Ultrasound

Quick guide
Introduction to transthoracic echo
Anne-Sophie Beraud, cardiologist
Clinique Pasteur, Toulouse, France

Toni Burkett
Philips Healthcare – Ultrasound

The more you see, the more you can do

The use of focused echo at the patient’s bedside allows the physician
to quickly assess chamber sizes, global LV and RV function, RV strain,
hypovolemia, and fluid responsiveness. In addition, pericardial effusion,
signs of tamponade, and significant valvular regurgitation can be identified.
POC echo is a valuable tool that allows the treating physician to answer
specific clinical questions that can guide the immediate care of patients.
Introduction to transthoracic echo

The basics

The transducer
• The optimal transducer for transthoracic
echo is a low-frequency phased array.

Orientation of the ultrasound image for echo

• Every transducer has an orientation marker on one side
(usually a notch, a groove or a ridge).
• The orientation marker on the transducer corresponds
to the orientation marker on the ultrasound monitor.
• By convention, for echo, the orientation marker is located
to the upper right of the ultrasound image.

orientation
marker

RV LV

RA
LA

In this example, the transducer orientation marker is pointing to the patient’s

left, thus the patient’s left will be on the right side of the ultrasound image.

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Introduction to transthoracic echo

Techniques to adjust the transducer

Locate the ultrasound “window” on the patient’s chest. Adjust transducer
manipulation step by step and with small movements.

Align Rotation
Place the transducer so the ultrasound Clockwise or counterclockwise rotation
beam is aligned with the anatomy of the transducer is required to change
views and to optimize the image.

Tilt
Tilt the transducer to identify and Tilt may be up/down or side-to-side
optimize the anatomy of interest. depending on the ultrasound view.

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Introduction to transthoracic echo

Using gain

Optimal gain Under gained Over gained

The gain controls the An image that is An image that is
amplification of the under gained will result over gained will result
displayed images. in an image that is too in an image that is too
With an optimal gain black and some of the white and some of the
setting, the cardiac anatomical information anatomical detail will
structures will be shades will be missing. be lost.
of gray and the blood
will be almost black.

Using depth

Optimal depth Insufficient depth Excess depth

The depth control Insufficient depth will not Excess depth may not
increases or decreases display all of the anatomy allow the visualization
the field of view. It is very that is of interest. of details needed.
important to have the
appropriate depth
setting for each view.

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Introduction to transthoracic echo

Parasternal long-axis

• Transducer is placed in 3rd-4th

intercostal space.

• Transducer orientation marker is pointing

toward the patient’s right shoulder
(˜10 o’clock).

• Depth 12-16 cm.

• For assessment of a pericardial and

pleural effusion use a depth of 20-24 cm.

3
Parasternal long-axis view

RV
IVS

AV AO
LV
MV

LA

Pericardium

Parasternal long-axis view.

Right side of the image is cephalad.
The pericardium is a strong echo reflector
and appears as a bright white echo.

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Parasternal short-axis aortic valve level

• From the parasternal long-axis view,

rotate the transducer 90 degrees
clockwise.

• Transducer orientation marker is pointing

toward the patient’s left shoulder
(˜2 o’clock).

• Tilt the transducer face slightly upward

toward the patient’s right shoulder.

• Depth 12-16 cm.

5
PSS: Aortic valve level

RVOT
Pulmonic
Tricuspid valve
valve Aortic
valve PA
RA

LA

Parasternal short-axis view aortic valve level.

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Introduction to transthoracic echo

Parasternal short-axis mitral valve level

• From the parasternal long-axis view,

rotate the transducer 90 degrees
clockwise.

• Transducer orientation marker is pointing

toward the patient’s left shoulder
(˜2 o’clock).

• Transducer is perpendicular to the

chest wall.

• Depth 12-16 cm.

PSS - Mitral valve level

RV
IVS

LV
Mitral valve

Pericardium

Parasternal short-axis view mitral valve level.

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Parasternal short-axis papillary muscle level

• From the parasternal long-axis view,

rotate the transducer 90 degrees
clockwise.

