Standard views and measurements in transthoracic echocardiography

Editors-in-chief: Eli V. Gelfand, MD; Anne B. Riley, MD (Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, respectively)

Nomenclature

 * Each image is defined by the position of the transducer and the image plane
 * Transducer location
 * Parasternal
 * Apical
 * Subcostal
 * Suprasternal
 * Image plane
 * Vertical Long axis: parallel to the long axis of the left ventricle (2 chamber view)
 * Horizontal long axis: (4 chamber view)
 * Short axis: perpendicular to the long axis of the ventricle, resulting in circular cross sections of left ventricle


 * Transducer terminology
 * Tilted: the transducer is rocked to image different structures in the same tomographic plane
 * Angled: the transducer is moved from side to side to obtain different tomographic planes parallel to the original image plane
 * Rotated: transducer is twisted with a circular motion to provide a different image plane (i.e. to go from short axis to long axis)

Parasternal Long Axis

 * Probe position: 3rd or 4th intercostal space, adjacent to the sternum


 * Echo/Diagram:
 * most anterior structure is the muscular RVOT
 * then, proximal structure of ascending aorta, including aortic root, sinuses of valsalva, and sinotubular junction
 * aortic valve- right coronary cusp is anterior and noncoronary cusp is posterior
 * anterior and posterior mitral valve leaflets are visible
 * chordal attachments leading to the medial papillary muscle
 * left atrium is posterior to the aortic root
 * posterior to left atrium, descending thorasic aorta in cross-section
 * left ventricular septum and posterior wall is seen at the base and midventricular level
 * true apex is not seen- what appears to be the apex an oblique image through the anterolateral wall

Right Ventricular Inflow and Outflow Tracts

 * Probe position: from the parasternal long axis, move the probe apically and then angulate medically
 * Echo/Diagram:
 * view the right atrium, tricuspid valve, and right ventricle
 * septal and anterior leaflets of tricuspid valve are visible
 * appreciate entrance of coronary sinus entering the right atrium
 * note the crista terminalis: muscular ridge running from the superior to inferior vena cava, dividing the RA

Parasternal Short Axis

 * Probe position: from parasternal long axis, rotate the transducer clockwise 90 degrees and angulate superior/inferior to see views of the aortic valve, mitral valve, papillary muscle, and apical left ventricular level
 * Echo/Diagram:
 * can see all 3 aortic leaflets- right, left and non coronary cusps
 * in diastole, see Y shaped arrangement of the coaptation lines of the leaflets
 * can identify the number of valve leaflets most accurately in systole
 * surrounding the aortic valve is the atria and the intratrial septum, septal and anterior leaflets of the tricupid valve, right ventricular free wall, RVOT, pulmonic valve, and main pulmonary artery
 * by tilting the probe inferiorly, can see the level of the mitral valve which has a "fish-mouth" appearance
 * mitral commissures are located medically and laterally
 * additional inferior tilting shows the papillary muscle level of the left ventricle

Apical Four Chamber View

 * Probe position: patient lying left lateral recumbant, transducer placed on the apex
 * Echo/Diagram:
 * left ventricle (lateral): anteriolateral wall, apex and inferior septum lie in the tomographic plane
 * right ventricle(medial): basal, mid, apical free wall, and moderate band seen, more trabeculated than left ventricle
 * mitral annulus: see anterior (next to septum) and posterior (next to lateral wall) mitral leaflets
 * tricupid annulus well visualized
 * left and right atria are located inferiorly on the screen

Apical Two Chamber View

 * Probe position: from the four chamber view, transducer is rotated counterclockwise
 * Echo/Diagram:
 * used to view the anterior, inferior, and apical walls of the left ventricle, the left atrium and its appendage

Apical Long Axis

 * Probe position: from the two chamber view, transducer is rotated another 60 degrees counter clockwise
 * Used to view the anterior septum, posterior or inferolateral wall of the left ventricle, aortic valve, LVOT, mitral valve

Subcostal Four Chamber

 * Patient position: patient supine, knees bent to relax abdominal musculature, full inspiration to bring heart closer to transducer
 * Probe position: just below or to the right of the xyphoid process
 * Echo/Diagram:
 * used to view the basal, mid and apical right ventricle, the midsection of the interventricular septum, and the anterolateral left ventricular free wall
 * interatrial septum is perpendicular to probe, making this a good view for evaluation of atrial septal defects/aneurysms

Suprasternal Notch

 * Patient position: patient supine, neck extended
 * Transducer position: suprasternal notch or right supraclavicular position
 * Used to view the aortic arch
 * Long axis view shows ascending aorta, arch, proximal descending aorta and original of right brachiocephalic and left common carotid and subclavian arteries
 * Short axis view shows aortic arch in cross section

Normal echocardiogram - demonstration of standard views


Echocardiography: A Tutorial

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