Subcostal

S Series: Subxiphoid View

Read more about S Series: Subxiphoid View

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S Series: Subxiphoid View

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Cardiology

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Image

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Cardiac Ultrasound Views: Subxiphoid

Read more about 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.

Applications

Cardiology

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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
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

Body

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.

How to: Focused Echo: Subcostal View

Read more about How to: Focused Echo: Subcostal View

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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

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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

3D How To: Ultrasound Guided Pericardiocentesis

Read more about 3D How To: Ultrasound Guided Pericardiocentesis

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3D animation demonstrating an ultrasound guided Pericardiocentesis Procedure.

Applications

Cardiology

Media Library Type

How To Videos

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Subtitles

- [Voiceover] A phased array transducer
with a cardiac exam type,
is used to perform an ultrasound guided
trans-thoracic pericardiocentesis.
The patient is placed in a
left lateral decubitus position, if possible.
Place the transducer at the apex or point
of maximum impulse, with the orientation marker
to the patients left side, at a three o'clock position.
The apex of the heart is visualized closest
to the transducer.
Move between the apical and parasternal
long axis views of the heart, to determine the
most superficial and largest pocket of fluid.
The myocardium will appear grey,
and the blood filled chambers will appear hypoechoic.
The ventricles are in the near field,
and the atria are in the far field of the image.
A pericardial effusion will appear as
a dark anechoic fluid collection surrounding the heart.
For direct needle guidance, using an in plane technique,
the transducer is rotated 90 degrees counterclockwise.
So the orientation marker is at the 12 o'clock position.
This will create a view of the heart
that is between the apical fore chamber
and parasternal long axis views.
Note the absence of the lung,
to ensure it is not in the needle path.
The needle is inserted in the skin,
just proximal to the transducer,
opposite to the side of the orientation marker.
The needle is slowly advanced,
and is seen as a bright hypoechoic linear structure.
The needle is slowly advanced,
under direct ultrasound visualization,
until the tip is seen to puncture the
pericardial fluid collection.
The needle should be advanced until the needle tip
lies within the fluid collection,
which can then be aspirated.
Vascular structures to be avoided
include the internal mammary,
and the intercostal arteries.

Brightcove ID

5508123528001

https://youtube.com/watch?v=T6Z9DvPPmXg

3D How To: Subxiphoid View

Read more about 3D How To: Subxiphoid View

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3D animation demonstrating a Subxiphoid view of the heart.

Applications

Cardiology

Media Library Type

How To Videos

Media Library Tag

Subtitles

- [Voiceover] A phased-array transducer
with a cardiac exam type is used to perform
the subxiphoid, or subcostal view of the heart.
Place the transducer in the subxiphoid position,
with the transducer orientation marker
to the patient's left side at a three o'clock position.
As an alternative approach,
this exam may be performed using an abdomen exam type,
with the orientation marker to the patient's right side,
at the nine o'clock position.
This view uses the liver as an acoustic window
to visualize the four chambers of the heart.
Aim the transducer slightly toward the left shoulder,
with approximately a 15-degree angle to the chest wall.
In some cases, the transducer is almost flat
to the abdominal wall, so the ultrasound beam
is directed toward the left chest cavity.
A considerable amount of ultrasound gel
and downward pressure may be required
to maintain contact of the transducer face
with the abdominal wall.
Having the patient bend their knees
helps relax the abdominal wall muscles
for better transducer positioning.
The first structure seen closest to the transducer
is the liver.
The right side of the heart will appear closer
to the transducer than the left side of the heart
on the ultrasound image.
The myocardium will appear grey,
and the blood filled chambers will appear hypoechoic.
The bright white pericardium
is seen surrounding the heart adjacent
to the grey myocardium.
Evaluate the function of all chambers.
Compare the size of the
right and left ventricular cavities.
Note any wall motion abnormality,
and the presence or absence of pericardial effusion.

Brightcove ID

5752129241001

https://youtube.com/watch?v=1UJ6RodOSTw

3D How To: eFAST Subxiphoid View

Read more about 3D How To: eFAST Subxiphoid View

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3D animation demonstrating a subxiphoid view while performing an eFAST exam.

Applications

Cardiology

Media Library Type

How To Videos

Media Library Tag

Subtitles

- [Voiceover] A phased array transducer,
with an abdomen exam type,
is used to perform the subxiphoid or subcostal view
of the heart in the fast exam.
Place the transducer in the subxiphoid position
with the orientation marker
to the patient's right side at a nine o'clock position.
This view uses the liver as an acoustic window
to visualize the four chambers of the heart.
Aim the transducer slightly toward the left shoulder
at a 15 degree angle to the chest wall.
In some cases,
the transducer is almost flat to the abdominal wall,
so the ultrasound beam is directed toward
the left chest cavity.
A considerable amount of ultrasound gel
and downward pressure may be needed
to maintain contact of the transducer face
with the abdominal wall.
Increase scanning depth
to visualize all chambers of the heart.
The first structure seen closest
to the transducer is the liver.
The right side of the heart will appear closer
to the transducer than the left side of the heart
on the ultrasound image.
The myocardium will appear grey,
and the blood-filled chambers
will appear hypoechoic.
The bright white pericardium is seen surrounding
the heart adjacent to the grey myocardium.
Evaluate the function of all chambers.
Compare the size of the right and left ventricular cavities.
Note any wall motion abnormality,
and the presence or absence of pericardial effusion.

Brightcove ID

5508109897001

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

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S Series: Subxiphoid View

S Series: Subxiphoid View

Cardiac Ultrasound Views: Subxiphoid

Cardiac Ultrasound Views: Subxiphoid

How to: Focused Echo: Subcostal View

How to: Focused Echo: Subcostal View

3D How To: Ultrasound Guided Pericardiocentesis

3D How To: Ultrasound Guided Pericardiocentesis

3D How To: Subxiphoid View

3D How To: Subxiphoid View

3D How To: eFAST Subxiphoid View

3D How To: eFAST Subxiphoid View

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