Right Ventrical

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- 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 looking
specifically at the cardiac echo views of the heart.
In this module, we're going to focus entirely
on the parasternal short axis view of the heart.
Now we've covered the parasternal long axis
view of the heart previously in SoundBytes module
and recall that the probe will be positioned
for the parasternal views in Position A as shown
here in the pictorial to the right.
In upcoming segments, we'll cover the subxiphoid view
as shown in probe Position B, and finally the apical
view of the heart as shown here in probe Position C.
Now the parasternal short axis view of the heart
can be very helpful in emergency care as it gives
a great deal of information about the contractility
of our patient's heart.
So let's look now further into how
to perform this examination.
The probe will be placed just left of the sternum
at about intercostal space 3 or 4
as shown in the pictorial here to the right.
Now in variance to the parasternal long axis
view of the heart where the probe marker was
positioned down towards the patient's left elbow
we'll swivel the probe 90 degrees clockwise so now
the marker is down towards the patient's right hip.
That's with the caveat that the ultrasound screen
indicator is positioned towards the left of the screen.
Now moving the patient into left lateral
decubitus position may help imaging
from the parasternal short axis plane.
Here's what the views from the parasternal
short axis plane of the heart will look like.
We see a pictorial here to the left showing
the left ventricle cut in cross section as a cylinder
and the right ventricle as a little sliver
just to the left of the left ventricle.
We see an ultrasound image corresponding to the right
and note the left ventricle again, that cylinder
cut in cross-section and the right ventricle
above the left ventricle more anteriorally
and to the left.
In this way we get a good sense of the overall
cylinder of the left ventricle
and can gauge its contractility.
Here's a video clip showing extra contractility
of the left ventricle as taken from the parasternal
short axis plane and note the muscular contractions
of the left ventricle as a cylinder squeezing in
dramatically during systole.
We also note the mitral valve flipping up
and down within the left ventricle and the right
ventricle as seen up and above the left ventricle.
Now let's contrast this video clip showing
excellent contractility with another patient
who had an advanced cardiomyopathy.
Note again the left ventricle and note here
the poor percentage change from diastole through
systole, indicating an advanced cardiomyopathy
with low ejection fraction.
We can also see the right ventricle anterior
to the left ventricle.
For learning purposes, we'll identify the walls
of the LV, the septum in between the ventricles,
the anterior wall to the top of the screen,
posterior wall to the back, and the lateral wall
as shown here towards the right portion of the screen.
Now while I show the walls of the left ventricle here,
it's important to realize that the goal of emergency
echo at the bedside is to determine overall left
ventricular contractility rather than looking
for segmental wall motion abnormalities.
So in conclusion, the parasternal short axis view
of the heart gives a great deal of information
about the contractility of the left ventricle.
This will allow you to identify patients who may
have a cardiogenic cause for their presentation.
So I hope to see you back as SoundBytes continues
and we move on to discuss the subxiphoid views
and apical views of the heart.

Brightcove ID

5752151759001

https://youtube.com/watch?v=B731sgCuZU4

Case: Parasternal Long Axis Pt. 2

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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.

