Module 1: Apical Four Chamber 2D Protocol

Question 1

What is the apical window?

Answer 1

Anywhere form the anterior axillary (armpit) line to the posterior axillary line. May be in the 4th or 5th intercostal space

Question 2

What tips can we use in the apical window?

Answer 2

1. Use the PMI (point of maximal impulse) to find the apex
2. Probe indicator points towards the bed (2-3:00)

when in doubt go lateral

Question 3

In apical we do how many measurement methods? What are they?

Answer 3

Two biplane measurements
1. LA volume
2. Simpson s EF (LV)

Question 4

For both the Apical biplane measurements we do what to get volume?

Answer 4

Trace around the chambers to give us a volume. This is done in A4C+ A2C

Question 5

What is the method of disks?

Answer 5

Uses two orthogonal diameters to create “disks” throughout the traced volumes placed at 5mm intervals

Question 6

To assess the size of the LA we want to measure when?

Answer 6

At the largest End systole

The LA is largest during end systole, unlike the LV

Question 7

What does LAVI stand for? How do we calculate it? Why do we use it?

Answer 7

LA volume index
1. Divide it by the patients BSA
2. Greater accuracy

Question 8

LAVI tracing tips 3

Answer 8

1. Excludes the pulmonary veins and the DA from the tracing
2. Trace from the medial side of the MV annulus to the down and around to the lateral
3. Align the vertical axis from the middle of the MV annular diameter to the middle of the roof of the LA

Question 9

Several scenarios can increase the size/ volume of the left atria, what are they? 5

Answer 9

1. Systolic dysfunction
2. Diastolic dysfunction
3. Infiltrative muscle disease
4. Valvular heart disease
5. Obesity

Question 10

The biplane method of disks provides a much more accurate measurement of LA size compared to what?

Answer 10

PLAX LA dimension

Question 11

What is Simpsons EF (bi-plane)?

Answer 11

Similar biplane methods of disks

Question 12

For Simpsons EF trace LV at diastole in A4C when?

Answer 12

Largest, before the squeeze

Question 13

During Simpsons EF trace LV at end systole in A4C when?

Answer 13

Smallest and after the squeeze

Question 14

During Simpsons EF trace LV at end diastole A4C when?

Answer 14

Largest, before the squeeze

Question 15

During Simpsons EF trace LV at end systole A2C when?

Answer 15

Smallest, after the squeeze

Question 16

EF stands for what?

Answer 16

Ejection fraction

Question 17

What is the formula for EF?

Answer 17

EF = ((EDV-ESV)/EDV)x 100

Question 18

What is the Avg LA volume formula?

Answer 18

(A4C LA VOL + A2C LA VOL)/2

Question 19

What is the LAVI formula?

Answer 19

LAVI= LA vol/ BSA

Question 20

What is the LV EDV range?

Answer 20

Male < 128/ Female <91

Question 21

What is the LV ESV numbers?

Answer 21

Male <51/ female <35

Question 22

What is the normal Simpsons EF%?

Answer 22

M 52-72/ F 54-74

Question 23

What should we look for during A4C 2D? 4

Answer 23

1. LV long and lean (do not forshorten)
2. Clear definition on both TV and MV
3. Clear Endocardial definition
4. Focus at MV (mid)

Question 24

What are some tips for A4C LA volume trace? 3

Answer 24

1. Optimize the 2D first.
2. Trace at end systole
3. LA is at its largest just before the MV opening

Question 25

What do we need to see during A4C reduced depth 4

Answer 25

1. Bring depth to just below MV/mid LA
2. Optimize LV walls to assess wall motion
3. Focus up @ mid- LV
4. Can use colonize map

Question 26

What are some tips for A4C LV trace- Simpsons biplane during diastole? 4

Answer 26

1. Align LV apex before tracing
2. Make sure the LV is at the largest
3. Trace the endocardial boarder in the A4C view
4. Trace straight through the pap muscles

Question 27

What are some tips for A4C LV trace- Simpsons biplane during end systole? 3

Answer 27

1. Cine through to make the LV is at its smallest
2. Trace from one side of the MV annulus to the other
3. Adjust the vertical axis (length) to the long axis of the chamber

Question 28

What are some tips for A4C RT focused view? 2

Answer 28

1. Slide more laterally to use the LV as a window for the RV
2. Should see RV free wall more clearly
   you may not be able to above more laterally due to lung interference

Question 29

What is RVIDd?

Answer 29

RV internal dimension end- diastole

Question 30

What are some tips for A4C base RVIDd? 3

Answer 30

1. Measure RV base at end diastole
2. RV is at its largest and TV is closed
3. Basal 1/3 portion of the RV

Question 31

What are some tips for A4C right heart Mid diameter?

Answer 31

Same as the base, but midway down the RV from the IVS to the RV free wall

Question 32

What is the normal RVIDd base value?

Answer 32

<41 mm

Question 33

What is the normal RVIDd mid?

Answer 33

<35mm

Question 34

What does TAPSE stand for?

Answer 34

Tricuspid annular plane systolic excursion

Question 35

What are some tips for A4C TAPSE (M-mode)? 3

Answer 35

1. Use write zoom to zoom the lateral TV annulus
2. Place the cursor over the lateral TV annulus
3. Turn on M-mode (adjust gains appropriately)
   measure trough peak on the brightest line you can follow

Question 36

What is the process for A4C RA volume index? 3

Answer 36

1. Rotate probe until the RV/RA are largest while still in A4C view
2. Trace the entire RA chamber
3. Cut straight across at the TV annulus

Question 37

What is the normal RAVI values?

Answer 37

Female N <27ml/m
Male N < 32ml/m