will need a stat<br />pericardiocentesis procedure.</p>
<p begin="00:04:25.040" end="00:04:26.718" style="s2">So in conclusion I'm glad<br />I could share with you</p>
<p begin="00:04:26.718" end="00:04:27.770" style="s2">this Soundbytes module</p>
<p begin="00:04:27.770" end="00:04:30.041" style="s2">going over the apical views of the heart.</p>
<p begin="00:04:30.041" end="00:04:31.377" style="s2">This is an often neglected view</p>
<p begin="00:04:31.377" end="00:04:33.227" style="s2">but one that gives a<br />great deal of information</p>
<p begin="00:04:33.227" end="00:04:34.776" style="s2">about your patients heart</p>
<p begin="00:04:34.776" end="00:04:36.529" style="s2">and really should be routinely integrated</p>
<p begin="00:04:36.529" end="00:04:38.969" style="s2">into the cardiac echo examination.</p>
<p begin="00:04:38.969" end="00:04:40.100" style="s2">It's best to move the patient</p>
<p begin="00:04:40.100" end="00:04:42.153" style="s2">into the left lateral decutibus position</p>
<p begin="00:04:42.153" end="00:04:44.930" style="s2">to optimize imaging from<br />the apical view of the heart</p>
<p begin="00:04:44.930" end="00:04:46.698" style="s2">to see all four chambers of the heart</p>
<p begin="00:04:46.698" end="00:04:49.021" style="s2">in relation to one another.</p>
<p begin="00:04:49.021" end="00:04:53.188" style="s2">So I hope to see you back<br />as Soundbytes continues.</p>

<p begin="00:00:15.307" end="00:00:16.432" style="s2">- The other view that you wanna do</p>
<p begin="00:00:16.432" end="00:00:18.109" style="s2">as part of the focused echo examination</p>
<p begin="00:00:18.109" end="00:00:20.329" style="s2">is the apical four chamber view,</p>
<p begin="00:00:20.329" end="00:00:22.596" style="s2">and the orientation marker for this view</p>
<p begin="00:00:22.596" end="00:00:24.144" style="s2">is gonna be to the patent's left.</p>
<p begin="00:00:24.144" end="00:00:29.121" style="s2">So it actually matches the<br />orientation marker on the screen.</p>
<p begin="00:00:29.121" end="00:00:32.910" style="s2">To identify where you need<br />to go, palpate for the PMI,</p>
<p begin="00:00:32.910" end="00:00:36.577" style="s2">and then place the<br />transducer at this point.</p>
<p begin="00:00:38.037" end="00:00:40.311" style="s2">This is the apical four chamber view.</p>
<p begin="00:00:40.311" end="00:00:43.042" style="s2">On this view, we have an<br />overall assessment of the heart.</p>
<p begin="00:00:43.042" end="00:00:47.352" style="s2">We can see all chambers<br />of the heart in one view.</p>
<p begin="00:00:47.352" end="00:00:48.540" style="s2">On the left side of the screen,</p>
<p begin="00:00:48.540" end="00:00:50.652" style="s2">we're gonna see the<br />right side of the heart.</p>
<p begin="00:00:50.652" end="00:00:54.198" style="s2">So this is gonna be the right<br />atrium, tricuspid valve,</p>
<p begin="00:00:54.198" end="00:00:57.990" style="s2">right ventricle, intraventricular septum,</p>
<p begin="00:00:57.990" end="00:01:01.823" style="s2">left ventricle, mitral<br />valve, and left atrium.</p>
<p begin="00:01:03.021" end="00:01:05.872" style="s2">And what we're really looking<br />for here is a comparison</p>
<p begin="00:01:05.872" end="00:01:09.553" style="s2">of right to left side,<br />size of the left ventricle</p>
<p begin="00:01:09.553" end="00:01:13.720" style="s2">to the right ventricle, left<br />atrium to the right atrium.</p>
<p begin="00:01:15.915" end="00:01:16.968" style="s2">If you've determined that you need</p>
<p begin="00:01:16.968" end="00:01:20.506" style="s2">to do a pericardiocentesis,<br />this is a good view to evaluate</p>
