Module 11 : Apical Views

Question 1

apical window

Answer 1

• anterior axillary line to the posterior axillary line in 3th or 5th intercostal space
• use PMI TO FIND APEX = 2 to 3 o clock
• endocardium lining must be seen well in the whole LV

Question 2

point of maximum impulse (PMI)

Answer 2

• palpate on the body where you feel the most heart movement
• used to find apical window

Question 3

apical 4 chamber (A4C) structures - right heart

Answer 3

• RV free wall
• RV cavity
• Moderator band
• TV
  + ANTERIOR TRICUSPID VALVE LEAFLET
  + SEPTAL TRICUSPID VALVE LEAFLET
• RA
• eustachian valve
  +/- IVC SVC
  +/- chiari network (free floating filaments)

Question 4

apical 4 chamber (A4C) structures - left heart

Answer 4

• LV inferior septal wall
• LV anterolateral wall
• LV cavity
• MV
  + ANTERIOR MITRAL LEAFLET
  + POSTERIOR MITRAL LEAFLET
• right upper pulmonary vein RUPV
• left upper pulmonary vein LUPV
  +/- left atrial appendage
  +/- left lower pulmonary vein
  +/- coronary sinus

Question 5

Apical 5 chamber (A5C)

Answer 5

• LVOT and AO valve
• from A4C angle probe more anteriorly
• right heart structures will be lost
• both AV leaflets must be seen during both systole and diastole
• both AV leaflets must be seen to separate fully
• 5th chamber AORTA

Question 6

A5C visible structures

Answer 6

• LV apex
• IVS more anterior segment than A4C
• lateral LV wall
• LVOT
• AV
  + RIGHT AND LEFT CUSPS
• prox aorta including sinus of valsalva
• part of the LA

Question 7

Apical 2 Chamber (A2C)

Answer 7

• from apical 4 rotate counterclockwise 60’
• rotate only until RV disappears
• need to see anterior wall clearly
• sometimes may need to slide up one interspace
• don’t shorten LV apex

Question 8

leaflet location in A4C

Answer 8

• posterior on the left side and anterior on right side of screen

Question 9

A2C strucutres

Answer 9

• LV apex
• LV walls
  + inferior wall
  + anterior wall
  + inferolateral pap muscle
• MV
  + posterior mitral leaflet
  + anterior mitral leaflet
• LA
• coronary sinus
• sometimes see
  + one or more pulmonary veins
  + Left atrial appendage (LAA)
• ENDOCARDIUM MUST BE WELL SEEN IN ENTIRE LV

Question 10

apical 3 chamber (A3C)

Answer 10

• looks identical to PLAX view on its side
• rotate probe 30” counter clockwise from A2C
• rotate until the FULL LVOT and BOTH AV CUSPS
• AO sinus should be seen

Question 11

A3C structures

Answer 11

• LV apex
• LV chamber
• inferolateral pap muscle
• MV
  + ANTERIOR AND POSTERIOR CUSP
• LA
• CS
• LVOT
• AV
  + RIGHT AND NON CORONARY
  +/- pulmonary veins

Question 12

subcostal window

Answer 12

• pt supine with knees bent to relax abs
• 2cm inferior to to xyphoid process
• probe toward you in 3 o clock position
• must apply some downward pressure to allow th e probe to see under the rib cage
• uses liver as an acoustic window

Question 13

subcostal 4CH structures seen

Answer 13

• RV inferior wall
• TV
• IVS
• RA
• IAS
• LV
• IVS
• MV
• LA
• SVC sometime

Question 14

subcostal 4 is the best view to see what

Answer 14

ATRIAL SHUNT IS BEST SEEN IN THIS VIEW

Question 15

patent foramen ovale (PFO)

Answer 15

• occurs when the atrial foramen ovale doesnt shut all the way or isn’t there and flow between atria occurs
• BEST SEEN IN SUBCOSTAL 4 VIEW

Question 16

subcostal IVC

Answer 16

• rotate probe to the 12:30 position
• angle inferior from subcostal 4
• adjust depth to show IVC
• IVC
• want a tiny bit of RA

Question 17

subcostal aorta

Answer 17

• make sure lumen is anechoic

Question 18

suprasternal notch long axis (SSN)

Answer 18

• place the probe in the suprasternal notch
• move patient chin up
• may remove pillow and place under shoulders
• rotate probe to 1-2 o clock

Question 19

SSN structures visible

Answer 19

• SVC
• ascending AO
• descending AO
• right pulmonary artery
• aortic branches
  + brachiocephalic BSA
  + left common carotid LCC
  + left subclavian artery LSA