Standard views and measurements in transthoracic echocardiography

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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 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

References

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



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