The Transthoracic Examination, View by View

Introduction

This chapter presents the views acquired during the normal two-dimensional (2D) adult comprehensive transthoracic echocardiography (TTE) examination. These views are based on the standards recommended by the American Society of Echocardiography (see Chapter 8 ). Optimal image acquisition is a prerequisite for optimal interpretation and reporting of the adult transthoracic echocardiogram by the echocardiographer/cardiologist expert. This involves competency in cardiac sonographer skills and training, as well as optimizing patient and instrument settings (see Chapter 11 ).

The comprehensive adult 2D TTE examination (TTE) begins at the left parasternal window, followed by the apical, subcostal, and suprasternal notch windows ( Tables 9.1–9.6 ). Each standard echocardiographic view is described using three components (see Table 9.1 ; see also Chapter 8 ): (1) transducer position or window, namely the parasternal (P), apical (A), subcostal (SC), and suprasternal notch (SSN) windows; (2) echocardiographic imaging plane, namely long-axis (LAX), short-axis (SAX), or four-chamber (4C) planes; and (3) cardiac structures or regions of interest.

TABLE 9.1

Standard Two-Dimensional Adult Transthoracic Echocardiography Views

Window	Cardiac imaging plane	Region-Structures of Interest
Parasternal Views (see Figs. 9.1–9.4 )
Parasternal (P)	Long-axis (LAX)	LV inflow-outflow, LA, MV, LV, LVOT, RVOT, IVS, Aortic root, descending thoracic aorta
P	LAX	RV inflow, TV, RV, coronary sinus, IVC
P	LAX	RV outflow: RVOT, PV, PA
P	Short-axis (SAX)	Aortic valve level: AV, TV, PV, IAS, LA, IAS, coronary arteries; IVC
P	SAX	PA bifurcation: main PA, PV, RPA, LPA, coronary arteries
P	SAX	Mitral valve level: MV, basal LV walls, LVOT, IAS
P	SAX	Papillary muscle level: LV walls, papillary muscles; IAS
P	SAX	Apical level: apical LV walls; LV apex (apical tip)
Apical Views (see Figs. 9.5–9.8 )
Apical (A)	Four-chamber (4C)	LV, RV, LA, RA, MV, TV, pulmonary veins
A	Five-chamber (5C)	AV, LV, LVOT
A	Two-chamber (2C)	LV walls, LV, LA, LAA, MV
A	Three-chamber (3C); or long-axis (LAX)	LV walls, LV inflow-outflow, LA, MV, LV, LVOT, RVOT, IVS
Subcostal Views (see Fig. 9.9 )
Subcostal (SC)	Four-chamber	IAS, LV, RV, LA, RA, MV, TV
SC	Long-axis (LAX)	Inferior vena cava (IVC), hepatic veins
SC	LAX	Abdominal aorta (AA)
SC	Optional views	Family of SAX and LAX views of the heart when transthoracic windows unavailable, or in the pediatric examination SAX views of IVC and AA
Suprasternal Notch Views (see Fig. 9.10 )
Suprasternal notch	Long-axis	Aortic arch and branches, distal ascending aorta, proximal descending thoracic aorta
Suprasternal notch	Optional views	Short-axis views of the aortic arch with “crab” view of the LA and pulmonary veins, frontal view of the ascending aorta

AA, Abdominal aorta; AV, aortic valve; IAS, interatrial septum; IVS, interventricular septum; IVC, inferior vena cava; LA, left atrium; LV, left ventricle; LVOT, left ventricular outflow tract; MV, mitral valve; PA, pulmonary artery; PV, pulmonary valve; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract; TV, tricuspid valve

TABLE 9.2

Parasternal Long-Axis Views: Normal Examination (see Figs. 9.1 and 9.2 )

Transducer Position (Window)	2D ± M-MODE ± 3D	CFD	Spectral Doppler (PW, CW)
Parasternal long-axis (PLAX): LV inflow-outflow	PLAX 2D Use increased depth to rule out effusions, and then decrease depth. 2D zoom of the MV and AV Measure the aortic root leading edge to leading edge on 2D. Measure the LA at the largest dimension during the end of ventricular systole on PLAX view or on the PSAX/AV level view. Measure the LVIDd, IVSd, LVPwd at the end of diastole just when the MV closes and measure at the level of the mitral chordae level (MM or 2D). Measure the LVIDs at the end of systole at the same level that the diastolic measurements were made (MM or 2D). M-mode MV/AV, Aortic root/LA, LV 3D full-volume (optional)	CD to AV/MV, Zoom (on/off)	CW if VSD
RV inflow	2D depth 20 cm, then 15–16 cm Zoom on the TV	Color Doppler TV for TR	CW Doppler for Max; TR velocity
RV outflow (optional)	2D Zoom on the PV	Color Doppler PV for PR	—

