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<br /> Ultrasound<br /> Introduction to transthoracic<br /> echocardiography<br /> Philips tutorial<br /> Anne-Sophie Beraud, MD<br /> Division of Cardiovascular Medicine,<br /> Stanford University School of Medicine<br /> Toni Burkett<br /> Philips Healthcare – Ultrasound<br /> Contents<br /> Introduction to transthoracic echocardiography<br /> 1 What is point-of-care echo? 3<br /> 2 The basics 4<br /> 3 Transthoracic echo views 11<br /> Parasternal views 12<br /> Apical views 28<br /> Subcostal views 36<br /> 4 Tips for image optimization 44<br /> 5 Assessment of structures 48<br /> Left ventricle 48<br /<a title="Introduction to TransEchoPOC_Tutorial_Zmag page 1" href="http://viewer.zmags.com/publication/3c9e5062?page=1"> Ultrasound Introduction to transthoracic echocar</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 2" href="http://viewer.zmags.com/publication/3c9e5062?page=2"> Contents Introduction to transthoracic echocardi</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 3" href="http://viewer.zmags.com/publication/3c9e5062?page=3"> 1 What is point-of-care echo? Point-of-care (P</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 4" href="http://viewer.zmags.com/publication/3c9e5062?page=4"> 2 The basics The transducer </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 5" href="http://viewer.zmags.com/publication/3c9e5062?page=5"> Transducer manipulation Proper transducer placeme</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 6" href="http://viewer.zmags.com/publication/3c9e5062?page=6"> Use the following techniques to adjust the transd</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 7" href="http://viewer.zmags.com/publication/3c9e5062?page=7"> Tilt Tilt the transducer to identify and optimize</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 8" href="http://viewer.zmags.com/publication/3c9e5062?page=8"> Ergonomics and set-up • Stand at the level of </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 9" href="http://viewer.zmags.com/publication/3c9e5062?page=9"> Using gain Optimal gain The “gain” con</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 10" href="http://viewer.zmags.com/publication/3c9e5062?page=10"> Using depth Optimal depth The “depth” </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 11" href="http://viewer.zmags.com/publication/3c9e5062?page=11"> 3 Transthoracic echo views Main transthoracic </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 12" href="http://viewer.zmags.com/publication/3c9e5062?page=12"> Parasternal long-axis </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 13" href="http://viewer.zmags.com/publication/3c9e5062?page=13"> 3 Parasternal long-axis view – right side of the</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 14" href="http://viewer.zmags.com/publication/3c9e5062?page=14"> Parasternal long-axis RV LV AV</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 15" href="http://viewer.zmags.com/publication/3c9e5062?page=15"> [ Video 1 ] Paraste</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 16" href="http://viewer.zmags.com/publication/3c9e5062?page=16"> Parasternal short-axis – aortic valve level </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 17" href="http://viewer.zmags.com/publication/3c9e5062?page=17"> 5 Parasternal short-axis view – aortic valve lev</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 18" href="http://viewer.zmags.com/publication/3c9e5062?page=18"> RVOT Pulmonic valve Tricuspid valve </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 19" href="http://viewer.zmags.com/publication/3c9e5062?page=19"> [ Video 2 ] Paraste</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 20" href="http://viewer.zmags.com/publication/3c9e5062?page=20"> Parasternal short-axis – mitral valve level </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 21" href="http://viewer.zmags.com/publication/3c9e5062?page=21"> PSS - Mitral valve level </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 22" href="http://viewer.zmags.com/publication/3c9e5062?page=22"> Parasternal short-axis – mitral valve level </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 23" href="http://viewer.zmags.com/publication/3c9e5062?page=23"> [ Video 3 ] Paraste</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 24" href="http://viewer.zmags.com/publication/3c9e5062?page=24"> Parasternal short-axis – papillary muscle level </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 25" href="http://viewer.zmags.com/publication/3c9e5062?page=25"> Parasternal short-axis view – papillary muscle le</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 26" href="http://viewer.zmags.com/publication/3c9e5062?page=26"> Parasternal short-axis – papillary muscle level </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 27" href="http://viewer.zmags.com/publication/3c9e5062?page=27"> [ Video 4 ] Paraste</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 28" href="http://viewer.zmags.com/publication/3c9e5062?page=28"> Apical four-chamber (A4C) </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 29" href="http://viewer.zmags.com/publication/3c9e5062?page=29"> Apical four-chamber view – tilt the transducer up</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 30" href="http://viewer.zmags.com/publication/3c9e5062?page=30"> Apical four-chamber (A4C) RV LV T</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 31" href="http://viewer.zmags.com/publication/3c9e5062?page=31"> [ Video 5 ] Apical </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 