Cardiac Echocardiography – Subxiphoid View – SonoSite, Inc.

Cardiac Echocardiography – Subxiphoid View – SonoSite, Inc.


– Hello, my name is Phil Perera, and I’m the Emergency
Ultrasound Coordinator at the New York Presbyterian
Hospital in New York City, and welcome to SoundBytes Cases. In this module, we’ll continue our journey through the cardiac
echocardiography examinations, looking at the four standard views. In this module, we’re
specifically going to focus on probe position B, as shown
in the pictorial here, the subxiphoid view of the heart. Hopefully you’ve joined me prior for the parasternal views,
as shown in probe position A, and in an upcoming module
on the apical view, as shown in probe position C. The subxiphoid view of the heart is an excellent way of
imaging the patient’s heart, and getting a lot of information
directly at the bedside. Now let’s learn how to perform the subxiphoid view of the heart. As shown in the pictorial to the right, the probe is coming from
an abdominal position, placed just inferior to the
xiphoid tip of the sternum. It’s important to lay the probe flat and push down and under the sternum, aiming towards the
patient’s left shoulder. Now the marker dot on the probe should be over towards
the patient’s right side, with a caveat that the ultrasound’s screen indicator dot is over towards
the left of the screen. Now it’s very important to put your hands on top of the probe, and
really push down and up to get the good imaging plane underneath the sternum, to make the angle to get a good view of the heart from this plane. Let’s now take a look at the image that you’ll obtain from the
subxiphoid view of the heart. Here’s a pictorial to the left, and an ultrasound image to the right. The first chamber that we’ll encounter directly below the liver, which is our acoustic window in this case, on to the heart will be the right ventricle. Immediately posterior
to the right ventricle we’ll be seeing the left ventricle, and as shown in this pictorial, notice that it has more
muscular and hypertrophic walls. From the subxiphoid plane, we’ll also be able to image the right atrium to the left of the right ventricle, and the left atrium, just to the left of the left ventricle. We can also appreciate the white line that is the pericardium circumferentially surrounding the heart. Now that we know where the chambers are, let’s take a look at a video clip of a normal heart from
the subxiphoid plane. As we remember, the liver is our acoustic window onto the
heart from this plane, and so the liver will be seen anteriorly, just to the top of the screen. Just below the liver, we appreciate here the right ventricle, and notice here, just to the left of the right ventricle, we can appreciate the right atrium. Notice the tricuspid
valve flipping up and down in between the right atrium
and the right ventricle. Now let’s look posterior
to the right ventricle, and we appreciate the left ventricle. Notice again, its more muscular
and hypertrophic walls. Just to the left of the left ventricle we appreciate, in this
case, the left atrium, and we also get a glimpse
here of the mitral valve flipping up and down in between the left atrium and the left ventricle. Now let’s look at that white line, both anteriorly above the right ventricle, and posterior, below the left ventricle, that is the pericardium. Note here the absence of any significant pericardial effusions. In that last video clip, we noted good contractility of the left ventricle from diastole to systole. Let’s contrast that clip to this one from a patient who
presented with shortness of breath, and advanced cardiomyopathy. We see the right ventricle
just below the liver, anterior to the left ventricle. And what we see here
is a poorly contracting and dilated left ventricle, consistent with a cardiomyopathy heart. However, note the absence
of any significant dark or anechoic fluid collections consistent with a pericardial effusion. Here’s a patient who
presented with renal failure and acute shortness of breath. We’re again looking from
the subxiphoid plane, so we see a little strip
of the liver anteriorly. The right ventricle just below the liver, and the left ventricle seen posteriorly to the right ventricle. Notice how hypertrophic the walls of the left ventricle are in this patient. We also appreciate a dark fluid collection both anteriorly, just below the liver and above the right ventricle, and posterior below the left ventricle, consistent with a circumferential, or large, pericardial effusion. If we see a large pericardial effusion on bedside echo, our next move is to look for signs of cardiac tamponade. Here’s a patient who manifests all the signs of cardiac
tamponade on bedside echo. Let’s look specifically at
the right side of the heart. Notice the very large
pericardial effusion, and note the chaotic movement
of the right ventricle as it struggles to open during diastole. The compression of the right ventricle in this patient is consistent with advanced cardiac tamponade. The right side of the heart is preferentially compressed before the left ventricle, due to
its lower pressure circuit. In conclusion, I’m glad
I could share with you this SoundBytes module going over the subxiphoid view of the
cardiac echo examination. This is a very important exam to put into your routine practice in looking at your patient’s
heart at the bedside, and will tell you if the patient has a pericardial effusion, as well as giving a sense of left
ventricular contractility. Also, the subxiphoid view of the heart gives better views of the
right side of the heart than the more superior
parasternal views of the heart. So I hope to see you back
as SoundBytes continues, and as we move on to discuss the other echo exam planes of the heart.

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