IMBUS-Fundamentals

About The Exam

Screening Heart Exam with Advanced IMBUS

Point-of-care-ultrasound (POCUS) was developed in Emergency and Critical Care Medicine when ultrasound devices became portable and cheaper, and the 2021 edition of the American Society of Echocardiography’s textbook listed the characteristics of POCUS echocardiography as follows:

1. Performed by the physician at the bedside during clinical evaluation
2. Limited number of findings sought, usually brief (<5 minutes)
3. Can encompass more than one organ system
4. Has indication and value to affect diagnosis, management, or immediate triage
5. Uses small, inexpensive portable devices with limited data entry and measurements.
6. Limited reporting, often semiquantitative
7. Often repeated by subsequent physicians and used for monitoring or follow-up
8. Often lacks characterization of incidental findings
9. Variable imaging and training for each physician

Our Advanced IMBUS clinic physicians have patients that fit these POCUS criteria but also care for patients without focused complaints, such as new clinic patients, annual preventive visits, and preoperative exams for major surgery. These patients have traditionally received a hands/eyes/stethoscope screening exam of the heart, which is suboptimal for most heart pathology.

The ASE textbook does not discuss screening echocardiograms with advanced devices. However, it describes a LIMITED echocardiogram as a formal imaging test with imaging standards, study archiving, and an all-inclusive interpretation and report in which the user is responsible for all diagnoses. Our screening heart exam with Venue meets these criteria.

We published a study in 2021 that added a screening ultrasound exam with Venue to the Medicare Wellness visits of 108 patients; an important part was a heart exam. (J Ultrasound Med 2021: http://dx.doi.org/10.1002/jum.15788).  We found frequent previously unknown heart abnormalities, and the primary physicians graded the benefits of this information as mildly to moderately positive and rarely adverse for a patient.

Our screening exam uses only some parts of the heart exam described in the succeeding chapters because a limited heart screen must be efficient. We use nine views of the heart and are finished in 10-15 minutes with a reasonably normal heart and good views. However, it can take twice as long when multiple abnormalities are present. Each view is visually assessed (VA), and Color Doppler is used over each valve. The VA follows a logical pattern that becomes a habit, reducing the chance of missing something important. There are only five measurements that are routine during the exam. If abnormalities are noted, additional views and measurements may be added.

PLAX: analyze clockwise from the top

  • Begin cephalad to find and measure the distal ascending aorta diameter
  • Move caudad to a standard PLAX
  • Have enough initial depth to note posterior effusions, then decrease the depth
  • VA the proximal right ventricular outflow tract (RVOT)
  • VA the proximal ascending aorta and aortic valve (AV) (use Color)
  • VA the left atrium (LA)
  • VA the coronary sinus location and MV annulus movement
  • VA the mitral valve (MV) (use Color)
  • VA the basal left ventricle (LV)

PLAXR: analyze following the blood flow

  • VA the right atrium (RA)
  • VA the tricuspid valve (TV) (use Color)
  • VA the right ventricle (RV)

PSAX: with a successful PLAXR, only two structures need to be imaged

  • VA the LV doughnut
  • VA the AV


An apical4 is rarely optimal for both the right and left hearts. It is better to divide the analysis into separate left and right heart components and optimize each view. We begin with the left heart.

APICAL4 (Left): analyze following the blood flow

  • VA the LA
  • VA the septal and lateral MV annulus movement
  • VA the MV leaflets (use Color)
  • VA the LV
  • Obtain Auto-EF
  • Use Color over the LV inflow and obtain E and A
  • Use TDI on the septal mitral annulus to get s’, e’, and a’

APICAL5 (Left)

  • VA the left ventricular outflow tract (LVOT) and AV
  • Apply Color and get the plane with the best flow through LVOT and AV
  • Obtain Auto-VTI

APICAL4 (Right): analyze following the blood flow

  • VA the RA
  • VA the TV annulus movement
  • VA the TV (use Color)
  • VA the RV

APICAL2: analyze following the blood flow

  • VA the LA
  • VA the MV (use Color)
  • VA the LV

APICAL3: analyze following the blood flow

  • VA the LA
  • VA the MV (use Color)
  • VA the LV
  • VA the LVOT and AV (use Color)

APICAL3R: analyze following the blood flow

  • VA the RA
  • VA the TV (use Color)
  • VA the RV

SUBCOSTAL4: analyze following the blood flow

  • VA the RA
  • VA the TV
  • VA the RV
  • VA the LA and use Color over the interatrial septum
  • VA the MV
  • VA the LV
  • Fan to subcostal5 and VA the LVOT, AV, and AscA