RACE I Rapid Assessment by Cardiac Echo. Intensive Care Training Program Radboud University Medical Centre NIjmegen

Transcription

1 RACE I Rapid Assessment by Cardiac Echo Intensive Care Training Program Radboud University Medical Centre NIjmegen

2 RACE Goal-directed study with specific questions Excludes Doppler ultrasound Perform 50 full and complete RACE examiminations and discuss with supervisor RACE is not a comprehensive echocardiographic examination

3 Always... Place patient in left lateral position with left arm elevated Choose the correct transducer Enter patient s details in the machine Connect the ECG

4 Standard views Parasternal long axis (PLAX) Parasternal short axis (PSAX) Aortic, Basal (MV), Mid (Papillary), Apical Apical four chamber (A4C) Apical five chamber (A5C) Apical two chamber (A2C) Subcostal (SC) Inferior Vena Cava (IVC)

5 Parasternal - long axis Patient slightly turned toward left 3 d or 4 th intercostal space Scan plane from right shoulder left kidney Transducer index mark directed towards right shoulder (11 o clock)

6 Parasternal - long axis

7 Parasternal - long axis RV LV Ao LA

8 Parasternal - short axis Patient slightly turned toward left 3 d or 4 th intercostal space Turn transducer from long axis position 90 0 clockwise Transducer index mark directed toward mid left clavicle As much as possible parasternal Four planes: Aortic - Basal - Mid - Apical

9 PSAX - Aortic Tilt transducer superiorly Angle medially

10 PSAX - Aortic RVout RA LA PA

11 PSAX - Basal right ventricle Septal Anterior Anterior mitral leaflet Posterior Posterior mitral leaflet Lateral

12 PSAX - Mid

13 PSAX - Mid

14 Apical 4-chamber view Patient slightly turned toward left Transducer on apex - usually 5 th intercostal space in anterior axillary line Axis pointed towards right shoulder with index mark towards left axilla (3 o clock) Tilt transducer superiorly

15 Apical 4-chamber view

16 Apical 4-chamber view RV LV RA LA

17 Apical 5-chamber view Av Aorta From 4-chamber view Tilt transducer anteriorly

18 Apical 2-chamber view Patient slightly turned toward left Transducer on apex From 4-chamber view rotate 90 0 counter clockwise with index mark pointing upwards (12 o clock)

19 Apical 2-chamber view

20 Apical 2-chamber view Anterior Inferior LV LA

21 Subcostal view Patient on back Transducer just right from xyphoid pointed toward left midclavicular region Index mark pointed towards left hip Push transducer downwards in horizontal plane - tilt anteriorly

22 Subcostal view

23 Subcostal - long axis view

24 Subcostal - IVC view Patient on back From subcostal view turn 90 0 counter clockwise with index mark upwards - sweep towards patient s right side - tilt slightly posteriorly

25 Subcostal - IVC view

26 Left Heart Assessment Size: small - normal - dilated? Left atrial size Segmental wall defects Contractility: normal - decreased - hyperdynamic Left ventricular wall thickness Aortic and mitral valve appearance

27 Chamber Size Objective M-mode Cursor through tip of mitral leaflet in diastole perpendicular to LV axis Normal dimensions LIVDd: mm LIVDs: mm IVS and PW: < 11 mm

28 Chamber Size Objective PLAX: cineloop at end-expiration. Playback and freeze at end-diastole and peak-systole respectively. Measure LV dimension. A4C: idem. LV dimension at end-diastole at 1/3 from MV leaflet tips to apex. Length from apex to MV leaflet tips.

29 Chamber Size Objective

30 PLAX Subjective A4C PsAX A2C Crude review - small - normal - dilated

31 LV contraction Objective M-mode: systolic wall thickening in PLAX (IVS and posterior wall) and PSAX (anterior and posterior wall) Simpsons method - need A4C and A2C views

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33 PLAX Subjective A4C PsAX A2C Low - normal - hyperdynamic - symmetrical?