<p begin="00:01:20.506" end="00:01:23.141" style="s2">if you can get good<br />access from this point,</p>
<p begin="00:01:23.141" end="00:01:25.273" style="s2">because if you can get<br />access from this point,</p>
<p begin="00:01:25.273" end="00:01:27.316" style="s2">instead of going through<br />the subxiphoid approach,</p>
<p begin="00:01:27.316" end="00:01:29.117" style="s2">you avoid the liver altogether,</p>
<p begin="00:01:29.117" end="00:01:31.554" style="s2">and at this point, you're<br />very close to the heart</p>
<p begin="00:01:31.554" end="00:01:34.541" style="s2">and can quickly identify<br />where the fluid is</p>
<p begin="00:01:34.541" end="00:01:35.874" style="s2">and draw it out.</p>

<p begin="00:00:15.263" end="00:00:16.802" style="s2">- Okay, I'm going to walk<br />you through the steps of</p>
<p begin="00:00:16.802" end="00:00:18.776" style="s2">doing a focused echo exam.</p>
<p begin="00:00:18.776" end="00:00:20.792" style="s2">And, there's a couple of<br />different views that you do</p>
<p begin="00:00:20.792" end="00:00:22.069" style="s2">as part of the focused echo exam.</p>
<p begin="00:00:22.069" end="00:00:23.995" style="s2">I'm going to concentrate<br />first on the parasternal</p>
<p begin="00:00:23.995" end="00:00:26.170" style="s2">long axis, and then we'll<br />walk you through the</p>
<p begin="00:00:26.170" end="00:00:28.259" style="s2">apical four-chamber view as well.</p>
<p begin="00:00:28.259" end="00:00:31.285" style="s2">The parasternal long axis,<br />you can also use as part</p>
<p begin="00:00:31.285" end="00:00:34.932" style="s2">of your FAST examination<br />if you're having trouble</p>
<p begin="00:00:34.932" end="00:00:37.365" style="s2">doing the subcostal or subxiphoid view.</p>
<p begin="00:00:37.365" end="00:00:40.630" style="s2">The parasternal long axis<br />is a great alternative to</p>
<p begin="00:00:40.630" end="00:00:44.913" style="s2">get an overall estimation of<br />function of the left ventricle,</p>
<p begin="00:00:44.913" end="00:00:46.796" style="s2">as part of the FAST exam, and also</p>
<p begin="00:00:46.796" end="00:00:49.629" style="s2">evaluate for pericardial effusion.</p>
<p begin="00:00:50.470" end="00:00:52.396" style="s2">Okay, so the first thing<br />you're going to do with this,</p>
<p begin="00:00:52.396" end="00:00:54.254" style="s2">if you can, is have the patient</p>
<p begin="00:00:54.254" end="00:00:55.936" style="s2">turn over to their left side.</p>
<p begin="00:00:55.936" end="00:00:58.819" style="s2">The reason we like to do this<br />is as you have the patient</p>
<p begin="00:00:58.819" end="00:01:01.378" style="s2">turned to their left, the<br />heart's going to fall forward in</p>
<p begin="00:01:01.378" end="00:01:03.926" style="s2">the chest cavity and bring<br />it a little bit closer to the</p>
<p begin="00:01:03.926" end="00:01:07.756" style="s2">window that you're trying<br />to access, through the ribs.</p>
<p begin="00:01:07.756" end="00:01:10.491" style="s2">So in this case, if we're doing<br />a cardiac examination, with</p>
<p begin="00:01:10.491" end="00:01:14.367" style="s2">a cardiac exam type, we want<br />the orientation marker facing</p>
<p begin="00:01:14.367" end="00:01:17.284" style="s2">up to the patient's right shoulder.</p>
<p begin="00:01:18.903" end="00:01:21.939" style="s2">So once we have the orientation<br />figured out, we're going to</p>
<p begin="00:01:21.939" end="00:01:25.439" style="s2">put a little bit of gel on the transducer.</p>
<p begin="00:01:28.519" end="00:01:32.206" style="s2">And we're going to find where<br />the sternum is, and just move,</p>
<p begin="00:01:32.206" end="00:01:36.375" style="s2">just a little bit left of<br />the sternum, looking for the</p>
