Welcome to mastering and guidelines in ultrasound and Echo
The most common and
reliable technique for measuring ejection fraction is
Simpson or disk method. in this
technique we just go get apical four ( and two) chamber view. correct apical four chamber view and then zoom on the left ventricular and
then we go and
trace endocardium in two
spots: end diastolic and end systolic in apical four
and apical two chamber views
There is a general rule for tracing endocardium: we don't include
papillary muscle and
trabeculation or
Trabecula. as you see most of the time we have trabeculation more prominent in the right ventricular
But sometime in the left, as you will see in this image
trabeculation as round smooth cylinder or irregular bundle muscle that cover endocardium.
On these two cases if we needed to trace endocardium, for example measuring left ventricle mass
We should trace endocardium too and again, we don't include
Trabeculae and papillary muscle and we just traced correct, right functional Myocardium.
Now! how we can determine endocardium?
In most cases, endocardium at two spot is very clear
One is endocardium at the septum and another is on anterolateral
septum (wall). Inthese two spots, in most patient we will see clear endocardium, but
in apex and
in
basal lateral
Usually is not very clear.
How we can determine in those two spots?
Let's go with the apex. If you notice apex on this case, and this clip as you see .there are some
near field or reverberation artifact as
You see this line. that is fixed and doesn't move. we know this is artifact. how we can determine apex here?
there is one trick or tip you can do and
determine endoacrdium. as we know
myocardium at the apex and at the
atriventricular groove (level) are thinner than the other spot and
if we followed the endocardium at this anteroseptal or anterolateral and
find the epicardium as you see here at the apex very smooth
Curved, hyperecho as far line. this is epicardium. so
We can follow the endocaardium at this tow spots to the apex and give the same size thickness
to the (from) epicardium
So! we follow there and then almost the same thickness as I have here
I give to the apex and so my
Endocardium will be this line spot and at the systole we do the same
follow ....
the endocardium at those two spots- this is very clear- and then
give the same thickness as we will see here.
If I follow I can give this myocardium at antero- lateral and follow it will be top
If you are sure hundred percent this line (hyperecho) is endocardium, we go
Change your angle and everything and still you will see no!, this is my endocardium at the apex. in that case
there is (are)
two reasons it can be this area
This line your endocardium: 1), you are foreshortening; because in the
apex endocardium doesn't
go too much - a few millimeter thickness. So if end diastole was here and now is
here too much far
only you are foreshortening or the patient has
Apical hypertrophy. in this case. You have to show in other views, we have apical hypertrophy
for
mid-segment lateral and basal endocardium
We do the same way
Let's go to the question and answer to this one.
as you see here septal endocardium is very clear
I can go start with the medial hinge of the
Mitral valve. this is spot.
and then follow endocardium here. We have a little trabeculation
I cut the trabeculation at this spot-anterolateral next to the papillary muscle at this point.
I connected this point to the
lateral hinge of the mitral valve
The curve that's smooth and parallel to the epicardium
Here as you see.
so I am connecting that spot is very clear
to the hinge with the curve that is parallel to the epicardium. in that way
I won't miss anything and my tracing will be correct
As you maybe noticed, I didn't connect to this spot, because this a Z axis
artifact and there is some
maybe chordae tedineae
overlap and I
go and make it hinge
This V shape is the hinge- lateral hinge and medial hinge if you are not sure where is the hinge just cineloop, go
back and forth and you find it where the mitral valve go around that spot.
So that is hinge and then you connect those two spots with the parallel to do this
lateral epicardium.
.What about this case?
as you maybe noticed patient has prominent trubecualtion and most probably patient has apical non-compact
Cardiomyopathy and if you put color and decrease the scale color
You will notice the blood goes all the way in up to here. So this is not endocardium.
This is your real endocardium.. So you cut it that trabecualtion and trace the same way
what about when we have some mass or here as apical thrombosis? how we trace it ?
you deal with it as a PAPILLARY MUSCLE
So we don't you don't think we don't include that one and then trace
Endocardium in the same way. We did it the only disadvantage of this measurement
We don't include this mass is we are overestimating
stroke volume and you know why? and
here as you see the
lateral endocardium is not clear. should I go trace this area or what? and
Why if this is endocardium it goes suddenly become very thin at this spot? We follow the same rule. I find the
Endocardium at anterolateral part here. This is my endocardium at this very clear. Then I
Connect this line to the hinge
lateral hinge- mitral valve hinge
Parallel to the epicardium. as you see, this is my epicardium line.
so I connected this spot to the hinge with the parallel line to
lateral
epicardium at this spot.
I hope you
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up to next time. hasta la vista