Echocardiography
1) A bedside Cardiac Ultrasound or Echocardiogram is a quick Point of Care Ultrasound (POCUS) that
allows you to visualize and evaluate how the heart is functioning. In addition, bedside
echocardiography also allows you to evaluate hemodynamic changes and pathological heart
diseases.
2) The Cardiac Ultrasound Procedure is also known as: Echocardiography, Echocardiogram, or even
just “Echo.” They all refer to the same thing.
3) In addition, you may see cardiac ultrasound referred to as “Transthoracic” or Transesophageal”
echocardiography. Transthoracic Echocardiography (TTE) is when a cardiac ultrasound is performed
on the patient’s chest.
4) TTE is the most common cardiac ultrasound application and is non-invasive. TTE is what we will be
covering in this post. Transesophageal Echocardiography (TEE) is a more specialized cardiac
ultrasound with a special probe that is inserted into the patient’s esophagus. TEE requires sedation
and is considered more invasive than TTE.
5) In this Cardiac Ultrasound (Echocardiography) for Beginners Guide, we will be showing you how you
can get started on using basic Transthoracic Echocardiography (TTE) right away!
After reading this Echo Tutorial, you will be able to use bedside Cardiac Ultrasound (Echocardiography)
to:
1. Obtain the 5 Major Views of the Heart (including the Inferior Vena Cava(IVC) View)
Evaluate for Major Cardiac Ultrasound Pathology:
1. Evaluate Left Ventricular Ejection Fraction
2. Estimate Central Venous Pressure (CVP) for fluid status/ fluid tolerance using the IVC
3. Evaluate for Pericardial Effusion/Tamponade
4. Evaluate for Pulmonary Embolism
Cardiac Ultrasound Indications
Point of Care Bedside Cardiac Ultrasound can used in the following indications:
1. Significant EKG changes
2. Assessing Left ventricular Function
3. Chest Pain/Palpitations
4. Dizziness
5. Shortness of Breath
6. Hypotension
7. New Heart Murmurs
8. Cardiac Arrest (assess for cardiac standstill)
Cardiac Ultrasound Preparation
Patient Preparation
1. The patient should be supine with the head of the bed flat.
2. If you are unable to visualize the heart in the supine position, consider repositioning the patient
into the Left lateral decubitus. This will bring the heart away from the sternum and give you better
sonographic access.
Cardiac Ultrasound – Supine
Cardiac Ultrasound – Left Lateral Decubitus
Cardiac Ultrasound Machine Preparation
1) Transducer: Phased Array (AKA “cardiac probe”)
2) Preset: Cardiac
One of the most confusing parts of performing cardiac ultrasound (echocardiography) is understanding
where the indicator goes on the ultrasound screen and probe orientation.
With the Cardiac Preset:
1) Make sure the Ultrasound Image Indicator Marker is on the RIGHT side of the ultrasound screen.
2) This is different from almost all other standard applications where the Ultrasound Image Indicator
Marker is on the LEFT side of the screen.
Cardiac Ultrasound Machine Placement
Place the ultrasound machine on the patient’s right side, so you can scan with your right hand and
manipulate ultrasound buttons with your left hand.
Cardiac Ultrasound Machine and Patient Positioning
Cardiac Ultrasound Anatomy
1) Understanding the general anatomy of the heart is important in helping you to visualize the
different ultrasound views we will be performing. In addition, it will help keep you organized
throughout the cardiac ultrasound exam.
2) There are a total of 4 chambers in the heart: Right Atrium, Right Ventricle, Left Atrium, and Left
Ventricle. These are separated by their respective valves: Tricuspid Valve, Pulmonic
Valve, Mitral Valve, and Aortic Valve.
3) With transthoracic echocardiography (TTE) you are able to visualize all of these structures but
you will need to keep in mind that the heart is located much more medially (toward the sternum)
than you may think.
Cardiac Ultrasound Surface Anatomy
Cardiac Anatomy
Cardiac Ultrasound Views/Echocardiography Protocol
The 5 main/basic cardiac ultrasound views of the heart are the
1) Parasternal Long Axis,
2) Parasternal Short Axis,
3) Apical 4 Chamber,
4) Subxiphoid (Subcostal),
5) And IVC Views.
Step 1: Parasternal Long Axis (PSLA) View
1) The Parasternal Long Axis View is often abbreviated as PSLA or PLAX.