<p begin="00:01:36.375" end="00:01:39.208" style="s2">fourth to sixth intercostal space.</p>
<p begin="00:01:44.450" end="00:01:46.748" style="s2">And that should put you at<br />least in the ballpark area for</p>
<p begin="00:01:46.748" end="00:01:49.927" style="s2">where you're going to find<br />the parasternal long axis</p>
<p begin="00:01:49.927" end="00:01:51.427" style="s2">view of the heart.</p>
<p begin="00:01:53.630" end="00:01:57.463" style="s2">So remembering that the<br />heart sits in the body</p>
<p begin="00:01:58.530" end="00:02:00.896" style="s2">at a slight angle, this is going to be the</p>
<p begin="00:02:00.896" end="00:02:03.800" style="s2">long axis view of the heart itself.</p>
<p begin="00:02:03.800" end="00:02:05.963" style="s2">Not long axis of the body,<br />but we'll look at the long</p>
<p begin="00:02:05.963" end="00:02:07.496" style="s2">axis of the heart.</p>
<p begin="00:02:07.496" end="00:02:10.047" style="s2">When we look at the ultrasound<br />image, we should quickly</p>
<p begin="00:02:10.047" end="00:02:14.214" style="s2">be able to identify the left<br />ventricle, which we see here.</p>
<p begin="00:02:16.825" end="00:02:19.651" style="s2">And what we're evaluating for is a squeeze</p>
<p begin="00:02:19.651" end="00:02:22.136" style="s2">of this left ventricle.</p>
<p begin="00:02:22.136" end="00:02:25.839" style="s2">So on this image, we<br />have the right ventricle,</p>
<p begin="00:02:25.839" end="00:02:29.422" style="s2">left ventricle, left<br />atrium, and the aorta.</p>
<p begin="00:02:31.028" end="00:02:33.611" style="s2">Mitral valve, and aortic valve.</p>
<p begin="00:02:36.423" end="00:02:38.115" style="s2">Typically, we are doing<br />this examination to</p>
<p begin="00:02:38.115" end="00:02:41.220" style="s2">evaluate for pericardial effusion.</p>
<p begin="00:02:41.220" end="00:02:43.879" style="s2">So we want to identify the pericardium.</p>
<p begin="00:02:43.879" end="00:02:46.645" style="s2">This is going to be<br />this bright, white line</p>
<p begin="00:02:46.645" end="00:02:48.848" style="s2">around the heart.</p>
<p begin="00:02:48.848" end="00:02:50.482" style="s2">What's important in this view is that</p>
<p begin="00:02:50.482" end="00:02:52.683" style="s2">you have it deep enough<br />so that you can identify</p>
<p begin="00:02:52.683" end="00:02:55.682" style="s2">where the descending aorta is.</p>
<p begin="00:02:55.682" end="00:02:57.832" style="s2">The descending aorta is<br />going to appear posterior</p>
<p begin="00:02:57.832" end="00:02:59.452" style="s2">to the left atrium.</p>
<p begin="00:02:59.452" end="00:03:02.362" style="s2">And we're going to see<br />it as a round circle.</p>
<p begin="00:03:02.362" end="00:03:05.279" style="s2">If the fluid is in the pericardium,</p>
<p begin="00:03:06.504" end="00:03:09.935" style="s2">it's going to be above<br />this descending aorta.</p>
<p begin="00:03:09.935" end="00:03:12.793" style="s2">If it's a plural<br />effusion, it's going to be</p>
<p begin="00:03:12.793" end="00:03:14.547" style="s2">behind the descending aorta.</p>
<p begin="00:03:14.547" end="00:03:17.272" style="s2">So this is a very important<br />landmark that you need to</p>
<p begin="00:03:17.272" end="00:03:19.680" style="s2">identify, so you can clearly establish</p>
<p begin="00:03:19.680" end="00:03:22.415" style="s2">where the fluid is present.</p>
<p begin="00:03:22.415" end="00:03:25.090" style="s2">Another important area you<br />have to identify to determine</p>
<p begin="00:03:25.090" end="00:03:28.123" style="s2">exactly where the pericardial<br />effusion is, is the</p>
