Cardiac POCUS Example
Below you will find an example of Cardiac Imaging Acquisitions with the GE Venu Go done by the NeoCardioLab. This is the machine currently used for the NICU POCUS program at the Montreal Children's Hospital. The study below is an example of a Targeted Neonatal Echocardiography (TNE), but it also highlights the basic cardiac POCUS views. I have outlined some key views that I believe can be captured during a cardiac POCUS evaluation (compared to those that we usually obtain for a TNE, which are more exhaustive).
Cardiac POCUS is primarily used to assess:
RV/LV relationship in the short axis (more advanced application)
The ASE guidelines provide detailed indications for both TNE and cardiac POCUS.
Cardiac POCUS and TNE - Parasternal Long Axis (PLAX). A view that outlines global LV contractility. Provides information as well on filling and hypertrophy of the left ventricle. The view also allows to outline that the aortic valve opens and closes, as well as the mitral valve. There is no major outflow tract obstruction.
Cardiac POCUS and TNE: Quick sweep to the RV outflow tract (anteriorly)
TNE - M-Mode in the PSAX - For assessment of shortening fraction, LV mass and hypertrophy. E-point septal seperation (rarely used in the neonatal period). E-point septal separation (EPSS) is an echocardiographic measurement used to assess left ventricular function, particularly in cases of systolic dysfunction. It refers to the distance between the anterior mitral valve leaflet (specifically, the E-point of the mitral valve) and the interventricular septum during early diastole. In a healthy heart, the mitral valve leaflet comes close to the septum, with a small separation (this has not been validated in the newborn). This indicates good left ventricular function and normal systolic function.
TNE - M-Mode in the PLAX. Same applications as in the PSAX. Angle-dependent.
TNE - LA/Ao ratio in the PSAX
Cardiac POCUS and TNE - Sweep in PLAX posteriorly to the RV inflow.
TNE - Colour for flow at mitral valve, LVOT and RVOT. Visualization of portion of the interventricular septum for an inter-ventricular communication.
Cardiac POCUS - Right atrial - Right ventricular (RV inflow) view. In this view, one may sometimes appreciate the presence of line in the right atrium when they are too deep. It can also be used to visualize an ECMO cannual. Best views are typically the subcostal views.
TNE - Colour for presence of Tricuspid Regurgitant jet.
Cardiac POCUS - Another view of the RV inflow and right atrium
TNE: Colour over the RVOT for the inflow (in red) and to evaluate the presence of tricuspid regurgitation ("blue flicker").
TNE - Flow ("blue") originates in the RVOT and goes through the pulmonary valve to feed the pulmonary artery which is of normal caliber. There is no clear acceleration or signs of obstruction.
TNE - colour in the RVOT and zoom of the RVOT in the PLAX (for meaurement of the RVOT).
TNE: RVOT - Pulse Wave Doppler for PAAT/RVET assessment and RV output estimate.
Cardiac POCUS and TNE: View of the RVOT in parasternal short axis (PSAX). This view is particularly important in the pediatric ED POCUS for the application of ruling out pulmonary embolus (indirect signs: pulmonary artery dilatation, sometimes saddle clot can be seen).
TNE: one may appreciate in these views the tri-leaflet aortic valve (or to rule out bicuspid aortic valve or other anomalies of the aortic valve - pediatric cardiology). As well, in this view, one may appreciate the left coronary artery.
Cardiac POCUS: Sweep from the base of the heart to the mitral valve area ("fish mouth"). Important view for global contractility of the heart.
Cardiac POCUS: View at the level of the papillary muscles of the left heart (PSAX). Here we can appreciate the good circumferential contractility of the heart. There is no clear pericardial effusion in the posterior aspect of the heart (fluid tends to collect towards the apex and posteriorly due to gravity).
TNE and advanced cardiac POCUS: relationship between the RV and LV chambers. At peak of systole, septal flattening or bowing may indicate adverse systolic pressure relationship between the RV and the LV. One may assume (without a CHD) that the relationship between the Pulmonary Artery and Aorta are reflected to be similar than the relationship between RVSP and LVSP.
Cardiac POCUS: Sweep towards the apex outlining global contractility of the left ventricle.
TNE: The RV is crescenting and slim compared to the round muscular LV.
TNE: Nyquist / Velocity filter is decreased and the colour box is placed accorss the interventricular septum. The septum is scanned to rule out the presence of an inter-ventricular septal defect. Nyquist is decreased because the PVR may still be high in newborns with their ongoing transition, which may limit the velocity of the flow accross the septum in the first few days after birth (very easy to miss a VSD).
TNE: Other views with sweep in PSAX to rule out the presence of low velocity ventricular septal defect.
TNE: Another sweep to rule out a ventricular septal defect.
TNE: Another sweep to rule out a ventricular septal defect. One may appreciate trace pulmonary insufficiency
TNE: Pulse Wave Doppler at the RVOT for PAAT/RVET and RV output estimate.
TNE: CW-Doppler through the RVOT to evaluate for the presence of acceleration (or signs of RVOT obstruction). It is also good habbit to take a CW-Doppler to evaluate for the presence of pulmonary insufficiency when aligned with a potential jet.
TNE: Branch pulmonary arteries in B-mode.
