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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5769_Библиотеки_им_академика_М_И_Перельмана
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310 oracic ultrasound
. S (F. ) (C ).
Figure 8 – Subcostal scan: short axis mitral valve.
Clip 3 – Subcostal short axis mitral valve scan.
LIVER
MITRAL VALVE
. S (F. ) (C ).
Figure 9 – Subcostal scan: short axis papillary muscles.
Clip 4 – Subcostal scan: short axis papillary muscles.
PAPILLARY MUSCLES
Echocardiography 311
. S (F. ) (C ).
APEX
Figure 10 – Subcostal scan: short axis apex.
Clip 5 – Subcostal scan: short axis apex.
Figure 11 summarizes the 5 scans examined.
Figure 11 – Subcostal scan: short axis caval veins-apex.
312 oracic ultrasound
Orientation along the 4 chambers axis
e probe is rotated about 90° clockwise compared to the scan aligned along the cava veins.
. S (F. ) (C ).
RIGHT ATRIUM
LIVER
RIGHT VENTRICLE
LEFT ATRIUM
LEFT VENTRICLE
Figure 12 – Subcostal scan: 4 chambers.
Clip 6 – Subcostal scan: 4 chambers.
Apical scans
is approach provides for the acquisition of images scanning the heart from its apex to the
base, generating two, four and five chambers views (the “fifth” chamber is the aortic outflow
tract with the aortic valve and the visible ascending aorta).
Orientation along the 4 chambers and 5 chambers axis
Starting from the apical 4 chambers scan, the transducer is tilted slightly upward, to get the
display of the outflow tract of the left ventricle and aortic valve.
. A (F. ) (C ).
RIGHT VENTRICLE
RIGHT ATRIUM
Figure 13 – Apical scan 4 chambers.
LEFT VENTRICLE
LEFT ATRIUM
Echocardiography 313
Clip 7 – Apical scan 4 chambers.
. A (F. ) (C ).
OUTFLOW OF THE LEFT VENTRICLE
AORTIC VALVE
Figure 14 – Apical scan 5 chambers.
Clip 8 – Apical scan 5 chambers.
Figure 15 summarizes the two scans examined.
Figure 15 – Apical scan 4 and 5 chambers.
314 oracic ultrasound
Orientation along the long axis (two chamber view)
Starting from the apical 4 chambers scan, the probe is rotated 90° clockwise.
. A (F. ) (C ).
LEFT VENTRICLE
LEFT ATRIUM
AORTIC VALVE
Figure 16 – Apical scan 2 chambers.
Clip 9 – Apical scan 2 chambers.
Parasternal scans
e parasternal scans are acquired along the long and short axis of the heart.
Orientation along the long axis
. L (F. ) (C ).
LEFT VENTRICLE
LEFT ATRIUM
RIGHT VENTRICLE
Figure 17 – Parasternal long axis scan.
Echocardiography 315
Clip 10 – Parasternal long axis scan.
From the parasternal long axis, short axis scans are obtained by rotating the transducer about
90° clockwise and tilting the probe from the base toward the apex of the heart (aortic plane,
mitral valve, papillary muscles and apical views).
Orientation along the short axis
. P (F. ) (C ).
OUTFLOW OF THE RIGHT VENTRICLE
RIGHT ATRIUM
PULMONARY
LEFT ATRIUM
Figure 18 – Parasternal short axis aorta scan.
Clip 11 – Parasternal short axis aorta scan.
. P (F. ) (C ).
RIGHT VENTRICLE
Figure 19 – Parasternal short axis mitral valve scan.
Clip 12 – Parasternal short axis mitral valve scan.
MITRAL
316 oracic ultrasound
. P (F. ).
PAPILLARY MUSCLES
Figure 20 – Parasternal short axis papillary muscles scan.
. P (F. ).
CARDIAC APEX
Figure 21 – Parasternal short axis apex scan.
Figure 22 summarizes the parasternal scans short axis from the base to the apex of the heart.
Figure 22 – Parasternal short axis scans from the base to the apex of the heart.
Echocardiography 317
Suprasternal scan
e probe is placed in the suprasternal fossa and oriented anteriorly and to the left. is
approach is not always possible in all subjects and it is aimed at the study of the ascending
portion, arch and descending portion of the thoracic aorta (Fig. 23) (Clip 13).
AORTIC ARCH
Figure 23 – Suprasternal scan.
Clip 13 – Suprasternal scan.
SUBCLAVIAN A.
RIGHT BRANCH
PULMONARY ARTERY
➣ Principles
A basic, qualitative or semiquantitative goal-directed echocardiography can help the physician in the resolution of different critical cases (cardiac arrest, shock or hypotension, dyspnea,
chest pain, syncope, arrhythmia, abnormal findings on physical examination)6.
e acquisition of accurate information,
guided by the clinical scenario, yields
valuable output even in the absence of experience and knowledge typical of skilled
cardiologists.
is synthetic approach has been named
Focused Cardiac Ultrasound (FCU)
(International Liaison Committee on
Focused Cardiac Ultrasound, 2014)39. FCU
entails the features illustrated in Table 1.
Focused Cardiac Ultrasound is clinically
integrated and is useful to narrow the differential diagnosis in a critical care setting. Its fundamental role in the cardiovascular and respiratory patient is to complement the physical
examination.
Table 2 summarizes the conditions for which echocardiography is highly appropriate in the
acute setting, according to the appropriateness criteria of a group of scientific societies.
