– Optimal patient position: 45 degrees left lateral position; image often improves with expiration

– Place yourself on the patient’s right side

– Hold the transducer with a pencil grip with your right hand

– Place the transducer at the apex beat

– OM should be directed backwards and to the patient’s left side

– Adjust the transducer position with small incremental tilt and rotational movements

– Have the desired image clear in your mind and watch the screen until you achieve it

– Depth: 14-18 cm

In the video below, the anatomical structures are indicated on the beating heart

Observe: Liver, apex of the heart, basis of the heart, right atrium, right ventricle, left atrium, left ventricle, inter-ventricular septum, inter-atrial septum.

The probe is placed on the skin, the yellow fan-like sector (the scanning plane) diverges from the probe and intersects the heart

The orientation marker (OM – grey arrow) is pointing towards the left side of the patient (the right side of the screen)

To understand how the sector is presented on the screen, imagine that the upper border of the screen is the skin, and the sector diverges from the probe placed on the skin.

The blue radius on the screen corresponds to the blue margin of the yellow fan

The red radius on the screen corresponds to the red margin of the yellow fan

The left ventricle is displayed on the right side of the screen, when the OM is correctly pointing towards the patient

The target view is a 4 chamber image corresponding to the scanning plane indicated on the torso of the picture

All four chambers are viewed in long axis

As the transducer is placed at the apex, both the right (RV) and the left (LV) ventricles appear in the near field and the right (RA) and left (LA) atria appear in the far field

When a 4 chamber view is present on the screen, there is by definition zero degrees of rotation

The apical view is obtained by placing the transducer where the cardiac apex is most easily palpated

The orientation marker on the transducer should be directed towards the patient’s left side

Notice the location of the heart in the thoracic cavity and the orientation of the ultrasound sector beam

Page 1 on the FATE card is used for this part of the FATE examination

Position 2 is indicated on the FATE torso in the bottom right corner of page 1 on the card

The top right image is the target image to be obtained in position 2

Study the FATE card and memorise the position and what target image to look for before beginning the examination

You can download the FATE card from: usabcd.org/FATE-card

The apical view is a 4 chamber view (A4CH) imaging all 4 chambers of the heart

The position is obtained in position 2 indicated on page 1 of the FATE card

The apical 4 chamber view is suitable for a quick qualitative evaluation of:
– Pathology (pericardial effusion, pulmonary embolus)
– Wall thickness
– Chamber dimensions
– Bi-ventricular function

This lesson will go through position 2 in detail, focusing on how to obtain and interpret the right 2D ultrasound image

The relationship between the IVC and right atrium pressure can be characterised as follows:

IVC diameter <2.1 cm and >50% collapse (inspiratory sniff) suggests normal RA pressure (0-5 mmHg)

IVC diameter >2.1 cm and <50% collapse (inspiratory sniff) suggests high RA pressure (10-20 mmHg) IVC diameter and collapse that do not fit into these two scenarios indicate intermediate RA pressure increase (5-10 mmHg)

Before you start scanning, ask yourself:

1. Which position – 1, 2, 3 or 4?
2. How should I hold the probe?
3. Where should the orientation marker (OM) be pointing to?
4. What should appear on the screen?

Holding the probe in your right hand:

1. Apply gel without touching the footprint of the probe with the gel dispenser
2. Place the transducer on the chest wall where you expect to get the desired image
3. Circle with your hand until you recognise any anatomical structures on the screen
4. Then optimise the image in only one plane at a time by rotating / tilting / sliding

Anatomy

You have now learned:

– The anatomy of the FATE position 1 – the subcostal 4 chamber and IVC view
– How to obtain the correct images with respect to transducer orientation and the relationship of sector beam of the probe and the image on the screen
– To appreciate the biological variations
– IVC scanning and the limitations, especially that the IVC is an unpredictable guide in fluid management and should not be used as a single parameter for guidance of fluid therapy

When you feel confident move on to the next lesson on the FATE position 2, the apical 4 chamber view (A4CH)

You can download the FATE card here: usabcd.org/FATE-card