Parasternal Short Axis View (PSAX) Transducer position: left sternal edge; 2 nd – 4 th intercostal space Marker dot direction: points towards left shoulder(90 0 clockwise from PLAX view) By tilting transducer on an axis between the left hip and right shoulder, short axis views are obtained at different levels, from the aorta to the LV apex. Many structures seen

Papillary Muscle (PM)level PSAX at the level of the papillary muscles showing how the respective LV segments are identified, usually for the purposes of describing abnormal LV wall motion LV wall thickness can also be assessed

Apical 4-Chamber View (AP4CH) Transducer position: apex of heart Marker dot direction: points towards left shoulder The AP5CH view is obtained from this view by slight anterior angulation of the transducer towards the chest wall. The LVOT can then be visualised

Apical 2-Chamber View (AP2CH) Transducer position: apex of the heart Marker dot direction: points towards left side of neck (45 0 anticlockwise from AP4CH view) Good for assessment of LV anterior wall LV inferior wall

Sub–Costal 4 Chamber View(SC4CH) Transducer position: under the xiphisternum Marker dot position: points towards left shoulder The subject lies supine with head slightly low (no pillow). With feet on the bed, the knees are slightly elevated Better images are obtained with the abdomen relaxed and during inspiration Interatrial septum, pericardial effusion, desc abdominal aorta

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Normal Hypovolemia Vasodilatation Systolic failure Diastolic failure Systolic and diastolic failure RV failure Hemodynamic states

75yr male for hip surgery Starting BP 140/90 down to 85/50 after 10 mins of anesthesia HR unaltered lil bit improvement with aramine fall back to 80/50 CVL inserted RA pressures 17 mm hg PA Catheter: CI 1.8l/min/m2 & PCWP of 18 What next????????? TTE Case discussion?

Estimate volume Estimate systolic function Estimate filling pressures Final assessment (Put all together) Hemodynamic assessment

Estimate LV end diastolic vol ( preload) M mode; Simpsons biplane etc Estimate LV systolic function Eye balling; FS; FAC; EF RV systolic function mostly qualitative Estimate LA pressures: Intra atrial septum; LA size; surrogate from RA pressures Estimate RA pressures : IVC

Normal : LVEDA; EF & LAP normal Hypovolemia : LVEDA & LAP  ; EF = or  Diastolic failure : LVEDA  ; LAP  ; EF = Systolic failure : LVEDA  ; LAP =; EF  Systolic & diastolic: LVEDA & LAP  ; EF  RV failure : RV vol  ; LAP  Vasodilatation : LVEDA & LAP =; EF  Final Assessment

Normal Echo Dimensions LV Diastolic Dimension: cm LV Systolic Dimension: cm Interventricular septum* (Diastole): cm LV Posterior Wall* (Diastole): cm LVOT diameter (Systole): cm Aortic Root** (Diastole): cm Left Atrium (Systole): cm Left Atrial Area (4 chamber): <20cm2 Left Atrial Volume/m2 BSA: ml RV Diastolic Dimension: cm

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