Standard views and measurements in transthoracic echocardiography

# 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
Parasternal
Apical
Subcostal
Suprasternal
- 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
- 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)
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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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