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Good afternoon, good evening. Wherever you are joining us from. Uh we are really excited today to have Dr Syski joining us from the NIH Critical Care Medicine Department. And we're today going to be talking about point of care um ultrasound and it should be really exciting and hopefully really useful educational um session if you've got questions, um Please make this interactive, please pop your questions in the chat and we'll try to answer those at the end of the session. We launch a couple of polls throughout the session as well. Please answer some pools. Let's make this fun and interactive. Um But we're really excited to have Dr sins with us today and I'm going to hand straight over to learn lots about everything ultras signed today. Thank you. Hi, thanks for joining. Um So today I'm gonna talk to you guys about qualitative left ventricular assessment. So our goal next slide um so our goals will be to go through the four basic views um of the heart that we look at with ultrasound with a review of image acquisition. So how exactly do you get those images on your screen? And then the qualitative methods of assessing that left ventricle. So what exactly are you looking at to make your visual as assessment? This is not a talk about quantitative assessment. So we're not talking about specific calculations. It's not um you know, I have separate talks for that. Um But today's talk is really getting the basics down and getting that visual assessment of the left ventricle and see how it's functioning. Um And we will review some clips for practice. Um So if uh I don't know if the capability is there, um Doctor Mal, but if they can come off mute and join in and, and uh review the clips with me, that would be great. Um And then, so the goal for me for, you know, in terms of instructing you is to ensure that all of you by the end of this talk can do a visual assessment of that LV function next slide. So the four basic views of the heart are the parasternal long axis view, the parasternal short axis view, the subcostal view also known as the Subxiphoid view and the apical four chamber view next slide. And it's really these three views. So excluding the subcostal generally, but the parasternal long axis, parasternal short axis and the apical four that will help um help you determine the function of your left ventricle next slide. Now, there are some folks that are, you may hear about this down the line, but there are some folks especially in our um society of Critical Care Medicine here in the US that are um starting to think about doing a subcostal only view. I only mention this because I specifically teach you the other three views and not the subcostal in this talk. Um but the subcostal only view um is a quicker uh way uh in some patients where you have access to that subcostal space that have not been, you know, to the operating room for some abdominal surgery or not, are not severely distended with ileus or, you know, et cetera or ascites, right? So you can actually get that subcostal view in those patients. Uh maybe you can do an LV assessment. Now, uh I'm not entirely convinced. So in this um study, for example, um one out of um about 34 patients had a, had a misdiagnosis of a severely depressed uh left foot. So the cardiologist and the anesthesiologist, critical care um uh physician did not agree on that. And so w whereas the formal echocardiogram showed a severely depressed LV, the anesthesiologist, um critical care physician that had looked at it with point of care, ultrasound thought that it was normal function. And for me, one out of 30 is enough that I don't yet use a subcostal only view for this. Um but just to put it on your radar, um next slide. So the indications for doing a point of care, ultrasound test of the heart um move uh next slide please or next um is chest pain, next dyspnea, hypotension or shock trauma, respiratory failure and cardiac arrest, right? All of these things you wanna see how the left ventricle is doing. But I would say if you have access to an ultrasound, I would recommend that you use it as an extension of your physical exam. So instead of just listening um to heart sounds, you can actually if you have the capabilities, take a look with your ultrasound machine. Ultrasound is all about pattern recognition. So the more ultrasounds that you see in normal patients, you're gonna be able to pick up things that are then abnormal. OK. Next slide. Uh So let's talk about how you obtain the images for each of these basic views. And for this portion, I will include the subcostal. So um the parasternal long axis view um is what it sounds like. It's the long axis of the heart. And remember that the heart does not have a directly does just dangle in the chest vertically, right? It has a horizontal lie. Most of that cardio diaphragmatic border is actually made up of the right side of the heart, right, the right ventricle. So it had it's off axis. So you have to think about how you're gonna hold your probe so that you can get a slice of this long axis uh view of the left ventricle. Next, next. Um So the probe is placed immediately to the left of the sternum and you may uh wherever you are wanna kind of um touch on your own body where you would be placing the probe. So you get a hang of this, but the probe should be placed immediately to the left of the sternum. Next indicator, pointing to the patient's right shoulder next in the third, about the third to fifth intercostal space. This will depend on uh you know, depend on the size of your patient's heart next. And the left lateral decubitus positioning may help. So, um in patients that are able to actually turn all the way over to their left side, turning the patient to the left side, swings the heart anteriorly into the chest and makes the visualization um through the chest wall actually easier. So um that positioning, if they can do it and if they can't do it, uh for example, I, you know, work in an IC U. And so when we have critically ill patients and you can't do that, um I ha ha I have people help me put pillows underneath um the right side so that they are tilted over to the left side and sometimes that can help as well next. And so here's what you wanna bring up in the long axis view of the heart. Um Doctor mckinney, are you able to see my pointer if you can, uh I cannot see your pointer? Um So I'll just talk through it. Sure. OK. Um I wonder if there's a pointer function on here. Actually, no, there is not. That's OK. OK. So, um at the top, so on the right hand side is actually what you're gonna see using a phased array or cardiac probe. Um when you're doing a parasternal long axis view, this is the view that you want to get. And on uh the left hand side of the screen I have for you, um the anatomy. Uh So, so on the right side of the screen, um you see that right where you're, you know, if you, if you go all the way to the top of the screen, that is where your um probe is actually physically located on the chest wall. So immediately below that, you see the, this this chamber or a slice of this chamber, which is the right ventricular outflow tract RVOT. And you can correlate