Focused Echo: Interpretation

Following the IVC upwards will reveal the hepatic veins junction and the entrance to the RA. The Diaphragm can cause a mirror image of the heart.

The IVC diameter changes depending on intravascular volume status. The IVC collapse during spontaneous inspiration is normal.

An IVC of < 1 cm, particularly with complete collapse, is considered flat and indicates low preload and tolerance to fluid challenges.

An IVC diameter of ≥ 2 cm, especially with minimal or no collapsibility (notice the absence of collapse in this clip), is considered plethoric and correlates with increased RA pressure.

The IVC moves both anterolaterally and craniocaudally with inspiration, and this should be considered when measuring.

Don’t confuse the descending aorta for the IVC. The aorta has thicker walls and notorious abdominal branches.

Although the IVC may appear to pulsate, the aorta has a thicker wall, and its position is to the patient’s left.

You should already know the chambers. Now, explore the septum and LV free wall; notice the myocardial thickening and endocardial excursion. Appreciate the mitral valve activity and follow the movement of the anterior leaflet of the mitral valve

In the short-axis view compare the size and shape of the chambers. Notice the homogenous concentric contraction of the LV.

In the apical view explore the size and shape of the 4 chambers. Notice the myocardial thickening and endocardial excursion. Appreciate the valvular activity and the rise of both tricuspid and mitral annulus.

Again, explore the myocardial thickening and endocardial excursion. The subxiphoid view gives a good insight into the overall contractile activity.

22 y/o Female with recently diagnosed miliary TB complicated with CAP. Quickly developed septic shock + cardiogenic shock secondary to sepsis and severe acidosis (pH 6.8). The patient required emergency RSI and suffered a post-intubation cardiac arrest, successfully achieving ROSC after 20 minutes of standard ALS resuscitation. These clips were taken after stabilisation in ICU, running an infusion of adrenaline + noradrenaline, and continuous renal replacement therapy.

In this PSAX view, notice the severely poor circumferential contractility of the LV. The myocardium barely thickens.
In the previous PLAX image, despite the seemingly vigorous activity of the mitral valve (secondary to inotropic drugs), notice how the anterior leaflet of the mitral valve remains far from the septum, Likewise notice the LV free wall and septum barely thicken.

This A4C image is slightly off-axis (ballooned). Nonetheless, again notice the poor opening of the mitral valve and how the septum and LV free wall contract (thicken) poorly.

In this sub-xiphoid view, notice the overall depressed contractility of the LV. There is also a small amount pf fluid adjacent to the RV.

The IVC is plethoric and shows no variability (IPPV). This is also in keeping with the diagnosis of cardiogenic shock, as the retrograde congestion affects the pulmonary circulation (cardiogenic pulmonary oedema) and increases the RA pressure.

58 y/o Male. Background of dilated cardiomyopathy with an ICD in situ. Admitted to ICU in the context of acute heart & respiratory failure.
In this PLAX view notice the overrall poor cardiac activity and the severely dilated LV and LA chambers. Again the anterior leaflet of the mitral valve displays poor activity and opening.

PSAX view demonstrating a severely depressed contractility. The septum and LV wall barely thicken.

Notice the degree of chamber dilation and the overall reduced contractility. The ICD wire is visible within the RV.

Notice the degree of chamber dilation, the thin walls and the overall reduced contractility. The ICD wire is visible within the RV.

59 y/o Male with a background of dilated MCP and a mechanical mitral valve. Admitted to ICU with septic shock. Clips were taken with a running infusion of norepinephrine + dobutamine.
In this PLAX view notice the septum attempts to contract but the thickening is poor. The same is true for the LV free wall, there is movement but the contractile activity is severely reduced.

In this short axis view some degree of myocardial excursion is visible but severely abnormal and weak.

Assess the overall dilation of the cambers and poor contractility. The movement and artefacts caused by the mechanical mitral valve are also noticeable.

Notice the overall dilation of the cambers and poor contractility. The LV walls do not come together and the walls are thin. The movement and artefacts caused by the mechanical mitral valve are also noticeable.

Plethoric IVC (>2cm) and without respiratory changes.

51 y/o Female, admitted to ICU with septic shock, receiving ABX and norepinephrine. Spontaneous ventilation.
Despite the poor quality of the images, assess the increased contractile activity. There is a noticeable myocardial excursion and the LV walls come closer together.

Again, despite the poor quality of the images, notice the increased myocardial excursion and how the LV walls come close to each other. The RV is small (empty).

Notice the overall increased contractile activity and the active opening of the mitral valve.

Notice the overall increased contractile activity. There is an increased movement and thickening of the LV wall.

The IVC is small (<1.5 cm) and fully collapses on spontaneous inspiration, correlating with a low preload and RA pressure.