• Transducer orientation marker is pointing

toward the patient’s left shoulder
(˜2 o’clock).

• Tilt the transducer face slightly

downward toward the patient’s left flank.

• Depth 12-16 cm.

RV
IVS
Anterior wall
LV
Inferior
wall Papillary
muscles

Pericardium

Parasternal short-axis view papillary

muscle level.

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Apical four-chamber (A4C)

• The transducer is placed on the apical

impulse.

• Tilt the face of the transducer up until the

ultrasound beam cuts through the long
axis of the heart and all four chambers
are visualized.

• Transducer orientation marker is at

˜3 o’clock.

• Depth: 14-18 cm.

RV LV

TV
MV

RA
LA

Apical four-chamber view.

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Apical five-chamber (A5C)

• From the apical four-chamber view, tilt

the face of the transducer slightly upward
until the aortic valve appears.

• Transducer orientation marker is at

˜3 o’clock.

• Depth 14-18 cm.

• Note: The LV and RV will be

foreshortened in this view.

2
Apical 5-chamber

LV
RV

AV

RA LA

Apical five-chamber view.

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Introduction to transthoracic echo

Subcostal four-chamber

• Patient is supine.

• Transducer is placed 2-3 cm below

the xyphoid process.

• Direct the transducer toward the

patient’s chin/left shoulder.

• Transducer orientation marker is at

˜3 o’clock.

• Hold the transducer palm down to

facilitate cephalad angulation of the
ultrasound beam. • Tip: Directing the ultrasound beam
too posterior is a common mistake
• Depth 16-24 cm. in the subcostal view.

RV

TV
LV
RA
MV

LA

Subcostal four-chamber view.

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Introduction to transthoracic echo

Subcostal inferior vena cava (IVC)

• From subcostal four-chamber view,

rotate the transducer 90 degrees
counter-clockwise, always keeping
the right atrium on the screen.

• Transducer orientation marker at

˜12 o’clock.

• Depth 16-24 cm.

• It is important to see the IVC merging

into the RA. This will confirm that you
are not visualizing the aorta.

IVC RA

Subcostal inferior vena cava view.

The IVC should be seen merging into the RA.

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Introduction to transthoracic echo

Tips for image optimization

Optimal parasternal long-axis view

Interventricular septum and LV wall are
parallel and as horizontal as possible.
Aortic and mitral valves are in the center
of the image.

Caution: The septum and LV wall must be

parallel in order to estimate LV function
using the parasternal long-axis view. If the
septum and LV wall are NOT parallel, LV
function will be overestimated.

If the IVS and LV wall are vertical,

try moving the transducer one
intercostal space higher.

If the LV appears “closed,” rotate

the transducer to open it.

If the valves are off-center, tilt the

transducer away from the sternum.

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Tips for image optimization

Optimal parasternal short-axis view

The LV should be round and in the center.

If the LV is pear-shaped, you are too low,

try scanning one intercostal space higher.

If the LV is asymmetric, rotate the

transducer clockwise or counter-
clockwise.

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Tips for image optimization

Optimal four-chamber view

All four chambers are visualized and the

long-axis of the heart is vertical.

If you don’t see the atria, the transducer

may be aimed too posterior. Tilt the face
of the transducer upwards.

If the heart appears tilted to the right,

you are too medial. Move your
transducer laterally.

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 For additional resources related to critical care and emergency
medicine ultrasound visit www.philips.com/CCEMeducation

For more information about Lumify, the Philips app-based

ultrasound system, go to: www.Philips.com/Lumify
or call 1-844-MYLUMIFY

For information about Philips Sparq ultrasound system

go to www.philips.com/sparq

For feedback or comments regarding this tutorial or the iPad App,

please contact us at [email protected]

This Quick Guide is a companion tool to the Introduction to transthoracic echo

tutorial. The tutorial provides more detailed information as well as many cardiac
images and videos of normal anatomy and pathology.

©2016 Koninklijke Philips N.V. All rights are reserved. www.philips.com/CCEMeducation

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