Parasternal Long Axis
A selection of echo clips of the heart in the parasternal long axis view are shown below. Can you describe what you see? Is there any pathology present? Or is the clip normal?
Clip 1
A 45 year old man is brought to the emergency department after being stabbed in the chest with a screwdriver. He is hypotensive, tachycardic and appears pale and sweaty. A puncture wound is noticed in the 4th intercostal space. What do you see on echo?
This is a prasternal long axis view. There is a large circumferential pericardial effusion present. The heart is swinging. There is also a large left sided pleural effusion present. This is seen as the anechoic area in the farfield of the display. In this case, the pericardium is clearly seen to separate the pleural and pericardial effusion. The descending thoracic aorta is a useful landmark to differentiate the two. Pleural effusions will extend posteriorly beyond the descending thoracic aorta. On the other hand, pericardial effusions are always anterior to the descending aorta. In this scenario, the diagnosis in cardiac tamponade & pleural effusion. What other echo signs might you see in this case that are also highly specific for tamponade?
Clip 2
A 76 year old lady presents with vague central chest pain which has been increasing in frequency over the past few months. It is not related to activity and occurs at rest as well. She is hemodynamically stable. What do you see on echo?
This is a prasternal long axis view. The descending thoracic aorta is aneurysmal, measuring approximately 3-4cm in diameter. There does not appear to be a dissection flap, but further views are required . Left ventricular systolic function is normal and there is no significant pericardial or pleural effusion. The proximal ascending aorta and aortic valve are not clearly seen. The mitral valve leaflets open well. The diagnosis is aneurysm of the descending thoracic aorta. Further imaging should be obtained to rule in or out a dissection. What is the gold standard investigation to diagnose acute aortic syndrome?
Clip 3
A 58 year old man with chronic obstructive lung disease present is admitted to ICU with hypoxia, shortness of breath and hypotension. His CXR shows right lowe lobe consolidation and he is started on antibiotics for a community acquired pneumonia. You are concerned about his hypotension and perform a FoCUS scan. What is the visually estimated EF?
The left ventricle is poorly contracting. There is little change between the end diastolic and end systolic LV area. The LV walls do not thicken much in systole and there is hardly any wall excursion into the cavity. The anterior leaflet of the mitral valve is quite a distance away from the LV septal wall, consistent with severe LV systolic failure. The RVOT appears dilated, but should be further evaluated in other views. Qualitative eyeballing indicates that this patient has severe LV systolic failure. What quantitative methods can be used to determine LV systolic function?
Clip 4
These echo clips are obtained in a patient at the anaesthesia preoperative evaluation clinic. The patient is an 80year old man awaiting repair of his inguinal hernia. What is seen?
There is multiple pathology present here. Moderate to severe LV systolic failure is present. The is obvious calcification and leaflet thickening of the aortic valve. The aortic valve leaflets do not open well and appear to not coapt properly too. Colour doppler shows aortic regurgitation and mitral regurgitation. A consultative echo should be obtained to quantify to severity of LV dysfunction and valvular disease. How can the severity of aortic stenosis be determined by echocardiography?
Clip 5
A 76 year old lady presents for ORIF of a fractured neck of femur. She has a history of dementia and you are unable to determine her functional capacity. A FoCUS study is performed in the preop holding area. What are your findings?
This is a normal PLAX view. LV systolic function is normal and the mitral & aortic valves appear to open and coapt normally. There is no pericardial or pleural effusion present. Would you proceed with the case?
