Cardiac Ultrasound Views Transthoracic Echocardiography TTE Protocol Tutorial Featured Image

Cardiac Ultrasound (Echocardiography) Made Easy: Step-By-Step Guide

Primary Authors: Victor Lee, Vi Dinh; Co-authors: Jessica Ahn, Jade Deschamps, Satchel Genobaga, Annalise Lang, Devin Tooma, Seth White, Reed Krause. Oversight, Review, and Final Edits by Vi Dinh (POCUS 101 Editor).

A bedside Cardiac Ultrasound or Echocardiogram is a quick Point of Care Ultrasound (POCUS) that allows you to visualize and evaluate how the heart is functioning. In addition, bedside echocardiography also allows you to evaluate hemodynamic changes and pathological heart diseases.

The Cardiac Ultrasound Procedure is also known as: Echocardiography, Echocardiogram, or even just “Echo.” They all refer to the same thing.

In addition, you may see cardiac ultrasound referred to as “Transthoracic” or Transesophageal” echocardiography. Transthoracic Echocardiography (TTE) is when a cardiac ultrasound is performed on the patient’s chest. TTE is the most common cardiac ultrasound application and is non-invasive. TTE is what we will be covering in this post. Transesophageal Echocardiography (TEE) is a more specialized cardiac ultrasound with a special probe that is inserted into the patient’s esophagus. TEE requires sedation and is considered more invasive than TTE.

In this Cardiac Ultrasound (Echocardiography) for Beginners Guide, we will be showing you how you can get started on using basic Transthoracic Echocardiography (TTE) right away!

After reading this Echo Tutorial, you will be able to use bedside Cardiac Ultrasound (Echocardiography) to:

  • Obtain the 5 Major Views of the Heart (including the Inferior Vena Cava(IVC) View)
  • Evaluate for Major Cardiac Ultrasound Pathology:
    • Evaluate Left Ventricular Ejection Fraction
    • Estimate Central Venous Pressure (CVP) for fluid status/ fluid tolerance using the IVC
    • Evaluate for Pericardial Effusion/Tamponade
    • Evaluate for Pulmonary Embolism

Cardiac Ultrasound Indications

Point of Care Bedside Cardiac Ultrasound can used in the following indications:

  • Significant EKG changes
  • Assessing Left ventricular Function
  • Chest Pain/Palpitations
  • Dizziness
  • Shortness of Breath
  • Hypotension
  • New Heart Murmurs
  • Cardiac Arrest (assess for cardiac standstill)

Cardiac Ultrasound Preparation

Patient Preparation

  • The patient should be supine with the head of the bed flat.
  • If you are unable to visualize the heart in the supine position, consider repositioning the patient into the Left lateral decubitus. This will bring the heart away from the sternum and give you better sonographic access.
Cardiac Ultrasound Echocardiography Patient Position Supine
Cardiac Ultrasound – Supine
Cardiac Ultrasound Echocardiography Patient Position Left Lateral Decubitus
Cardiac Ultrasound – Left Lateral Decubitus

Cardiac Ultrasound Machine Preparation

One of the most confusing parts of performing cardiac ultrasound (echocardiography) is understanding where the indicator goes on the ultrasound screen.

With the Cardiac Preset:

Indicator Orientation Marker for Cardiac
Cardiac Ultrasound Application Preset

Cardiac Ultrasound Machine Placement:

  •  Place the ultrasound machine on the patient’s right side, so you can scan with your right hand and manipulate ultrasound buttons with your left hand.
Cardiac Ultrasound Echocardiography Patient Position and ultrasound machine placement POCUS
Cardiac Ultrasound Machine and Patient Positioning

Cardiac Ultrasound Anatomy

Understanding the general anatomy of the heart is important in helping you to visualize the different ultrasound views we will be performing. In addition, it will help keep you organized throughout the cardiac ultrasound exam.

There are a total of 4 chambers in the heart: Right Atrium, Right Ventricle, Left Atrium, and Left Ventricle. These are separated by their respective valves: Tricuspid Valve, Pulmonic Valve, Mitral Valve, and Aortic Valve.

