Prominent Rv1 And Right Axis

Parasternal Short Axis

Parasternal short-axis

Fig. 9. Parasternal short-axis view, mitral position. This view represents a "breadloaf" slice through the heart at the level of the mitral valve. From this view, you can see the mitral valve in cross-section ("fishmouth" view) with anterior and posterior leaflets (arrows) indicating the wide open early diastolic position. (Please see companion DVD for corresponding video.)

right of the screen; moving leftward, the aortic valve (AV) (right coronary AV leaflet superiorly and noncoronary leaflet inferiorly) and LV outflow tract (LVOT) are next. The left atrium (LA) and MV are at the bottom of the screen. The MV chordal apparatus and papillary muscles are also seen in this view.

The parasternal long-axis view is an excellent overview image of the heart. It is generally the best window for measuring the aortic root and LA, LV chamber dimensions, and LV wall thickness. The mitral and aortic valves are well seen, and anterior structures, such as the RV and pericardial effusions,

Systole

Parasternal short-axis

Parasternal Short Axis

Fig. 10. (A) Parasternal short-axis view, papillary muscle level. This view is similar to the short-axis mitral position but more apical in the ventricle. The papillary muscles (PM) are visualized. This is an excellent view for assessing regional wall motion in the left ventricle. (B) Short axis through the aortic valve, visualized in the center of the screen, is comprised of three cusps, the right coronary cusp (RCC), the non-coronary cusp (NCC) and the left coronary cusp (LCC). Anterior to the aortic valve is the right ventricular outflow tract, with the tricuspid valve seen at 10 o'clock, and the pulmonic valve seen at approx 2 o'clock to 3 o'clock. The left atrium is immediately posterior to the aortic valve in this view. (Please see companion DVD for corresponding video.)

Fig. 10. (A) Parasternal short-axis view, papillary muscle level. This view is similar to the short-axis mitral position but more apical in the ventricle. The papillary muscles (PM) are visualized. This is an excellent view for assessing regional wall motion in the left ventricle. (B) Short axis through the aortic valve, visualized in the center of the screen, is comprised of three cusps, the right coronary cusp (RCC), the non-coronary cusp (NCC) and the left coronary cusp (LCC). Anterior to the aortic valve is the right ventricular outflow tract, with the tricuspid valve seen at 10 o'clock, and the pulmonic valve seen at approx 2 o'clock to 3 o'clock. The left atrium is immediately posterior to the aortic valve in this view. (Please see companion DVD for corresponding video.)

can be visualized as well. This view is generally used for measurement of the LVOT diameter (see Chapter 11). In addition, color flow Doppler in this view can reveal evidence of mitral regurgitation or aortic insufficiency. There is generally no need for using spectral Doppler in this view.

RV Inflow View

With inferomedial tilt of the transducer (still in the same parasternal position), a longitudinal view of the RV and right atrium (RA) can be obtained (Fig. 8; please see companion DVD for corresponding video). In this window, the RA is to the right and bottom (posterior) and the

Mesure Lvot Diamter Apical

Fig. 11. Apical four-chamber view. From this view, the following structures are easily visualized: left ventricle (LV), right ventricle (RV), left atrium (LA), right atrium (RA), mitral valve (MV), and tricuspid valve (TV). Pulmonary veins (PV) can be visualized at the bottom of the left atrium. Note the prominent moderator band (MB), a normal structure, in the apical third of the right ventricle. (Please see companion DVD for corresponding video.)

Fig. 11. Apical four-chamber view. From this view, the following structures are easily visualized: left ventricle (LV), right ventricle (RV), left atrium (LA), right atrium (RA), mitral valve (MV), and tricuspid valve (TV). Pulmonary veins (PV) can be visualized at the bottom of the left atrium. Note the prominent moderator band (MB), a normal structure, in the apical third of the right ventricle. (Please see companion DVD for corresponding video.)

RV is above (anterior) and left. This view allows visualization of the tricuspid valve, as well as assessment of tri-cuspid regurgitation by colorflow and measurement of tricuspid regurgitant velocity utilizing spectral continuous-wave Doppler.

