Module · Heart
FUSIC Heart resources
50 scans, 10 directly observed, all competencies. The five FUSIC Heart questions: LV dilated/impaired? RV dilated/impaired? Low venous return? Pericardial effusion? Pleural effusion?
Standard views & probe techniquePLAX, PSAX, A4C, subcostal, IVC — getting consistent images every time.
Use the phased-array (sector) probe, 2–4 MHz, for all cardiac views. Confirm indicator orientation by tapping the probe edge — it should match the screen marker.
- PLAX: 3rd–4th left intercostal space, just left of sternum. Indicator to right shoulder. Shows LV, LVOT, aortic root, LA, MV, pericardium. Depth 14–16 cm.
- PSAX: Rotate 90° clockwise from PLAX. Indicator to left shoulder. Fan from base (AV “Mercedes Benz”) through mid-cavity (papillary muscles) to apex.
- A4C: Apex beat position, 5th–6th ICS, MCL. Indicator to left hip. All four chambers visible. Fan to A5C to see LVOT.
- Subcostal: Subxiphoid, probe flat, indicator to patient’s left. Best in ventilated patients and post-arrest. Best pericardial view.
- IVC view: Rotate to longitudinal from subcostal, indicator to head. Measure 2 cm proximal to RA, just distal to hepatic vein confluence.
LV size & systolic functionQualitative grading, fractional shortening, FAC — practical bedside assessment.
FUSIC Heart uses qualitative (eyeball) assessment. Biplane Simpson’s volumes are FUSIC HD territory.
Qualitative grading:
- Normal: Brisk inward motion; endocardium thickens clearly; cavity nearly obliterates at end-systole.
- Mildly impaired: Reduced but definite inward motion.
- Moderately impaired: Clearly reduced motion; LV does not contract well.
- Severely impaired: Minimal motion; large dilated LV barely changes size.
Fractional shortening (FS): M-mode cursor through LV in PLAX at chordal level. FS = (LVEDD − LVESD) / LVEDD × 100. Normal ≥25%. <20% = significantly impaired.
FAC (A4C): Trace endocardial border at ED and ES. FAC = (EDA − ESA) / EDA × 100. Normal ≥35%.
| LV size | Men (LVEDD) | Women (LVEDD) |
|---|---|---|
| Normal | <5.6 cm | <5.2 cm |
| Mildly dilated | 5.6–6.0 cm | 5.2–5.7 cm |
| Grossly dilated | >6.5 cm | >6.1 cm |
RV size & functionTAPSE, RV:LV ratio, D-shaped septum — the acutely stressed right heart.
Assess RV in A4C view — not from PLAX alone. The RV is the most frequently missed abnormality in critical care echo.
RV size (A4C): RV:LV end-diastolic area ratio. >0.6 = dilated. Ratio approaching 1:1 = severely dilated.
D-sign (PSAX at papillary level): D-shaped LV = RV pressure overload. Flat septum throughout systole = pressure overload. Flattening only in diastole = volume overload.
TAPSE: M-mode through lateral tricuspid annulus in A4C. Measure annular excursion. Normal ≥17 mm. <17 mm = impaired RV function.
IVC & venous returnWhat the IVC tells you — and its significant limitations.
Measure IVC ~2 cm from RA entry, just proximal to hepatic vein confluence, in subcostal longitudinal view.
| IVC finding | Estimated RAP |
|---|---|
| <2.1 cm + collapses >50% | Low (0–5 mmHg) |
| >2.1 cm + collapses <50% | Elevated (>10 mmHg) |
Collapsibility index (spontaneous breathing): (IVC max − IVC min) / IVC max × 100. >50% = likely fluid responsive.
Distensibility index (ventilated): (IVC max − IVC min) / IVC min × 100. >12% suggests responsiveness — only valid with no spontaneous breaths and TV ≥8 ml/kg.
Pericardial effusion & tamponadeRecognition, sizing, and the echo signs of tamponade physiology.
Echo-free space surrounding the heart, outside the pericardial line. Best seen in PLAX and subcostal views.
Size: Small <1 cm (posterior only); Moderate 1–2 cm; Large >2 cm; Very large >2 cm + swinging heart.
Tamponade signs:
- RV free-wall collapse in early diastole (most sensitive)
- RA collapse for >1/3 of systole
- Dilated IVC with <50% respiratory collapse
- Swinging heart in large effusion
Pericardial vs pleural: In PLAX, pleural effusion lies posterior to the descending aorta; pericardial lies anterior to it. The descending aorta is the landmark.
Pleural effusion from cardiac windowsIdentifying costophrenic fluid from PLAX and subcostal views.
From PLAX: pleural fluid lies posterior to the descending thoracic aorta as an echo-free space. Collapsed or consolidated lung may be seen floating in large effusions (“jellyfish sign”).
The descending aorta is the single most useful landmark for distinguishing pericardial from pleural fluid — a bright, round cross-section in PLAX.
Severe valvular diseaseRecognition only — features that should trigger expert referral.
FUSIC Heart does not require quantification of valve disease. Recognise the pattern and refer.
- Aortic stenosis: Thickened, calcified, immobile AV leaflets in PLAX. Turbulent colour jet through restricted orifice in A5C/PSAX.
- Aortic regurgitation: Diastolic colour jet into LVOT in PLAX/A5C.
- Mitral stenosis: Doming leaflets in PLAX (“hockey stick”), restricted opening, LA enlargement.
- Mitral regurgitation: Systolic colour jet into LA in A4C/PLAX. Severe = large turbulent jet filling >40% of LA.
Pitfalls & artefactsCommon image traps and how to avoid them.
- Reverberation behind pericardium: Bright parallel lines — can mimic effusion. True effusion is echo-free and moves with the heart; reverb stays fixed.
- Epicardial fat: Anterior to RV, inside pericardium. Grey/echogenic, not echo-free. Stays anterior and does not cross the descending aorta landmark.
- Near-field clutter: Fuzzy bright signal in first ~1 cm. Reduce gain or increase depth. Can obscure RV free wall.
- Foreshortened apex in A4C: LV looks spherical — move probe medially and caudally.
- Over-reading hyperdynamic LV as normal: Small cavity with brisk motion in a shocked patient = likely vasodilated or hypovolaemic. Not a reassuring finding.
- Pericardial vs pleural: Use descending aorta as landmark in PLAX.