With transthoracic echocardiography (TTE) you are able to visualize all of these structures but you will need to keep in mind that the heart is located much more medially (toward the sternum) than you may think.

Cardiac Ultrasound Echocardiography Surface Anatomy - POCUS 101
Cardiac Ultrasound Surface Anatomy
Cardiac Ultrasound Echocardiography Anatomy
Cardiac Anatomy

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Cardiac Ultrasound Views/Echocardiography Protocol

The 5 main/basic cardiac ultrasound views of the heart are the Parasternal Long Axis, Parasternal Short Axis, Apical 4 Chamber, Subxiphoid (Subcostal), and IVC Views.

Step 1: Parasternal Long Axis (PSLA) View

The Parasternal Long Axis View is often abbreviated as PSLA or PLAX.

It is usually the first cardiac ultrasound view obtained and will give you an immediate assessment of the general condition of the heart including ejection fraction and overall left and right ventricular sizes.

  • Point the probe indicator toward the patient’s right shoulder
  • Place the probe at the 4th intercostal space which is approximately the nipple line for males or the inframammary fold to the sternum (females).
Cardiac Ultrasound Echocardiography Parasternal Long Axis View PSLA Hand Position
Hand and Probe position for the Parasternal Long Axis View

Structures to identify in the Parasternal Long Axis (PSLA) View:

  • RV: Right Ventricle
  • LV: Left Ventricle
  • LA: Left Atrium
  • AV: Aortic Valve
  • MV: Mitral Valve
  • AO: Aorta
  • DA: Descending Aorta
  • Pericardium
Cardiac Ultrasound Echocardiography Parasternal Long Axis View PSLA PLAX Illustration
Parasternal Long Axis View Structures – Illustration
  • Optimize the gain to visualize the different chambers of the heart in view
  • Optimize the depth to makes sure you can see the Descending Aorta.
  • POCUS 101 TIP: If you are having trouble orienting yourself, just remember “the 3 L‘s“: For the Parasternal Long Axis view, the Left Ventricle is on the Left side of the screen.
Parasternal Long Axis View Ultrasound Echocardiography Video eFAST FAST scan POCUS
Cardiac Ultrasound – Parasternal Long Axis View
Video Summary of the Parasternal Long Axis (PSLA) View

Here is a video we made summarizing exactly how to get the Parasternal Long Axis view on transthoracic echocardiogram (TTE):

Step 2: Parasternal Short Axis (PSSA) View

The Parasternal Short Axis view is often abbreviated as PSSA or PSAX.

  • From the Parasternal Long Axis view, rotate your probe 90 degrees clockwise so that the indicator is now pointing towards the patient’s left shoulder.
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA Hand Position
Hand and Probe position for the Parasternal Short Axis View

We will go over the three main levels of the Parasternal Short Axis (PSSA) view you can see:

  1. Mid-Papillary Level
  2. Mitral Valve Level (Fish mouth view)
  3. Aortic Valve Level (Mercedes Benz view)

Here is a quick overview of the Parasternal Short Axis levels we will be covering:

Cardiac Ultrasound Echocardiography Parasternal Short Axis Protocol for all the Views POCUS
Parasternal Short Axis Views. RV: Right Ventricle; LV: Left Ventricle; MV: Mitral Valve; LA: Left Atrium; RA: Right Atrium

Parasternal Short Axis – Mid-Papillary Level

The first Parasternal Short Axis view on echocardiography you should focus on is the Mid-Papillary level. The Mid-Papillary level gives you information regarding overall ejection fraction, right ventricular dysfunction, and left ventricular regional wall motion abnormalities.

Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Mid Papillary Probe Placement
Probe placement for Mid-Papillary View.
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Mid Papillary Illustration
Mid-Papillary Level Illustration

Structures to identify in the Parasternal Short Axis (PSSA) Mid-Papillary Level:

  • RV: Right Ventricle
  • LV: Left Ventricle 
  • Papillary Muscles
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Mid Papillary Video
Cardiac Ultrasound of Mid-Papillary Level

Parasternal Short Axis – Mitral Valve Level (Fish Mouth View)

The Mitral Valve level is common view seen and allows you to view the anterior and posterior valves of the mitral valve.

