Focused Cardiac

enlarged left atrium, rvot

extra grainy - reduced EF, dilated LA

"foreshortened" PLAX - apical outline of LV should not be visible; this could be fixed with some ccw rotation, also would slide up just a bit within same rib space to try to avoid lung obscuring left side of image

could've increased depth a bit to see desc thoracic ao; pt had echo with EF 25-30%, reduced RV f(x), severely dilated LA

left atrium looks dilated

critically ill patient with new onset HFrEF; if I had to guess I'd say 20-25%, note how little movement of the LV walls there is (reduced endomyocardial excursion) and how the mitral valve just flickers open (EPSS)

LAE

poor function, very sclerotic AV and MV - check out that right coronary cusp, no movement

kind of a crummy view but I included it because the patient was in A Fib and the LA is enlarged (compare to aorta)

reduced EF, dilated RVOT and LA

infective endocarditis - note the aortic valve vegetation.

big LA, dilated LV with poor function (20-25% EF), moderate pericardial effusion, sclerotic AV

Note how big the RVOT looks - often this means you're a bit off axis and need to fan toward the left shoulder (drop the tail of the probe toward the patient's right hip). The RV sits on bottom of the heart (kinda) so if you're seein a bunch of it your image would be improved by 'aiming up', so to speak.

small pericardial effusion, LA's a bit plump, EPSS right around 1 cm

Cool look at an impella device in action

Patient with new onset heart failure. EF on echo a week later was 25-30%. Bilateral atrial enlargement and poor RV function also noted as well as a small pericardial effusion.

xtra grainy - PSAX w/ reduced EF, level of MV

mid ventricular to valvular psax with a lil septal flattening

RV sitting on the LV like a hat, sort of looks like a toadstool - usually it's centered at 10-11 o'clock on LV; function/relative size appear normal

notice tricuspid valve visible in RV; pt's echo reported EF 25-30% - notice decreased myocardial thickening and endomyocardial shortening

at level of MV to start, then fanning to the base to see aorta centrally with LA central below Ao, RA/TV/RV taking up 9-12 o'clock around Ao

normal (real world) psax

psax in a critically ill pt with severely reduced EF

starts as psax between MV and papillary muscles, then beam fans toward base of heart (AV in middle with RV toward top of screen and LA below AV)

PSAX with a lil pericardial effusion in the far field

apical 5-ish (aorta central)

gain's up a bit high, though sometimes the butterfly images seem bleached after they're uploaded; visualization would've been aided by having patient roll to left and hold breath briefly

"Do you intentionally cloud the near field of your apical 4's with intolerable gain?" you ask.
"No, not intentionally," as I weep into my cupped hands. Sometimes I think maybe it's something that happens in post production when the image is uploaded to the cloud. Anywho, EF's a bit reduced and the patient was in A Fib.

I think this wound up a bit foreshortened. It's tough to get a good apical 4 without having the patient left lateral recumbent.

this subcostal wound up being a cool view of the LVOT/aortic valve

normal sc4

looks like there could be a pericardial effusion, but I don't see definitive evidence of fluid in the far field - could also be epicardial fat or ascites

functionally looks pretty good, maybe a small effusion, and a thick RV free wall; SC4 is the best view to assess the thickness of the RV free wall because you're perpendicular to it and axial resolution is best; normal RV free wall is about 0.1 to 0.6 cm thick - thick wall generally indicates chronic issue (if RV is big and wall is thick think pHTN rather than acute PE)

I like this image a lot because the axis is so interesting - it's from the subcostal window but it's essentially a backwards PLAX view and the LA looks quite enlarged. Also, patient was in A Fib so the rhythm's irregularly irregular as you may have noticed.

biventricular heart failure (EF 25-30%), enlarged atria, small pericardial effusion

dilated cardiomyopathy

normal IVC

mechanically ventilated patient on high PEEP, little in the way of respiratory variation of IVC but tough to draw conclusions given all the positive pressure being transmitted from the chest - combine, however, with diffuse b lines and newly reduced EF and you can make the case of elevated CVP

This was a tachycardic patient with rough cardiac windows. Wound up getting an IVC view and making a prelim diagnosis of A Flutter - when I scrubbed with a finger to slow the video down I counted about 260 oscillations of the IVC per minute which was about twice the ventricular rate. When the ECG machine was available 10 minutes later I was able to confirm. Check out my tweetorial or rejected case report

normal, collapsible IVC

Plethoric IVC with flow reversal in hepatic vein - the hepatic vein can serve as a nice proxy for elevated CVP. Flow should be blue exclusively (away from probe) - when there's red flow (reversal of flow) that can indicate elevated filling pressures on the right

hepatic vein with forward flow into IVC (blue is away from probe - look at key in top left corner)

1. find IJ in transverse and follow cephalad until it tapers to a point

2. rotate probe 90 degrees to catch the meniscus in long axis - should look triangular where walls of IJ come together at meniscus

following that jugular vein superiorly - notice the light touch at the end - you can see the probe come up off the skin on the right side of the image; gotta make sure you're not compressing the JV to get a good read on the level of the meniscus