2) It is usually the first cardiac ultrasound view obtained and will give you an immediate assessment
of the general condition of the heart including ejection fraction and overall left and right ventricular
sizes.
1. Point the probe indicator toward the patient’s right shoulder
2. Place the probe at the 4th intercostal space which is approximately the nipple line for males
or the inframammary fold to the sternum (females).
Hand and Probe position for the Parasternal Long Axis View
Structures to identify in the Parasternal Long Axis (PSLA) View:
1) RV: Right Ventricle
2) LV: Left Ventricle
3) LA: Left Atrium
4) AV: Aortic Valve
5) MV: Mitral Valve
6) AO: Aorta
7) DA: Descending Aorta
8) Pericardium
Parasternal Long Axis View Structures – Illustration
1) Optimize the gain to visualize the different chambers of the heart in view
2) Optimize the depth to makes sure you can see the Descending Aorta.
3) POCUS 101 TIP: If you are having trouble orienting yourself, just remember “the 3 L‘s“: For the
Parasternal Long Axis view, the Left Ventricle is on the Left side of the screen.
Cardiac Ultrasound – Parasternal Long Axis View
Step 2: Parasternal Short Axis (PSSA) View
1) The Parasternal Short Axis view is often abbreviated as PSSA or PSAX.
2) From the Parasternal Long Axis view, rotate your probe 90 degrees clockwise so that the
indicator is now pointing towards the patient’s left shoulder.
Hand and Probe position for the Parasternal Short Axis View
We will go over the three main levels of the Parasternal Short Axis (PSSA) view you can see
1) Mid-Papillary Level
2) Mitral Valve Level (Fish mouth view)
3) Aortic Valve Level (Mercedes Benz view)
Here is a quick overview of the Parasternal Short Axis levels we will be covering
Parasternal Short Axis Views.
1)
2)
3)
4)
5)
RV: Right Ventricle;
LV: Left Ventricle;
MV: Mitral Valve;
LA: Left Atrium;
RA: Right Atrium
Parasternal Short Axis – Mid-Papillary Level
1) The first Parasternal Short Axis view on echocardiography you should focus on is the MidPapillary level.
2) The Mid-Papillary level gives you information regarding overall ejection fraction, right ventricular
dysfunction, and left ventricular regional wall motion abnormalities.
Probe placement for Mid-Papillary View.
Mid-Papillary Level Illustration
Structures to identify in the Parasternal Short Axis (PSSA) Mid-Papillary Level:
1) RV: Right Ventricle
2) LV: Left Ventricle
3) Papillary Muscles
Cardiac Ultrasound of Mid-Papillary Level
Parasternal Short Axis – Mitral Valve Level (Fish Mouth View)
The Mitral Valve level is common view seen and allows you to view the anterior and posterior valves of
the mitral valve.
1) To get the Mitral Valve level from the Mid-Papillary level, slide the Transducer towards the
sternum towards the mitral valve (base of the heart).
2) The Anterior and Posterior leaflets of the Mitral Valve should come into view.
Probe placement for Mitral Valve Level
Mitral Valve Level (Fish Mouth View) Illustration
Structures to identify in the Parasternal Short Axis (PSSA) Mitral Valve Level
1) RV: Right Ventricle
2) LV: Left Ventricle
3) MV: Mitral Valve (Anterior and Posterior leaflets)
Cardiac Ultrasound – Mitral Valve Level (Fish Mouth View)
Parasternal Short Axis – Aortic Valve Level (Mercedes Benz View)
1) The aortic valve level of the parasternal short axis view allows you to visualize the right ventricle,
right atrium, left atrium, aortic valve, tricuspid valve, and pulmonic valve.
2) You can use this view to perform some advanced Point of Care Ultrasound (POCUS) applications
such as evaluation of a bicuspid aortic valve, the severity of aortic stenosis, tricuspid
regurgitation, and measuring of pulmonary pressures.
1. To get the Aortic Valve level from the Mitral Valve level, tilt the tail of the probe inferiorly and
point it towards the Aortic Valve.
2. As you do so the Aortic Valve should come into view with its leaflets representing the
“Mercedes Benz Sign.”
