Objectives

After reading this article, the physician should be able to:

• Describe the indications to evaluate for regional wall motion abnormalities (RWMAs).
• Perform focused point-of-care echocardiography.
• Identify anterior, inferior, and lateral RWMAs.
• Identify potential coronary artery occlusion based on RWMAs and electrocardiogram findings.

Probe Selection, Technique, and ECG Views

Patient positioning: The patient should lie supine or be placed in the left lateral decubitus position.

Probe selection: The low-frequency phased array transducer (5-1 MHz) is recommended. A curvilinear probe (5-2 MHz) can also be used but may be suboptimal.

Imaging views:

• Parasternal long axis (PLAX): Place the transducer on the left chest near the sternum, with the indicator probe pointing to the patient’s right shoulder. Starting at the level of the nipples/areola, slide the probe down the left border of the sternum to find the best acoustic window. Minor rotation (either clockwise or counterclockwise) will allow for a clear PLAX view (see Figure 1A).
• Parasternal short axis (PSAX): After the parasternal long axis is obtained, rotate the probe 90 degrees in a counterclockwise direction until the probe indicator points to the patient’s right hip. Subtle cephalad/caudal movements of the transducer will allow for the best acoustic window (see Figure 1B). The sonographer should move the probe just distal to the mitral valve to the level of the papillary muscles to obtain an ideal view for detecting RWMAs.
• Apical four-chamber view (A4C): From the position of the parasternal long/short, slide the transducer laterally along the axis of the heart toward the apex. From this location, angle the beam toward the right scapula (with the probe marker toward the right hip). The goal is to have the transducer footprint at the cardiac apex, with the beam directed through both ventricles and atria. (The ultrasound view will ideally have the intraventricular septum oriented vertically in the center of the screen.) Once again, make subtle movements for the best acoustic window (see Figure 1C). This is often the most difficult view to obtain and generally requires the patient be positioned in the left lateral decubitus position. RWMAs are often evident on parasternal long and short, and the A4C view may not be needed if the other two views are obtained.