34 Asymmetrical contraction

35 Valvular abnormalities Aortic valve: PLAX-PSAX-A5C-A2C Movement and thickness of cusps - abnormal masses Measure diameter aorta above coronary sinuses - PLAX Mitral valve: PLAX-PSAX-A4C-A2C-SC Movement and thickness of leaflets - abnormal masses

36 Valvular abnormalities Aortic valve stenosis?

37 Valvular abnormalities AV and MV endocarditis Aortic ascending aneurysm

38 Valvular abnormalities Mitral valve stenosis?

39 Left atrial size PLAX: M-mode through aortic root and left atrium (diameter ) normal mm A4C: diameter (diagonal and cross section in mid chamber position), area, volume (Simpsons method)

40 Left atrial size PLAX - Dilated cardiomyopathy A4C - Mitral stenosis

41 RACE II Rapid Assessment by Cardiac Echo Intensive Care Training Program Radboud University Medical Centre NIjmegen

42 Right heart assessment Size: small, normal, dilated Thickness Elevated RV pressure Tricuspid valve appearance Intracardiac masses RA size Contractility: decreased, normal, hyperdynamic

43 RV size Subjective: PLAX, PSAX, A4C, SC

44 RV size Objective Compare with LV: normal ratio < severely dilated > 1

45 RV contractility Objective: TAPSE M-mode Tricuspid Annular Plane Systolic Excursion Peak-to-peak displacement normally > 2.0 cm

46 RV contractility Subjective: PLAX, PSAX, A4C, SC

47 RV wall thickness SC, A4C, PLAX Obtain still frame - measure diastolic thickness > 5 mm abnormal

48 Elevated RV pressure Dilated RA and RV Hyperdynamic RV Paradoxical septal motion PSAX and A4C Systolic flattening - pressure overload Diastolic flattening - volume overload Fixed flattening - D shaped LV: both

49 Valvular abnormalities Tricuspid valve (PSAX, A4C, SC): movement an thickness of cusps - abnormal masses Tricuspid valve prolaps Tricuspid valve endocarditis

50 Intracardiac masses Right atrial myxoma Right ventricular thrombus

51 RA size A4C and SC Subjective - high error rate Objective - A4C: AP and XS dimensions, area RA compression by hematoma

52 Pericardial assessment Pericardium Pericardial space Right atrium Right ventricle Inferior vena cava

53 Thickening Calcification Pericardium PLAX, PSAX, A4C Posterior pericardial calcification

54 Pericardial space Pericardial effusion - PLAX Minimal Small 5 mm Moderate/ Severe 5-10 mm Large swinging heart Exclude fat pad and pleural effusion

55 Tamponade Right atrium Early systolic collapse Right ventricle Early diastolic collapse Right ventricle Early diastolic collapse With tamponade IVC is dilated and/or fixed

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57 Preload assessment Inferior vena cava Right atrium Right ventricle Left ventricle Coronary sinus

58 Inferior vena cava Subcostal - IVC view Measure diameter either with 2-D or M- mode within 2 cm from the IVC-RA junction - with M-mode make sniff manoeuvre

59 Estimation of RAP In spontaneously breathing patients IVC size at RA-IVC J/C Respiratory change RAP (mm Hg) Small (< 1.5 cm) Decrease > 50% or Collapse 0-5 mm Hg Normal ( cm) Decrease > 50% 5-10 mm Hg Normal ( cm) Decrease < 50% mm Hg Dilated (> 2.3 cm) Decrease < 50% mm Hg Dilated (> 2.3 cm) No change > 20 mm Hg

60 IVC at RA junction

61 Right atrium A4C Enlarged RA + leftward septal bowing points to elevated RAP

62 Right ventricle PSAX and A4C Diameter (A4C) - see RV size IV septum (PSAX) - shape and paradoxical motion

63 Left ventricle PLAX - PSAX - A4C Wall kissing unless significant LV hypertrophy

64 Coronary sinus PLAX If dilated consider RAP elevation, PH or persistent left superior vena cava

65 Other pathologies Type A aortic dissection

66 At the end... What is left heart function like? What is right heart function like? Is there a hemodynamically important pericardial effusion? Is significant hypovolemia present? Are there other relevant findings?