63 y/o Female, assessed in the ED with suspected sepsis. VBG with acidosis and rising lactate.
Despite the poor quality images, notice how the septum and LV free wall actively move, thicken and virtually touch each other.

The same in this short axis view, there is increased contractility and excursion of the LV myocardium. The RV is small and empty.

Notice the overall increased contractile activity of the LV.

21 y/o Female, assessed in ED with low GCS, agitation, hypotension & metabolic acidosis. Oral mucose and skin appear severely dry on examination.
In this PLAX view, observe the “small” size of the chambers and the active opening of the mitral valve anterior leaflet, touching the septum. Notice the exaggerated excursion of the septum and LV free wall, both thicken to almost kiss each other.

The increased myocardial excursion is rather noticeable in this short axis view at the level of the papillary muscles.

Despite the poor quality of the clip, the IVC is small and fully collapses on spontaneous inspiration.

49 y/o Female, admitted to ICU with dyspnoea and acute heart failure. No CHF background. The working diagnosis was a suspected Takotsubo syndrome and a formal echo performed after these images measured an EF of 35%-40% (moderate dysfunction)

Both in this apical view and the PLAX view, notice how the contractility is globally reduced but worse towards the apex, exhibiting poor apical myocardial excursion.

68 y/o Male with a background of cardiac sarcoidosis admitted to ICU with respiratory failure (IPPV), persistent hypotension requiring vasopressors, and new LBBB + raised troponins.
Notice there is some myocardial thickening but the overall LV contractility is significantly depressed. Likewise, the mitral valve movement is poor.

M-Mode represents exclusively a small linear section of the 2D image (Upper image: thick grey vertical line in the middle of the screen) perpetually updated across time. Below, the horizontal “wavy” middle line is the movement across time of the anterior leaflet of the mitral valve. The EPSS, measured between the open mitral valve and the septum is >7mm (1.08cm) and, therefore, abnormal.

This clip highlights how adjusting the depth is useful. Notice that at 21 cm depth, you can more easily visualise the descending aorta.
Also, the presence of a left pleural effusion and lung consolidation adjacent to the LV free wall becomes evident.

The circumferential contractile activity of the LV is significantly reduced.

There is reduced global contractility of the LV. The chambers are not significantly dilated

There is reduced overall contractility of the LV and the chambers are not significantly dilated. There is a small but noticeable pericardial effusion adjacent to the RV & RA.

Plethoric, full IVC (>2 cm). There is no respiratory variability (IPPV).

Abundance of diffuse pathologic B-lines bilaterally.

Abundance of diffuse pathologic B-lines bilaterally.

This patient is on cardiogenic shock. There is marked hypotension requiring inopressor support and qualitative features of significantly impaired LV contractility. The EPSS is abnormal. The IVC is plethoric. There are bilateral pathologic B-lines which in this case represent cardiogenic pulmonary oedema.

The patient was transferred to a cardiac ICU and underwent PCI given the suspicion of ACS.

49 y/o Female who presents with severe respiratory distress and desaturation to 90%. Suspecting an airway obstruction secondary to a known thyroid mass, she’s been intubated in ED, after which the SpO2 has not improved and she’s become severely hypotensive requiring vasopressor support.

This PLAX view shows a hyperdynamic LV. There’s also a somewhat enlarged RV when compared to the LA and aortic root, breaking the 1:1:1 rule.

The short axis view reveals a clearly flattened septum and a D-shaped LV.
The RV is at least the same size as the LV if not larger.

This apical view demonstrates a massively dilated RA. The RV appears dilated in comparison to the LV; however, the RV free-wall is not well characterised in this clip so it is difficult to say more about it.
When this happens, small adjustments might improve the image.

This improved view demonstrates a significantly dilated RV with septal deviation to the left. Notice the akinetic RV free wall and the ‘apical wink’ at the RV tip; both these findings constitute the McConnell's sign.

The patient received emergency thrombolysis with immediate correction of the hypotension and shock. You can find the full case in detail including CT images here: https://ultra-sono.com/cases/airwayobstruction

SubXiphoid view demonstrating the massively dilated right chambers.

Significantly plethoric IVC with no respiratory variation or compressibility.

59 y/o Male with severe ARDS and a prolonged period of mechanical ventilation.

Short axis view with D-shaped septum and dilated RV.

Severely dilated right chambers. The US scan for DVT was negative rasing the presumption of sub-acute Cor Pulmonale in the context of raised ventilatory pressures.

SuXiphoid view with severely dilated right chambers.

33 y/o Female presents to ED with acute dyspnoea. On assessment, there is a raised D-dimer and the following clips.