TNE: Branch pulmonary arteries with colour flow.
TNE: Branch pulmonary arteries with colour flow.
TNE: Pulse-Wave Doppler of the left pulmonary artery to rule out presence of distal pulmonary stenosis.
TNE - Flow originating before the pulmonary valve in the RVOT and feeding the main pulmonary artery and the right and left pulmonary arteries.
TNE: Pulse-Wave Doppler of the right pulmonary artery to rule out presence of distal pulmonary stenosis.
TNE - Nyquist is decreased to evaluate for the pulmonary veins coming back to the left atrium.
TNE: PW-Doppler of the Right Upper Pulmonary Vein.
TNE: PW-Doppler of the Right Lower Pulmonary Vein.
Cardiac POCUS and TNE: Quick sweep towards the LVOT in the apical view.
Cardiac POCUS and TNE - Apical 4 Chamber view to appreciate the LV and RV function, the opening of the mitral and tricuspid valves, as well as the right and left atriums (presence of clot, dilatation).
Cardiac POCUS - TNE: One may also sometimes appreciate the presence of a pericardial effusion in this view, although it is not the best view for that since it tends to accumulate posteriorly and at the apical level. As such, best views are often the subcostal views and the PSAX views. In situation of low preload, the LA is often subjectively small and the LV wall are often kissing - although this is a subjective assessment (more formal assessment come from TNE applications such as a narrow LVOT-VTI with a high peak systolic velocity).
TNE: Colour over the LV inflow. Ruling out the presence of mitral insufficiency or stenosis, visualization of the filling of the LV.
TNE: Colour flow views in the A4C. Here the box can also be placed higher with a decrease in the Nyquist to visualize the Right Upper Pulmonary veins and the left pulmonary veins.
TNE - LV inflow velocities for the E and A velocities of the mitral inflow. Diastolic parameter. Allows for also evaluation during tamponade physiology.
Cardiac POCUS and TNE: LV focused apical 4 chamber view.
Cardiac POCUS and TNE: Apical 5 Chamber view for the mitral-aortic continuity. Visualization of the LV outflow tract (ruling out obstruction such as in the context of infant of diabetic mother with septal hypertrophy).
Cardiac POCUS and TNE: Apical 5 Chamber view
TNE: Apical 5 Chamber view with colour for the inflow-outflow visualization.
TNE: Apical 5 Chamber view with colour over the interventricular septum (one of the views to rule out a perimembranous VSD).
TNE: LVOT-VTI for estimation of LV output. Also may be used for assessment of filling depending on the pattern (although controversial application). One may consider also a CW-Doppler through the LVOT if there is acceleration and a concern for obstruction.
TNE: Inflow-Outflow Pulse-Wave Doppler for the evaluation of the IVRT (iso-volumetric relaxation time).
Cardiac POCUS - TNE - Apical 2 Chamber view for assessment of the anterior and posterior wall of the LV.
TNE: This view is important to calculate the EF by Simpsons's Biplane.
Cardiac POCUS - TNE: Apical 2 Chamber view.
TNE: RV inflow-outflow (3-chamber view) for assessment of RV Function. Also a good view to put colour on the tricuspid valve and assess for TR. This view is also used sometimes for its alignment with the RVOT to obtain a RVOT Doppler (PW or CW).
TNE: Sweep anterior towards the mid-area of the heart. One may appreciate anteriorly the RVOT, the pulmonary valve and the MPA with its bifurcation in the right and left pulmonary arteries.
TNE: TAPSE (tricuspid annular plane systolic excursion) as a marker of RV systolic function. The line of interrogation needs to pass from the Apex to the attachment of the tricuspid valve at the level of the free wall.
Cardiac POCUS - TNE: RV focuse view in the apical view in order to assess RV systolic function and dimensions.
TNE - Tissue Doppler Imaging of the RV free wall below the tricuspid valve attachment for the Myocardial performance index, the systolic and diastolic velocities.
TNE - Tissue Doppler Imaging of the septum below the mitral valve attachment for the LV Myocardial performance index, the LV systolic and diastolic velocities.
TNE - Tissue Doppler Imaging of the LV wall (anterolateral) below the mitral valve attachment for the LV Myocardial performance index, the LV systolic and diastolic velocities.
Cardiac POCUS - TNE: Subcostal view (long axis) where we can appreciate the RA and LA, the presence of a pericardial effusion (if there was one).
Cardiac POCUS - TNE: Subcostal view (short axis) where we can appreciate the RA and LA, the presence of a pericardial effusion (if there was one). The bicaval view is particularly interesting to appreciate the line tip position (when there is one).
Cardiac POCUS - TNE: Sweep in the subcostal short axis view to evaluate for contractility and the presence of an effusion.
TNE: Colour to evaluate for the presence of a inter-atrial shunt, as well as for evaluation of SVC flow.
TNE: Colour for the evaluation of an inter-atrial septal defect or inter-ventricular septal defect as we sweep towards the apex.
TNE - Colour to evaluate the presence of a shunt at the atrial level. Here there is a small left to right (red) Patent foramen ovale.
TNE: Sweep to evaluate of the presence of a PDA (no PDA in this case).
TNE application: Below you will find examples of the arch view in the suprasternal area.