Transducer Position (Window)

2D ± M-MODE ± 3D

CFD

Spectral Doppler (PW, CW)

Parasternal long-axis (PLAX):
LV inflow-outflow

PLAX 2D

Use increased depth to rule out effusions, and then decrease depth.
2D zoom of the MV and AV
Measure the aortic root leading edge to leading edge on 2D.
Measure the LA at the largest dimension during the end of ventricular systole on PLAX view or on the PSAX/AV level view.
Measure the LVIDd, IVSd, LVPwd at the end of diastole just when the MV closes and measure at the level of the mitral chordae level (MM or 2D).
Measure the LVIDs at the end of systole at the same level that the diastolic measurements were made (MM or 2D).
M-mode MV/AV, Aortic root/LA, LV
3D full-volume (optional)

CD to AV/MV, Zoom (on/off)

CW if VSD

RV inflow

2D depth 20 cm, then 15–16 cm
Zoom on the TV

Color Doppler TV for TR

CW Doppler for Max; TR velocity

RV outflow (optional)

2D
Zoom on the PV

Color Doppler PV for PR

—

2D, Two-dimensional echocardiography; 3D, three-dimensional echocardiography; AV, aortic valve; CFD, color flow Doppler echocardiography; CW, continuous-wave Doppler echocardiography; IVS, interventricular septum; LA, left atrium; LV, left ventricle; LVIDd, LV internal diameter at end diastole; LVIDs, LV internal diameter at end systole; LVPwd, LV posterior wall thickness at end diastole; MM, M-mode/motion-mode; MV, mitral valve; PR, pulmonary regurgitation; PV, pulmonary valve; PW, pulsed-wave Doppler echocardiography; RV, right ventricle; TR, tricuspid regurgitation; TV, tricuspid valve; VSD, ventricular septal defect.

TABLE 9.3

Parasternal Short-Axis Views: Normal Examination (see Figs. 9.3 and 9.4 )

Transducer Position (Window)	2D ± M-MODE ± 3D	CFD	Spectral Doppler PW, CW
Parasternal short-axis (PSAX): aortic valve level (AVL)	2D to AV Zoom AV 2D 2D to TV 2D to PV M-mode (optional) 3D full-volume (optional)	CFD to AV CFD to TV for TR CFD to PV for PR	CW to TR max velocity
PSAX: pulmonary artery bifurcation (PAB)	2D image of PAB	CFD for PR and PDA	PW-CW of PV
PSAX: Mitral valve level (MVL)	2D image at the MV and basal LV walls	CFD to MV	—
PSAX: papillary muscle level (PML)	2D image at PML, mild LV walls	—	—
PSAX: apical level	2D image at LV apical walls and LV apical segment	—	—

2D, Two-dimensional echocardiography; 3D, three-dimensional echocardiography; AV, aortic valve; CFD, color flow Doppler echocardiography; CW, continuous-wave Doppler echocardiography; LV, left ventricle; MV, mitral valve; PDA, patent ductus arteriosus; PR, pulmonary regurgitation; PV, pulmonary valve; PW, pulsed-wave Doppler echocardiography; TR, tricuspid regurgitation; TV, tricuspid valve.