<p begin="00:03:28.123" end="00:03:30.011" style="s2">anterior aspect of the heart.</p>
<p begin="00:03:30.011" end="00:03:32.620" style="s2">You have to be careful when<br />you evaluate this area,</p>
<p begin="00:03:32.620" end="00:03:34.731" style="s2">because there could be<br />a fat pad in this area</p>
<p begin="00:03:34.731" end="00:03:37.226" style="s2">that appears hypoechoic.</p>
<p begin="00:03:37.226" end="00:03:40.163" style="s2">So for it to be a true<br />pericardial effusion, we want to</p>
<p begin="00:03:40.163" end="00:03:43.192" style="s2">see the fluid wrapping all<br />the way around the heart,</p>
<p begin="00:03:43.192" end="00:03:44.616" style="s2">to the posterior aspect.</p>
<p begin="00:03:44.616" end="00:03:47.104" style="s2">If it's just here, in the anterior aspect,</p>
<p begin="00:03:47.104" end="00:03:49.604" style="s2">it's probably just a fat pad.</p>

<p begin="00:00:07.145" end="00:00:09.034" style="s2">- [Voiceover] A phased array transducer</p>
<p begin="00:00:09.034" end="00:00:11.398" style="s2">with a cardiac exam<br />type is used to perform</p>
<p begin="00:00:11.398" end="00:00:14.044" style="s2">the apical four chamber view of the heart.</p>
<p begin="00:00:14.044" end="00:00:16.203" style="s2">If possible, place the patient</p>
<p begin="00:00:16.203" end="00:00:18.549" style="s2">in a left-lateral decubitus position</p>
<p begin="00:00:18.549" end="00:00:21.190" style="s2">to reduce any lung artifact<br />and to bring the heart</p>
<p begin="00:00:21.190" end="00:00:23.645" style="s2">closer to the anterior chest wall.</p>
<p begin="00:00:23.645" end="00:00:25.659" style="s2">Place the transducer at the apex</p>
<p begin="00:00:25.659" end="00:00:27.843" style="s2">or point of maximum impulse,</p>
<p begin="00:00:27.843" end="00:00:30.226" style="s2">with the orientation<br />marker to the patient's</p>
<p begin="00:00:30.226" end="00:00:32.892" style="s2">left side at a three o'clock position.</p>
<p begin="00:00:32.892" end="00:00:35.499" style="s2">As an alternative<br />approach, this exam may be</p>
<p begin="00:00:35.499" end="00:00:37.954" style="s2">performed using an abdomen exam type,</p>
<p begin="00:00:37.954" end="00:00:42.421" style="s2">with the orientation marker<br />to the patient's right side.</p>
<p begin="00:00:42.421" end="00:00:44.588" style="s2">Aim to the right shoulder.</p>
<p begin="00:00:47.866" end="00:00:50.113" style="s2">The apex of the heart is visualized</p>
<p begin="00:00:50.113" end="00:00:52.001" style="s2">closest to the transducer.</p>
<p begin="00:00:52.001" end="00:00:54.267" style="s2">The myocardium will appear gray,</p>
<p begin="00:00:54.267" end="00:00:57.939" style="s2">and the blood-filled chambers<br />will appear hypoechoic.</p>
<p begin="00:00:57.939" end="00:01:00.250" style="s2">The ventricles are in the near field,</p>
<p begin="00:01:00.250" end="00:01:03.429" style="s2">and the atria are in the<br />far field of the image.</p>
<p begin="00:01:03.429" end="00:01:06.094" style="s2">This view is used to compare<br />the size of the right</p>
<p begin="00:01:06.094" end="00:01:09.410" style="s2">and left ventricles and<br />evaluate contractility.</p>
<p begin="00:01:09.410" end="00:01:11.504" style="s2">The right side of the heart,</p>
<p begin="00:01:11.504" end="00:01:14.305" style="s2">which is located on the<br />left side of the screen,</p>
<p begin="00:01:14.305" end="00:01:16.631" style="s2">should be smaller than the left.</p>
<p begin="00:01:16.631" end="00:01:19.589" style="s2">Th apical, septal, and lateral walls</p>
<p begin="00:01:19.589" end="00:01:23.756" style="s2">of the left ventricle are<br />visualized in this view.</p>