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. 2024 Jun 10;22(1):7.
doi: 10.1186/s12947-024-00326-y.

Echocardiogram by apical-subcostal protocol in prone position during invasive mechanical ventilation in cardiovascular intensive care unit

César Del Castillo  1   2 , Fernando Verdugo  3 , Franco Appiani  4   5 , Francisca Yáñez  6 , Camila Bontá  6 , Carlos Torres-Herrera  5 , Angela Garcia  7 , Zorba Blázquez-Bermejo  8 , Javier Castrodeza  8 , Daniel Requena  4 , Andreina Rodríguez  4 , Arquimedes Silvio  4   5 , Agustín Gatica  4 , Arnulfo Begazo  4   5 , Mario Alfaro  6
Affiliations

Echocardiogram by apical-subcostal protocol in prone position during invasive mechanical ventilation in cardiovascular intensive care unit

César Del Castillo et al. Cardiovasc Ultrasound. .

Abstract

Aims: To evaluate the feasibility of a transthoracic echocardiogram using an apical-subcostal protocol in invasive mechanical ventilation (IMV) and prone position.

Methods: Prospective study of adults who required a prone position during IMV. A pillow was placed only under the left hemithorax in the prone position to elevate and ease the apical and subcostal windows. A critical care cardiologist (prone group) acquired and evaluated the images using the apical-subcostal protocol. Besides, we used ambulatory echocardiograms performed as a comparative group (supine group).

Results: 86 patients were included, 43 in the prone and 43 in the supine. In the prone group, the indication to perform an echocardiogram was hemodynamic monitoring. All patients were ventilated with protective parameters, and the mean end-expiratory pressure was 10.6 cmH2O. The protocol was performed entirely in 42 of 43 patients in the prone group because one patient did not have any acoustic window. In the 43 patients in the prone group analyzed and compared to the supine group, global biventricular function was assessed in 97.7% (p = 1.0), severe heart valve disease in 88.4% (p = 0.055), ruled out of the presence of pulmonary hypertension in 76.7% (p = 0.80), pericardial effusion in 93% (p = 0.12), and volume status by inferior vena cava in 93% (p = 0.48). Comparing prone versus supine position, a statistical difference was found when evaluating the left ventricle apical 2-chamber view (65.1 versus 100%, p < 0.01) and its segmental function (53.4 versus 100%, p < 0.01).

Conclusion: The echocardiogram using an apical-subcostal protocol is feasible in patients in the IMV and prone position.

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Conflict of interest statement

Nothing to declare.

Figures

Fig. 1
Fig. 1
Position to perform apical-subcostal protocol. The head was turned to the left side, the left arm was extended overhead, and the left hip and knee flexed. A pillow was placed only under his left hemithorax to elevate and facilitate an apical and subcostal view of the area. The operator is standing on the left side of the patient and taking the transducer with the right hand. Illustrated by Camila Bonta, MD
Fig. 2
Fig. 2
Showing the images obtained by apical-subcostal protocol. A: Apical Four-chamber. B: Apical Two-chamber. C: Apical three-chamber. D: Mitral Inflow by Pulsed-wave Doppler (E and A wave). E: Pulsed Tissue Doppler of the Lateral Mitral Valve Annulus. F: Aortic Flow by Continuous Doppler. G: LV Outflow Tract VTI. H: TAPSE. I: Gradient Insufficient Tricuspid. J: Subcostal Cardiac Chamber. K: Inferior Vena Cava
Fig. 3
Fig. 3
Showing the images obtained by apical-subcostal protocol in Venovenous ECMO patients. Yellow arrows indicate the cannulas and its flow
See this image and copyright information in PMC

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