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)

• 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)

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

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1. Otto, C.M. Textbook of Clinical Echocardiography.

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