Probe placement for Aortic Valve Level
Aortic Valve Level (Mercedes Benz View) Illustration
Structures to identify in the Parasternal Short Axis (PSSA) Aortic Valve Level
1)
2)
3)
4)
5)
6)
7)
RV: Right Ventricle
TV: Tricuspid Valve
AV: Aortic Valve
PV: Pulmonic Valve
RVOT: Right Ventricular Outflow Tract
RA: Right Atrium
LA: Left Atrium
Cardiac Ultrasound – Aortic Valve Level (Mercedes Benz View)
Step 3: Apical Views
1) The Apical Views are some of the most important views to be able to obtain when doing
hemodynamic assessment of the heart.
2) This includes looking at diastolic dysfunction, valvular regurgitation, cardiac output, etc.
3) Unfortunately, it can be one of the most challenging views to obtain when first starting out. In this
section, we will show you exactly how to get the mail apical views including the apical 4 chamber
view, 5 chamber view, and the coronary sinus view.
Apical 4 Chamber (A4C) View
1) From the Parasternal Short Axis View, slide the Transducer towards the apex of the heart
keeping the indicator pointed towards the patient’s left side.
2) Once you reach the apex of the heart, as indicated by the left ventricle decreasing in size, tilt the
tail of the probe down towards the patient’s foot.
3) For females, the Point of Maximal Impulse (PMI) is usually just under their left breast.
4) As you do this the Apical Four Chamber view should appear.
Hand and Probe position for the Apical 4 Chamber View
Structures to identify in the Apical 4 Chamber (A4C) View
1)
2)
3)
4)
5)
6)
LV: Left Ventricle
RV: Right Ventricle
LA: Left Atrium
RA: Right Atrium
TV: Tricuspid Valve
MV: Mitral Valve
Apical 4 Chamber (A4C) View Illustration
1) Optimize the gain and depth to visualize the 4 chambers of the heart.
2) POCUS 101 TIP: If you are having trouble getting the Apical 4 Chamber view, try placing the
patient in the left lateral decubitus position. It will reduce lung artifact and bring the heart more
proximal to your ultrasound probe, usually giving you an optimal view.
Cardiac Ultrasound -Apical 4 Chamber (A4C) View
Since the Apical 4 Chamber view can be a challenging view to obtain, you will most likely encounter
variants of the apical view including the Apical 5 chamber view and the coronary sinus view. We will go
over these views below.
Apical 5 Chamber (A5C) View
1) A common view produced when attempting to do the apical 4 chamber view is the “Apical 5
Chamber View.”
2) Of course, there are not really 5 chambers in the heart but in echocardiography, the “5th
chamber” is when you can see the appearance of the aortic valve and the left ventricular outflow
tract.
3) Sometimes you will want to intentionally obtain this view in order to calculate the cardiac output
of the left heart.
4) From the Apical 4 Chamber view, slightly tilt the tail of your probe towards the patient’s feet to
get the Apical 5 chamber view. If you want to go back to the Apical 4 chamber view just tilt the
probe tail back towards the patient’s head. Often the difference between the two views is just a
5-10 degree tilt!
Apical 5 Chamber (A5C) View Illustration
Cardiac Ultrasound -Apical 5 Chamber (A5C) View
Coronary Sinus View
1) Another common view produced by novice sonographers when attempting to do the apical 4
chamber view is the Coronary Sinus View. You will rarely intentionally need to get this view and
it is important to know what to do if you see this view.
2) The coronary sinus view will give the appearance of an atrial septal defect between the right and
left atrium. Don’t be fooled by this.
3) The reason the Coronary Sinus view is coming into view and not the Apical 4 chamber is because
the tail of your transducer is tilted too much towards the patient’s head. Tilt your probe tail slightly
towards the patient’s feet and it should give you the apical 4 chamber view.
Cardiac Ultrasound – Apical Coronary Sinus(CS) View
Step 4: Subxiphoid (Subcostal) View
1) The Subxiphoid or “Subcostal” view allows you to see similar structures as the Apical 4 Chamber
view but just approached from a different angle.
2) This Subxiphoid view is useful when you are having difficulty getting adequate parasternal views
(i.e. COPD patients) or when you are evaluating a trauma patient when doing the eFAST scan.
1. With the patient’s knees bent, position the probe under the costal arch (beneath the xiphoid
process) with the indicator pointing towards the patient’s left.