that with, on the left hand side of the screen, this anatomical long axis view of the heart. So RVOT, exactly, perfect. Thank you. Um And then immediately below that, you start to see the intraventricular septum. So the RVOT is a slice of the RV. So you see that up top and then you see the in interventricular septum and that is going to be between your right ventricle and your left ventricle, right. So that big ventricle, the the the big cavity that you're seeing below that is your left ventricle oops. Um So, and you can correlate that with the, the anatomic view, I mean, uh the uh depiction there on the left hand side of the screen, OK. Um The, oh, this would be easier with a pointer if you can place the probe within the left at uh the the pointer within the left atrium. So the the left atrium is here exactly. This is the left atrium and this is a still view, right? So you're not seeing the mitral valve opening and closing yet, I'll show you that in a clip that we see next, but this is the left atrium. So blood is flowing in through the left atrium through this mitral valve that you see, you see the anterior lea foot there, yeah, through, into the left ventricle and out through the left ventricular outflow tract which you see there. And that is the aortic valve, they look like little hands, like kind of almost like little prayer hands opening and closing. Um When you see them on a click, OK. Um So be beneath that, that circular structure that you see is actually the descending aorta. It's a good idea in this parasternal long axis view to always adjust your depth uh on your machine. So that you're actually getting this at the bottom of your screen this circle. And the reason is because sometimes when a patient has a large pleural effusion um or a pericardial effusion, it's hard to tell which one is, you know, if it's pleural or if it's pericardial. Now, the descending aorta helps you with this cause in this long axis view. What you will see is you will see um dark anechoic fluid cause remember, fluid is anechoic on um on ultrasound, you will see that anterior to this descending aorta. So if you see it anterior to the descending aorta, you know that it's a pericardial effusion and if you see it below or behind it, then you know it's a pleural effusion. OK. Next, then um to get the parasternal short axis view, you pretty much are in the same place as the long axis, except you wanna rotate your probe to be facing the patient's left shoulder. So you're rotating 90 degrees. So you could get this cross section of the left ventricle. You wanna see it in almost this donut shape, right? Um Can you go to um next? OK. The probe is again placed to the left of the sternum indicator now pointing instead of to the patient's right shoulder, the patient's left shoulder, right. So just that ninety-degree turn next, I need the same sort of positioning, third diff intercostal space and the left lateral DQ positioning may help for this as well. OK. Next. All right. Here, we have the short axis view on the right hand side of the screen is what you would see on your ultrasound machine. On the left hand side is the depiction um anatomical dis depiction there. And, and here you get that perfect circular structure of uh the perfect circle of that LV, right? So you're kind of like looking into the LV. Um It is very important in this view to see both papillary muscles, the papillary muscles. Um you will see there, yeah, the um anterolateral pap that you're pointing to now. And the other PAP is the posteromedial papillary muscle. Both of those papillary muscles must be in view. And the reason is because you want to assess the short axis view in the mid ventricular plane. So you wanna be mid ventricle. You can imagine if you had accidentally fanned down all the way to the apex of the heart, that cavity is gonna look really tiny, right? And you're gonna say, oh, my patient is really under resuscitated volume down with, you know, they, they, they need more volume and you're not looking at the right part of the heart, you're, you're actually all the way fanned down to the apex. So these papillary muscles are your guide to tell you I'm in the middle of the ventricle. Now, I can look and make my assessment if you see one papillary muscle and not the other, you know that you're off axis. If you're off a access, your, your ventri left ventricle can be appear sort of oblique and that will give you that might miss uh you know, misguide you in the direction of, you know, it looks like my septum is flattened, right. So if that interventricular septum, there appears sort of flattened, then you, that makes me think that there's elevated pressures in the right side of the heart. All right. So when there's elevated pressures on the right side of the heart, it's gonna push up against that septum and make it appear flat. And so if you're off axis, you can be mis you can misinterpret your image. So again, just to kind of reiterate that it is important to see both of those papillary muscles. OK. Um So now let's look at this view um in a little bit of a different uh uh point of view, which is that this, I love this, this view of the heart because it also tells me about a heart attack, a patient might have had. Um How does it tell me that? Well, you look for this, this gives you all of the coronary distributions um the coronary artery distributions in one view, right? So up top, um so first, actually let's point out the the right ven the right ventricle, the right ventricle is here. Yeah, in interventricular septum, perfect. Um And if you kind of bring the pointer clockwise, um that up top is that anterior wall. So if you think of on your EKG, the patient has SS T elevations on in leads V one V two V three V four, right, the anteroseptal leads. Um this is where you would see a wall motion abnormality instead of a nice movement in with each systolic beat, you may see no movement or you may see minimal movement. It might be hypokinetic or akinetic, right. And so that is consistent with the left, anterior descending coronary artery. And if you move, if you continue to move out clockwise, um including the pear. Exactly. That is the lateral portion of the LV. So that's, that's the lateral LV, wall segments. And if you have a patient who has, let's say an ST elevation that you see and leads um one A VLVF with V four V five, right? Uh I'm sorry, V five V six. So those lateral leads right? One A VLV five VV six. That's gonna tell you that, that, you know, that may correlate with akinesis or hypokinesis here of the lateral left ventricle wall. And what coronary artery is that distribution? That is the left circumflex in most patients. And then if you come down even further. Yup, that is the inferior um part of the heart. Um So the inferior part of the LV. And so um what coronary artery distribution is that, that is your RC A and that involves that um posterior papillary muscle that you see there. Um Just so, you know, in general, you'll see things if you're reading about this or if you're looking at videos online, you'll see like posterior heart uh versus inferior. And that can get a little bit confusing just to make it more simple, just call it the inferior