POCUS - Cardiac Flashcards
What are the ranges for TAPSE?
Less than 1.6 cm is positive
1.6 to 2.0 cm is indeterminate
Greater than 2.0 cm is negative
McConnell’s sign is what?
Hypokinesis of the lateral wall of the RV and hyperkinesis of the RV apex.
Normal IVC diameter is what?
1.5 to 2.0 cm
With respiratory variation!
Describe the orientation of the probe and the heart in the subxiphoid view.
The probe marker on the curvilinear probe pointes to the patient’s right.
The heart will show the RV in the 12 o’clock position, the LV in the 3 o’clock position, the LA in the 6 o’clock position, and the RA in the 9 o’clock position.
The best position for the cardiac exam is _____________.
LLD
In the subxiphoid view with the cardiac probe, the indicator bump should be on the patient’s ___________.
left
Actually, in all views except the parasternal long, the probe points to the patient’s left.
In the IVC view with the cardiac probe, the indicator bump should be on the patient’s __________ side.
caudal side
This makes it so that on the screen the cephalad side is on the left.
With an abdominal probe (such as during a FAST exam) the probe dot should point up to recreate the same orientation on the screen.
Explain the “bagel and croissant” view.
In the parasternal short axis, the LV looks circular (like a donut) and the RV looks crescent-shaped (like a croissant).
The ___________ is just posterior to the aortic outflow tract.
LA
To find the optimal intercostal space for the parasternal view, ______________.
palpate the border of the sternum and then slide the probe from high to low just lateral to the border
To get the best angle for the apical four-chamber view, try to match the probe up to this axis: ________________.
the axis that goes from the right shoulder to below the left nipple
In the apical four-chamber view, the probe marker should point to the patient’s _______.
left (so in cardiac mode, where the dot on the screen is on the right, the LV will appear on the screen’s right)
Actually, in all views except the parasternal long, the probe points to the patient’s left.
EPSS stands for _________________.
E-point septal separation
In evaluating for EPSS, the first wave is ___________.
the E wave, which occurs during ventricular diastole
Give the measurement criteria for EPSS.
< 8 mm: EF 55%
8 - 18 mm: EF 30-50%
> 18 mm: EF < 30%
What is the 1:1:1 rule?
In the parasternal long access view of the heart, the RV, LVOT, and LA should all be equivalently sized.
Review the ways you can evaluate for RV strain.
- Using the parasternal long access, look for the 1:1:1 rule to assess for RV enlargement.
- Using the parasternal short access, look for the D sign (the bowing of the ventricular septum toward the LV).
- Using either the subxiphoid or apical four-chamber views, look for RV>LV size.
- Using the apical four-chamber view, check for dipping of the RV apex (McConnell’s sign).
- Using the apical four-chamber view, check for TAPSE (tricuspid annular plane systolic excursion). To do this, place the M-mode marker over the lateral edge of the tricuspid valve. < 17 mm is abnormal.
** Be sure to differentiate chronic from acute RV strain. Someone with COPD might have a dilated RV without acute strain. To evaluate this, measure the RV wall at the end of diastole. If > 5 mm, then chronic RVH is likely.
In the transverse abdominal view, an IVC:aorta ratio < _____ has been shown to predict dehydration in pediatric patients.
0.8
What is the rating system for pericardial effusions in adults?
Find the deepest part of the pocket during diastole and measure.
- < 1 cm: mild
- 1-2 cm: moderate
- > 2 cm: severe
If you see signs of RV failure in a patient with chronic lung disease and you’re trying to assess acute insult (like a superimposed PE), what can you look at to gauge chronicity?
RV wall thickness
If greater than 5 mm then they likely have chronic RV failure and acute insult is less likely.
In the subxiphoid view, the apex of the heart should be pointing to the __________ of the screen.
upper right corner
To achieve this, the cardiac mode probe points to the right and the abdominal mode probe points to the left.
In the subxiphoid view, you have to be careful about interpreting LV:RV ratio because _____________.
it’s easy to get an angled section of the heart that can exaggerate either side
For the parasternal long axis, the probe should be in axis with the line that points from the right should to the ____________.
left hip
For the parasternal short axis, the probe should be in axis with the line that points from the left shoulder to the ____________.
right hip
If you see a large effusion and you want to differentiate acute vs chronic, what can you look for?
Look at the IVC!