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- Hello, my name is Philips Perera
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital
in New York City.
Welcome to SoundBytes Cases.
In this module, entitled Cardiac Echocardiography,
Parasternal Long Axis View Part Two,
we're going to look further into
the uses of the parasternal long axis view
at the patient's bedside.
Recall that the parasternal long axis view
of the heart is going to be obtained
by placing the probe into position A as shown here.
That will configure the probe
just left of the sternum at about intercostal space three
with the marker dot down towards
the patient's left elbow.
Now, the first two goals from the parasternal long axis view
of the heart are going to be first of all,
to look for left ventricular
contractility.
The second goal is going to be
to investigate for a pericardial effusion.
Let's begin by looking at some clips,
going over left ventricular contractility.
Here's a video clip, showing excellent contractility
of the left ventricle as taken
from a medical student triathlete.
Recall the chambers of the heart,
as taken from the parasternal long axis plane,
the left atrium, as seen in the posterior location;
the mitral valve, just to the left of the left atrium;
and the left ventricle,
as seen with it's hypertrophic walls.
Notice the strong contractility
of this left ventricle as the endocardial walls
almost meet during ossicle.
We see the aortic valve to the right
of the left ventricle
and the right ventricle in a superficial location
above the left ventricle.
Recall the descending aorta,
the cylinder cut and cross section,
just posterior to the left atrium.
Note the posterior pericardial reflection
coming off just anterior to the descending aorta
and posterior to the left ventricle.
With the small indicator arrow,
I'll trace out the posterior
pericardial reflection.
Note here the absence of any dark
or anechoic fluid collections.
Now let's contrast that last video clip
with this one taken from a patient
with an advanced cardiomyopathy.
We recall the left ventricle
and the right ventricle in a superficial location
above the LV.
Notice the very poor percentage change
of the endocardio walls
of the left ventricle during ossicle,
indicating a very decreased
ejection fraction.
Here's a clip taken from a patient
who presented with a transplanted heart
and acute shortness of breath.
We'll begin by identifying the descending aorta
as shown here to the bottom part of the picture.
Note the posterior pericardial reflection,
that white line coming off just anterior
to the descending aorta.
But what we see here is the presence
on a dark, fluid collection,
a pericardial effusion that layers out posteriorly
above the posterior pericardial reflection
and comes anteriorly to surround the heart.
With a small indicator arrow,
I'll point to the anterior portion
of the pericardial effusion and note the chaotic movement
of the right ventricle
as shown here.
This is indicative of early tamponade or high pressures
within the pericardial sac.
Here's a video clip
showing a potential mimic of a pericardial effusion.
Let's being by identifying the descending aorta
as a cylinder cut and cross section
posterior to the left atrium.
We identify the posterior pericardium, as shown here,
coming off just anterior to the descending aorta.
Note the presence here of a large,
dark or anechoic fluid collection,
but note that it layers our posteriorly there
to the pericardium.
Thus, this fluid is within the pleural cavity
and not within the pericardial cavity.
With a small indicator arrow I'm again reinforcing
the pericardial reflection
and the presence of the fluid
within the thoracic cavity,
a pleural effusion.
Next we'll look at a video clip
from a patient who present with acute
shortness of breath requiring intubation.
First, we'll begin by identifying the descending aorta,
then the posterior pericardial reflection.
Note here, the presence of fluid,
both within the pericadial sac, as shown here,
layering anterior to the pericardium
and posteriorly within the pleural cavity
layering out just below the pericardial reflection.
Why, you might ask, does the patient have all this fluid?
Well, let's look closely at the mitral valve
and on the posterior mitral valve leaflet,
we see a calcified vegetation.
This patient, in fact,
had an infected dialysis catheter
with mitral valve endocarditis
and had developed wide-open mitral valve regurgitation
resulting in heart failure
and all the fluid layering out
within the pericardium and
the thoracic cavity.
In conclusion, the parasternal long axis view
of the heart gives a great deal of information
about our patient's condition
and can be instrumental in emergency care.
Through this module,
I hope now that you'll have a better idea
on how to grade left ventricular contractility
as good through poor.
Also, to be able to identify the presence
of a pericardial effusion.
I hope to see you back as SoundBytes continues
and we look further at the
cardiac echocardiography examinations.

Brightcove ID

5794989698001

https://youtube.com/watch?v=uciGL4TaoaA

Case: Parasternal Long Axis Pt. 1

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Bedside ultrasound imaging and a phased array probe can be used to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluation of the left heart chamber valves and size.