  • To get the Mitral Valve level from the Mid-Papillary level, slide the Transducer towards the sternum towards the mitral valve (base of the heart).
  • The Anterior and Posterior leaflets of the Mitral Valve should come into view.
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Mitral Valve Fish Mouth Probe Placement
Probe placement for Mitral Valve Level
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Mitral Valve Fish Mouth Illustration
Mitral Valve Level (Fish Mouth View) Illustration

Structures to identify in the Parasternal Short Axis (PSSA) Mitral Valve Level:

  • RV: Right Ventricle
  • LV: Left Ventricle 
  • MV: Mitral Valve (Anterior and Posterior leaflets)
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Mitral Valve Fish Mouth Ultrasound Video
Cardiac Ultrasound – Mitral Valve Level (Fish Mouth View)

Parasternal Short Axis – Aortic Valve Level (Mercedes Benz View)

The aortic valve level of the parasternal short axis view allows you to visualize the right ventricle, right atrium, left atrium, aortic valve, tricuspid valve, and pulmonic valve. You can use this view to perform some advanced Point of Care Ultrasound (POCUS) applications such as evaluation of a bicuspid aortic valve, the severity of aortic stenosis, tricuspid regurgitation, and measuring of pulmonary pressures.

  • To get the Aortic Valve level from the Mitral Valve level, tilt the tail of the probe inferiorly and point it towards the Aortic Valve.
  • As you do so the Aortic Valve should come into view with its leaflets representing the “Mercedes Benz Sign.”
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Aortic Valve Level Mercedes Benz Sign Probe Placement POCUS
Probe placement for Aortic Valve Level
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Aortic Valve Level Mercedes Benz Sign Illustration
Aortic Valve Level (Mercedes Benz View) Illustration

Structures to identify in the Parasternal Short Axis (PSSA) Aortic Valve Level:

  • RV: Right Ventricle 
  • TV: Tricuspid Valve
  • AV: Aortic Valve
  • PV: Pulmonic Valve
  • RVOT: Right Ventricular Outflow Tract
  • RA: Right Atrium
  • LA: Left Atrium
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Aortic Valve Level Mercedes Benz Sign Ultrasound Video
Cardiac Ultrasound – Aortic Valve Level (Mercedes Benz View)
Video Summary of the Parasternal Short Axis Views

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Step 3: Apical Views

The Apical Views are some of the most important views to be able to obtain when doing hemodynamic assessment of the heart. This includes looking at diastolic dysfunction, valvular regurgitation, cardiac output, etc.

Unfortunately, it can be one of the most challenging views to obtain when first starting out. In this section, we will show you exactly how to get the mail apical views including the apical 4 chamber view, 5 chamber view, and the coronary sinus view.

Apical 4 Chamber (A4C) View

  • From the Parasternal Short Axis View, slide the Transducer towards the apex of the heart keeping the indicator pointed towards the patient’s left side.
  • Once you reach the apex of the heart, as indicated by the left ventricle decreasing in size, tilt the tail of the probe down towards the patient’s foot.
  • For females, the Point of Maximal Impulse (PMI) is usually just under their left breast.
  • As you do this the Apical Four Chamber view should appear.
Cardiac Ultrasound Echocardiography Apical 4 Chamber View A4C Hand Position
Hand and Probe position for the Apical 4 Chamber View

Structures to identify in the Apical 4 Chamber (A4C) View:

  • LV: Left Ventricle 
  • RV: Right Ventricle 
  • LA: Left Atrium
  • RA: Right Atrium
  • TV: Tricuspid Valve
  • MV: Mitral Valve
Cardiac Ultrasound Echocardiography Apical 4 Chamber view A4C Illustration
Apical 4 Chamber (A4C) View Illustration
  • Optimize the gain and depth to visualize the 4 chambers of the heart.
  • POCUS 101 TIP: If you are having trouble getting the Apical 4 Chamber view, try placing the patient in the left lateral decubitus position. It will reduce lung artifact and bring the heart more proximal to your ultrasound probe, usually giving you an optimal view.