Remember that the RV can be chronically enlarged, and the presence of acute symptoms does not necessarily indicate there is an acute massive PE.

This patient was clinically stable and underwent a CTPA that ruled out PE. She was admitted under medicine to define the cause of her chronic pulmonary hypertension.

19 y/o Male. Suffered cardiac arrest secondary to a massive PE and subsequent ROSC. Thrombolysis was withheld as sustained a significant head injury.

These clips were taken 24 hours post-admission with the patient haemodynamically stable and ventilating spontaneously.

A4C demonstrates evidently enlarged RV (equal size to LV or 1:1). Notice, however, that the rest of the views are only suggestive but don’t categorically show an enlarged or abnormal RV. This highlights the value of the apical view for chamber size comparison and the importance of performing a full study before reaching any conclusions.

Small pericardial effusion adjacent to the RV.

Small apical pericardial effusion

52 y/o Male admitted to.a medical ward in the context of pleural effusion and suspected autoimmune disease.

PLAX shows a small to moderate pericardial effusion.

Short axis view shows a moderate amount of fluid surrounding both ventricles.

Small to moderate pericardial effusion. There is no evident right chamber collapse in this view.

Moderate pericardial effusion.

The RV contracts during ventricular systole and re-expands during ventricular diastole, there is no diastolic collapse of the RV. This is normal and rules out tamponade.

The RA empties (collapses) during ventricular diastole and fills (re-expands) during ventricular systole. There is no systolic collapse of the RA. This is normal and rules out tamponade.

The IVC is < 2 cm and presents some degree of inspiratory collapse.

33 y/o Female with a background of diffuse B-cell lymphoma. Admitted to a medical ward with progressive legs and facial oedema, bradypsychia, lethargy and cold intolerance. TFT was compatible with hypothyroidism.

PLAX shows a moderate to large amount of fluid surrounding both ventricles and causing a “swinging heart”.

There is a moderate to large pericardial effusion surrounding both ventricles and causing a swinging motion with each contraction.

Moderate pericardial effusion. There is no evident RV diastolic collapse.

Moderate pericardial effusion. There is no evident RV diastolic collapse.

Both this one and the previous image represent pleural effusions. Notice how in the PLAX view, pleural fluid tracks posterior to the thoracic aorta, while pericardial fluid would position between the descending aorta and the LA.

In the second clip, also appreciate a large lung consolidation (echogenic material) floating within the pleural effusion, which makes it easier to differentiate. Lastly, have you noticed the dilated LA? This patient had severe mitral regurgitation.

56 y/o Male. Background of cirrhotic liver disease. Admitted to ICU with UGIB complicated with respiratory sepsis.

Pleural effusion on PLAX. The fluid tracks behind the descending aorta.

Apical view. Left pleural effusion, lung consolidation & B-lines adjacent to the LV.

Pleural effusion accumulated on the left costophrenic angle. See the consolidated lung floating within the fluid.

Pleural effusion and large organised consolidation of the right basal zone of the lung. The dense structure that resembles the liver is the hepatised lung with air bronchograms (the bright white bits within). Although a hepatised lung resembles the liver the aspect is not identical, compare this to the next image.

There is an abundance of ascitic fluid. The liver is slightly more homogenous in aspect than the hepatised lung of the previous clip.

PLAX view with severely depressed LV contractility. There is a pleural effusion adjacent to the LV. Increasing the depth would be an ideal way to assess this i more detail.

Fluid collection located outside the pericardium in short axis view

Fluid collection adjacent to the RV but outside the pericardium. Notice the consolidation within this pleural effusion and some protein organization of the fluid. There is also an ICD wire within the RV.

Lung consolidation adjacent to the RV

In the PLAX view, the sizes of RV, AoR, and LA are roughly 1:1:1. This is Normal.

In this PLAX view, the AoR appears slightly larger than the RV and LA. A formal Echo identified a 39 cm AoR and was considered normal for the patient’s demography.

This PLAX view shows and evidently enlarged AoR, measuring 5 cm. The 1:1:1 rule is not respected. There are no obvious signs of complication in this clip.

AoR 5cm transversal diameter.

A suprasternal view can be used to explore beyond the aortic root towards the arch and the emergence of its branches. The probe is placed in the supraesternal notch pointing caudally and with the marker oriented to the left ear.
(BCA: Brachiocephalic Artery. LCA: Left Carotid. LSA: Left Subclavian. DA: Descending Aorta)

Suprasternal notch view of the same patient in the previous set (5cm AoR). This view is not the best to measure as anatomy is slightly distorted. Notice, however, that the inner wall definition is adequate and, if present, it could demonstrate a dissection flap.

Same patient. Fine probe adjustment allows further exploration of the Ao Arch.