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- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
ad the New York Presbyterian Hospital in New York City
and welcome to SoundBytes Cases.
Let's begin by reviewing the four standard views
of the cardiac echo exam.
The first view, as shown in probe position A
is the parasternal views both and long and short axis planes
and this is going to be performed directly
on the anterior chest wall.
The second view is where probe position B is shown here
coming from the abdominal position
or the subxiphoid view of the heart.
The last view is going to be shown by probe position C,
the apical view of the heart at
the point of maximum impulse.
This module will specifically focus on
the parasternal views, specifically looking
at the long axis plane.
There's a great deal of information
we can get from the parasternal long axis planes
so let's learn how to perform the examination.
For this examination, it's optimal to use a small footprint
phase to ray type probe that
can easily sit between the ribs.
We're going to place the probe just left of the sternum
at about intercostal space three or four
with the marker dot on the probe aimed down
toward the patient's left elbow,
if the patient's left elbow is down by the side.
That's with the caveat that ultrasound screen indicator
would be over toward the left of the screen.
This will align the probe in the long axis of the heart.
Occasionally it can be someone difficult to get
a good view of the heart from this plane
and moving the patient into the left lateral
decubitus position can sometimes help imaging
from the parasternal long axis plane of the heart.
So now let's take a look at the images
that we'll obtain by performing
the parasternal long axis view of the heart.
Here's a nice pictorial to the left
and what we see is that the most superficial
structure will be the right ventricle.
Notice that the right atrium is not seen from this plane.
Directly posterior to the right ventricle
will be the left ventricle and to the right
of the left ventricle will be seen the left atrium.
We can also see the mitral valve in between
the left atrium and the left ventricle
and a little bit of the aorta above the left atrium.
Let's look at the ultrasound still image, here, to the right
and, again, we see the superficial right ventricle,
posterior we see the left ventricle
with it's more muscular and hypertrophic walls.
Notice the left atrium, as seen to the right
of the left ventricle, and the mitral valve
in between the two chambers.
We categorize this as left ventricular inflow tract.
Note the aortic valve sitting right above the left atrium
and we see a little bit of the aortic root there.
This is what we categorize as aortic outflow tract.
Let's now take a look at the parasternal
long axis view of the heart in action.
Remember, again, that the most superficial chamber
will be the right ventricle
and the normal dimensions of the right ventricle
are that it should be about half
the size of the left ventricle.
If the right ventricle is the same size
of the left ventricle,
that could be a sign of RV strain.
We see the left ventricle posterior to the right ventricle.
Note it's hypertrophic walls.
This patient actually had long standing hypertension.
Let's look at the percentage change from
diastole through systole and here we see
that the walls come in well with each heartbeat
indicating good contractility.
We see the left atrium to the right of the left ventricle
and notice the mitral valve flipping up
and down in between the left atrium and the left ventricle.
We see here good movement of the mitral valve
indicating a good amount of blood flowing
between the left atrium and the left ventricle.
Now, just above the left atrium and
to the right of the left ventricle,
we see the aortic valve
and notice there just to the right of the aortic valve,
a little bit of the diamond shaped aortic root.
This will be our left ventricular outflow tract.
Now, another very important structure to identify
on bedside sonography is the descending aorta
which is a cylinder cut in cross section
right below the mitral valve, as seen in this image.
This is a very important landmark
because the posterior pericardium reflection,
that white line seen posterior to the left ventricle,
comes off anterior to the descending aorta.
This allows us to tell if the fluid
that we see there may be pericardial or plural.
In conclusion, I'm glad I could share with you
the SoundBytes module going over part one
of parasternal long axis view of the heart.
There's a great deal of information that we can gain
by looking at the parasternal long axis view,
looking for left ventricular contractility,
the presence of a pericardial effusion,
and also the possibility of right ventricular strain.
So, I hope to see you back in the future
as we're going to cover further modules
going over the parasternal views,
the subxiphoid views, and the apical views
so I'll see you back as sono access continues.

Brightcove ID

5794981632001

https://youtube.com/watch?v=H_3V9xlDMA0

Cardiac Ultrasound Views: Subxiphoid

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Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.