Cardiac Ultrasound Echocardiography Apical 4 Chamber view A4C Ultrasound Video
Cardiac Ultrasound -Apical 4 Chamber (A4C) View

Since the Apical 4 Chamber view can be a challenging view to obtain, you will most likely encounter variants of the apical view including the Apical 5 chamber view and the coronary sinus view. We will go over these views below.

Apical 5 Chamber (A5C) View

  • A common view produced when attempting to do the apical 4 chamber view is the “Apical 5 Chamber View.”
  • Of course, there are not really 5 chambers in the heart but in echocardiography, the “5th chamber” is when you can see the appearance of the aortic valve and the left ventricular outflow tract.
  • Sometimes you will want to intentionally obtain this view in order to calculate the cardiac output of the left heart.
  • From the Apical 4 Chamber view, slightly tilt the tail of your probe towards the patient’s feet to get the Apical 5 chamber view. If you want to go back to the Apical 4 chamber view just tilt the probe tail back towards the patient’s head. Often the difference between the two views is just a 5-10 degree tilt!
Cardiac Ultrasound Echocardiography Apical 5 Chamber view A5C Illustration
Apical 5 Chamber (A5C) View Illustration
Cardiac Ultrasound Echocardiography Apical 5 Chamber view A5C Ultrasound Video
Cardiac Ultrasound -Apical 5 Chamber (A5C) View

Coronary Sinus View

  • Another common view produced by novice sonographers when attempting to do the apical 4 chamber view is the Coronary Sinus View. You will rarely intentionally need to get this view and it is important to know what to do if you see this view.
  • The coronary sinus view will give the appearance of an atrial septal defect between the right and left atrium. Don’t be fooled by this.
  • The reason the Coronary Sinus view is coming into view and not the Apical 4 chamber is because the tail of your transducer is tilted too much towards the patient’s head. Tilt your probe tail slightly towards the patient’s feet and it should give you the apical 4 chamber view.
Cardiac Ultrasound Echocardiography Apical 4 Chamber view A4C with Coronary Sinus View
Cardiac Ultrasound – Apical Coronary Sinus(CS) View
Video Summary of Apical Views

To put everything together, we made this video summarizing how to get the Apical 4 Chamber view as well as the Apical 5 Chamber and coronary sinus views.

Step 4: Subxiphoid (Subcostal) View

The Subxiphoid or “Subcostal” view allows you to see similar structures as the Apical 4 Chamber view but just approached from a different angle. This Subxiphoid view is useful when you are having difficulty getting adequate parasternal views (i.e. COPD patients) or when you are evaluating a trauma patient when doing the eFAST scan.

  • With the patient’s knees bent, position the probe under the costal arch (beneath the xiphoid process) with the indicator pointing towards the patient’s left.
  • Since the plane of the heart is superficial, you need to use an overhand grip on the probe in order to be parallel with the skin
Cardiac Ultrasound Echocardiography Subxiphoid View Hand Position
Hand and Probe position for the Subxiphoid (Subcostal) View

Structures to identify in the Subxiphoid (Subcostal) View:

  • RV: Right Ventricle 
  • LV: Left Ventricle 
  • TV: Tricuspid Valve
  • MV: Mitral Valve
  • LA: Left Atrium
  • RA: Right Atrium
  • Pericardium
Cardiac Ultrasound Echocardiography Subxiphoid Subcostal View Illustration
  • Make sure to use the Liver as an acoustic window!
  • If you approach from the left side your view will be obstructed by the stomach or bowel gas.
  • If you are still having trouble getting a clear image, try applying gentle downward pressure on the probe.
Subxiphoid View Ultrasound Echocardiography Video POCUS
Video Summary of Subxiphoid (Subcostal) View

Step 5: Inferior Vena Cava (IVC) View

Evaluating the Inferior Vena Cava (IVC) with ultrasound is one of the most commonly used Point of Care Ultrasound (POCUS) applications. It is a great way to estimate central venous pressure (CVP) and fluid tolerance.