um segment of the LV. Um Even cardiologists are sort of starting to move away from, from posterior because the posterior segments of the um LV are actually just two basal or segments within the inferior wall. So now we just inferior. OK. So, anterior um lateral and, and inferior uh L uh LV, wall segments are all visualized here. Um And can give you a sense of whether your patient has had a heart attack. I've actually picked up on patients heart attacks just by looking with the ultrasound before they, you know, troponin or other things are back. OK. Um Next, um Next is the apical four chamber view and this is what it sounds like. You wanna be at the apex of the heart and you wanna see all four chambers. So the probe generally in this is a little bit more variable depending on the patient, the size of the heart. So the probe generally is placed inferior to the nipple line in men in the inframammary crease in one. And then, um generally, you know, you know, if you remember learning about the point of maximal impulse, um so sort of feeling um uh around that nipple side or the infra mammary crease for that point of maximal impulse, that is the apex of the heart that you're feeling. And so that's actually where you can go ahead and place your probe. Um Next, the indicate, oh in the fifth, it's generally gonna be in the fifth to sixth intercostal space. Next. Um The indicator pointing loosely, I'll say to the left. And the reason is because some people, if you have a patient with a pretty horizontal lie to the heart, you might have to be up and your indicator might be actually be pointing sort of um cephalad. Um And if a patient has a smaller heart, then you might actually need to be more medial and it's gonna be pointing um really more horizontally to the left. So the loosely the indicator is pointing to the left hand side of the patient next and again, in this left lateral decubitus positioning can help. OK. And so here's the view that you wanna see. And again, you know, if you felt for that point of maximal impulse, you really wanna be, you know, the probe should be placed on your patient at the apex of their heart. So you see the apex at the top of the screen there. Um And then let's start with sort of what we're seeing on the right hand side of the screen. So that that first ventricle that you're seeing, um you can point that out is the left ventricle, right. So there is the left ventricle and um below that you see the left atrium and then on the other side, you have the right ventricle and the right atrium and in general, and normal hearts. And as you do this more, you know, more and more in, in, in patients that are, you know, have normal anatomy, you'll pick this up. The, the right ventricle should be two thirds the size, uh or less of your left ventricle. So if you start to see the right ventricle start to look like it's the same size, then that can signify increased pressures on the right side. Um If you have a patient when it with an acute pulmonary embolism, so they come to you short of breath. Um And you have an ultrasound, you take a look. Um and you can, you, it's, it's possible that you see a very large RV, the RV can sometimes look like it's twice the size of the LV um in those cases. So this is a great view to assess the differences in the right ventricular size, compare it to the left ventricle. It gives you an idea in this view when we start to do quantitative things. This is qualitative, right? So we're just gonna, I'm just gonna teach you how to look at this and know what the left ventricle is doing. But once we start to get into higher level ultrasound, in terms of um you know, doing uh the uh the, the uh tricuspid annual or plain systolic excursions, uh maps see uh mitral annual plain systolic excursion, you can do inflow velocities, all these different kinds of measurements in this view. So this is a good view So when you're starting your practice for point of care, ultrasound to get this view down pat, because a lot of calculations um building on this will come from this view and they're not complex complicate, uh you know, calculations. It's, it's something that just you just need to have this view down before you can move to the next levels. Um I think we did a and, and, you know, just to look at the anatomy we in the mitral valve uh is, is visualized on the left side between the left atrium and the left ventricle. And the tricuspid valve is visualized between the right atrium and right ventricle. And you see the intra atrial septum there as well. OK. Next subcostal view. So this is uh I'll, I'll teach you how to get the image, but then I'm sort of gonna um stop there in terms of lb assessments. OK. Um So the probe is placed inferior to the sternum. So you again, you might wanna just um as we're practicing this um point, feel it on yourself where you would place the probe so inferior to the sternum indicator, pointing to the patient's left side. Um And this generally, you have to be flattened against the abdomen and aim that ultrasound beam towards the patient's left shoulder cause you wanna get this view um coming from beneath all the way um all four chambers across. OK. And, and um in a supine patient and bending their knees can actually help you, um, get in further, um, where you need to be, this, this can be sometimes uncomfortable. It shouldn't be like frankly painful for your patient, but it can be a little bit uncomfortable. So make sure that, that you're asking them, um, how they're feeling, um, if they're able to communicate that with you. Ok. Next. Um, so here we're actually, since we're coming in sub costly, right? So below, um uh below the xiphoid there, you actually often get a bit of the liver. So you get that liver tip initially up top at the top of your screen. And then remember that you're coming in inferiorly here, right? So your sound waves are coming in from below and coming up. So if they're coming in from below, um what is the first ventricle? Remember I told you that the heart has this horizontal line, the dia cardio diaphragmatic border is made up of the right side of the heart. So the first chamber that you see is the right ventricle there. And then you see the right atrium, the intraatrial septum, you see the intraventricular septum and then you see the left ventricle and you see the left atrium. Um Sometimes this view is the only view you can get on a patient. If they, for example, have subcutaneous emphysema, they've had some sort of chest surgery, they have um uh you know, they have uh a um chronic Obstructive Pulmonary disease, severe asthma that has caused their lungs to be hyperinflated and come up over um the heart. And so you can't actually have any bed windows because remember sound waves do not travel well through air, right? So you will lose your image if there are any of those things um that exist. And so the subcostal view sometimes is what we call like the poor man's view. It's like the only view that you, you know, it is the only view you have sometimes. So um so uh getting used to doing this view is actually um is important and it will give you information. Um once you sort of train your eyes to see what you need to see. Um And the, and