Parasternal Short-Axis Views

Still in position at the left parasternal third or fourth intercostal space, the transducer is rotated 90° clockwise to obtain the short-axis views (Figs. 9 and 10; please see companion DVD for corresponding video). The index is now facing the patient's left shoulder. From this position, the LV is imaged in cross-section. Slices (as from a loaf of bread) can be obtained at three levels: the base, the midventricle, and the apex. The basal third of the heart is seen by angling the transducer superiorly and rightward; this view includes the MV leaflets and extends to the tips of the papillary muscles. Directing the transducer so that it is perpendicular to the chest wall visualizes the middle third of the LV; this view comprises the length of the papillary muscles, from their chordal attachments to their insertion in the LV. In this position, the RV is seen at the top (because it is anterior) and to the left of the screen. The LV should appear round in this view; if it appears oval, then the LV is being imaged obliquely. This is generally an excellent view for assessing global and regional LV contractility. The apical third of the LV can be seen with further inferior tilting of the probe.

When the transducer is moved even further up the torso or angulated slightly caudally, a cross-section through the aortic valve is obtained (Fig. 10B; please see companion DVD for corresponding video). Color flow Doppler in the short axis through the aortic valve can be useful for assessing aortic insufficiency.

Apical Position

With the patient still in the left lateral decubitus position, the probe is moved to the cardiac apex, just lateral and caudal to the point of maximal impulse. From this position, the transducer direction is varied to obtain the four-, five-, and two-chamber views of the heart: as a general rule, the apical position is superior to the paraster-nal for looking at mitral or aortic regurgitation, because the regurgitant jets tend to be more parallel to the color Doppler imaging beam.

Apical Four-Chamber View

From the apex, the transducer is angled superiorly toward the patient's right shoulder with the index pointing down (toward the patient's left flank) to obtain the four-chamber view; the imaging plane is perpendicular to the interventricular septum (Fig. 11; please see companion DVD for corresponding video). On the screen, the heart is

Apical Chamber View Aorta

Fig. 12. Apical five-chamber view. Obtained by tilting the scan head 10-20° from the apical four-chamber view, this view allows for visualization of the aortic valve (arrow) and left ventricular outflow tract (LVOT). It is also the best view for obtaining Doppler flow through the aortic valve. (Please see companion DVD for corresponding video.)

Fig. 12. Apical five-chamber view. Obtained by tilting the scan head 10-20° from the apical four-chamber view, this view allows for visualization of the aortic valve (arrow) and left ventricular outflow tract (LVOT). It is also the best view for obtaining Doppler flow through the aortic valve. (Please see companion DVD for corresponding video.)

Tri Cusp Heart Echo Doppler

Fig. 13. Apical two-chamber view. Obtained by rotating the transducer 90° counterclockwise from the apical four-chamber view. This view shows the left ventricle (LV) and left atrium (LA), but the right-sided structures are no longer visible. This view is useful for visualizing regional wall motion of the anterior and inferior walls and is also the best angle from which to view the plane of mitral valve coaptation, useful in the diagnosis of mitral valve prolapse. (Please see companion DVD for corresponding video.)

Fig. 13. Apical two-chamber view. Obtained by rotating the transducer 90° counterclockwise from the apical four-chamber view. This view shows the left ventricle (LV) and left atrium (LA), but the right-sided structures are no longer visible. This view is useful for visualizing regional wall motion of the anterior and inferior walls and is also the best angle from which to view the plane of mitral valve coaptation, useful in the diagnosis of mitral valve prolapse. (Please see companion DVD for corresponding video.)

displayed upside down, from the perspective of the api-cally placed transducer. The apex is the structure closest to the transducer and, therefore, it is at the top of the screen; the atria are at the bottom. The LV and LA are on the right and the RV and RA on the left, divided by the interventricular septum and interatrial septum. Notice that the inner surface of the RV is more heavily trabecu-lated than that of the LV, and that the RV apex does not reach the LV apex. In many patients, a prominent moderator band can be visualized in the RV; this is a normal

Apical long-axis

Fig. 14. Apical long-axis view. Obtained by further rotating the transducer another 45° counterclockwise from the apical two-chamber view. This view is almost identical to the parasternal long-axis, although the image is rotated 90° clockwise and the apex is well visualized. This view provides good images of the left ventricular posterior wall, interventricular septum, mitral valve, and aortic valve. (Please see companion DVD for corresponding video.)

finding. Also notice that the attachment of the septal leaflet of the tricuspid valve is approx 5-8 mm closer to the cardiac apex than the mitral attachment. These findings can be helpful in distinguishing the cardiac chambers. The apical four-chamber view is good for assessing ventricular function, particularly the motion of the inter-ventricular septum and the lateral wall of the LV. The anterior RV wall and the AV valves are visualized in this view as well.