2. Since the plane of the heart is superficial, you need to use an overhand grip on the probe in order
to be parallel with the skin
Hand and Probe position for the Subxiphoid (Subcostal) View
Structures to identify in the Subxiphoid (Subcostal) View
1)
2)
3)
4)
5)
6)
7)
RV: Right Ventricle
LV: Left Ventricle
TV: Tricuspid Valve
MV: Mitral Valve
LA: Left Atrium
RA: Right Atrium
Pericardium
1) Make sure to use the Liver as an acoustic window!
2) If you approach from the left side your view will be obstructed by the stomach or bowel gas.
3) If you are still having trouble getting a clear image, try applying gentle downward pressure on the
probe.
Video Summary of Subxiphoid (Subcostal) View
Step 5: Inferior Vena Cava (IVC) View
Evaluating the Inferior Vena Cava (IVC) with ultrasound is one of the most commonly used Point of Care
Ultrasound (POCUS) applications. It is a great way to estimate central venous pressure (CVP) and fluid
tolerance.
1) From the Subxiphoid view with the patient still in the supinated position with knees bent, keep
the right atrium in view.
2) Locate the Inferior Vena Cava within the Liver and center it on the ultrasound screen.
3) Once the IVC is centered on the screen, rotate the transducer clockwise (to your right) to bring
the indicator down toward the feet (play the instructional video).
4) This will give a longitudinal view of the Inferior Vena Cava entering the Right Atrium.
IVC Ultrasound Probe Position
IVC View – Going from Short Axis to the Long Axis View
Structures to identify in the Inferior Vena Cava (IVC) View
1) IVC: Inferior Vena Cava
2) RA: Right atrium
3) HV: Hepatic Vein (sometimes seen)
IVC View
Assessing for IVC Collapsibility
1) After you obtain the IVC view you will need to assess for IVC collapsibility in either your
spontaneously breathing or ventilated patients.
2) For Spontaneously Breathing Patients: have them take a deep breath or have them sniff in. The
maximum IVC diameter will be seen during expiration and the minimum IVC diameter will be
seen during inspiration for these patients.
3) For Ventilated Patients: The positive pressure from the ventilator will have the opposite effect on
the IVC compared to spontaneously breathing patients. The maximum IVC diameter will be seen
during inspiration and the minimum IVC diameter will be seen during expiration for these
patients.
Evaluate for IVC Collapsibility with Respirations
Cardiac Ultrasound (Echo) Pathology
1) Using bedside echocardiography (echo) is one of the most useful Point of Care Ultrasound
(POCUS) applications.
2) It can help you assess the hemodynamic status of your patients, estimate fluid status, and look
for life-threatening causes of shock such as tamponade or pulmonary embolism.
3) In this section, we will show you how to use cardiac ultrasound to help you in your daily practice.
Central Venous Pressure (CVP) Estimation
1) Ultrasound of the Inferior Vena Cava (IVC) can be used to estimate the central venous pressure
(CVP) of a patient by looking at the size (diameter) and collapsibility of the IVC.
2) This is especially useful when you are trying to evaluate fluid tolerance or the presence of venous
congestion in your patients.
Here is a simplified and practical table you can use to interpret your IVC findings
IVC Size
IVC Collapsibility
Interpretation (CVP)
< 1.5cm
>50% collapsibility
0-5 mm Hg (Low CVP)
< 1.5-2.5cm
>50% collapsibility
6-10 mm Hg
1.5-2.5cm
<50% collapsibility
11-15 mm Hg
>2.5cm
<50% collapsibility
16-20 mm Hg (High CVP)
Adapted from Kircher et al.
1) The caveat about IVC measurements is that it just gives you a static measurement to estimate
the central venous pressure.
2) So all of the limitations of using CVP will also pertain to IVC measurements.
3) We find it most useful when the IVC either estimates a low CVP or high CVP.
4) The measurements in between can be considered indeterminate and more advanced
hemodynamics measurements should be obtained to assess for venous congestion and fluid
responsiveness (change in cardiac output)
Small and Collapsible IVC
Dilated and Non-collapsible IVC and hepatic vein
Left Ventricular Function/ Ejection Fraction
1) Patients with Systolic Heart Failure also known as “Heart Failure with Reduced Heart Function
(HFrHF)” will commonly present with shortness of breath, orthopnea, paroxysmal nocturnal
dyspnea (PND), exercise intolerance, irregular heartbeats, and edema in the bilateral upper and
lower extremities. This is usually accompanied by cardiogenic pulmonary edema and B-lines on
ultrasound.
