Figure 318 demonstrates normal parasternal long axis

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Figure 3.18 demonstrates normal parasternal long-axis views. Note that the descending thoracic aorta is visible as a brightly outlined circle in the far field deep to the heart. Figure 3.19 demonstrates normal parasternal short-axis views. The left ventricle appears as a circle. Figure 3.20 demonstrates normal apical four-chamber views. The right ventricle should be on the same side as the probe marker, and the left and right ventricle sizes can be compared well in this view. 74 Diagnostic ultrasound Cardiac ultrasound
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Figure 3.17 Normal subxiphoid four-chamber views. Figure 3.18 Normal parasternal long-axis views. Diagnostic ultrasound 75 Cardiac ultrasound
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Abnormal images Pericardial fluid Pericardial effusions are defined as the presence of fluid in the pericardial space. They can be caused by a variety of local and systemic disorders or trauma, or they can be idiopathic. They can be acute or chronic, and the time course of development has a great impact on the patient’s symptoms. The pericardium itself is a dense, fibrous sac that completely encircles the heart and a few centimeters of the aorta and pulmonary artery. The dense parietal pericardial tissue is highly echogenic (looks white on ultrasound) and is recognized both anteriorly and posteriorly as the sonographic border of the cardiac image. A pericardial effusion is characterized on ultrasound by an anechoic (black) fluid collection between the visceral and parietal pericardium Figure 3.19 Normal parasternal short-axis views. Figure 3.20 Normal apical four-chamber views. Note that the right ventricle diameter is smaller than the left. 76 Diagnostic ultrasound Cardiac ultrasound
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( Figure 3.21A ) – keeping in mind that the visceral pericardium is not usually seen by transthoracic cardiac ultrasound. Therefore, a pericardial effusion appears as a fluid collection that separates the bright white, highly reflective parietal pericardium from the heterogeneous gray myocardium. (A) (B) Figure 3.21 ( A ) The black stripe (*) separating the pericardium from the myocardium is the surrounding pericardial effusion. ( B ) Here, the pericardial effusion (asterisk) is grainy and gray, consistent with coagulating blood, pus, or other echogenic material. The fluid (*) separates the right (R) and left (L) ventricles from the pericardium (arrows). Diagnostic ultrasound 77 Cardiac ultrasound
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If the fluid has pus, blood mixed with fibrin, or is malignant, it can appear echogenic or have a gray appearance ( Figure 3.21B) . Although this can make the diagnosis more challenging, in real time this “gray” appearance is swirling in a pocket of black fluid that separates the parietal pericardium from the myocardium. In certain clinical scenarios, pericardial fluid volumes of up to 50 mL can be physiologic. Small effusions are usually located posterior and inferior to the left ventricle. Moderate effusions extend toward the apex of the heart, and large effusions circumscribe the heart. Most textbooks define a moderate effusion as an echo-free pericardial space (anterior plus posterior) of 10–
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