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This video details the use of bedside ultrasound imaging and a phased array probe to evaluate cardiac health and structure, especially when evaluating the left heart chambers and valves, or investigating for paracardial effusion.
Subtitles
<p begin="00:00:10.056" end="00:00:11.560" style="s2">- Hello, my name is Philips Perera</p>
<p begin="00:00:11.560" end="00:00:13.405" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:13.405" end="00:00:15.261" style="s2">at the New York Presbyterian Hospital</p>
<p begin="00:00:15.261" end="00:00:16.904" style="s2">in New York City.</p>
<p begin="00:00:16.904" end="00:00:19.938" style="s2">Welcome to SoundBytes Cases.</p>
<p begin="00:00:19.938" end="00:00:22.407" style="s2">In this module, entitled<br />Cardiac Echocardiography,</p>
<p begin="00:00:22.407" end="00:00:24.818" style="s2">Parasternal Long Axis View Part Two,</p>
<p begin="00:00:24.818" end="00:00:26.116" style="s2">we're going to look further into</p>
<p begin="00:00:26.116" end="00:00:28.037" style="s2">the uses of the parasternal long axis view</p>
<p begin="00:00:28.037" end="00:00:29.913" style="s2">at the patient's bedside.</p>
<p begin="00:00:29.913" end="00:00:31.651" style="s2">Recall that the parasternal long axis view</p>
<p begin="00:00:31.651" end="00:00:33.215" style="s2">of the heart is going to be obtained</p>
<p begin="00:00:33.215" end="00:00:36.776" style="s2">by placing the probe into<br />position A as shown here.</p>
<p begin="00:00:36.776" end="00:00:37.933" style="s2">That will configure the probe</p>
<p begin="00:00:37.933" end="00:00:41.094" style="s2">just left of the sternum at<br />about intercostal space three</p>
<p begin="00:00:41.094" end="00:00:42.560" style="s2">with the marker dot down towards</p>
<p begin="00:00:42.560" end="00:00:44.739" style="s2">the patient's left elbow.</p>
<p begin="00:00:44.739" end="00:00:47.312" style="s2">Now, the first two goals from<br />the parasternal long axis view</p>
<p begin="00:00:47.312" end="00:00:49.257" style="s2">of the heart are going to be first of all,</p>
<p begin="00:00:49.257" end="00:00:50.863" style="s2">to look for left ventricular</p>
<p begin="00:00:50.863" end="00:00:52.747" style="s2">contractility.</p>
<p begin="00:00:52.747" end="00:00:54.186" style="s2">The second goal is going to be</p>
<p begin="00:00:54.186" end="00:00:57.377" style="s2">to investigate for a pericardial effusion.</p>
<p begin="00:00:57.377" end="00:00:58.989" style="s2">Let's begin by looking at some clips,</p>
<p begin="00:00:58.989" end="00:01:01.855" style="s2">going over left ventricular contractility.</p>
<p begin="00:01:01.855" end="00:01:04.155" style="s2">Here's a video clip, showing<br />excellent contractility</p>
<p begin="00:01:04.155" end="00:01:05.310" style="s2">of the left ventricle as taken</p>
<p begin="00:01:05.310" end="00:01:07.477" style="s2">from a medical student triathlete.</p>
<p begin="00:01:07.477" end="00:01:09.015" style="s2">Recall the chambers of the heart,</p>
<p begin="00:01:09.015" end="00:01:11.093" style="s2">as taken from the<br />parasternal long axis plane,</p>
<p begin="00:01:11.093" end="00:01:14.290" style="s2">the left atrium, as seen<br />in the posterior location;</p>
<p begin="00:01:14.290" end="00:01:16.775" style="s2">the mitral valve, just to<br />the left of the left atrium;</p>
<p begin="00:01:16.775" end="00:01:17.745" style="s2">and the left ventricle,</p>
<p begin="00:01:17.745" end="00:01:20.727" style="s2">as seen with it's hypertrophic walls.</p>
<p begin="00:01:20.727" end="00:01:22.247" style="s2">Notice the strong contractility</p>
<p begin="00:01:22.247" end="00:01:24.849" style="s2">of this left ventricle<br />as the endocardial walls</p>
<p begin="00:01:24.849" end="00:01:27.003" style="s2">almost meet during ossicle.</p>
<p begin="00:01:27.003" end="00:01:28.744" style="s2">We see the aortic valve to the right</p>
<p begin="00:01:28.744" end="00:01:29.729" style="s2">of the left ventricle</p>
<p begin="00:01:29.729" end="00:01:32.197" style="s2">and the right ventricle<br />in a superficial location</p>
<p begin="00:01:32.197" end="00:01:34.151" style="s2">above the left ventricle.</p>
<p begin="00:01:34.151" end="00:01:35.812" style="s2">Recall the descending aorta,</p>
<p begin="00:01:35.812" end="00:01:37.469" style="s2">the cylinder cut and cross section,</p>
<p begin="00:01:37.469" end="00:01:40.008" style="s2">just posterior to the left atrium.</p>