2) One of the most commonly used surrogates in assessing systolic function in these patients is
done by measuring the Left Ventricular Ejection Fraction. For a more COMPLETE tutorial on
qualitative and quantitative evaluation of Ejection Fraction Click HERE.
Ejection fraction (EF) in percentage is defined as: EF(%) = SV/EDV x 100
Where SV: Stroke Volume and EDV: End Diastolic Volume
3) Ejection fraction (EF) is basically a percentage, of how much blood the left ventricle pumps out
with each contraction. For example, an ejection fraction of 60 percent means that 60 percent of
the total amount of blood in the left ventricle is pushed out during each systolic contraction
Mildly
Moderately Severely
Hyperdynamic Normal Reduced Reduced Reduced
Ejection
Fraction
>70%
55-69%
45-54%
30-44%
<30%
Measuring Ejection Fraction on ultrasound can be approached either qualitatively or quantitatively. In this
post, we will go over the qualitative technique to assess ejection fraction.
Qualitative Approach to Assessing Ejection Fraction:
1) Look at how well the left ventricle walls are moving. Are they coming close to each other during
systole?
2) Look at how well the anterior mitral valve leaflet is moving. Is it coming close to the ventricular
septum during diastole?
3) If the left ventricular walls are moving well and coming close together during systole and the
anterior mitral valve leaflet is almost touching the septum during diastole then the patient likely
has a normal ejection fraction.
4) Conversely if the left ventricular walls are barely moving during systole and the anterior mitral
valve leaflet is barely moving during diastole the patient likely has a low ejection fraction.
5) Here are cardiac ultrasound (echo) images of patients with different degrees of ejection fraction
from hyperdynamic to severely reduced:
Hyperdynamic Ejection Fraction
Normal Ejection Fraction
Mildly Reduced Ejection Fraction
Moderately Reduced Ejection Fraction
Severely Reduced Ejection Fraction
Pulmonary Embolism (PE)
1) A Pulmonary Embolism is a blood clot that has dislodged from a distal site which has lodged into
one of the pulmonary arteries.
2) Predominantly the clot originates from a deep vein thrombosis (DVT) in the lower
extremities where it will travel in the venous circulation, enters the right side of the heart, and
eventually into the pulmonary arteries.
3) Learn how to perform DVT Ultrasound here.
4) Considering the rapid onset/timing of a Pulmonary embolism, patients typically show symptoms
or complain of chest pain, shortness of breath, cough, hemoptysis, or even syncope.
5) Risk factors include cancer, oral contraceptive (OCP) or hormone replacement therapy (HRT),
immobility, and recent travel.
Here are the different types of pulmonary embolism you may encounter:
1) Submassive Embolism– Submassive (or intermediate-risk) PE refers to those patients with acute
PE without systemic hypotension but with evidence of either right ventricle (RV) dysfunction or
myocardial necrosis. RV dysfunction is characterized by RV dilation, hypokinesis, or elevation of
brain natriuretic peptide (BNP); myocardial necrosis is suggested by elevated troponin. There is
evidence that these patients may possibly benefit from “half dose” thrombolytic therapy.
2) Massive Pulmonary Embolism-Massive (or high-risk) PE is a term used to designate patients
with right ventricular dysfunction and sustained hypotension (systolic blood pressure <90 mmHg
for at least 15 minutes or requiring inotropic support, not due to a cause other than PE). These
patients may benefit from thrombolytic therapy.
3) Saddle Embolism-A Saddle is a large pulmonary embolism that straddles the bifurcation of
the pulmonary trunk, extending into both the left and right pulmonary arteries. Although it only
occurs in about 2-5% of all pulmonary embolism, Saddle Embolisms can completely obstruct
both left and right pulmonary arteries resulting in right heart failure and, unless treatment is
prompt, death.
Bedside echo is extremely valuable in risk stratifying patients with pulmonary embolism to see if they may
benefit from anticoagulation or thrombolytic therapy.
Ultrasound findings of Pulmonary Embolism
The most definitive way to diagnose a pulmonary embolism is to directly visualize the clot either in the
pulmonary artery itself or as a clot in transit.
Direct Visualization of Mobile Clot in the Right Atrium – Apical 4 Chamber view
1) Unfortunately directly visualizing a clot in the heart or pulmonary artery is a rare finding. Most of
the echocardiography findings for pulmonary embolism are “indirect signs” that evaluate for the
dysfunction of the right ventricle from a significant clot burden. Usually, this is seen as an
enlarged right ventricle.