In tamponade (which you would expect from a large acute effusion), the IVC will be dilated. If it is normal or collapsed then you can be reassured that they don’t have tamponade physiology.
In the PLAX, how can you differentiate pleural effusion from pericardial effusion?
Pericardial effusion will go above the descending aorta, whereas pleural effusion will stop at the aorta.
Post CABG patients are more likely to have _____________ pericardial effusions.
loculated left-sided
The best place to get the apical four chamber view is the ______________.
inframamillary fold in the mid-clavicular line
Where do you measure the depth of a pericardial effusion?
At the deepest pocket
When you see a pericardial effusion, you must get the __________ view.
IVC
This can help differentiate if there is tamponade physiology or not. If the IVC is collapsible then tamponade is effectively ruled out.
RV free wall greater than ______ is indicative of chronic RV strain (at end diastole).
1.0 cm
What is the normal value of the ascending aorta in the PSLA?
It varies depending on the slice that you take, but it varies from 2.0 cm to 3.6 cm.
What diameter is the upper limit of normal for the LA?
4 cm
A caval index greater than _______ suggests fluid responsiveness.
50%
The caval index is calculated by the following equation:
CI = (expiratory IVC diameter - inspiratory IVC diameter) / (expiratory IVC diameter)
Thew IVC is normally ______ in diameter.
1.5 - 2.5 cm
Less than 1.5 cm indicates need of fluids.
Less than 1.0 cm in a trauma indicates transfusion.
Greater than 2.5 cm indicates volume overload.
You can use the ______ mode to measure the respiratory variation of the IVC.
M
In the traditional cardiac mode, the indicator dot is on the __________ of the screen.
right side
When doing the subxiphoid view, you should start with a depth of about _____.
22 cm
One key to epicardial fat pads is that they do not extend ______________.
posterior to the left ventricle
Which part of the ventricles should you look at for evaluating EF?
The endocardial cushion
It’s easier to see dysfunction at this border than the outer border. Part of the reason this is so is that the endocardial border should thicken.
IVC size does not predict CVP in patients who are _________.
mechanically ventilated
Dynamic measurements are reliable.
What mode should you use to obtain phasicity of the IVC?
M mode
This will give you the undulations over time.
What are the most sensitive and specific signs of tamponade?
Sensitive: RA diastolic collapse
Specific: RV diastolic collapse
Note, the systole refers to atrial systole.
What mode can you use to study if the RV has diastolic collapse?
PLAX M-mode and look for RV wall collapse in relation to there mitral valve
The narrowest width of a regurgitant jet (between the leaflets) is called the ______________.
vena contracta
What is PISA?
Proximal isovelocity surface area
This is the flow convergence on the ventricular side (like a turbulent pool).
Why is severity of valvular stenosis not a POCUS domain (even for advanced users)?
It requires spectral Doppler which is extremely difficult.
You can look for gross findings (calcific valve, turbulent color flow jet, adaptive LV hypertrophy), but grading requires formal echo.
In the apical 4-chamber view, the septum should be ___________.
straight up and down
In the PLAX view, if the septum is tilted upward then you need to ______________.
move your probe one intercostal space upward
If your PLAX appears like the ventricles are too small, then _____________.
fan your probe back and forth; aim to get the ventricles as big as possible
What are two ways you can improve the subxiphoid view?
Have the patient flex their hips and knees, then have them inhale
What are two pitfalls of EPSS measurement?
Mitral stenosis and aortic regurgitation can artificially lower it even with a normal EF
Pulsus paradoxus is also called ____________.
respirophasic inflow variation
What is sonographic pulsus paradoxus?
Excessive variation of the velocity of flow through the AV valves. Put pulse-wave doppler on each valve in apical 4.
MV: > 25%
TV: > 40%
The mitral valve has how many leaflets?
Two (aka bicuspid)
The surface contact of valves is the ___________ height.
coaptation
Loss of this is an early sign of valve failure.
In apical 4, the RV should be what size compared to the LV?
About 2/3 the size of the RV
Put another way, the RV should take up 1/3 of the heart.
How do you measure the RV free wall?
End diastole (maximally full heart)
If < 5 mm is normal.
Acute right heart enlargement could be PE or _______.
right-sided MI
When using color flow doppler, always use ____________.
the smallest box needed
An eccentric regurgitant jet is likely what grade of regurgitation?
Severe
Criteria for severe AR?