  • From the Subxiphoid view with the patient still in the supinated position with knees bent, keep the right atrium in view.
  • Locate the Inferior Vena Cava within the Liver and center it on the ultrasound screen.
  • Once the IVC is centered on the screen, rotate the transducer clockwise (to your right) to bring the indicator down toward the feet (play the instructional video).
  • This will give a longitudinal view of the Inferior Vena Cava entering the Right Atrium.
Cardiac Ultrasound Echocardiography IVC View Inferior Vena Cava Hand Position
IVC Ultrasound Probe Position
IVC Inferior Vena Cava Cardiac Ultrasound Echocardiography Short to Long Axis
IVC View – Going from Short Axis to the Long Axis View

Structures to identify in the Inferior Vena Cava (IVC) View:

  • IVC: Inferior Vena Cava
  • RA: Right atrium
  • HV: Hepatic Vein (sometimes seen)
Cardiac Ultrasound Echocardiography Inferior vena cava IVC View Illustration POCUS
IVC View

Assessing for IVC Collapsibility:

  • After you obtain the IVC view you will need to assess for IVC collapsibility in either your spontaneously breathing or ventilated patients.
  • For Spontaneously Breathing Patients: have them take a deep breath or have them sniff in. The maximum IVC diameter will be seen during expiration and the minimum IVC diameter will be seen during inspiration for these patients.
  • For Ventilated Patients: The positive pressure from the ventilator will have the opposite effect on the IVC compared to spontaneously breathing patients. The maximum IVC diameter will be seen during inspiration and the minimum IVC diameter will be seen during expiration for these patients.
IVC Inferior Vena Cava Cardiac Ultrasound Echocardiography Inspiration Expiration
Evaluate for IVC Collapsibility with Respirations
Video Summary of IVC View:

This video summarizes how to obtain the IVC view. Of note, the orientation used in the video below is the standard orientation (orientation marker towards the left of the screen). If you are using the cardiac orientation then your indicator will just need to be rotated 180 degrees.

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Cardiac Ultrasound (Echo) Pathology

Using bedside echocardiography (echo) is one of the most useful Point of Care Ultrasound (POCUS) applications. It can help you assess the hemodynamic status of your patients, estimate fluid status, and look for life-threatening causes of shock such as tamponade or pulmonary embolism. In this section, we will show you how to use cardiac ultrasound to help you in your daily practice.

Central Venous Pressure (CVP) Estimation

Ultrasound of the Inferior Vena Cava (IVC) can be used to estimate the central venous pressure (CVP) of a patient by looking at the size (diameter) and collapsibility of the IVC. This is especially useful when you are trying to evaluate fluid tolerance or the presence of venous congestion in your patients.

Here is a simplified and practical table you can use to interpret your IVC findings.

IVC SizeIVC CollapsibilityInterpretation (CVP)
< 1.5cm>50% collapsibility0-5 mm Hg (Low CVP)
< 1.5-2.5cm>50% collapsibility6-10 mm Hg
1.5-2.5cm<50% collapsibility11-15 mm Hg
>2.5cm<50% collapsibility16-20 mm Hg (High CVP)
Adapted from Kircher et al.

The caveat about IVC measurements is that it just gives you a static measurement to estimate the central venous pressure. So all of the limitations of using CVP will also pertain to IVC measurements.

We find it most useful when the IVC either estimates a low CVP or high CVP. The measurements in between can be considered indeterminate and more advanced hemodynamics measurements should be obtained to assess for venous congestion and fluid responsiveness (change in cardiac output)

Collapsible IVC Long Axis cardiac ultrasound echocardiography
Small and Collapsible IVC
Dilated Non-Collapsible IVC Long axis cardiac ultrasound echocardiography
Dilated and Non-collapsible IVC and hepatic vein

Left Ventricular Function/ Ejection Fraction

Patients with Systolic Heart Failure also known as “Heart Failure with Reduced Heart Function (HFrHF)” will commonly present with shortness of breath, orthopnea, paroxysmal nocturnal dyspnea (PND), exercise intolerance, irregular heartbeats, and edema in the bilateral upper and lower extremities. This is usually accompanied by cardiogenic pulmonary edema and B-lines on ultrasound.