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- 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
through the cardiac echocardiography examinations,
looking at the four standard views.
In this module, we're specifically going to focus on
probe position B, as shown in the pictorial here,
the subxiphoid view of the heart.
Hopefully you've joined me prior
for the parasternal views, as shown in probe position A,
and in an upcoming module on the apical view,
as shown in probe position C.
The subxiphoid view of the heart
is an excellent way of imaging the patient's heart,
and getting a lot of information directly at the bedside.
Now let's learn how to perform
the subxiphoid view of the heart.
As shown in the pictorial to the right,
the probe is coming from an abdominal position,
placed just inferior to the xiphoid tip of the sternum.
It's important to lay the probe flat
and push down and under the sternum,
aiming towards the patient's left shoulder.
Now the marker dot on the probe
should be over towards the patient's right side,
with a caveat that the ultrasound's screen
indicator dot is over towards the left of the screen.
Now it's very important to put your hands
on top of the probe, and really push down and up
to get the good imaging plane underneath
the sternum, to make the angle to get
a good view of the heart from this plane.
Let's now take a look at the image
that you'll obtain from the subxiphoid view of the heart.
Here's a pictorial to the left, and an
ultrasound image to the right.
The first chamber that we'll encounter
directly below the liver, which is our
acoustic window in this case, on to
the heart will be the right ventricle.
Immediately posterior to the right ventricle
we'll be seeing the left ventricle,
and as shown in this pictorial,
notice that it has more muscular and hypertrophic walls.
From the subxiphoid plane, we'll also
be able to image the right atrium
to the left of the right ventricle,
and the left atrium, just to the left
of the left ventricle.
We can also appreciate the white line
that is the pericardium circumferentially
surrounding the heart.
Now that we know where the chambers are,
let's take a look at a video clip
of a normal heart from the subxiphoid plane.
As we remember, the liver is our
acoustic window onto the heart from this plane,
and so the liver will be seen anteriorly,
just to the top of the screen.
Just below the liver, we appreciate here
the right ventricle, and notice here,
just to the left of the right ventricle,
we can appreciate the right atrium.
Notice the tricuspid valve flipping up and down
in between the right atrium and the right ventricle.
Now let's look posterior to the right ventricle,
and we appreciate the left ventricle.
Notice again, its more muscular and hypertrophic walls.
Just to the left of the left ventricle
we appreciate, in this case, the left atrium,
and we also get a glimpse here of the mitral valve
flipping up and down in between
the left atrium and the left ventricle.
Now let's look at that white line,
both anteriorly above the right ventricle,
and posterior, below the left ventricle,
that is the pericardium.
Note here the absence of any significant
pericardial effusions.
In that last video clip, we noted good
contractility of the left ventricle
from diastole to systole.
Let's contrast that clip to this one
from a patient who presented with shortness
of breath, and advanced cardiomyopathy.
We see the right ventricle just below the liver,
anterior to the left ventricle.
And what we see here is a poorly contracting
and dilated left ventricle, consistent
with a cardiomyopathy heart.
However, note the absence of any significant
dark or anechoic fluid collections
consistent with a pericardial effusion.
Here's a patient who presented with renal failure
and acute shortness of breath.
We're again looking from the subxiphoid plane,
so we see a little strip of the liver anteriorly.
The right ventricle just below the liver,
and the left ventricle seen posteriorly
to the right ventricle.
Notice how hypertrophic the walls of
the left ventricle are in this patient.
We also appreciate a dark fluid collection
both anteriorly, just below the liver
and above the right ventricle,
and posterior below the left ventricle,
consistent with a circumferential,
or large, pericardial effusion.
If we see a large pericardial effusion
on bedside echo, our next move is to
look for signs of cardiac tamponade.
Here's a patient who manifests
all the signs of cardiac tamponade on bedside echo.
Let's look specifically at the right side of the heart.
Notice the very large pericardial effusion,
and note the chaotic movement of the right ventricle
as it struggles to open during diastole.
The compression of the right ventricle
in this patient is consistent with
advanced cardiac tamponade.
The right side of the heart is
preferentially compressed before
the left ventricle, due to its lower pressure circuit.
In conclusion, I'm glad I could share with you
this SoundBytes module going over
the subxiphoid view of the cardiac echo examination.
This is a very important exam to
put into your routine practice
in looking at your patient's heart at the bedside,
and will tell you if the patient
has a pericardial effusion, as well as
giving a sense of left ventricular contractility.
Also, the subxiphoid view of the heart
gives better views of the right side of the heart
than the more superior parasternal views of the heart.
So I hope to see you back as SoundBytes continues,
and as we move on to discuss the other
echo exam planes of the heart.

Brightcove ID

5752154065001

https://youtube.com/watch?v=ew6uJvZDhmw

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Using bedside cardiac ultrasound and a phased array probe to evaluate cardiac structures and health, the presence of pericardial effusion, and evaluating the left heart chamber size and valves.

Heart PLAX Zoomed

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Heart - PSAX View

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Left ventricular short-axis image of the left sternum

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Heart - PLAX View

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Heart - PLAX Mitral Regurg

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M-Turbo: Apical 4 Chamber

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M-Turbo: Apical 4 Chamber.

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3D How To: Parasternal Short Axis View

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3D animation demonstrating a Parasternal Short Axis view of the heart.

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