Parasternal- clockwise 90° rotation.

Apical- counterclockwise 90° rotation.

Posterior leaftlet of mitral valve- smaller and less mobilized, away from septum.

Mitral valve (anatomy), A1-A3, named from left to right, in US pic, opposite.

Leafleat near the center is the thickest, thinner at commissure.

Mitral stenosis- rarest

Rheumatic fever- affects aortic valve too; calcification (annulus/valve)

Increased pressure in LA AFib more stasis systemic embolism

LVLA- N: 1mmHg

Death usually due to 1) HF; pulmonary edema 2) Systemic embolism 3) Pulmonary embolism

Can lead to atrium enlargement, pulmonary hypertension, pulmonary edema, right ventricle
enlargement, right atrium enlargement/ tricuspid regurgitation

MVArea opening – N: 3cm² Severe stenosis/hemodynamically important: <1.5cm² Really very

severe: <1.0cm²

LA- measure area (more precise), diameter of atrium

IVC- close during inspiration, open during expiration ; if constantly closed, increased CVP

Treatment:

1) Percutaneous valvuloplasty of mitral valve (in patients without severe calcification)

2) Replace valve
3) Pharmacological treatment

Mitral regurgitation – 2nd most common damaged mitral annulus; short/lengthened chordae

Etiology:

1) Organic (anatomical problem)

 Degenerative
 Rheumatic fever- floppy, not elastic, stone hitting stone
 Infective endocarditis
 After radiotherapy
 Congenital- 3 leaflets
2) Functional (myocardial muscle dysfuntion)
 MI- displacement of papillary muscle, pull on post. leaftlet, makes it doesn’t move at all
 Dilated cardiomyopathy (tenting, increased area, increased regurgitation)

Primary problem- just repair the valve

Secondary problem- problem with heart, no problem with valve

* Left ventricle pumps a lot more blood than the one in mitral stenosis (volume overload)

Diagnostic tests:

 Colour jet map- only can tell severity, not volume

 Vena contracta- measure narrowest part of mitral valve during closing
 PISA- amount of blood flowing through the hemisphere, bigger hemisphere, higher
volume rate ; on the ventricular side, measure radius of sphere, at the end, get efficient
regurgitant orifice area (EROA) >40ml- severe

Repairing of valve: Lifelong warfarin treatment +suboptimal functioning

Aortic stenosis- Most common

LV&Aorta- N: <5 mmHg Severe: >40

Valve area- N: 3.0-4.0cm² Severe: <1.0cm²

Etiologies:

1) Calcification of valve/degeneration- due to aging, high BP, high blood cholesterol

2) Rheumatic fever ( calcification and fusion of commisure)
3) Bicuspid- fish valve (congenital)

Clinical manifestations:

 HF ECG left axis deviation

 Angina
 Syncope

Natural history: remain latent for several years until acute onset of symptoms; treatment need
to be started as soon as possible when there are symptoms

Diagnostic test:

 Measure pressure gradient

 Planimetry- during systolic phase, measure the area of opening valve
 AreaLVOT X VolumeLVOT = AreaAortic valve X Volume Aortic valve

Grading is based on:

 Aortic jet velocity

 Mean gradient
 Valve area

Treatments:

Mechanical valve Biological valve

3-300 years of life span 15 years
Patients <50 years old Patients >50/60 years old
Warfarin treatment is needed No warfarin treatment is needed

BAV (Balloon aortic valvuloplasty) – palliative treatment

Bridge to:

 Decision for surgery later

 TAVI- indication: high risk of doing surgery Transfemoral (85%), Transapical, Transaortic
 AVR (aortic valve replacement)

Aortic regurgitation- 3rd most common

Etiologies:

1. Degenerative disease
2. Bicuspid valve
3. Connective tissue disease (Marfan syndrome)- dilated ascending aorta/aortic root
4. Aortic dissection- by four mechanisms: dilation of the sinuses with incomplete
coaptation of the leaflets at the center of the valve; involvement of a valve commissure
resulting in inadequate leaflet support; direct extension of the dissection into the base
of a leaflet, resulting in a flail valve leaflet; and prolapse of the dissection flap across the
aortic valve into the left ventricular outflow tract in diastole impeding leaflet closure.
Patients with a bicuspid aortic valve are at higher risk of aortic dissection.
5. Infective endocarditis – infection of aortic valve cusp (eaten??)
6. Rheumatic fever

Clinical manifestations:

 HF
 Syncope
 Palpitations
 Angina

PHT(pressure half time)- severe <200ms Mild >500ms

Diastolic reversal

Aortic replacement valve

Lipid rich plaque- more prone to rupture, more inflammation thrombus formation risk of
stroke

Differentiate ICA from ECA:

 ICA is usually wider

 ICA lies external to ECA
 Different spectrum pattern ECA- wide resistance index, great difference in systolic and
diastolic pressure, dicrotic notch (could be in ICA too)
 ECA has side branches
 Tapping on temporal artery is visible on ECA pattern

X collateral flow- distal protection (filters) ; If there is, can choose distal/proximal protection
based on the characteristics of plaque ( fibrous/calcified/lipid-rich)

Proximal protection is better than distal protection in preventing ischemic stroke and also
decrease incidence of clinically silent event.