One of the most commonly used surrogates in assessing systolic function in these patients is done by measuring the Left Ventricular Ejection Fraction. For a more COMPLETE tutorial on qualitative and quantitative evaluation of Ejection Fraction Click HERE.

Ejection fraction (EF) in percentage is defined as: EF(%) = SV/EDV x 100

Where SV: Stroke Volume and EDV: End Diastolic Volume

Ejection fraction (EF) is basically a percentage, of how much blood the left ventricle pumps out with each contraction. For example, an ejection fraction of 60 percent means that 60 percent of the total amount of blood in the left ventricle is pushed out during each systolic contraction

HyperdynamicNormalMildly ReducedModerately ReducedSeverely Reduced
Ejection Fraction>70%55-69%45-54%30-44%<30%

Measuring Ejection Fraction on ultrasound can be approached either qualitatively or quantitatively. In this post, we will go over the qualitative technique to assess ejection fraction.

Qualitative Approach to Assessing Ejection Fraction:

  1. Look at how well the left ventricle walls are moving. Are they coming close to each other during systole?
  2. Look at how well the anterior mitral valve leaflet is moving. Is it coming close to the ventricular septum during diastole?

If the left ventricular walls are moving well and coming close together during systole and the anterior mitral valve leaflet is almost touching the septum during diastole then the patient likely has a normal ejection fraction.

Conversely if the left ventricular walls are barely moving during systole and the anterior mitral valve leaflet is barely moving during diastole the patient likely has a low ejection fraction.

Here are cardiac ultrasound (echo) images of patients with different degrees of ejection fraction from hyperdynamic to severely reduced:

Hyperdynamic LV Left Ventricle Ejection Fraction Function Cardiac Ultrasound Echocardiography
Hyperdynamic Ejection Fraction
Normal LV Left Ventricle Ejection Fraction Function Cardiac Ultrasound Echocardiography Parasternal Long Axis
Normal Ejection Fraction
Mild Decreased LV Left Ventricle Ejection Fraction Function Cardiac Ultrasound Echocardiography
Mildly Reduced Ejection Fraction
Moderate Decreased LV Left Ventricle Ejection Fraction Function Cardiac Ultrasound Echocardiography POCUS
Moderately Reduced Ejection Fraction
Severe Severely Decreased LV Left Ventricle Ejection Fraction Function Cardiac Ultrasound Echocardiography
Severely Reduced Ejection Fraction

Pulmonary Embolism (PE)

A Pulmonary Embolism is a blood clot that has dislodged from a distal site which has lodged into one of the pulmonary arteries. Predominantly the clot originates from a deep vein thrombosis (DVT) in the lower extremities where it will travel in the venous circulation, enters the right side of the heart, and eventually into the pulmonary arteries. Learn how to perform DVT Ultrasound here.

Considering the rapid onset/timing of a Pulmonary embolism, patients typically show symptoms or complain of chest pain, shortness of breath, cough, hemoptysis, or even syncope. Risk factors include cancer, oral contraceptive (OCP) or hormone replacement therapy (HRT), immobility, and recent travel.

