Apical Window
A selection of echo clips of the heart in the apical window are shown below. Can you describe what you see? Is there any pathology present? Or is the clip normal?
Clip 1
A 56 year old lady on chemotherapy for Ca Breast is admitted the the ICU with hypotension. Her BP is 85/52mmHg. A FoCUS study is performed. The apical 4 chamber view is shown. What is the seen, and what would you do next?
The apical 4 chamber vuew shows a large circumferentail pericardial effusion. The heart is swinging. The diagnosis in this setting is pericardial tamponade, which will require drainage. What other echo signs may be seen in tamponade? What would you expect the respiratory variability of the mitral and tricuspid inflow to be?
Clip 2
This patient is 2 days post op following a TKR. He complains of breathlessness and is hypotensive. His BP improves to 110/75 with phenyepherine. The apical 4 chamber view is shown. Describe your findings.
The RV is significantly dilated, being larger that the LV. The basal RV:LV ratio is >1.0. The RV free wall is akinetic with preserved apical contractility. The interventricular septum is flatenned. The LV is small in volume. These findings are called McConnell's sign. The features seen are consistent with acute cor pulmonale. Pulmonary embolism is a possible cause. What other echo features may be seen in acute pulmonary embolism? The patient is hemodynamically stable at present. What is your management?
Clip 3
This 85 year old man is seen in the preop assessment clinic. He is going for a laparoscopic right hemicolectomy. He is quite frail and has limited mobility. A FoCUS study is performed to evaluate LV systolic function. What are your findings?
This apical 4 chamber view is abnormal. Both the LA and RA are severely dilated, being larger than the ventricles. There is moderate the so severe LV systolic failure. The LV septal wall is dyskinetic. The RV systolic function is also impaired. The mitral valve leaflets are calcified but appear to open in this view. Further views should be obtained. What is the coronary blood supply to the anterior and septal LV walls?
Clip 4
An apical 5 chamber view is shown. A pulse wave doppler velocity time integral (VTI) of the LVOT is obtained. What do these findings indicate about LV systolic function?
The apical 5 chamber view shows an LV that contracts well. LV systolic function appears normal in this view. This is confirmed by the LVOT VTI of 22.6cm. A normal LVOT VTI is usually between 18-22cm. Other echo findings include calcified aortic valve leaflets that appear to open well. How do you determine stroke volume and cardiac output?
Clip 5
A 48 year old man complains of chest pain in the PACU. He has just undergone a laparoscopic cholecystectomy. You perform a FoCUS scan. What are your findings and what could be the diagnosis?
The apical 4 chamber view shows the presence of significant RWMAs involving the septal and apical walls. This is consistent with myocardial ischaemia/infarction involving the LAD territory. What would you do next?
