- Massively enlarged RA - RV also enlarged - Diastolic inter-ventricular septal flattening - TAPSE can also be measured for RV function. Here it is decreased. - pericardial effusion also seen

Background on the case: From right heart cath, PASP 1114 mm Hg. In this view: - Enlarged RV - Diastolic septal flattening prominent in diastole consistent with RV volume overload - RV strain also seen in systole, indicating RV pressure overload - Circumferential pericardial effusion - right and left ventricular hypertrophy with thickened walls

- Both pericardial effusion and pleural effusion are present - moderate pleural effusion with collapsed lung seen posteriorly - trace pericardial effusion tracking above descending aorta

Note, that in one cardiac cycle, more than two occurrences are seen for septal movements. Normally, there can be up to two occurrences- one in systole and one in diastole. However, this patient had RV paced rhythm, in which according to the pacing rate RV contraction will occur first and the rate can also vary depending on pacemaker settings. - LV is dilated and has severely reduced EF - biatrial enlargement

Fox tail sign refers to moderate or large pleural effusion being visualized along with collapsed lingula in apical view of cardiac ultrasound. Hence, collapsed lung as fox tail as seen in the video.

Spontaneous contrast phenomenon demonstrates as swirling pattern or speckled echoes within the imaging field. This phenomenon can be seen in conditions such as slow blood flow, stasis, or turbulence, and is often associated with low reflectivity or echogenicity within the affected area. This is from a patient with heart failure with reduced EF (15%), which correlates with venous stasis in microcirculation due to do impaired cardiac contractility and function.

Normal appearing subcostal view with - normal RV thickness - normal RV and LV contractility - no pericardial effusion

Note the markedly increase echogenecity in right kidney when compared with Liver also available anteriorly in the field. Normal kidney is iso-echoic to liver,

Note the atrial septal bowing towards LA occuring during systole. On color doppler, this patient had moderate Tricuspid regurgitation. Hence, due to chronic TR, right atrium has enlarged here. Furthermore, during systole, the increase in right atrial pressure due to TR leads to septal bowing seen here,

Probe: Linear probe with lung settings Note, that there is no movement when observing pleural line with respiration. Normally, 'crawling ants' appearance is seen due to sliding of pleura. This finding is very sensitive and specific for pneumothorax. B lines here also represent pulmonary edema if 3 or more are present in one lung field.

How to differentiate Z lines from B lines: B line has to have these two features: - Extending along with whole depth of field - Get wider as it goes deeper in the field In this case, the vertical lines do get broader, however they do not cover the entire depth of the field. Hence, these vertical artifacts are different from B lines, and are called Z lines. They do not have any clinical significance.