Here are the different types of pulmonary embolism you may encounter:

  • Submassive Embolism– Submassive (or intermediate-risk) PE refers to those patients with acute PE without systemic hypotension but with evidence of either right ventricle (RV) dysfunction or myocardial necrosis. RV dysfunction is characterized by RV dilation, hypokinesis, or elevation of brain natriuretic peptide (BNP); myocardial necrosis is suggested by elevated troponin. There is evidence that these patients may possibly benefit from “half dose” thrombolytic therapy.
  • Massive Pulmonary Embolism-Massive (or high-risk) PE is a term used to designate patients with right ventricular dysfunction and sustained hypotension (systolic blood pressure <90 mmHg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE). These patients may benefit from thrombolytic therapy.
  • Saddle Embolism-A Saddle is a large pulmonary embolism that straddles the bifurcation of the pulmonary trunk, extending into both the left and right pulmonary arteries. Although it only occurs in about 2-5% of all pulmonary embolism, Saddle Embolisms can completely obstruct both left and right pulmonary arteries resulting in right heart failure and, unless treatment is prompt, death.

Bedside echo is extremely valuable in risk stratifying patients with pulmonary embolism to see if they may benefit from anticoagulation or thrombolytic therapy.

Ultrasound findings of Pulmonary Embolism:

The most definitive way to diagnose a pulmonary embolism is to directly visualize the clot either in the pulmonary artery itself or as a clot in transit.

Massive Submassive Pulmonary Embolism with Mobile Clot and McConnell's Sign cardiac ultrasound echocardiography echo
Direct Visualization of Mobile Clot in the Right Atrium – Apical 4 Chamber view

Unfortunately directly visualizing a clot in the heart or pulmonary artery is a rare finding. Most of the echocardiography findings for pulmonary embolism are “indirect signs” that evaluate for the dysfunction of the right ventricle from a significant clot burden. Usually, this is seen as an enlarged right ventricle.

The two most common and easy to recognize signs to look for right ventricular dysfunction on echo are the “D Sign” and McConnell’s sign.

The “D Sign” on Echocardiography

  • The “D Sign” is an ultrasound/echo finding that shows the left ventricle as a D-shaped structure. It is a result of right ventricular strain causing a shift of the septum towards the left side of the heart.
  • For a complete guide on evaluating the “D Sign” on echocardiography click here.
RV Pressure Overload D Sign
Right Ventricular Strain – D Sign

McConnell’s Sign” on Echocardiography

  • McConnell’s sign is where there is akinesia of the right ventricular lateral wall with hyperdynamic appearance of the right ventricular apical wall.
McConnell's Sign - Book
RV Strain with McConnell’s Sign

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Pericardial Effusion

A Pericardial Effusion is when there is a collection of excess fluid within the pericardial cavity. When enough pressure builds up from a pericardial effusion, it can turn into Cardiac Tamponade.

Patients with Pericardial effusion will typically present with exercise intolerance, tachycardia, pleural friction rub, tachypnea, shortness of breath, and chest pain. The causes of a pericardial effusion can be from various causes including pericarditis, myopericarditis, uremia, malignancy, infections, rheumatologic, etc.

An important point you must remember about Pericardial effusions is that is it not just based on size, the deleterious effects of pericardial effusions are actually more dependent on how quickly a pericardial effusion accumulates rather than it’s size.

In the figure below, a rapidly accumulating pericardial effusion can increase the pericardial pressures significantly and lead to cardiac tamponade despite a relatively small size. Conversely, an end-stage renal disease patient can have a chronic pericardial effusion that slowly accumulates with over 200-400 ml with no hemodynamic consequences.

Pericardial Effusion Tamponade Pressure versus Time Rapid vs Slow accumulation Graph Chart

Ultrasound Findings of Pericardial Effusion:

  • The parasternal long-axis and subcostal four-chamber views are typically favored for inspection of pericardial effusions
  • The Descending aorta is a distinguishing landmark used to distinguish between a Pericardial Effusion and a pleural effusion
  • A pericardial effusion will appear anterior to the descending aorta whereas a pleural effusion will appear posterior to the descending aorta.
Pericardial Effusion Cardiac ultrasound echocardiography echo
Pericardial Effusion lying Anterior to the DA
Pericardial Effusion Subxiphoid Subcostal View Cardiac Ultrasound Echocardiography Echo
Subxiphoid view of aPericardial Effusion

The cardiac ultrasound image below shows both a pericardial effusion (anterior to the descending aorta) and a pleural effusion (posterior to the descending aorta).

