1. Turandot Saul, M.D., RDMS St. Luke’s Roosevelt Hospital New York, NY

2. Cardiac Windows

3.  Subxiphoid  Parasternal long axis  Parasternal short axis  Apical 4 chamber

4. Ultrasound probe Low Frequency Curved Array

5. Subxiphoid  Under costal margin  Marker to patient’s right  Shallow angle (15°)  Liver as acoustic window  Bend knees  Deep inspiration  FAST exam

6. Parasternal Long Axis  Marker to left hip  4 th intercostal space  Left sternal boarder

7. Parasternal Short Axis  Marker to right hip  4 th intercostal space  Left sternal boarder

8. Apical 4 Chamber  Left lateral decubitus  PMI  Marker to right hip  Aim towards right shoulder

9. Yes / No Questions

10. Wall Motion? Yes or no?  B -mode

11. Wall Motion?  M –mode  More accurate

12. Wall Motion Using M-mode Ventricular Contractions Asystole

13. Yes / No Question

14. CC: Shortness of Breath

15. Emergency Echo

16. Pericardial Effusion  Fluid lays dependently  Adjust depth to fit on screen  Image in 2 views

17. Cardiac Function

18. Systole

19. Left Ventricular Function  Fills at low enough pressures to not cause pulmonary congestion  Deliver enough blood to periphery at high enough pressure to perfuse tissues No one quantity measures these assessments of performance Ejection fraction

20. Ultrasound for LV Function Strengths  Can assess morphology  Cheap  No radiation  Portable  Readily available

21. Ultrasound for LV Function Limitations  Finding an acoustic window - narrow inter-costal spaces - all regions of LV not visualized in all patients - obesity - intervening lung tissue in pt with COPD - musculoskeletal deformities

22. Ejection Fraction Qualitative - visual inspection - severity: mild, moderate, severe - focality - global: reported in intervals of 5- 10% - regional: 17 segments

23. Global Function Normal Cardiomyopathy

24. Global Function Normal Cardiomyopathy

25. 17 Cardiac Segments

26. CC: Chest Pain

27. Inferior Wall - PSLA

28. Inferior Wall - PSSA

29. CC: Chest Pain

30. Anterior Wall - PSLA

31. Anterior Wall - PSSA

32. CC: SOB 3 weeks later

33. Emergency Echo

34. Ejection Fraction Quantitative - accuracy, reproducibility limited - assumes symmetric shape of LV cavity

35. Simpson’s Rule – the biplane method of disks  Volume left ventricle - trace in systole and diastole - divide area into disks LV-ED LV-ES Σ volume of each disk ( πr 2 * h ) = ventricular volume

36. Simpson’s Rule – the biplane method of disks  EF is calculated : LV diastolic volume - LV systolic volume x 100% LV diastolic volume  Edge detection software Normal > 50% 35 - 50% moderately depressed <35% severely depressed

37. Superiority of Visual Versus Computerized Echo Estimation of Radionuclide LVEF - Amico, A. American Heart Journal, 1989  Blinded study, 44 patients  Gold Standard - equilibrium radionuclide angiography (ERNA)  7 different echocardiographic methods  Best correlation - subjective estimation by experienced cardiologist

38. Accuracy of Emergency Physician Assessment of Left Ventricular Ejection Fraction – Randazzo, M. Academic Emergency Medicine, 2003  Cross-sectional observational study, convenience sample  115 patients  Three-hour training session  LVEF poor, moderate, or normal  Formal echo within four hours interpreted by cardiologist  LVEF correlation 86.1% overall agreement  Highest (91%) in normal LVEF category, 70.4% poor LVEF, 47.8% moderate LVEF

39. Clinical utility  Patients with active chest pain - regional wall motion abnormality - high sensitivity for ischemia or infarction - moderately specific  Prognostic information short and long term

40. Limitations  Operator dependence - inter/intra observer variability is 10-30%  Limited utility - MR high EF but little forward flow - AS low EF but possibly reversible

41. Diastole

42. CC: SOB, long hx of HTN

43. Emergency Echo

44. Diastolic Dysfunction  Impaired diastolic relaxation  LV wall thickness usually increased  Increase LA size

45. Other Pathology

46. CC: SOB, transatlantic flight

47. Emergency Echo

48. Right Ventricle  Increased pulmonary vascular resistance - right ventricular dilation  Limited accuracy in the diagnosis of PE  Trans-esophageal echocardiography: sensitivity for central PE 82%

49. CC: Fever / chills

50. CC: 20 yo with Syncope

51. CC: Progessive SOB, Syncope

52. Reources  UptoDate: Noninvasive methods for measurement of left ventricular systolic function  Zipes: Braunwald’s Heart Disease: A Textbook of Cardiovascular Diseases. Elsevier Inc, 2007.  Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients. American Journal of Emergency Medicine - Volume 25, Issue 8 (October 2007) - Copyright © 2007 W. B. Saunders Company  Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Randazzo MR - Acad Emerg Med - 01-SEP-2003; 10(9): 973-7  Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Moore CL - Acad Emerg Med - 01-MAR-2002; 9(3): 186-93  Subjective visual echocardiographic estimate of left ventricular ejection fraction as an alternative to conventional echocardiographic methods: comparison with contrast angiography. Mueller X - Clin Cardiol - 01-NOV-1991; 14(11): 898-902  Superiority of visual versus computerized echocardiographic estimation of radionuclide left ventricular ejection fraction. Amico AF - Am Heart J - 01-DEC-1989; 118(6): 1259-65  The Yale Atlas of Echocardiography http://www.med.yale.edu/intmed/cardio/echo_atlas/contents/index.html