Jet width > 65% of LV chamber
Vena contract > 6 mm
Wall-hugging eccentric jet
Criteria for severe MR?
Jet width > 40% of LA
Vena contracta > 7 mm
Eccentric jet
Criteria for severe TR?
Jed width “large”
Vena contract > 7 mm
Eccentric jet
What is the systolic ejection velocity measurement?
In the apical 4, you use pulse wave doppler to measure the movement of the RV free wall. The peak velocity should be > 10 cm/s.
Describe measuring the fractional area change for RV strain.
In the apical 4, measure the area of the RV in systole and diastole. The area change should be > 35%.
What are the two 60s of the 60/60 sign?
PA systolic pressure < 60 mm Hg
Pulmonary acceleration time < 60 milliseconds
Presence of both of these is 94% specific for PE.
What are the three grades of CVP on US?
Collapsible = 3 mm Hg
Normal = 8 mm Hg
Plethoric = 15 mm Hg
How do you measure PA systolic pressure?
You need tricuspid regurgitation. Apical 4 chamber view, find the regurgitant jet, and but continuous wave Doppler over the peak velocity of the jet. Record theee peak velocity on the waveform.
Usually cardiac modes will have an automatic calculator that gives PA SP, but if not then you can find calculators online.
How do you measure pulmonary acceleration time?
Go to the PSAX view and then slide one rib space superior to get the pulmonary valve. Put continuous wave doppler over the valve. On the wave that’s generated, measure the horizontal length of the whole wave from start to peak. This is the PAT.
What is mitral a surrogate for?
Diastolic function
How do you measure mitral inflow?
Put pulse wave doppler gating right over the tips of the mitral valve leaflets when they are most open
What are the four views of the TEE?
Mid esophageal 4 chamber
Mid esophageal long-axis
Bicaval
Transgastric short
A fractional area change of less than _______ suggests RV dysfunction.
35%
Which ventricle has the moderator band?
RV
What is the formula for PASP?
RA + 4(Vmax of tricuspid regurgitant jet)^2
Explain how to use the mitral annulus to study diastolic dysfunction.
In the A4, you use TDI on the mitral annulus at the septal wall. Measure the E to E’
How do you calculate a velocity time integral?
A4
Pulse wave doppler on the LVOT
Measure the duration of the outflow
Although this is not entirely agreed upon, what are the rough estimates for normal IVC variability in spontaneously breathing and ventilate patients
Spont: 40-50%
Vent: 20%
If there is greater variability, then consider fluids.
According to the American College of US, what are the criteria for IVC and volume status?
< 2.1 cm and > 50% collapsible: 3 mm Hg
Combination of the two: 8 mm Hg
> 2.1 cm and < 50% collapsible: 15 mm Hg
If the IVC appears pulsatile (which it sometimes can), how can you confirm?
Look for the RA – the IVC will dump into it, the aorta will not
What are the depth criteria for small, moderate, and large pericardial effusions?
Small: less than 1.0 cm
Moderate; 1-2 cm
Large: greater than 2 cm
Note: you need to measure during diastole.
What four things can mimic a pericardial effusion?
Pleural effusion
Epicardial fat pad
Ascites
Pericardial cyst
How many segments are there for WMAs?
16 or 17 depending on the source
The septum is broken into how many segments?
Apical
Inferoseptal
Basal septal
If you are in the PSAX, what three arteries supply the walls you are seeing?
RCA: RV, posterior septum, and posterolateral LV (with circumflex)
LAD: anterior LV, anterior septum, and anterolateral LV (with Cx)
Cx: lateral LV, anterolateral LV (with LAD), and posterolateral LV (with RCA)
As you go more apically on the PSAX, the ________ artery supplies more of the septum.
LAD
Normal wall motion is what?
Endocardium moving > 5 mm
When a section of myocardium moves out during systole, this is called?
Dyskinetic
Takotsubo cardiomyopathy occurs almost exclusively in ____________.
post-menopausal women (90%)
Papillary muscle rupture is usually associated with which wall MI?
Inferior
The posteromedial papillary muscle has single blood supply, whereas the anterolateral has dual.
Why do those with papillary muscle rupture often have no murmur?
They have rapid equalization of pressures, so there is often little-to-no turbulent flow
True or false: papillary muscle rupture is usually visualizable on TTE?
False
A study in the late 2010s showed that even skilled cardiologists were frequently unable to identify PMR on TTE.