2) The two most common and easy to recognize signs to look for right ventricular dysfunction on
echo are the “D Sign” and McConnell’s sign.
The “D Sign” on Echocardiography
1) The “D Sign” is an ultrasound/echo finding that shows the left ventricle as a D-shaped structure.
It is a result of right ventricular strain causing a shift of the septum towards the left side of the
heart.
.
Right Ventricular Strain – D Sign
“McConnell’s Sign” on Echocardiography
McConnell’s sign is where there is akinesia of the right ventricular lateral wall with hyperdynamic
appearance of the right ventricular apical wall.
RV Strain with McConnell’s Sign
Pericardial Effusion
1) A Pericardial Effusion is when there is a collection of excess fluid within the pericardial cavity.
When enough pressure builds up from a pericardial effusion, it can turn into Cardiac Tamponade.
2) Patients with Pericardial effusion will typically present with exercise intolerance, tachycardia,
pleural friction rub, tachypnea, shortness of breath, and chest pain.
3) The causes of a pericardial effusion can be from various causes including pericarditis,
myopericarditis, uremia, malignancy, infections, rheumatologic, etc.
4) An important point you must remember about Pericardial effusions is that is it not just based
on size, the deleterious effects of pericardial effusions are actually more dependent on
how quickly a pericardial effusion accumulates rather than it’s size.
5) In the figure below, a rapidly accumulating pericardial effusion can increase the pericardial
pressures significantly and lead to cardiac tamponade despite a relatively small size.
6) Conversely, an end-stage renal disease patient can have a chronic pericardial effusion that
slowly accumulates with over 200-400 ml with no hemodynamic consequences.
Ultrasound Findings of Pericardial Effusion
1) The parasternal long-axis and subcostal four-chamber views are typically favored for inspection
of pericardial effusions
2) The Descending aorta is a distinguishing landmark used to distinguish between a Pericardial
Effusion and a pleural effusion
3) A pericardial effusion will appear anterior to the descending aorta whereas a pleural effusion will
appear posterior to the descending aorta.
Pericardial Effusion lying Anterior to the DA
Subxiphoid view of aPericardial Effusion
The cardiac ultrasound image below shows both a pericardial effusion (anterior to the descending aorta)
and a pleural effusion (posterior to the descending aorta).
Pericardial effusion vs Pericardial Fat Pad
Being able to determine the difference between a Pericardial Effusion and a Pericardial Fat Pad is
important as they may have similar sonographic appearances.
1) Pericardial fat pads are usually located anteriorly and can usually be seen on the Parasternal
Long Axis view.
2) Pericardial fat pads are usually not completely anechoic and can appear to have striations.
3) Lastly, pericardial fat pads can usually be seen to move with the motion of the heart.
4) If you are in doubt, ask another more experienced POCUS user to look at it or order a formal
echo to clarify if needed.
Anterior Pericardial Fat Pad on Parasternal Long Axis View
Cardiac Tamponade
1) Cardiac Tamponade occurs when the pericardial pressure exceeds the pressure of the right
atrium or right ventricle leading to decreased preload of the left ventricle and eventually a drop
in cardiac output/blood pressure. It is considered an obstructive type of shock.
2) Recall that cardiac tamponade is more dependent on the rate of pericardial fluid accumulation
versus the actual size.
3) On physical exam you may see Beck’s Triad defined as hypotension, jugular venous distension,
and muffled heart sounds. You can also detect pulsus paradoxus as well. However, other
diagnoses can cause false positives for these findings including severe COPD, tension
pneumothorax, or other causes of obstructive shock.
4) Point of Care Ultrasound can offer a more definitive diagnoses of pericardial effusion and cardiac
tamponade.
Ultrasound Findings of Cardiac Tamponade
1) Using transthoracic echocardiography (TTE) you can see if the pericardial pressure exceed the
right atrial or right ventricular pressures.
2) Since the lowest pressures in the heart is the right atrium, the first echo sign you will see of
cardiac tamponade is right atrial systolic collapse.
3) The second echo sign you will see in cardiac tamponade is right ventricular diastolic collapse.
4) Either of these signs are considered positive echocardiographic signs of cardiac tamponade.
Apical View: Cardiac Tamponade – RA Systolic Collapse
Parasternal Long Axis: Cardiac Tamponade – RV Diastolic Collapse