<p begin="00:01:40.008" end="00:01:42.108" style="s2">Note the posterior pericardial reflection</p>
<p begin="00:01:42.108" end="00:01:44.997" style="s2">coming off just anterior<br />to the descending aorta</p>
<p begin="00:01:44.997" end="00:01:47.284" style="s2">and posterior to the left ventricle.</p>
<p begin="00:01:47.284" end="00:01:48.837" style="s2">With the small indicator arrow,</p>
<p begin="00:01:48.837" end="00:01:50.328" style="s2">I'll trace out the posterior</p>
<p begin="00:01:50.328" end="00:01:52.619" style="s2">pericardial reflection.</p>
<p begin="00:01:52.619" end="00:01:54.506" style="s2">Note here the absence of any dark</p>
<p begin="00:01:54.506" end="00:01:57.006" style="s2">or anechoic fluid collections.</p>
<p begin="00:01:57.841" end="00:01:59.936" style="s2">Now let's contrast that last video clip</p>
<p begin="00:01:59.936" end="00:02:01.462" style="s2">with this one taken from a patient</p>
<p begin="00:02:01.462" end="00:02:03.568" style="s2">with an advanced cardiomyopathy.</p>
<p begin="00:02:03.568" end="00:02:04.965" style="s2">We recall the left ventricle</p>
<p begin="00:02:04.965" end="00:02:07.382" style="s2">and the right ventricle<br />in a superficial location</p>
<p begin="00:02:07.382" end="00:02:08.907" style="s2">above the LV.</p>
<p begin="00:02:08.907" end="00:02:10.528" style="s2">Notice the very poor percentage change</p>
<p begin="00:02:10.528" end="00:02:11.798" style="s2">of the endocardio walls</p>
<p begin="00:02:11.798" end="00:02:13.468" style="s2">of the left ventricle during ossicle,</p>
<p begin="00:02:13.468" end="00:02:14.832" style="s2">indicating a very decreased</p>
<p begin="00:02:14.832" end="00:02:16.332" style="s2">ejection fraction.</p>
<p begin="00:02:17.185" end="00:02:18.565" style="s2">Here's a clip taken from a patient</p>
<p begin="00:02:18.565" end="00:02:20.472" style="s2">who presented with a transplanted heart</p>
<p begin="00:02:20.472" end="00:02:22.180" style="s2">and acute shortness of breath.</p>
<p begin="00:02:22.180" end="00:02:24.579" style="s2">We'll begin by identifying<br />the descending aorta</p>
<p begin="00:02:24.579" end="00:02:27.244" style="s2">as shown here to the<br />bottom part of the picture.</p>
<p begin="00:02:27.244" end="00:02:29.098" style="s2">Note the posterior pericardial reflection,</p>
<p begin="00:02:29.098" end="00:02:31.079" style="s2">that white line coming off just anterior</p>
<p begin="00:02:31.079" end="00:02:33.257" style="s2">to the descending aorta.</p>
<p begin="00:02:33.257" end="00:02:34.497" style="s2">But what we see here is the presence</p>
<p begin="00:02:34.497" end="00:02:36.338" style="s2">on a dark, fluid collection,</p>
<p begin="00:02:36.338" end="00:02:39.627" style="s2">a pericardial effusion<br />that layers out posteriorly</p>
<p begin="00:02:39.627" end="00:02:41.966" style="s2">above the posterior pericardial reflection</p>
<p begin="00:02:41.966" end="00:02:45.060" style="s2">and comes anteriorly<br />to surround the heart.</p>
<p begin="00:02:45.060" end="00:02:46.507" style="s2">With a small indicator arrow,</p>
<p begin="00:02:46.507" end="00:02:48.320" style="s2">I'll point to the anterior portion</p>
<p begin="00:02:48.320" end="00:02:51.217" style="s2">of the pericardial effusion<br />and note the chaotic movement</p>
<p begin="00:02:51.217" end="00:02:52.376" style="s2">of the right ventricle</p>
<p begin="00:02:52.376" end="00:02:53.984" style="s2">as shown here.</p>
<p begin="00:02:53.984" end="00:02:56.870" style="s2">This is indicative of early<br />tamponade or high pressures</p>
<p begin="00:02:56.870" end="00:02:59.360" style="s2">within the pericardial sac.</p>
<p begin="00:02:59.360" end="00:03:00.193" style="s2">Here's a video clip</p>
<p begin="00:03:00.193" end="00:03:03.042" style="s2">showing a potential mimic<br />of a pericardial effusion.</p>
<p begin="00:03:03.042" end="00:03:05.328" style="s2">Let's being by identifying<br />the descending aorta</p>
<p begin="00:03:05.328" end="00:03:07.065" style="s2">as a cylinder cut and cross section</p>
<p begin="00:03:07.065" end="00:03:08.831" style="s2">posterior to the left atrium.</p>
<p begin="00:03:08.831" end="00:03:11.382" style="s2">We identify the posterior<br />pericardium, as shown here,</p>
<p begin="00:03:11.382" end="00:03:15.099" style="s2">coming off just anterior<br />to the descending aorta.</p>