32" href="http://viewer.zmags.com/publication/3c9e5062?page=32"> Apical five-chamber (A5C) • From the apical fou</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 33" href="http://viewer.zmags.com/publication/3c9e5062?page=33"> 2 Apical five-chamber view – tilt the transducer</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 34" href="http://viewer.zmags.com/publication/3c9e5062?page=34"> Apical five-chamber (A5C) RV LV </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 35" href="http://viewer.zmags.com/publication/3c9e5062?page=35"> [ Video 6 ] Apical </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 36" href="http://viewer.zmags.com/publication/3c9e5062?page=36"> Subcost7al fouSru-bcohstal mber © 2015 K</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 37" href="http://viewer.zmags.com/publication/3c9e5062?page=37"> Subcostal four-chamber view – directing the ultra</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 38" href="http://viewer.zmags.com/publication/3c9e5062?page=38"> Subcostal four-chamber RV TV </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 39" href="http://viewer.zmags.com/publication/3c9e5062?page=39"> [ Video 7 ] Subcost</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 40" href="http://viewer.zmags.com/publication/3c9e5062?page=40"> 8 SubcostalSiunbcfoestralioIVCr vena cava (IVC) </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 41" href="http://viewer.zmags.com/publication/3c9e5062?page=41"> Subcostal inferior vena cava view – the IVC shoul</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 42" href="http://viewer.zmags.com/publication/3c9e5062?page=42"> Subcostal inferior vena cava (IVC) IVC</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 43" href="http://viewer.zmags.com/publication/3c9e5062?page=43"> [ Video 8 ] Subcost</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 44" href="http://viewer.zmags.com/publication/3c9e5062?page=44"> 4 Tips for image optimization Parasternal long-</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 45" href="http://viewer.zmags.com/publication/3c9e5062?page=45"> Optimal parasternal long-axis view Aortic and mit</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 46" href="http://viewer.zmags.com/publication/3c9e5062?page=46"> Parasternal short-axis, papillary muscle level: o</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 47" href="http://viewer.zmags.com/publication/3c9e5062?page=47"> Apical four-chamber: optimizing the image Opti</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 48" href="http://viewer.zmags.com/publication/3c9e5062?page=48"> 5 Assessment of structures Left ventricle LV</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 49" href="http://viewer.zmags.com/publication/3c9e5062?page=49"> LV function For most clinical purposes, visual es</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 50" href="http://viewer.zmags.com/publication/3c9e5062?page=50"> LV function Normal LV function The walls thicken</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 51" href="http://viewer.zmags.com/publication/3c9e5062?page=51"> Severe LV dysfunction There is only minimal chang</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 52" href="http://viewer.zmags.com/publication/3c9e5062?page=52"> [ Video 9 ] Video d</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 53" href="http://viewer.zmags.com/publication/3c9e5062?page=53"> [ Video 10 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 54" href="http://viewer.zmags.com/publication/3c9e5062?page=54"> Left ventricular hypertrophy (LVH) Note the thick</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 55" href="http://viewer.zmags.com/publication/3c9e5062?page=55"> Normal parasternal short-axis papillary muscle le</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 56" href="http://viewer.zmags.com/publication/3c9e5062?page=56"> Left ventricular hypertrophy (LVH) Note the thick</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 57" href="http://viewer.zmags.com/publication/3c9e5062?page=57"> [ Video 11 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 58" href="http://viewer.zmags.com/publication/3c9e5062?page=58"> Right ventricle RV function RV can be assessed</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 59" href="http://viewer.zmags.com/publication/3c9e5062?page=59"> RV assessment • Normal RV size < 2/3 LV size. • </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 60" href="http://viewer.zmags.com/publication/3c9e5062?page=60"> RV assessment All examples are the parasternal sh</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 61" href="http://viewer.zmags.com/publication/3c9e5062?page=61"> [ Video 12 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 62" href="http://viewer.zmags.com/publication/3c9e5062?page=62"> RV assessment All examples are the apical four-ch</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 63" href="http://viewer.zmags.com/publication/3c9e5062?page=63"> [ Video 13 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 64" href="http://viewer.zmags.com/publication/3c9e5062?page=64"> Pericardium Pericardial effusion • Pericardial </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 65" href="http://viewer.zmags.com/publication/3c9e5062?page=65"> Pericardial effusion Small pericardia</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 66" href="http://viewer.zmags.com/publication/3c9e5062?page=66"> [ Video 14 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 67" href="http://viewer.zmags.com/publication/3c9e5062?page=67"> [ Video 15 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 68" href="http://viewer.zmags.com/publication/3c9e5062?page=68"> Pericardium Main criteria for tamponade Peri</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 69" href="http://viewer.zmags.com/publication/3c9e5062?page=69"> Pericardial versus pleural effusion • Best assess</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 70" href="http://viewer.zmags.com/publication/3c9e5062?page=70"> Mitral valve Mitral valve can be assessed from: </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 71" href="http://viewer.zmags.com/publication/3c9e5062?page=71"> Apical four-chamber Subcostal four-</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 72" href="http://viewer.zmags.com/publication/3c9e5062?page=72"> Mitral valve Detection of mitral valve stenosis</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 73" href="http://viewer.zmags.com/publication/3c9e5062?page=73"> [ Video 16 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 74" href="http://viewer.zmags.com/publication/3c9e5062?page=74"> Mitral valve Detection of mitral regurgitation </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 75" href="http://viewer.zmags.com/publication/3c9e5062?page=75"> [ Video 17 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 76" href="http://viewer.zmags.com/publication/3c9e5062?page=76"> Aortic valve Aortic valve can be assessed from:</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 77" href="http://viewer.zmags.com/publication/3c9e5062?page=77"> Apical five-chamber </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 78" href="http://viewer.zmags.com/publication/3c9e5062?page=78"> Aortic valve Detection of aortic valve stenosis</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 79" href="http://viewer.zmags.com/publication/3c9e5062?page=79"> [ Video 18 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 80" href="http://viewer.zmags.com/publication/3c9e5062?page=80"> Aortic valve Detection of aortic regurgitation </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 81" href="http://viewer.zmags.com/publication/3c9e5062?page=81"> [ Video 19 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 82" href="http://viewer.zmags.com/publication/3c9e5062?page=82"> Tricuspid valve Tricuspid valve can be assessed</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 83" href="http://viewer.zmags.com/publication/3c9e5062?page=83"> Subcostal four-chamber </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 84" href="http://viewer.zmags.com/publication/3c9e5062?page=84"> Tricuspid valve Detection of tricuspid regurgit</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 85" href="http://viewer.zmags.com/publication/3c9e5062?page=85"> [ Video 20 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 86" href="http://viewer.zmags.com/publication/3c9e5062?page=86"> Inferior vena cava (IVC) IVC and volume status </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 87" href="http://viewer.zmags.com/publication/3c9e5062?page=87"> [ Video 21 ] Video </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 88" href="http://viewer.zmags.com/publication/3c9e5062?page=88"> Inferior vena cava (IVC) IVC respiratory variat</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 89" href="http://viewer.zmags.com/publication/3c9e5062?page=89"> Inferior vena cava and volume status In mechani</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 90" href="http://viewer.zmags.com/publication/3c9e5062?page=90"> 6 Measurements and calculations This section wi</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 91" href="http://viewer.zmags.com/publication/3c9e5062?page=91"> Reference values for LV size and wall thickness </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 92" href="http://viewer.zmags.com/publication/3c9e5062?page=92"> Formula for the calculation of ejection fraction </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 93" href="http://viewer.zmags.com/publication/3c9e5062?page=93"> Steps for using the Simpson’s method St</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 94" href="http://viewer.zmags.com/publication/3c9e5062?page=94"> Formula for the calculation of stroke volume (SV)</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 95" href="http://viewer.zmags.com/publication/3c9e5062?page=95"> Step 2 In apical five-chamber view, place pulsed </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 96" href="http://viewer.zmags.com/publication/3c9e5062?page=96"> Formula for the calculation of right ventricular </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 97" href="http://viewer.zmags.com/publication/3c9e5062?page=97"> Calculation of RVSP Step 1 Identify tricuspi</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 98" href="http://viewer.zmags.com/publication/3c9e5062?page=98"> 7 Echo during CPR A protocol for the use of ul</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 99" href="http://viewer.zmags.com/publication/3c9e5062?page=99"> 8 Abbreviations Ao – ascending aorta AV – aort</a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 100" href="http://viewer.zmags.com/publication/3c9e5062?page=100"> 9 POC echo pocket card This companion pocket </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 101" href="http://viewer.zmags.com/publication/3c9e5062?page=101"> Additional resources For additional resources </a> <a title="Introduction to TransEchoPOC_Tutorial_Zmag page 102" href="http://viewer.zmags.com/publication/3c9e5062?page=102"> This paper reflects the opinion of the author, no</a>