Color flow Doppler is used in this view to look for and assess possible mitral regurgitation, aortic insufficiency, and tricuspid regurgitation. The color flow sector should be positioned over the appropriate valve for proper visualization. In addition, color flow of the LVOT can alert the viewer of possible turbulence in this region that might be caused by subaortic stenosis owing to hyper-trophic cardiomyopathy or a subaortic membrane.

Spectral Doppler is used to assess mitral inflow. The Doppler cursor is placed at the tips of the leaflets and the mitral inflow signal is assessed. Tricuspid regurgitant velocity can be assessed by continuous-wave Doppler through the tricuspid valve. The tricuspid regurgitant velocity is dependent on the gradient between the RV and the RA. Using the Bernoulli equation (see Chapter 1), the pulmonary systolic pressure can be estimated (in the absence of pulmonic stenosis) by adding the estimated gradient between the RV and the RA to an estimate of RA pressure (see Chapter 1).

Apical Five-Chamber View

Without changing the position or rotation of the transducer, tilting of the scan head 10-20° anteriorly reveals the five-chamber view, with the imaging plane now traversing the AV and LVOT (the "fifth chamber;" Fig. 12; please see companion DVD for corresponding video). This is often the best view for assessing the structure and function of the aortic valve. Doppler color flow mapping and Doppler pulsed-wave images obtained in this view are useful in determining the presence and severity of aortic regurgitant or stenotic lesions.

Apical Two-Chamber View (Fig. 13; Please See

Companion DVD for Corresponding Video)

The anterior and inferior walls of the LV are not visualized in the four- and five-chamber views because the imaging plane does not traverse them; these can be seen by rotating the imaging plane 90° counterclockwise (so the index now points to the patient's left shoulder), producing the apical two-chamber view (the two chambers are the LA and LV). Regional wall motion of the anterior and inferior walls is seen in this view; it is also the best angle from

Subcostal View Pericardial Thickening

Fig. 15. Subcostal view, showing interatrial septum. The subcostal view demonstrates the right heart structures well. In addition, this view is useful for examination of the interatrial septum, and is used to help rule out atrial septal defects. This is also a useful view for asessing the hepatic veins and inferior vena cava (IVC). (Please see companion DVD for corresponding video.)

Fig. 15. Subcostal view, showing interatrial septum. The subcostal view demonstrates the right heart structures well. In addition, this view is useful for examination of the interatrial septum, and is used to help rule out atrial septal defects. This is also a useful view for asessing the hepatic veins and inferior vena cava (IVC). (Please see companion DVD for corresponding video.)

Abnormal Inferior Vena Cava
Fig. 16. Subcostal view showing hepatic veins and inferior vena cava (IVC). Elevated right atrium pressure may lead to IVC dilation and loss of the expected inspiratory collapse. (Please see companion DVD for corresponding video.)

which to view the plane of MV coaptation, useful in the diagnosis of MV prolapse. Color flow Doppler should be used in this view as well to visualize potential mitral regurgitation in the orthogonal plane to the four-chamber view.

Apical Long-Axis View

Further counterclockwise rotation of the transducer head produces the apical long-axis or three-chamber view (Fig. 14; please see companion DVD for corresponding video). This imaging plane is very similar to cAby

Fig. 17. Suprasternal view. The suprasternal transducer position allows visualization of the aortic arch and its major branches. The inominate artery arises from the ascending aorta (seen on the left of the screen); the left carotid and subclavian arteries arise from the left arch as it becomes the descending thoracic aorta. The right pulmonary artery (RPA) may be seen in cross-section beneath the aortic arch. (Please see companion DVD for corresponding video.)

the parasternal long-axis, and provides a good image of the LV posterior wall, interventricular septum, MV, and aortic valve. Color flow Doppler in this view can be useful to view potential aortic insufficiency.