this is the best view um to look for pericardial effusions. So this view is actually the one view that we use when we do the fast exam, which is a sonographic um trauma assessment. Um So, if you have had a patient who's a trauma victim and you wanna see if they have any hemopericardium or blood within the pericardial sac, then you, you will use this as your one view um of the heart. And the reason is because up top, at the top of the screen is where you would see is a little bit of fluid there um or maybe a lot of fluid if they're unlucky. But um that is where you wanna train your eyes to look in this view cause I think when you look at this, the first thing you wanna, you think about when oh where's the, where's fluid gonna accumulate? You wanna look at the bottom of your screen? That's actually no, that's the top of the heart. Think about where the sound waves are coming from. They're coming from below. So the tap of the screen there, that tap um right ventricle, that's where you're gonna train your eyes to see any pericardial effusion. That's small. OK. Next. So now here are these big goofy eyes but the Q but really, I want you to think about what you are looking for. What exactly are you training your eyes to look at when you're looking at these images? OK. Next. Um So after you train your eyes to look at something there, the, the the goal for you in looking at the left ventricle is to say is to bin your description of the LV function into one of these categories um is the function severely reduced and that is correlative of an ejection fraction of less than 30%. Is it mild to moderately reduced? Which is an ejection fraction of 30 to 50%. Um Is it normal, does the ejection fraction look like it's greater than 50% or is it hyperdynamic? Now, when they use Simpsons method and they're doing a formal echocardiogram, you will say an ejection fraction of greater than 70% is hyperdynamic for us in point of care ultrasound. The simplicity of it is for us to call hyperdynamic is to see near or complete end systolic effacement of the lb cavity. So if the LV cavity walls are touching, that tells you that your uh patient has a hyperdynamic heart and that can be indicative of, you know, a very a patient in hemorrhagic shock or a patient who um has I is severely under resuscitated, severely dehydrated, um needs more volume. Um So that's what we look for for hyper uh for hyperdynamic. So if there's com ends systems lic effacement of the L cavity. And actually studies show that we can bind as, as you know, just doing a visual assessment, we can actually bend um LV function into one of these pretty well where we're bad is doing mild to moderately reduced. But I think clinically that's not gonna change your management so much. You wanna know if it's severely reduced, mild to moderately reduced, normal or hyperdynamic, all of those things are gonna change your um management. OK. Next. Um So, well, let's talk about what you're gonna look at in each of these views. So let's start with the parasternal long axis. So here you're actually gonna look at the motion of the ma mitral valve leaflet. It's the anterior leaflet of the mitral valve in the parasternal long axis view that you will see the mitral anterior leaflet of the mitral valve has good excursion and normal LV function. And that pretty much slaps the septum, right. So it should be opening up and hitting the septum. We're nearly hitting the septum. And if you don't visually see that and you see motion of the mitral valve an into your leaflet that looks like this, that can be indicative of poor, um uh poor systolic function. And then you wanna look at the thickening of all the LV wall segments. Is it thickening by at least a third? And then you wanna look at the change in the area of the LV cavity is the cavity size actually decreasing by at least a third. All of those things are suggestive of good LV function. And then next. So here is an example of uh parasternal long access view. This is a clip. OK. So um first is there is it, can this be participatory? You want me to just move forward? Doctor mckenley, uh Sorry, Doctor Sins. It's uh not possible for delegates cameras on. So it, it's just uh just visual, sorry. OK. No, no, no problem at all. So we'll just talk through what we're seeing here. So the top of the screen, remember in this view is the right ventricular outflow tract. Then we see that in interventricular septum there, um We see the intra lateral wall of the LV down below. Um If you forget which wall that is, you could just call it the free wall and you see the LV cavity decreasing with each systolic beat. Right. So, ok. So, um, let's take a look first. What we're training our eyes to do is look at that motion of the uh anterior leaflet of the mitral valve. So here the mitral valve opens, it pretty much nearly touches the septum. It's very, getting very close to the septum there. Right. And let's look at the thickening of the LV wall segments. Look at the intraventricular septum. Look at that infra lateral wall are those wall segments thickening with each systolic beat. Yes, they are, right. They're thickening by at least a third. Now, look at the change in the area of the LV cavity. Is it decreasing by at least a third? Yes, it is. So this is a patient with normal LV function. OK. Right next. OK. Now, this looks a little different just up front. But you want, you wanna be systematic about this. So let's talk about the motion of the mitral valve leaflet. Look at that anterior leaflet of the mitral valve. Is it approaching the septum? It's not even crossing midline, midline being this invisible line from the apex through. Um Is it crossing the midline of the LV? No, it's not. So that's pretty bad, thickening of the LV segments. Now, look at the intraventricular septum. Is it thickening? Pretty much? Not at all? Right? And then look at the infra lateral wall there. Is it thickening? Not really, it's moving, but it's not thickening. Um And then now, look at the cavity size change in the area of the LV cavity is the cavity size changing at all. Again, you see some movement but there's really no big changes. Not at least not by a third, certainly not by a third. Um So visually looking at this, I would say this is a severely depressed function. So, so this is severely depressed LV, right? It's gonna correlate with an ejection fraction of less than 30%. OK. Next. Now this is a little bit of a grainy view. Um I still in include grainy views cause if I teach you only with perfect views, when you start to see something like this in, you're a patient, you'll panic and you'll say, huh, I don't know what I'm looking at. So the reason I include these is because you, you can still train your eyes to look for what it needs to look for. So here, um look at that anterior leaflet of the mitral valve. Look for it. You can see it, it's slapping the septum, right? Look at the thickening of the LV wall segments. They look like they're thickening by at least a third. Now, look at the change in the area of the LV cavity. You can actually, if you look carefully, you will see that the cavity walls are actually touching. So the intraventricular septum is touching the inflater