TABLE 9.4

Apical Views (see Figs. 9.5–9.8 )

Transducer Position (Window)	2d ± M-Mode ± 3d	CFD	Spectral Doppler Pw, Cw	Tissue Doppler Imaging (Tdi)
Apical four-chamber (A4C)	2D image; depth 15–16 cm. LV and LV walls Optimize endocardial borders for LV volumetric EF assessment MV assessment 2D Measurement of LA volume- measure LA volume at the end of systole and the shorter length of the LA 3D full-volume (optional) Evaluate RV function on 2D focus RV image. TAPSE (tricuspid annular plane systolic excursion)	CFD to MV for MR, MS CFD the Pulmonary veins, PW of right upper or lower pulmonary vein Color M-Mode flow propagation velocity CFD to TV and CW for TR max velocity.	PW Doppler at the tips of the mitral leaflets for MV inflow CW Doppler of the MV	TDI (PW) of MV annulus (lateral and septal) Color TDI to LV walls TDI of TV annulus
Apical five-chamber view (A5C)	2D visualization of the AV-Zoom on the valve	CFD to the AV	PW Doppler of the LVOT (1–2 cm) from the valve leaflets, closing AV click CW for transaortic velocities
Apical two-chamber view (A2C)	2D image LV and LV walls Optimize endocardial borders for LV volumetric EF assessment Volumetric measurement of the LA	CFD to MV		TDI (PW) of MV annulus (anterior and inferior) Color TDI to LV walls
Apical three-chamber view (A3C) or apical long-axis (ALAX) view	2D image for wall motion evaluation	CFD to AV and MV	—	—

2D, Two-dimensional echocardiography; 3D, three-dimensional echocardiography; AV, aortic valve; CFD, color flow Doppler echocardiography; CW, continuous-wave Doppler echocardiography; EF, ejection fraction; LA, left atrium; LV, left ventricle; LVOT, left ventricular outflow tract; MR, mitral regurgitation; MS, mitral stenosis; MV, mitral valve; PW, pulsed-wave Doppler echocardiography; RV, right ventricle; TR, tricuspid regurgitation; TV, tricuspid valve

TABLE 9.5

Subcostal Views (see Fig. 9.9 )

Transducer Position (Window)	2D ± M-MODE ± 3D	CFD	Spectral Doppler PW, CW	Tissue Doppler	3D
Subcostal views	Subcostal four-chamber (SC-4C) On - off zoom	CFD to interventricular and interatrial septum CFD to TV, CW if TR velocity (optional)	Optional	Optional	Optional
	Subcostal view short-axis view at the AV level 2D	Color Doppler	Optional	Optional	Optional
	Subcostal view IVC-Long-axis 2D image Respiratory Changes of the IVC; Use M-mode or 2D (sniff) IVC/Hepatic vein LV short axis	Color Doppler	PW Doppler	—	—
	Subcostal view Abdominal aorta-long-axis	2D color Doppler	PW Doppler	—	—

2D, Two-dimensional echocardiography; 3D, three-dimensional echocardiography; AV, aortic valve CFD, color flow Doppler echocardiography; CW, continuous-wave Doppler echocardiography; IVC, inferior vena cava; LV, left ventricle; PW, pulsed-wave Doppler echocardiography; SC , subcostal; SSN, suprasternal notch view; SVC, superior vena cava; TR, tricuspid regurgitation; TV, tricuspid valve

TABLE 9.6

Suprasternal Notch Views (see Fig. 9.9 )

Transducer Position (Window)	2D	Color Flow Doppler	Spectral Doppler PW, CW	Tissue Doppler	3D
SSN	2D image Aortic arch, distal ascending aorta, proximal descending aorta	CFD	PW/CW	—	—

2D, Two-dimensional echocardiography; 3D, three-dimensional echocardiography; CFD, color flow Doppler echocardiography; CW, continuous-wave Doppler echocardiography; PW, pulsed-wave Doppler echocardiography; SSN, suprasternal notch view.

At each window, each echocardiographic view must be optimized and recorded. This includes video loops, still frames, and recommended pertinent measurement ( Figs. 9.1–9.10 and corresponding , , , , , , , , , , , , , , , , , , , , , , , , , , , ). The typical sequence of the modalities employed are as follows:

1.
2D examination for cross-sectional anatomy of the cardiac structures
2.
M-mode examination for timing of cardiac events and linear measurements
3.
Color flow Doppler examination for the initial visual assessment of normal and abnormal flows, and a guide to quantitative assessment of velocities using spectral Doppler
4.
Spectral Doppler examination—namely continuous-wave (CW) Doppler to measure maximum transvalvular velocities and gradients, followed by pulsed-wave (PW) Doppler to detect flows at specific anatomical sites when indicated
5.
Tissue Doppler imaging (TDI) to assess myocardial velocities
6.
Three-dimensional (3D) echocardiography incorporated when available and as indicated (see Chapter 10 )