Pericardial Effusion and Pleural Effusion Cardiac Ultrasound Echocardiography

Pericardial effusion vs Pericardial Fat Pad

Being able to determine the difference between a Pericardial Effusion and a Pericardial Fat Pad is important as they may have similar sonographic appearances.

  • Pericardial fat pads are usually located anteriorly and can usually be seen on the Parasternal Long Axis view.
  • Pericardial fat pads are usually not completely anechoic and can appear to have striations.
  • Lastly, pericardial fat pads can usually be seen to move with the motion of the heart.
  • If you are in doubt, ask another more experienced POCUS user to look at it or order a formal echo to clarify if needed.
Pericardial Fat Pad Cardiac Ultrasound Echocardiography POCUS
Anterior Pericardial Fat Pad on Parasternal Long Axis View

Cardiac Tamponade

Cardiac Tamponade occurs when the pericardial pressure exceeds the pressure of the right atrium or right ventricle leading to decreased preload of the left ventricle and eventually a drop in cardiac output/blood pressure. It is considered an obstructive type of shock.

Recall that cardiac tamponade is more dependent on the rate of pericardial fluid accumulation versus the actual size.

On physical exam you may see Beck’s Triad defined as hypotension, jugular venous distension, and muffled heart sounds. You can also detect pulsus paradoxus as well. However, other diagnoses can cause false positives for these findings including severe COPD, tension pneumothorax, or other causes of obstructive shock.

Point of Care Ultrasound can offer a more definitive diagnoses of pericardial effusion and cardiac tamponade.

Ultrasound Findings of Cardiac Tamponade:

Using transthoracic echocardiography (TTE) you can see if the pericardial pressure exceed the right atrial or right ventricular pressures.

Since the lowest pressures in the heart is the right atrium, the first echo sign you will see of cardiac tamponade is right atrial systolic collapse.

The second echo sign you will see in cardiac tamponade is right ventricular diastolic collapse.

Either of these signs are considered positive echocardiographic signs of cardiac tamponade.

Pericardial Effusion with Tamponade and RA systolic collapse
Apical View: Cardiac Tamponade – RA Systolic Collapse
Pericardial Effusion Tamponade - RV Diastolic Collapse
Parasternal Long Axis: Cardiac Tamponade – RV Diastolic Collapse

Editor’s note: Keep in mind that there is a difference between echocardiographic and clinical cardiac tamponade. Echocardiographic cardiac tamponade just exams to see if the right heart (RA or RV) are affected, the echo can’t tell if your patient is actually hypotensive. Clinical cardiac tamponade requires the patient to be hypotensive and in shock. Even though the echocardiographic signs of cardiac tamponade will usually correlate clinically with a hypotensive patient, it is not always the case.

Video Summary of Cardiac Ultrasound (Echocardiography)

Here is a video we made that summarizes the cardiac ultrasound views and pathology:

References

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  18. Goodman, Adam, et al. “The Role of Bedside Ultrasound in the Diagnosis of Pericardial Effusion and Cardiac Tamponade.” Journal of Emergencies, Trauma, and Shock, Medknow Publications & Media Pvt Ltd, Jan. 2012.
  19. Kircher, B., Himelman, R., Schiller, N. (1990). Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava The American Journal of Cardiology 66(4), 493-496. https://dx.doi.org/10.1016/0002-9149(90)90711-9

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Delcy

This is so so helpful!

Nikita

I only searched for 1 echo related topic and this have given me so many more!!’ Thanks… this is so helpful and definitely a refresher!!!

turki

its great ! thanks so much.

Anca

Thank you!! It’s so nicely done! It helped me a lot! Great job !! Thank you very much!!🤓🤓

[…] Cardiac Ultrasound (Echocardiography) Made Easy: Step-By-Step Guide […]

[…] most common views to assess for left ventricular ejection fraction are the parasternal long axis, parasternal short axis (mid-papillary level), and apical 4 chamber view. The subxiphoid view can […]

Shital Baste

Thank you so much
Great work
Can I get a PDF of this , so I can print

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