wall there. And so the cavity is essentially nonexistent. So this patient, it has a hyperdynamic l va hyperdynamic left ventricle. Now, in this particular case, this patient had hypertrophic obstructive cardiomyopathy and they have like very, you know, thickened walls. But in a patient that is hyper, which is similar but different. So this is a tachycardic patient in shock who genuinely needs more fluids. And so in this case, you see, um let's look at the motion of the an the anterior leaflet of the mitral valve. Um Yeah, that looks like it's pretty much uh slapping the septum thickening of the LV wall segments. Yeah, they look like they're getting thicker, the inner in interventricular septum and uh the the infra lateral wall. Um And what do you think about the change in the area of the lb cavity? Again, the walls are touching, right? So this patient needs fluids. So and, and just so, you know, this particular um image is not optimized because remember that descending aorta that circle below the, the long axis of the heart that you're seeing should be at the bottom of your screen. So someone forgot to adjust the depth appropriately. You can still see what you need to see, but um it's not optimized. OK. Next. OK. So looking here again, let's look at the motion of the mitral valve leaflet. So not doing great there, it's not really opening, it's not approaching the septum, right? And then the thickening of the LV segments, look at the intraventricular septum, not, not really thickening look at the infra lateral wall, not really thickening. You think about the cavity size, not really decreasing by at least a third. No. And so here you have again, a severely depressed LV. Next, I'm asking myself why I included this image to teach you maybe it's just another example of the hazy image. Um So motion of the mitral valve leaflet approaching the septum there, right? Um thickening of the LV wall segments. here, they do appear to be thickening. You catch them, you you know in between. Yup. Mhm And then the change in the uh cavity size, you do see it decreasing by at least a third. So not the best view, but you can still make out these three things and kind of as long as you're sys systematic about it and come up with a conclusion where you're binning your findings into one of those descriptive descriptors of LV function. And this would be a normal LV function. OK. Next. OK. Now I'm really challenging you with your view. So motion of the anterior leaflet of the mitral valve, you can actually still see it flopping the septum. There's something going on here that right ventricular outflow tract is huge, that RVOT is big. Even in this hazy image, you can make that out that big circle at the top of the screen, right? So that is abnormally large and this patient had a pulmonary embolism, right? So what's happening to their left ventricle you see the intraventricular septum, I can, I can't really make out the walls. Well, so I won't comment on those, but I will say the cavity size is pretty small. It's pretty much there's no cavity there. Um So what's happening is you have an acute pulmonary embolism, severe right heart strain. It's actually causing uh um decreased cardiac output um because of this obstructive shock picture and you're seeing a hyperdynamic LV. So you're seeing the walls touching, OK. Next, next, we are gonna move on to the parasternal short axis view. So what exactly in this view do you wanna look at? So some of this stuff stays the same actually all the way through which is in all of these views. You're gonna take a look at the thickening of the LV wall segments. You wanna make sure they're thickening by at least a third. You also want to look at the change in the area of the LV cavity by at least, should be decreasing by at least a third. Um And the and then wall motion abnormalities. So this particular view, you can actually look like we talked about um at the different coronary artery distributions and actually look at the LV wall segments. Next. Um And here's an image um from the American Society of Echocardiography about um you know which coronary artery distributions. Now, these are cardiologists. So they're, they're adding some complexity to it because not every patient has the same um anatomy, right? So, um but in the majority of patients anteroseptal re region is L ad lateral is circ and your um inferior port part, uh wall segments are your RC. And so you can see that there next. Um And so let's play this video. OK. Um So here you see, um let's, let's talk through again, just like we did for long axis. Um Are we seeing thickening of the, all the wall segments here? It looks like the LV, wall segments are indeed thickening by at least a third um change in the area of the LV cavity. That's a little bit more easily visualized here. Um But it does look like it's decreasing by at least a third, right? So it's the cavity size is decreasing. And then is there any specific wall motion abnormalities that you see? So the, the way that I recommend that you look at this is actually cover up the other portion. So I showed you where the interior LV um uh the, the anterior wall segments are. So cover, actually use your hand to cover the other two, the lateral and the inferior portion of the heart. And see with systole if it's actually coming towards your hand, and if you do that throughout, so to isolate out the lateral part of the wall and then the inferior, if you actually do that, you will see that with each systolic beat, every, you know, it's all coming towards your hand. And so, um, all things are normal and this is a normal LV. Next. And so here things on, you know, just upfront look very different, right? But, um, now you wanna be s, you know, systematic about it. And so, um, you see thickening of the, uh, you're looking for the thickening of the LV wall segments and if you actually look carefully, you'll see it's not thickening, it's not thickening by at least a third. Um And then what about the change in the area of the LV cavity? Is it decreasing by at least a third? Uh Not really. So, and then wall motion abnormalities, you're specifically isolating out different walls and actually gonna look at each part. There's no particular wall motion abnormality here. Here, it's, it's a patient with global um uh global hypokinesis. So it's just not moving well all throughout. Um But this patient has an ejection fraction consistent, less than 30% because this is severely next. Sorry, these are supposed to automatically play. But if you could just play that, yeah. Um There you are. And then again, um here, let's keep with our systematic approach. So we're looking for thickening of the LV wall segments. Um So not seeing good thickening here as well um change in the cavity size. So if you actually put your hand on the screen, you can actually see that it's not changing much at all. And then wall motion abnormalities. Do you see any specific wall motion. Well, it looks like maybe it looks globally hypokinetic, but it looks like maybe the lateral wall is moving better and maybe the um anti anteroseptal region looks particularly thinned out and with each systolic beat, it's going out instead of in towards