The Woman with a Big Heart

51 y/o female with a PMH of pulmonary HTN, R heart failure, tricuspid insufficiency, hepatitis C, and DM II presented with worsening pulmonary HTN and was admitted to the MICU. Her pulmonary HTN had been present for many years, which caused R heart strain and eventually R heart failure.

Given this significant medical history, one would expect to see the right side of her heart enlarged on ultrasound. However, if this information was not available, scanning this patient may become very confusing.

It is important to remember the key structures required for proper cardiac views. It is good to obtain the different views in a specific order: parasternal long, parasternal short, apical four chamber, and then subxiphoid. Finding the parasternal long view provides insight on the anatomical placement of the heart and will help you find the rest of the views. Once you find a good window between the rib spaces, small movements with rotation, rocking and fanning will get you the appropriate views. With a methodical plan and practice, pathologies can be easily picked up and interpreted.

Key cardiac structures:

  • Parasternal long-axis → aortic valve, mitral valve, LV
    • [another way to think about this view is the 3 L’s = Long axis, Left ventricle, on the Left side of the screen]
  • Parasternal short-axis, mid-ventricle → LV with papillary muscles, RV
  • Parasternal short-axis, base → aortic valve, tricuspid valve, RA, RV outflow tract
    • [for a more complete view, include pulmonic valve and pulmonary artery]
  • Apical four chamber → tricuspid valve, mitral valve, RA, RV, LA, LV
    • [for the five chamber view, include aortic valve]
  • Subxiphoid → tricuspid valve, mitral valve, RA, RV, LA, LV

 

-Jasmine Fu, MS4

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