002 // How to Image

CONTENTS
22 How to Move the Transducer
22 Imaging Windows
22 Image View
28 Abbreviations
21
002 // HOW TO IMAGE

NOTES HOW TO MOVE THE TRANSDUCER

Use enough
ultrasound gel.

Displacement Rotation Angulation

IMAGING WINDOWS

Suprasternal
Use as many views as Parasternal 2nd–4th intercostal space R L

possible, including left sternal border

atypical views. Always
image so that the Apical 4th – 5th intercostal space,
pathology of interest lateral Right parasternal Left parasternal
is seen best.
Subcostal Below xiphoid

Right parasternal 2nd–4th intercostal space,

right sternal border Apical

Suprasternal Suprasternal notch Subcostal

IMAGE VIEW

Parasternal Long-Axis Views

RV

AV
Ao
LV
MV
AMVL
LA

Parasternal
long-axis view

RV
Anterior

Posterior TV

Right
parasternal long axis

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 002 // HOW TO IMAGE

IMAGE VIEW NOTES

Parasternal Short-Axis Aiews

RV

RA RC
AC
LC
PA
LA

l-PA
r-PA
Parasternal short
axis – base

Move down one intercostal

space to obtain good image
quality and a “more“ spherical
RV (round) configuration of the

MV distal parts of the left

ventricle.

Parasternal short axis –

mitral valve

PM
PMPM AL
PM

Parasternal short axis

– mid-ventricle

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002 // HOW TO IMAGE

NOTES IMAGE VIEW

Use a medial position (A) to Apical Views Rotate counterclockwise

visualize the lateral wall of the
LV and a lateral position (B) to
visualize the RV. RV LV LV LV
RV
TV MV MV AV
MV
LA Ao
LA
RA LA

4-chamber view 2-chamber view 3-chamber view

The orientation of the

septum indicates
whether you are in
lateral or medial
position relative to the
true apex. Use all views
to fully examine all Parasternal Parasternal Parasternal
approach approach approach
aspects of the left and
right ventricle. A B

Four-chamber view Two-chamber view Three-chamber view

Orientation of the Apical Views

Four-chamber view

Three-chamber view
Two-chamber view

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 002 // HOW TO IMAGE

IMAGE VIEW NOTES

Five-chamber view The five-chamber view shows

the anterior portions of the
LV interventricular septum.

RV LVOT

Ao
RA LA

Avoid foreshortening; place

Coronary sinus view the transducer as lateral and
caudal as possible.

RV LV

RA CS
RL – PV
LL – PV
RU – PV
LA LU – PV

Subcostal Views
Abdominal gas may
Subcostal four-chamber view obscure the apex on
the subcostal view.

LIVER

RV
RA LV

LA

In some patients it
Inferior vena cava view (rotate counterclockwise) may be possible to see
the superior vena cava
on this view.
LIVER
IVC

RV
RA

LA

SVC

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002 // HOW TO IMAGE

NOTES IMAGE VIEW

Obtain subcostal Subcostal short-axis view (rotate clockwise)

views in all patients.

RV
RA
Ao PA

ry
ry

te
te

ar
ar
The suprasternal view allows Suprasternal View

tid
ry

lic
te

ro
ha
ar

ca
you to detect coarctation, a

ep
an

on
oc
persistent Botalli‘s duct, or vi

m
a

hi
cl

m
ac
b

co
aortic dissection, as well as su
Br

ft
t
ef

Le
quantify retrograde flow in L
the aorta (aortic
regurgitation). r-PA
Asc Ao

Desc Ao
Suprasternal view

MMode – LA is measured in MMode MMode aorta/left atrium

its largest extension at end
systole. The dimensions of
the aorta are measured at
end diastole, shortly before AO

the aortic valve opens.

LA

MMode left ventricle

Measure the end-diastolic

diameter where the LV is RV
IVS
largest, shortly before
LV
contraction starts (beginning Posterior Wall
of the QRS complex).

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 002 // HOW TO IMAGE

IMAGE VIEW NOTES

Reference Values – MMode

Aorta (mm) < 40 LVEDD (mm) 42 – 59

Left atrium (mm) 30 – 40 Posterior wall (mm) 6 – 10

IVS (mm) 6 – 10 Fractional shortening (%) > 25

Tricuspid Annular Plane MAPSE (longitudinal

Systolic Excursion (TAPSE) > 16 mm LV function) > 12 mm

Reference Values – Doppler

Aortic valve velocity (m/sec) CW 0.9 – 1.7

LVOT velocity (m/sec) PW < 1.3

Pulmonary valve velocity (m/sec) CW 0.5 – 1.0

Tricuspid valve PW 0.3 – 0.7

Tricuspid regurgitation (m/sec) CW 1.7– 2.3

E wave (m/sec) PW < 1.3

Mitral annulus e‘ (cm/sec) TDI PW 0.8 – 1.3

Right ventricular lateral wall (cm/sec) TDI PW 12.2 (41 – 60a)/

10.4 (>60a)

Color Doppler Optimize the 2D image

before using color
• Optimize the 2D image before you use color Doppler Doppler.
• Look for aliasing to detect jets
• Reduce pulse repetition frequency (PRF) to detect low velocity
flow (e.g. ASD, PFO)
• Use higher frame rates
• Use multiple views
• Use color flow as a guide for CW/PW sample volume

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002 // HOW TO IMAGE

NOTES ABBREVIATIONS

AC = acoronary cusp
AL = anterolateral papillary muscle
Ao = aorta
Asc Ao = ascending aorta
AV= aortic valve

CS= coronary sinus

Desc Ao = descending aorta

IVC = inferior vena cava

IVS = interventricular septum

LA= left atrium

LC= left-coronary cusp
LL-PV = left-lower pulmonary vein
l-PA= left pulmonary artery
LU-PV= left-upper pulmonary vein
LV = left ventricle
LVOT = left ventricular outflow tract

MV = mitral valve

PA = Pulmonary artery
PM= posteriomedial papillary muscle

RC = right-coronary cusp
RL-PV= right lower pulmonary vein
r-PA = right pulmonary artery
RU - PV= right upper pulmonary vein
RV= right ventricle

SVC = superior vena cava

TV = tricuspid valve

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