POCUS · MCS Eval
Point-of-care ultrasound assessment
Assessment checklist
Systematic MCS evaluation
0 of 14 complete
Cardiac function LV/RV
LV size & systolic function
EF estimation, WMA
RV size & function
D-sign, TAPSE, free wall motion
Valvular pathology
MR, AR — impact on unloading
Pericardial effusion / tamponade
Hemodynamics Flow
LVOT-VTI (stroke volume)
A4C, 5MHz PW Doppler
IVC collapsibility
Subxiphoid, M-mode or 2D
Mitral inflow E/A, E/e′
Filling pressures estimate
Pulmonary Congestion
B-line quantification
≥3 per zone = significant congestion
Pleural effusion
Bilateral, size estimate
Lung sliding present bilaterally
Organ perfusion VExUS
Hepatic vein Doppler pattern
S/D ratio, systolic reversal
Portal vein pulsatility
PVP index
Intrarenal venous Doppler
Continuous vs phasic vs discontinuous
IVC ≥ 2 cm (VExUS prerequisite)
Hemodynamic calculators
Enter measurements from your images
Cardiac output (LVOT method)
LVOT diameter (cm) 2.0
LVOT-VTI (cm) 18
Heart rate (bpm) 75
Cardiac output
3.2 L/min
42
SV (mL)
1.8
CI (BSA 1.8 m²)
IVC / CVP estimate
IVC max diameter (cm) 2.0
IVC min / sniff (cm) 1.4
Collapsibility index
30%
E/e′ ratio (filling pressure)
Mitral E velocity (cm/s) 80
e′ septal (cm/s) 8
E/e′ ratio
10.0
Device-specific evaluation
Select device to review findings
Impella CP positioning PLAX/A3C
Key rule: Inlet mid-point ~3.5 cm below AoV annulus
Inlet tip location
3–3.5 cm below AoV (CP-specific)
Access
Percutaneous femoral (14Fr)
Support level
~4.0 L/min
Inlet in LV
Clear of MV, chordae
Outlet in aorta
Above AV leaflets
No obstruction
AV fully open each cycle
LV unloading
LV size ↓, PCWP ↓
Red flags
Malposition signals
Suction alarmsMR worseningAI on echo
Impella 5.5 positioning PLAX/A3C
Key rule: Same 3–3.5 cm AoV rule applies — larger shaft, confirm no MV interference
Inlet tip location
3–3.5 cm below AoV
Access
Surgical (axillary/cut-down)
Support level
~5.5 L/min
Echo appearance
Shaft slightly larger than CP
Inlet in LV
Clear of MV, chordae
Outlet in aorta
Above AV leaflets
No obstruction
AV fully open each cycle
LV unloading
LV size ↓, PCWP ↓
Red flags
Malposition signals
Suction alarmsMR worseningAI on echo
IABP positioning SSNE/PLAX
Tip location
Distal to L subclavian
Proximal extent
Above celiac axis
Balloon inflation
At dicrotic notch
AR assessment
CI to IABP if severe AR
VA-ECMO cannula check
Venous (drainage) tip
IVC/RA junction
Return cannula
Femoral artery
LV distension
Monitor — vent if needed
Aortic valve opening
Should open each beat
North-south syndrome
SpO₂ R arm vs leg
Native cardiac recovery
LV function trend
Serial EF comparison
LVOT-VTI on ECMO
Tracks native output
LVAD assessment
Inflow cannula
LV apex, no obstruction
Outflow graft
Ascending aorta flow
AV opening
Should open intermittently
RV function
Critical — screen for RVF
Ramp study
Optimize speed setting
Weaning assessment
Pre-decannulation evaluation
Weaning trial parameters
EF on reduced support (%) 35
LVOT-VTI on minimal support 14
B-lines (bilateral zones) 4
Weaning readiness
Minimum criteria checklist
EF ≥ 20–25% on minimal support
LVOT-VTI ≥ 10 cm
Indicates meaningful native forward flow
No severe MR or AR
RV function adequate
MAP ≥ 65 on reduced vasopressors
B-lines improving / resolving
No new pericardial effusion
Micro-axial flow placement
Impella CP & 5.5 — POCUS positioning guide
Key positioning rule PLAX
AoV annulus → mid-inlet distance (Impella CP)
~3.5 cm
Below aortic valve annulus into LV — applies to Impella CP specifically
Impella 5.5: Same 3–3.5 cm AoV rule applies. Larger shaft profile — confirm no mitral valve apparatus interference.
Optimal view
PLAX or A3C (3-chamber)
Pigtail location
LV apex or mid-cavity
Inlet region (CP)
3–3.5 cm below AoV, in LV
Inlet region (5.5)
3–3.5 cm below AoV, in LV
Outlet region
Above AoV leaflets, in aorta
Motor housing
Straddles AoV — do not mistake for mass
Device anatomy diagram
Hand-annotated reference — pigtail, inlet, outlet, motor
Illustration from: Cardiac Critical Care Made Visual: An Illustrated Study Guide by Caitlyn Nichols BSN
Echo appearance — PLAX view
Device crossing AoV — LV, AoV, inlet, LV cannula, LA labeled
Measurement reference — 3.5 cm rule (Impella CP)
Impella CP: AoV annulus to mid-inlet ~3.5 cm | Impella 5.5: same 3–3.5 cm target applies
Placement checklist CP & 5.5
Pigtail visible in LV, not in aorta
Confirm in PLAX or A3C
Inlet 3–3.5 cm below AoV annulus (CP & 5.5)
Impella CP: ~3.5 cm target — measure from annulus to mid-inlet area
Inlet free of MV subvalvular apparatus
Not entangled in chordae or papillary muscles
Outlet (aortic cannula) above AoV leaflets
In ascending aorta, not LV outflow tract
AoV leaflets not obstructed by device
Leaflets should partially coapt around shaft
No significant worsening of AR
Color Doppler — new/worsening AR = malposition
LV decompression confirmed
LV size reduced vs baseline
No suction events on device console
Correlate with hemodynamic controller alarms
CP vs 5.5 differences
Impella CP
~4.0 L/min support
Impella 5.5
~5.5 L/min support
5.5 access
Surgical (axillary/cut-down)
CP access
Percutaneous femoral (14Fr)
Echo appearance
5.5 shaft slightly larger
3.5 cm AoV rule
Impella CP primary target
5.5: same 3–3.5 cm rule applies
5.5: same 3–3.5 cm rule applies
Malposition red flags
Pigtail seen in aorta — device pulled back too far
Inlet < 3 cm from AoV — too shallow, risk of migration
Inlet > 5 cm from AoV — too deep, risk of MV interference
New/worsening MR — possible chordal entanglement
Persistent suction alarms with adequate LV filling
⚠ Clinical reminder
This tool is a bedside reference aid. All positioning decisions should be confirmed by a trained echocardiographer and correlated with device hemodynamics and console alarms.