<p begin="00:03:15.099" end="00:03:16.632" style="s2">Note the presence here of a large,</p>
<p begin="00:03:16.632" end="00:03:18.929" style="s2">dark or anechoic fluid collection,</p>
<p begin="00:03:18.929" end="00:03:20.948" style="s2">but note that it layers<br />our posteriorly there</p>
<p begin="00:03:20.948" end="00:03:22.875" style="s2">to the pericardium.</p>
<p begin="00:03:22.875" end="00:03:25.296" style="s2">Thus, this fluid is<br />within the pleural cavity</p>
<p begin="00:03:25.296" end="00:03:27.658" style="s2">and not within the pericardial cavity.</p>
<p begin="00:03:27.658" end="00:03:30.296" style="s2">With a small indicator<br />arrow I'm again reinforcing</p>
<p begin="00:03:30.296" end="00:03:31.708" style="s2">the pericardial reflection</p>
<p begin="00:03:31.708" end="00:03:33.304" style="s2">and the presence of the fluid</p>
<p begin="00:03:33.304" end="00:03:34.951" style="s2">within the thoracic cavity,</p>
<p begin="00:03:34.951" end="00:03:36.534" style="s2">a pleural effusion.</p>
<p begin="00:03:38.006" end="00:03:39.196" style="s2">Next we'll look at a video clip</p>
<p begin="00:03:39.196" end="00:03:40.703" style="s2">from a patient who present with acute</p>
<p begin="00:03:40.703" end="00:03:43.164" style="s2">shortness of breath requiring intubation.</p>
<p begin="00:03:43.164" end="00:03:45.644" style="s2">First, we'll begin by<br />identifying the descending aorta,</p>
<p begin="00:03:45.644" end="00:03:48.541" style="s2">then the posterior pericardial reflection.</p>
<p begin="00:03:48.541" end="00:03:50.072" style="s2">Note here, the presence of fluid,</p>
<p begin="00:03:50.072" end="00:03:52.333" style="s2">both within the pericadial<br />sac, as shown here,</p>
<p begin="00:03:52.333" end="00:03:54.255" style="s2">layering anterior to the pericardium</p>
<p begin="00:03:54.255" end="00:03:57.375" style="s2">and posteriorly within the pleural cavity</p>
<p begin="00:03:57.375" end="00:04:00.277" style="s2">layering out just below<br />the pericardial reflection.</p>
<p begin="00:04:00.277" end="00:04:03.021" style="s2">Why, you might ask, does the<br />patient have all this fluid?</p>
<p begin="00:04:03.021" end="00:04:04.985" style="s2">Well, let's look closely<br />at the mitral valve</p>
<p begin="00:04:04.985" end="00:04:06.933" style="s2">and on the posterior mitral valve leaflet,</p>
<p begin="00:04:06.933" end="00:04:09.307" style="s2">we see a calcified vegetation.</p>
<p begin="00:04:09.307" end="00:04:10.253" style="s2">This patient, in fact,</p>
<p begin="00:04:10.253" end="00:04:12.306" style="s2">had an infected dialysis catheter</p>
<p begin="00:04:12.306" end="00:04:14.481" style="s2">with mitral valve endocarditis</p>
<p begin="00:04:14.481" end="00:04:17.637" style="s2">and had developed wide-open<br />mitral valve regurgitation</p>
<p begin="00:04:17.637" end="00:04:19.055" style="s2">resulting in heart failure</p>
<p begin="00:04:19.055" end="00:04:20.389" style="s2">and all the fluid layering out</p>
<p begin="00:04:20.389" end="00:04:21.708" style="s2">within the pericardium and</p>
<p begin="00:04:21.708" end="00:04:23.961" style="s2">the thoracic cavity.</p>
<p begin="00:04:23.961" end="00:04:26.114" style="s2">In conclusion, the<br />parasternal long axis view</p>
<p begin="00:04:26.114" end="00:04:28.300" style="s2">of the heart gives a<br />great deal of information</p>
<p begin="00:04:28.300" end="00:04:29.681" style="s2">about our patient's condition</p>
<p begin="00:04:29.681" end="00:04:32.597" style="s2">and can be instrumental in emergency care.</p>
<p begin="00:04:32.597" end="00:04:33.430" style="s2">Through this module,</p>
<p begin="00:04:33.430" end="00:04:34.874" style="s2">I hope now that you'll have a better idea</p>
<p begin="00:04:34.874" end="00:04:37.422" style="s2">on how to grade left<br />ventricular contractility</p>
<p begin="00:04:37.422" end="00:04:39.610" style="s2">as good through poor.</p>
<p begin="00:04:39.610" end="00:04:41.511" style="s2">Also, to be able to identify the presence</p>
<p begin="00:04:41.511" end="00:04:44.277" style="s2">of a pericardial effusion.</p>
<p begin="00:04:44.277" end="00:04:46.655" style="s2">I hope to see you back<br />as SoundBytes continues</p>
<p begin="00:04:46.655" end="00:04:47.889" style="s2">and we look further at the</p>
<p begin="00:04:47.889" end="00:04:51.056" style="s2">cardiac echocardiography examinations.</p>
Brightcove ID
5794989698001
https://youtube.com/watch?v=uciGL4TaoaA