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Cardiac US

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A4C

SUBXYPHOID

Almost a complete echo can be performed from the subcostal view, especially in patients with hyperexpanded lungs. Excellent images are usually obtained in the COPD patient. If visualisation is difficult due to bowel gas, translate laterally to the patient's right and image through the liver fanning towards the heart. Images are best on held inspiration and after continuous downwards graded pressure. 

Probe placement
  • Transducer horizontal with the marker to 3 o'clock, hand above/ below the transducer
  • Go directly caudal to the xiphisternum and push into the space and look left towards the heart
  • Maintain continuous downward graded pressure
  • Ask patient to hold deep inspiration

In this view: remember that the RV and RA (being the most anterior parts of the heart), are closest to the liver. LA and LV will be posterior. Assess all chambers for size and function. This is a good view to look for a pericardial effusion and signs of tamponade. 

SHORT AXIS VIEW FROM SUBXYPHOID

short axis view at the level of the MV

To get a short axis view of the heart from the subxyphoid, just rotate your transducer 90 degrees anticlockwise and fan towards the left. You should see a PSAx fishmouth like view of the heart with the RV anteriorly and the LV posteriorly. If you then fan towards the patient's right shoulder you will see the PSAx AV view and then if you fan towards the left shoulder you will see the PSAx pap muscle view and then the apex of the heart. This is expecially helpful in the patient with hyperexpanded lungs when the parasternal views are inadequate. 

short axis view at the level of Ao valve

TROUBLE SHOOTING FOR SUBXYPHOID

AORTA SEEN 

Sometimes, you may see the aorta arising out of the LV in the four chamber subxyphoid view. This occurs because you're fanning too anteriorly. When this occurs, sometimes, the LA which is posterior to the ascending aorta can look like a small localised pericardial effusion. To go back to an on axis 4 chamber view fan the transducer slightly posteriorly towards the patient's spine. 

IVC

The IVC is useful for assessing RV pressure overload (eg acute PE, tamponade) and for fluid responsiveness. The IVC travels through the liver - so you should see liver on either side of the vein. Also, you may sometimes see the hepatic vein opening into it just before it enters the RA,

Always ensure the IVC is seen to open into RA to avoid confusion with the aorta.

Probe placement:

  • Flat against the patient's abdomen
  • Subxiphoid
  • Probe marker to 12 o'clock
  • Fan towards the patient's right shoulder and liver

What to look for:

  • IVC size and collapsibility with respiration
  • If you are going to meassure the change in IVC size, assess distal to the hepatic vein or 2cm from the RA.

IVC opening into RA. Annotated on the right. Measure the IVC in inspiration and expiration about 2 cm from the RA, proximal to the hepatic vein. 

TROUBLE SHOOTING FOR IVC

AORTA NOT IVC  


Sometimes, if you rotate too far anticlockwise or accidentally translate towards the left you will visualise the aorta instead of the IVC. It can sometimes be difficult to differentiate the two. Important differentiators are: the aorta is thick walled and has the spine posteriorly. Also in this view you usually don't see any branches except the coeliac trunk.

To get back to the IVC fan towards the liver and ensure the transducer marker is at 12 o'clock. 

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Supraclavicular