Ch 7 Apical Flashcards
List the apical views we do?
-AP4 (home base)
-Modified AP4 (RV focus)
-AP5
-AP2
-AP3 (apical long axis, like PLAX)
How to obtain AP4?
-Pt in LLD
-Probe in 4th, 5th or 6th intercostal space (often in inframammary fold)
-Indicator facing to the right at pt’s left side (3 o’clock)
-Can palpate for apical pulse (not always possible)
What structures can we see in AP4?
-LA (RUPV or RLPV sometimes)
-MV (ant/post leaflets)
-IAS
-LV (IS + AL wall segs)
-IVS
-RV
-TV (ant/sept leaflets)
(leaflets spell “ASAP”, wall segs spell “ISAL”)
What does the moderator band do?
Helps regulate size of RV
List distinguishing features with AP4?
-Moderator band in RV
-Trabeculations in RV
-False tendon in LV (normal variant)
-Chordae tendinae in LV
-IVS + IAS are vertical
-All 4 chambers are seen
-Full excursion of MV + TV leaflets
List 3 additional AP4 structures of interest we may see?
-Coronary sinus (angle posterior)
-Pericardium (check for presence of effusion)
-Normal RA variants (chiari network + eustachian valve)
What is the coronary sinus?
Returns deoxygenated blood from myocardium into RA
How can we bring the coronary sinus into our AP4 view?
Angle posterior/inferior
(image shows CS going through IAS into the RA)
Name 2 normal RA variants?
-Chiari Network
(normal adult variant that looks like a web + is a longer protrusion than an eustachian valve)
-Eustachian valve
(remnant from fetal life, is a shorter protrusion than a chiari network)
Which apical view are we assessing for any pacemaker wires?
AP4 + modified AP4 (look in RA + RV)
What must we ensure we are NEVER doing when imaging the apex?
Do not foreshorten it!
What does foreshortening the apex mean?
Means we are not visualizing the true LV apex + are overestimating the EF
Should the LV apex squeeze down much?
No
(should see IS + AL walls should be coming in toward one another)
Should the LV appear bullet shaped or globular?
Bullet!!
How can we fix our view if our LV appears foreshortened?
-Translate down rib space + more laterally
-Rotate slightly to expand chambers
-Adjust gains to see endocardium better
-Utilize pt breathing (sm breathe in or all breathe out)
What technique can we do to center our LV in the middle of our sector in AP4?
Rock the probe
(tilted to right = move lateral, tilted to left = move medial)
How can we get the modified AP4 view?
-Rotate slightly counter clockwise from AP4
-Move probe slightly lateral
Purpose of modified AP4?
RV focused view:
-Better visualization of complete RV width
-Better assessment of RV function
Do we visualize both apex’s in modified AP4?
Yes - LV apex still seen in center of image, while RV apex is also visualized fully now
How do pacer wires look on u/s?
Hyperechoic line coming from RV apex
How does viewing the moderator band + RV trabeculations help us when scanning prenatally?
Helps us determine ventricular situs prenatally
Does the RV or LV have more trabeculations?
RV
Structures visualized in modified AP4?
-RV
-TV (ant/sept)
-RA
-LV
-MV (ant/post)
-LA
-Moderator band RV
-Trabeculations RV
How to optimize for the modified AP4 view?
-Ensure no RV apex foreshortening!!
-Fine adjustments with probe rotation counter clockwise to extend RV width fully
-Translate probe laterally to elongate RV
-Angle anteriorly/superiorly to see apex
How can we acquire the AP5 view?
Angle anteriorly/superiorly from AP4
(angle until we see LVOT + AoV in center)
What structures are seen in AP5?
-LV
-LVOT
-AoV
-IVS
(MV, LA, RV, TV + RA are not mandatory to see)
M/c location of VSDs?
Perimembranous area
4 things we are assessing for in AP5?
-LVOT for obstructions
-AoV for structure/function
-LV for size/function/thrombus
-VSD (good at seeing perimembranous ones)
How can we optimize for AP5?
-Ensure LV apex is not foreshortened!!
-Rock to center LV
-Angle anteriorly to see LVOT + AoV
-Rotate counter clockwise to open up AoV to see both cusps + to see Ao root
(some structures may be out of plane for this view which is fine: IAS, LA/RA, TV/MV)
What are blood clots due to?
Due to areas of slow flow
How do we obtain the AP2 view?
Rotate 60 degrees counter clockwise from AP4
(indicator points to pt’s left shoulder)
What is the hardest view for beginners?
AP2
Structures visualized in AP2?
-LV (inf/ant walls: think spells “INFANT”)
-LA
-LAA (left atrial appendage at times)
-MV (ant/post leaflets)
List 2 additional AP2 structures of interest we may see?
-Descending thoracic AO
(angle posteriorly + rotate counter clockwise)
-LAA
What is a LAA?
-Remnant of embryonic LA
-May play a role in modulating LA pressure
-Site for thrombus (blood clot) formation
Which view can we assess for coronary sinus dilatation + descending AO aneurysm/dissection?
AP2
How can we optimize for AP2?
-Ensure LV apex is not foreshortened!!
-Rock to center LV
-Rotate counter clockwise if we see any right sided structures
-Rotate clockwise if we see LVOT + AoV
-Sm breathe in can help bring in anterior wall (remember “infant” wall segments)
In which view does the MV look like a flying UFO/disk?
AP2
How can we obtain AP3?
Rotate 30 degrees further counter clockwise from AP2
(point indicator to pt’s right shoulder + angle inferiorly)
Which view is similar to PLAX?
AP3 - b/c it is the apical long axis
(can gets lots of info here, similar to PLAX but with the inclusion of the LV apex now)
Structures visualized in AP3?
-LV (IS + AS wall segs + apex seen)
-IVS
-LVOT
-LA
-MV (ant/post leaflets)
-Descending AO
-RVOT
How can we optimize for AP3?
-Ensure LV apex is not foreshortened!!
-Rock to center LV
-Rotate counter clockwise to open up AoV to see both cusps + to see AO root
(view shows AO root on the right side of screen, while LA is on left side of screen)
Is right or left handed scanning best for apical views?
LEFT!!!