Subcostal Position

For the subcostal views, the transducer is placed in the subxiphoid region, just to the right of center (Figs. 15 and 16; please see companion DVD for corresponding video). In this position, the ultrasound beam travels through the abdominal wall, part of the liver, and the diaphragm on its way to the heart. In some patients, such as those with emphysema, this may be the best imaging position (hyperinflated lungs obscure the parasternal windows, and flattened diaphragms optimize subcostal windows). However, in obese patients, subcostal windows may be difficult to obtain. For the subcostal views, the patient is placed in the supine position with knees flexed to relax the abdominal muscles. Deep inspiration with breath hold facilitates optimal imaging in this view.

From this position, a four-chamber view can be obtained by angulation of the transducer head toward the left shoulder, with the index facing the patient's left flank. In this image, the apex of the heart points up and to the right; the RA and RV are above the left heart chambers, adjacent to the liver. The right heart structures are well visualized in this view. The interatrial septum can be examined with color Doppler imaging for septal defects or patent foramen ovale. Rotating the transducer so the index points to the patient's head emphasizes the right heart structures as well as the hepatic veins and inferior vena cava (IVC). This is the optimal view for assessing the IVC, which can provide an indirect assessment of RA pressure; elevated RA pressure may lead to IVC dilation and loss of the expected inspiratory collapse. Clockwise rotation of the transducer produces a subcostal short-axis view of the LV and RV.

Color flow Doppler should be used to interrogate the interatrial septum for possible atrial septal defects, particularly secundum defects, which are best visualized in this view.

Suprasternal Position

The suprasternal transducer position allows visualization of the aortic arch and its major branches (Fig. 17; please see companion DVD for corresponding video). The transducer is placed in the suprasternal notch with the index toward the patient's head and the tip angled caudally; slight anterior or posterior tilting of the transducer maneuvers the imaging plane along the major axis of the aorta. The innominate artery arises from the ascending aorta (seen on the left of the screen); the left carotid and subclavian arteries arise from the left arch as it becomes the descending thoracic aorta. The right pulmonary artery may be seen in cross-section beneath the aortic arch. Ninety degree rotation of the transducer head reveals the aortic arch in cross-section and the right pulmonary artery in longitudinal axis. This view can be useful in the diagnosis of some aortic diseases and congenital anomalies, including severe aortic insufficiency and aortic coarctation.

summary

A solid understanding of the normal echocardiogram is a necessary prerequisite to the identification of disease states. Watch this normal study several times, paying close attention to the valve structures and Doppler patterns in each window, the normal thickening of the myocardium, and the relative sizes of the various cardiac chambers. It may be useful to refer back to this study when abnormalities in subsequent chapters are encountered. The next chapter

(Chapter 3) describes technical details of the standard echocardiography examination in greater detail, and is designed to complement the overview presented in this chapter.

suggested reading

Jawad IA. Ultrasound in cardiology. In: Jawad IA, ed. A Practical Guide to Echocardiography and Cardiac Doppler Ultrasound, 2nd ed. Boston: Little, Brown, and Co, 1996:13-85. Oh JK, Seward JB, Tajik AJ. Transthoracic echocardiography. In: Oh JK, Seward JB, Tajik AJ, eds. The Echo Manual, 2nd ed. Philadelphia: Lippincott-Raven, 1999:7-22. Sehgal CM. Principles of Doppler imaging and ultrasound. In: St. John Sutton MG, Oldershaw PJ, Kotler MN, eds. Textbook of Echocardiography and Doppler in Adults and Children, 2nd ed. Cambridge: Blackwell Science, 1996:3-30. St. John Sutton MG, Oldershaw PJ, Plappert TJ. Normal transtho-racic Doppler echocardiographic examination. In: St. John Sutton MG, Oldershaw PJ, Kotler MN, eds. Textbook of Echocardiography and Doppler in Adults and Children, 2nd ed. Cambridge: Blackwell Science, 1996:31-66.

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Responses

  • marcel
    What is the best view to see the aortic cusps?
    7 years ago

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