your hand. So, um, we certainly in that led distribution but, um, hypokinetic throughout, but this is consistent with a, a low ejection fraction. So a severely depressed LV. OK. Next and here we have um thickening of the LV wall segment. So let's look at that. Well, yeah, looks like it's thickening um throughout a change in the area of the LV cavity. And that's where we see an issue, right? It's coming to near complete effacement. So you have in this view, um what's called kissing papillary muscles and when your papillary muscles kiss that's inappropriate and we don't wanna see that. So that is, yeah. And so that tells you that this is a hyperdynamic LV. So this patient, for example, might be a patient that needs fluids. And again, you know, think about it in this view, how do I know that I'm not at the apex? I'm seeing the small LV, you know, that would be normal at the apex, right? I know because I'm looking at my papillary muscles and I confirmed that I'm indeed midventral and even in this mid ventricular view, I'm seeing near complete effacement. And so in this patient, um you know that came in. I would, I would, you know, especially if they were hypotensive, I would definitely give this patient fluids. Um, ok. And then specifically wall motion abnormalities. This patient doesn't have any a see them coming in throughout. Ok. Next. Um, I'm challenging you with some hazy views here. Um, but this is uh a patient that has um, actually pul pulmonary embolism. So this isn't the best view to look at the A, you know, um This isn't the, the crisps view to show you that, that D shape of that ventricle, but this RV is, is very generously sized and there's some flattening of the LV wall there. So instead of that perfect circle, you're actually starting to see a little bit of septal flattening there. Um And this patient hasn't uh si significantly under filled LV as well. You could see that the wall segments are indeed thickening. Um There's no specific wall motion abnormality but the change in the area of the LV cavity. When you get to that checkpoint in your systematic approach, you will see that the papillary muscles are pretty much touching. OK. Next. Um So now moving on to your apical four chamber view, what exactly are you looking for in this view? Next? Um So you're gonna look for, um So let's skip over the first one, look at the last two. So thickening of the LV, wall segments and change in the area of the LV cavity that remains the same throughout, right? But in this particular view, you wanna also look for longitudinal shortening. So um you can see the mitral valve annulus actually um its excursion towards the apex of the heart. Remember that the heart and sys systole actually has three movements, right? It's not just moving circumferentially, it's actually also moving longitudinally. So it's getting shorter as it's as it uh it has circumferential movement, right? Circumferential compression, longitudinal, um shortening. And then there's actually this twisting motion of the LV called strain. So it's all these move that helps move blood efficiently out of the LV. We in point of care, ultrasound, we're not, you know, doing formal cardiology level um echocardiograms. Uh We don't really look at strain at all. We look at um circumferential. So that's that cavity size decreasing, right? Um But we also look at longitudinal shortening in the apical four chain review. So we do look at that. Um Next. So here, let's look at longitudinal shortening compress play, sorry, the videos aren't playing right off the bat. Uh There we are. Um So, so that longitudinal shortening. OK. So where are you training your eyes to look for that? Look at that lateral annulus of the mitral valve. So not towards the in, in interventricular septum, but um the lateral annulus, if you don't mind putting the pointer on that and I will guide you in the direction of where it should be. Yup. Perfect. Um So you will see that annulus moving towards the apex of the heart. And visually, you wanna see that it's moving by at least a centimeter, right? Um And, and you often on the side of your screen will have little centimeter um points, um a little tick marks there to, to signify a centimeter. So you can visually see if it's moving towards the apex. So here, um you see movement of the lateral annuus towards the apex. You do see thickening of the LV wall segments and then you do see a change in the um area of the LV cavity by at least a third. And so this is normal LV function. OK. Next. OK. Um Here you um again, yup, looking for that longitudinal shortening at the um lateral annulus of the mitral valve. You see that it is indeed moving about a centimeter visually. You can see that it almost looks like a shark fin, right, like that triangular shape moving towards the apex of the heart. So that looks good and then thickening of the LV wall segments, they're thickening um maybe just about a third and then the cavity size um is decreasing. But for me, this is not decreasing. It quite as much as I want it to remember, ejection fraction. When they actually measure out the area of the LV cavity, it should be decreasing by at least a half. We're giving it a generous, we're doing it by a third when we're doing point of care, ultrasound just visually looking at it, right? Um So this is not quite meeting my, this isn't really decreasing exactly by a third. So this um patient actually had mild reduction in their LV function. So this is a mildly reduced LV. OK. Next. Well, this is gonna be one of my challenging views. Um So in this view, um and again, I want, I wanna train you your eyes, right? Cause every patient is not gonna give you that gorgeous, beautiful view of, of the all four wall segments. But my challenge to everyone is always look at it. Can you at least make out some something clinically in your, you know, patient at the bedside when you're doing an emergency um study. So longitudinal shortening. Do you see the lateral annulus moving? Oh yeah, it's a little hazy but it looks like there's some movement there. So not, I can't call it entirely reassuring but somewhat reassuring and then thickening of the LV wall segments. Um Yeah, look like there's thickening. But really the big thing here, the big takeaway here is that the change in the area of the LV cavity is such that the LV cavity walls are entirely touching, right? That black that where they're supposed to be a nice cavity full of blood, it just isn't there. So this patient presented again with, you know, hypotension and um let's say they were a trauma patient. You do a fast exam which is another exam. If you guys need that lecture, I'm happy to give it to you. Um uh You know, you see free fluid in the belly in this 25 year old uh male um who was just in a motorcycle accident, you see free fluid in the belly and you see this in the heart, I would say this patient needs blood guaranteed. So um so it gives you a lot of clinical information. Next, here we are. OK. Oh Just going back to the last example. So longitudinal shortening. So again, look at the lateral annulus there here, it's really not moving well, right? It's not moving by at least a centimeter. So that's an example of where it's not