Case studies.

4 · Reveal

• The IVC moves in and out of the image plane. When the beam cuts the edge of a tube instead of its centre, the tube looks narrower, so movement can look like collapse.
• Fix the picture first. Keep the IVC in long axis, show it entering the right atrium, and find the hepatic vein joining it. Rock and sweep until you have the widest diameter, then hold that plane through the whole breath.
• Measure the diameter 1–2 cm from the junction of the right atrium and IVC, at end-expiration (Lang 2015, ASE/EACVI chamber quantification).

What the right plane looks like

Reveal

• The COPD is only presumed. Repeated weaning failure is a reason to look for a cause you have not proven or excluded, and the heart is the obvious one.
• Taking away positive pressure raises venous return and left ventricular afterload. A ventricle that coped on NIV may fail when the support comes off, and the patient becomes breathless again with pulmonary oedema.
• Repeating a test that has not helped, or simply waiting, does not change the plan.

Reveal

• All three views show severe global LV dysfunction: little wall thickening and a cavity that barely changes size. Across three windows that is enough to call the EF severely reduced by eye.
• You do not need Simpson’s biplane to answer this bedside question. Grade by eye in more than one view, and measure when the answer would change management or when you are tracking change.
• What happened: a negative fluid balance was achieved and he was weaned off NIV.

Doppler indices of diastolic function (mitral inflow and tissue Doppler) can also guide weaning (Mayo et al. 2016). They belong to advanced echo, so their thresholds are not given here.

4 · Reveal

• A large echogenic mass sits in the left atrium, and there is pericardial fluid around the heart.
• What happened: thoracotomy showed the lung cancer extending into the left atrium through the pulmonary veins.
• Ultrasound describes; it does not give histology. Where the mass is, what it attaches to, how it moves and the clinical story narrow the list. In a patient with a new cancer, think of direct spread or metastasis as well as thrombus.

4 · Reveal

• The right ventricle looks vigorous because the left ventricle next to it is hypokinetic. Read the ventricles against each other, not one in isolation.
• This is not hypovolaemia: a CVP of 18 mm Hg and a poorly contracting LV do not fit an empty circulation.
• It is not McConnell sign either. McConnell sign is akinesia of the RV free wall with a normally moving RV apex; it describes the RV itself, not how it compares with the LV.
• What happened: he received aggressive fluid resuscitation and developed respiratory distress. Work-up found left anterior descending (LAD) coronary artery disease.

4 · Reveal

• After the arrest there is severe hypokinesis to akinesis of the anterior wall, apex and septum, while most of the lateral wall (circumflex territory) and the inferior wall (right coronary territory) move normally. That pattern fits the LAD territory.
• After VT or VF arrest, a segmental wall motion abnormality after return of circulation is a surrogate for coronary artery disease and should prompt referral for cardiac catheterisation (Levitov 2016).
• Ventricular arrhythmia after cardiac surgery should make you think of ischaemia. A root replacement also involves reattaching the coronary arteries, so a new territorial abnormality needs a coronary answer.
• Resternotomy, mechanical support or fluid treat other problems; none of them answers the question this scan raises. The decision belongs with the cardiac surgical and cardiology teams, and your scan should reach them early.

Reveal

All four were scanned. Look at each clip before you read its caption.

4 · Reveal

• Pericardial tamponade after pacing-wire removal. The clip is labelled “RV haematoma post wire removal”: a localised collection compressing the right ventricle.
• After cardiac surgery, blood around the heart is often clotted and localised rather than a free circumferential effusion, so a needle is unlikely to drain it. Surgical re-exploration treats both the collection and the bleeding.
• Fluid and inotropes may buy minutes while the team assembles; they do not fix the problem.
• Transthoracic echo can give useful clues after cardiac surgery, but windows are often poor. A limited scan without a large effusion does not exclude tamponade. TOE may be needed if TTE is inadequate.