Table 1 – Features of Focused Cardiac Ultrasound
• Problemoriented
• Goaldirected
• Limitedinscope
• Simplied
• Repeatable
• Performedatpointofcare
• Qualitative/Semiquantitative
• Performedbyclinicians
318 oracic ultrasound
Table 2 – Appropriateness criteria for performing echocardiagraphy in the acute setting
• Evaluationofhypothensionorhaemodynamicinstabilityofuncertainorsuspectedcardiacetiology.
• Evaluationofacutechestpainwithsuspectedmyocardialischemiainpatientswithnon
diagnosticlaboratorymarkersandECGandinwhomarestingechocardiogramcanbe
performedduringpain.
• Evaluationofsuspectedcomplicationofmyocardialischemia/infarctionincludingbutnotlimited
toacutemitralregurgitation,hypoxemia,abnormalchestx-ray,ventricularseptaldefect,free
wallrupture,tamponade,shock,rightventricularinvolvement,heartfailureorthrombus.
• Evaluationofrespiratoryfailurewithsuspectedcardiacaetiology.
• Evaluationofpatientwithknownorsuspectedacutepulmonaryembolismtoguidetherapy
(throbolyticsandthrombectomy).
Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Brindis RG, Patel MR
SCAI, SCCT, SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography.
J Am Med Coll Cardiol 2007;50:187-204.
et al.
ACCF, ASE, ACEP, ASNC,
e conditions summarized in Table 2 are serious, often life threatening, and their initial
presentation may require an instrumental differential diagnosis. Recently, the European
Association of Cardiovascular Imaging38 provided recommendations for the safe and efficient
use of echocardiography in patients presenting with cardiovascular emergency. In this document, the term “emergency echocardiography” refers to the use of echocardiography in the
assessment of patients with unstable cardiovascular diseases. erefore, emergency echocardiography is a comprehensive echocardiographic study, which should be distinguished from
the Focused Cardiac Ultrasound, generally employed as part of the clinical examination.
Anyway, these recommendations should not be intended to limit the physician (cardiologist
or non cardiologist), who is encouraged to use echocardiography in emergency according to
existing guidelines and recommendations
3,38,40
, to his or her clinical thinking, and in all the
situations that he or she believes to be advantageous for the patient.
In order to reduce diagnostic errors during the echocardiographic evaluation, Neskovic et al. pro-
posed the ABCD approach, summarizing the clinical thinking and the practical steps that should
be followed in order to perform the best sonographic approach to the critically ill patient (Tab. 3).
Table 3 – ABCD approach in performing emergency echocardiography
A
Awareness
B
Besuspicious
C
Comprehensiveness
DoubleR(Recordand
D
Review)
Neskovic AN, Hagendorff A, Echocardiography in the Emergency Room. In: Galiuto L, Badano L, Fox
K, Sicari R, Zamorano JL, eds. The EAE Textbook of Echocardiography, Oxford University Press, 2011,
pages 431-436.
• Fightagainstroutine
• Thinkbeyondapparentexplanations
• Referraldiagnosismaybemisleading
• Nevertrust,conrm
• Performanexaminationascompleteassuitable
• Carefulinterpretation
• Thestudyshouldberecordedandreviewed
• Teamworkiscrucial
Tables 4 and 5 summarize some normal values of measurements in M-Mode, 2D and Doppler.
Echocardiography 319
Table 4 – Normal values of some cardiac measurements in 2D, M-mode and Doppler
Measurement Average (range)
Parasternal long axis (cm)
Leftventricle(diast.)
Leftventricle(syst.)
Rightventricle
Leftatrium(area)
Aorta
Parasternal short axis (cm)
Aorta
Rightventricularoutowtract
Rightatrium
Leftatrium
Leftatrium(area)
Leftventricle(diast.)(papillarylev.)
Leftventricle(syst.)(papillarylev.)
Apical 4 chambers (cm)
Leftventricle
• diastolegreaterdimension.
• diastolesmallerdimension.
• systolesmallerdimension.
Rightventricle
• greaterdimension.
• smallerdimension.
Leftatriumgreaterdimension.
Leftatriumsmallerdimension.
Rightatrium(area)
Apical 2 chambers (cm)
Arealeftventricle(diast.)
Arealeftventricle(syst.)
Suprasternal (cm)
Aorticarch (20-36mm)
M-Mode (mm)
Interventricularseptumthickness
Posteriorwallthicknessdiast.
Posteriorwallthicknesssyst.
Rightventricularfreewallthickness
Doppler (m/sec)
Tricuspidow
Pulmonaryow
Mitralow
Aortaow
4.8(3.9-5.9)
3.1(2.1-4)
2.8(1.9-3.8)
13.8cm2(9-19.3cm2)
2.9(2.2-3.6)
(2.3-3.7)
2.7(1.9-2.7)
(1.5-2.5)
3.6(2.6-4.5)
10.8cm2(7.2-13cm2)
4.7(3.5-5.8)
3.1(2.2-4)
8.6(6.9-10.3)
4.7(3.3-6.1)
2.8(1.9-3.7)
8(6.5-9.5)
3.5(2.2-4.4)
4.3(3.5-5,5)
3.7(2.5-4-9)
14cm2(11.3-16.7cm2)
35.6(19.4-48)
14.3(8.9-27)
9(7-12)
9(7-12)
16(13-20)
(2-5)
(0.3-0.7)
(0.6-0.9)
(0.6-1.3)
(1-1.7)
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