moving well. And then thickening of the LV wall segments really not thickening and the cavity size is even more dramatic, really not decreasing when you have um each systolic beat, right? So this is severely reduced LV function. OK. Next. So um I went through this but summary of the LV changes in systole, you have both longitudinal and circumferential changes that we look at from beginning to end of systole. You have increased wall thickness, right? Um You have decreased cavity size as that blood is ejected and you have displacement of the mitral annulus towards the apex. So that's what we're looking at next. Um And here you might um if you have a, you know, you know, phone to take a picture of the screen, et cetera. You might wanna take this and keep this with you because this is, this is the algorithmic process that you're gonna go through each time initially to train your eyes to do this left ventricular systolic assessment visually and then it becomes second nature. So the first I would say do it systematically after that, you know what you're looking for and it gets quicker and quicker and quicker and, and with any trainee, um what I always say is remember, you have be good before you're good and fast, right? So it's not about how fastly I can get to the um uh the, the bottom line there, it's, it's going through the process. So do you see greater than one third increase in the wall thickness, greater than a third decrease in LV cavity greater than a centimeter, longitudinal shortening is the anterior mitral valve leaflet past the midline. If all of those things are true, do you see end systolic effacement of the LV cavity? If you see end systolic effacement, it's a hyperdynamic gy, if you don't, then that's normal. Now, if you now move to the other side, if you don't see all of those things, the question that you should have for yourself is are all of those things reduced. If they're all reduced, then it's a severely reduced ejection fraction. If not all of them are reduced, you know, the cavity size is not really decreasing by a third, but the wall thickness looks OK. Things look like some things look, OK. Some things don't, then generally it's a mild to moderate reduction in the EF OK. So that's the, uh, the process next. Yeah, and just have a process, whatever you wanna start with, uh, make it your own practice but whatever you wanna start with and however you wanna end, you know, it's, it's your, um, it's however you wanna do but just have the, just do it the same way every time. So your brain can do it quickly as you progress in using ultrasound. Next. And there are limitations to doing um ultrasound in general. And then um specifically looking um doing a qualitative LV assessment, right? So, obesity. So in uh very obese patients, the sound waves have to travel through a good amount of tissue and it can make the windows really difficult. So it it can make it difficult to see the heart obstructive pulmonary diseases. So patients with COPD, um patients with um asthma where they have the lungs really hyperinflated and it's coming up over the heart can make it very difficult to see cause sound waves will not travel through air. And so um and will not conduct down to the heart. So you won't be able to see anything. Um mechanical ventilation can also cause that kind of remember, instead of that negative pressure breathing where you kind of have good distribution, you're gonna have a patient on a ventilator. Um their, their lungs may be um coming up over their heart as well, make it difficult to see, especially if you have them in uh high peep settings. Um Mitral or aortic valve disease, you can imagine since we're looking for mitral valve excursion, if you have a patient with mitral stenosis, um you can underestimate the um uh the LV function cause you, you look at the mitral stenosis and you say, oh, that mitral valve leaflet isn't really opening, but it's really because it's stenotic. One clue to look for that is kind of like that thickening calcification or something like this as well. Um But those can, that can make it a little bit difficult or if you have a patient with severe aortic valvular regurgitation, right. So severe aortic regurgitation can make it look like your ef is better than it actually is if you're just doing the visual assessment. Um LV, hypertrophy, I showed you one example of that but LV hypertrophy can make it look like you have a hyperdynamic LV cause the lb cavity is under control. Um But for the wrong reasons, right? Not because they're volume down, but because they actually have a hypertrophic heart, um regional wall motion abnormalities can sometimes make it difficult to do the um assessment. But then it'll give you other information that you have a wall motion abnormality and you might have had a heart attack, um conditions that alter cardiac anatomy like congenital diseases. Um and then operative competence. So how good you are at. Actually taking a look is one of the limitations. Um So I would just say practice, practice, practice. If you have access to an ultrasound, just keep doing it on everybody and anyone. And then when things, when you, you know, you, you'll pick up, first of all, you'll pick up a ton of stuff that you wouldn't expect. But second, you will start to see normal from abnormal ultrasound is all just pattern recognition next. And then just remember normal ejection fraction uh does not equal a normal heart. Um you can still have diastolic dysfunction. Um So the heart is not relaxing as well as it should and is stiff. And so um doesn't have good function. Um And so just keep that in mind we uh in this. Uh so when you're doing a visual LV assessment, you have not taken into account diastolic dysfunction. Next. And um some points to remember is that the principal role for focus, which is another fancy, you know, you know, cardiac. Uh So it's focused cardiac ultrasound as opposed to point of care ultrasound. But um so focus is a time sensitive assessment of the symptomatic patient. Um It I I it's more accurate than the physical exam for qualitative lb assessment. Um And remember that your ejection fraction is not equivalent to cardiac output. Um You should not replace the physical exam with ultrasound only you should use it as an extension of your physical exam. So after listening for, you know, murmurs and other things and gallops and you know, then you wanna, then you wanna move to the next step, which is taking a look. So instead of listening, looking with the ultrasound, um but it also should not replace a formal echocardiogram. So if you have access to a formal echocardiogram, read by a cardiologist, then it shouldn't replace that either. You can still do it at the bedside and then get a formal echocardiogram to follow up. OK. Next, uh so any questions or comments? Thank you so much. What an amazing session. We've got a few questions. Um Just turn my camera on so you can see me. Um And I'm just going to stop sharing my screen. Is that OK? Stop sharing and then I can see everything. So uh we've got some great questions um uh how to calculate the ejection fraction. Uh Someone is asking. Yeah, so I so doing visual point, you know, qualitative