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)
Overview
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 location
- 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
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Echocardiography: A Tutorial
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References
- Otto, C.M. Textbook of Clinical Echocardiography.