Case Discussion

This study demonstrates a limited point of care transthoracic echocardiogram (TTE) with an absence of the indicated pathologies specifically sought in a point of care study, namely:

• there is a normal qualitative left ventricular systolic function, with the following features informing this assessment:

  • anterior mitral valve leaflet contacts septum during early diastole

  • vigorous apical excursion of the mitral annulus toward the apex during systole

  • symmetric and appropriate (>50%) systolic thickening of all visualised left ventricular myocardial segments accompanied by inward endocardial motion reducing chamber diameter by more than a third of the diastolic diameter

  • left ventricle forms a geometric truncated ellipsoid with a normal long to short axis dimensional relationship

• there is no evidence of right ventricular dysfunction, with the following features noted:

  • the right ventricle in the apical 4 chamber view is triangular, area appears to be qualitatively less than two thirds that of the left ventricle, LV is the apex forming chamber, vigorous apical excursion of the lateral tricuspid annulus during systole with normal systolic inward excursion and thickening of the visualised free wall

  • there is normal subjective wall thickness (<5mm) of the right ventricular outflow tract and free wall

  • parasternal short axis at the mid papillary level demonstrates septal concavity with respect to the left ventricle throughout systole and diastole, implying the normal physiologic presence of higher left sided pressures

  • right ventricular outflow tract diameter in the parasternal long axis view approximates that of the aortic root and the left atrium

  • the IVC dimensions and respiratory variability may allow rough estimation of a right atrial (and central venous) pressure; the above findings correlate with an absence of pathologic elevation of CVP, classically described relationship with "volume status" is controversial

• there is no pericardial effusion (and therefore no pericardial tamponade)

Cardiac POCUS can also be used to guide relevant procedures, such as transvenous pacemaker placement and pericardiocentesis.

Suspected abnormalities related to atrial dimensions, diastolic function, derivation of pressures from (spectral Dopper derived) jet velocities, and valvular structure and function i.e. the presence of regurgitation and/or stenosis should warrant comprehensive, formal echocardiography.

Key learning points:

• POCUS largely focuses on dichotomous questions addressing the presence or absence of defined, time-sensitive pathologies

• cardiac point of care echocardiography is commonly used to rapidly assess for the following to improve detection and expedite time-sensitive management:

  • severe left or right ventricular systolic dysfunction or severe chamber dilation

  • pericardial effusions

  • estimation of central venous pressure via IVC size and dynamics

  • procedural guidance