assessment, we're not doing that. Um But when you do an actual ejection fraction calculation um on a formal echocardiogram, what you're doing is using something called Simpsons method and you're actually measuring out the area of the LV cavity at end diastole and systole. Um And then you're also looking in the apical two chamber view, which is another view, a more advanced view of the heart. Um And looking at the difference there. So you can actually measure out like the the um actual vol like volumetric change, right? And so we don't at the, at the bedside, the clinical information I need for most of my patients, I don't need to do that. Yes, I get a formal echocardiogram when I need when I need to or when I wanna know that exact number. But if I have a hypotensive patient and I need information at the bedside like this, I'm not waiting for a formal assessment and, and like an exact number on that ejection fraction. What I'm doing is exactly what I showed you. And I'm getting an a sense of does this patient have severely reduced function? Less than 30% mild to moderately reduced, 30 to 50% or is it normal greater than 50% or are they hyperdynamic? Those are the four things that matter to me at the bedside in an uh in an urgent situation. Um I've got a question from Ahmed, who is asking what is the difference between the subcostal view and the four chamber view? Ok. So the subcostal view, you do see four chambers, but remember your probe is not um I don't know if you could bring that up, but your, your, your probe is not going to be at the apex of the heart. You're actually looking through the bottom beneath underneath here and you're looking upwards towards the um all four chambers through the right ventricle there. Um So if you just go back to the initial anatomy, thanks so much. Is that the right slide? Uh huh. So this here um and actually if you can go back even further one. Yeah, so here you, you see, you're, you're actually not, you see where the xiphoid is, right? So, so you're not at the subxiphoid region. So, so it's a, it's a different view cause here you're looking through the apex and getting all four chambers. Um And so, so this is why it's called the apical four chamber view. And then if you can just, I think subcostal is next after this can just show. So subcostal is this view, right? So the probe is placed inferior to the sternum and then you can actually see there. Um You can, you can look at RV size compared to all V size in this view. Um Visually, you can see uh the excursion, uh you can see that sort of longitudinal shortening. There are things similar to the apical four chamber view that you can look at in this view. Um but the LV is further away from your ultrasound beams, therefore, it will be less accurate. The RV is actually better looked at in this view. Um And actually in that one study that I showed you early on in the talk, um it, the RV, uh the cardiologist doing a formal echocardiogram assessment versus um a point of care ultrasound assessment, the RV was actually they were able, they had 100% agreement. So the RV is actually better visualized but LV um is further away. I hope that answered the question. Uh We've got a couple more questions. I, I'm conscious of your time as well. Doctor. Do you have time for one more question? Yes, I do. OK. Um Apart from volume changes, this is a question from Dennis. Um apart from volume changes, are there any other things that can be noted? I'm guessing from, from point of care. Ultrasound in septic shock. Yeah. So um in septic shock, you're gonna have um you can see an unfilled LV. Um So hyperdynamic heart, you can see tachycardia on ultrasounds, you'll actually see the, the, the heart, you know, uh heart rate on there. Um And then um you when you know, I have a separate talk for the uh inferior vena cava, but you can look at the IVC and actually look at um you know, whether it's unfilled, et cetera. So, um you, there's more, there's more that you can do. And I think, I think the best if you have a diagnosis of septic shock, you can um you already have that diagnosis. This patient, for example has had fevers for a few days. Um they had cough, they had fevers, you're thinking pneumonia. Now, they might be bacteremia bacteria within the bloodstream. And um they come to you hypotensive, right? You're already thinking septic shock and you have that answer and you can confirm by showing a hyperdynamic lb. Do I need to give this facial fluids? Checking the IVC? Um A point here, point checking for the IVC and um seeing if that is, you know, small, under filled uh res Spiric variation of the IVC completely collapsing with um each breast. Ok. All those things will give you an idea, but really, it's I I find it to be especially helpful in a patient with undifferentiated shock and sometimes these things come up where you don't even expect it. So, for example, I had a patient recently who was 36 years old, who um had a pneumonia and was admitted to the hospital for severe pneumonia and was on antibiotics and was on fluids and you know, everything and then she decompensated, she um became hypotensive. So she was brought up to the IC U in the ICU. Um, the physician assistant was admitting her and said this is septic shock like I know what this is, right? 100% septic shock. This is so easy. Yes. Ok. So you give antibiotics or escalate antibiotics. Even from where she was. We're giving fluids. Now, she's on pressors. She's on norepinephrine, epinephrine, she's on vasopressin, she's on three pressors. Now, this young, 36 year old. So now I say, ok, well, let me just take a look with the ultrasound and make sure that this is indeed septic shock, right? So I take a look, her IVC is big. PVC is big. I did not expect that in a septic shock patient. Right. So take a look at her heart, she had a huge pericardial effusion. She was in tamponade. And so she had this obstructive shock where the fluid around the heart was actually pushing up against her heart, not allowing it to fill appropriately. So she was in a tamponade state and right there at the bedside drained the effusion uh by with a needle, um drained the effusion and then she was her nor normal BP. So this was not septic shock. So this is an example of just using uh you know, the more you use this at the bedside, the more you're gonna pick up things, I mean, this patient would have died this young woman, right? And so instead I was able to pick this, this, this if uh you know, effusion up um just by saying, OK, you know, I, I know this is septic shot, but let me just take a look and it wasn't. So that's an another example of uh using it super um guys, we're kind of at time. But uh thank you so much, Doctor Sy for uh sharing with us amazing educational session. And um I've learned lots and I think it's probably fair to say that that everyone in the audience has learned lots. We're really grateful for your time um for everyone who's attending. There is a link for a feedback form in the chat which will allow you to claim an attendance certificate as well. Um, and um, I I'm just gonna say thank huge. Thank you Doctor Syski for, for joining us. Um Everyone has a really great rest of their day. Thank you.