Module 1: Apical Four Chamber 2D Protocol Flashcards
What is the apical window?
Anywhere form the anterior axillary (armpit) line to the posterior axillary line. May be in the 4th or 5th intercostal space
What tips can we use in the apical window?
- Use the PMI (point of maximal impulse) to find the apex
- Probe indicator points towards the bed (2-3:00)
when in doubt go lateral
In apical we do how many measurement methods? What are they?
Two biplane measurements
1. LA volume
2. Simpson s EF (LV)
For both the Apical biplane measurements we do what to get volume?
Trace around the chambers to give us a volume. This is done in A4C+ A2C
What is the method of disks?
Uses two orthogonal diameters to create “disks” throughout the traced volumes placed at 5mm intervals
To assess the size of the LA we want to measure when?
At the largest End systole
The LA is largest during end systole, unlike the LV
What does LAVI stand for? How do we calculate it? Why do we use it?
LA volume index
1. Divide it by the patients BSA
2. Greater accuracy
LAVI tracing tips 3
- Excludes the pulmonary veins and the DA from the tracing
- Trace from the medial side of the MV annulus to the down and around to the lateral
- Align the vertical axis from the middle of the MV annular diameter to the middle of the roof of the LA
Several scenarios can increase the size/ volume of the left atria, what are they? 5
- Systolic dysfunction
- Diastolic dysfunction
- Infiltrative muscle disease
- Valvular heart disease
- Obesity
The biplane method of disks provides a much more accurate measurement of LA size compared to what?
PLAX LA dimension
What is Simpsons EF (bi-plane)?
Similar biplane methods of disks
For Simpsons EF trace LV at diastole in A4C when?
Largest, before the squeeze
During Simpsons EF trace LV at end systole in A4C when?
Smallest and after the squeeze
During Simpsons EF trace LV at end diastole A4C when?
Largest, before the squeeze
During Simpsons EF trace LV at end systole A2C when?
Smallest, after the squeeze
EF stands for what?
Ejection fraction
What is the formula for EF?
EF = ((EDV-ESV)/EDV)x 100
What is the Avg LA volume formula?
(A4C LA VOL + A2C LA VOL)/2
What is the LAVI formula?
LAVI= LA vol/ BSA
What is the LV EDV range?
Male < 128/ Female <91
What is the LV ESV numbers?
Male <51/ female <35
What is the normal Simpsons EF%?
M 52-72/ F 54-74
What should we look for during A4C 2D? 4
- LV long and lean (do not forshorten)
- Clear definition on both TV and MV
- Clear Endocardial definition
- Focus at MV (mid)
What are some tips for A4C LA volume trace? 3
- Optimize the 2D first.
- Trace at end systole
- LA is at its largest just before the MV opening
What do we need to see during A4C reduced depth 4
- Bring depth to just below MV/mid LA
- Optimize LV walls to assess wall motion
- Focus up @ mid- LV
- Can use colonize map
What are some tips for A4C LV trace- Simpsons biplane during diastole? 4
- Align LV apex before tracing
- Make sure the LV is at the largest
- Trace the endocardial boarder in the A4C view
- Trace straight through the pap muscles
What are some tips for A4C LV trace- Simpsons biplane during end systole? 3
- Cine through to make the LV is at its smallest
- Trace from one side of the MV annulus to the other
- Adjust the vertical axis (length) to the long axis of the chamber
What are some tips for A4C RT focused view? 2
- Slide more laterally to use the LV as a window for the RV
- Should see RV free wall more clearly
you may not be able to above more laterally due to lung interference
What is RVIDd?
RV internal dimension end- diastole
What are some tips for A4C base RVIDd? 3
- Measure RV base at end diastole
- RV is at its largest and TV is closed
- Basal 1/3 portion of the RV
What are some tips for A4C right heart Mid diameter?
Same as the base, but midway down the RV from the IVS to the RV free wall
What is the normal RVIDd base value?
<41 mm
What is the normal RVIDd mid?
<35mm
What does TAPSE stand for?
Tricuspid annular plane systolic excursion
What are some tips for A4C TAPSE (M-mode)? 3
- Use write zoom to zoom the lateral TV annulus
- Place the cursor over the lateral TV annulus
- Turn on M-mode (adjust gains appropriately)
measure trough peak on the brightest line you can follow
What is the process for A4C RA volume index? 3
- Rotate probe until the RV/RA are largest while still in A4C view
- Trace the entire RA chamber
- Cut straight across at the TV annulus
What is the normal RAVI values?
Female N <27ml/m
Male N < 32ml/m