Normal direction of flow:

 MCA towards probe

 ACA away from probe; if stenosis on either side, flow of ipsilateral ACA is towards the
probe

www.echo.mp.pl
Emergency ultrasound/ First contact ultrasound- Use linear/ curved probe

Top 10 reasons for admission to emergency unit:

1. Chest pain
2. Dyspnea
3. Abdominal pain
4. Headache
5. Vomiting
6. Fracture/ sprain
7. Syncope
8. Motor vehicle accident
9. Fever
10. Cough

US lungs:

 Pneumothorax
 Pleural effusion
 Interstitial-alveolar syndrome – look for B lines

A lines: reverberation of pleural line. Is normal means full of air

Seashore sign- Sea (skeletal muscles); Shore (moving of underneath pleural line)

FAST ultrasound: check indication for surgery!! Cannot be greater than 5 minutes.

 Hepatorenal (Morrison’s pouch)

 Splenorenal
 Pericardium (subcostal view)
 Pelvis: rectovesical pouch (male) ; Douglas pouch (female)

Complications of ACS:

 VSD cleft
 Acute mitral regurgitation (infarction of papillary muscle)
 Rupture of ventricular wall

FATE views- check for contractility, pleural fluid, pericardium, valve, aneurysm of aorta

 Subcostal 4-chamber
 Apical 4-chamber
 Parasternal long axis
 Parasternal short axis (papillary muscle level)
 Pleural scanning

Differential diagnosis of patients present with chest pain and dyspnea

Acute aortic syndrome (aortic dissection)

Typical sites: aortic bulb approximately 2cm from aortic valve (60%), aortic arch (15%),
descending aorta distally to left subclavian artery (25%)

Consequences: Dilated ascending aorta, aortic regurgitation

Check using TTE immediately whenever there is suspicion of it!!

TEE

 Aortic valve morphology, function; other valves as well

 LV function
 Cardiac tamponade

Acute PE

CT angiography is the first choice of method!! If no, use echocardiography RV overload.

(enlarged).

 RV/LV >1
 Flattened interventricular septum (IVS) – D sign
 Mc connell’s sign- hypokinetic of mid-free wall but hyperkinetic of apical segment
 60/60 sign RVSP< 60mmHg ACT (activated clotting time)<60ms

Chronic Heart Failure – Give diuretics and inotropes

 Increased urination at night, abdominal pain with no appetite.

 Impaired LV function
 Functional tricuspid/mitral regurgitation
 Abnormal LV geometry (more round) long axis=short axis
 Pericardical effusion (small, no features of pericardial tamponade)
 Pleural effusion, peritoneal effusion
 Secondary pulmonary hypertension- IVC constantly being opened
 Lung US B lines (borderline of fluid-filled interlobular septa with normal aerated lung
tissues)

A lines and B lines do no coexist!!

A lines- same distance between each other, parallel to pleural line

B lines- perpendicular to pleural line

Pericardial tamponade- is based on clinically reasoning

 Separated pericardial lamina

 RV collapse in systole
 Compressed RV cavity
 Collapse of RA, LA and LV

Puncture has to be performed as soon as possible, exception if is due to aortic dissection. Can’t
puncture tamponade, can drain the patient through that.

Dilated IVC (>2.1cm), vena cava plethora (no respiratory variation), one inspiration, should
collapse more than 50%

Pleural effusion- sensitivity and specificity of US is higher than chest X-ray

 Hypoechoic (water); hyperechoic (blood/hematoma) in pleural cavity

 Differentiate pericardial tamponade from left pleural effusion LOOK at parasternal long
axis view of the descending aorta, if at the same level of it, it is pericardial tamponade.

Pneumothorax

 A profile
 No pleural sliding
 Presence of lung point (parts of lungs are moving, parts are not)
 Stratosphere/ bar-code sign

Shockable rhythm- VF & pulseless VT

Non-shockable rhythm- PEA & Asystole

Echocardiography can detect 4 correctable causes of cardiac arrest, namely hypovolemia,

pericardial tamponade, tension pneumothorax and thromboembolism.

In PEA/Asystole, start CPR 30:2, give adrenaline 1mg via venous acess. After 2 mins of CPR,
recheck the rhythm. At this moment, you only have 10s to examine using echo ( a sub-xiphoid
probe position) is recommended.

www.cricticalusg.pl

sonocloud; sonokids; sonogeeks

lifeinfastlane.com
free open access education

THE EMC MD; youtube video: EMC R Heart strain

Infective endocarditis- Duke’s criteria

Echo should be performed as soon as IE is suspected. Exception if there is high level of S.aureus
in bloodstream.

On echo:

 Vegetation
 Abscess
 New dehiscence of prosthetic valve (perivalvular leakage)

TTE- first line screening test!!

TEE must be repeated 7-10 days later after the first negative test if clinical suspicion is still very
high.

Consequences:

 LV dimensions and function

 Valvular regurgitation/stenosis; Aortic regurgitation
 RV function, pulmonary artery pressure
 Pericardial effusion

ASD primum is associated with mitral regurgitation

Bicuspid valve of aortic valve is associated with dilated ascending aorta, embryological point of
view

Pericardial temponade pulsus paradoxus and non-collapsed IVC.

As is usual with inspiration, the heart rate is slightly increased, due to decreased left ventricular
output.
Ascending aorta- N: <3.4cm ; 3cm at arch, 2.5cm at descending aorta

Aortic root: N: <3.7cm

Pulmonary artery: <2.4

Right aortic cusp is the most ant; left is near to pulmonary artery; non-coronary cusp is near to
interatrial septum.

Continuous Doppler is used to assess flow inside ventricle, assess max/mean velocity + pressure
gradient. Pulsed Doppler normally used in vascular ultrasound.

Pressure gradient= 4 X squared peak velocity

PA systolic pressure- TR Vmax + RA pressure

PA diastolic pressure- velocity at the end of pulmonary regurgitation jet + RA pressure