Table 1 Subcostal and apical four-chamber view

Goal

Volume status - IVC collapse. LV and RV size and function. Pericardial effusion. Right pleural effusion

LV size and function, RV size and function, and pericardium. RV/LV ratio. Pericardial effusion. Left pleural effusion. Aortic and mitral valve thickening. Significant valvular regurgitation - color Doppler

Patient position

Supine with pillow under knees to relax abdominal wall

Far left lateral, when possible

Initial transducer placement

Transducer at the subxyphoid position and angled slightly medially, pointing the transducer (soundwave beam) to the patient’s left side. Transducer marker at approximately 3 o’clock. Transducer almost flat against the abdominal wall, approximately at a 15 degree angle

Start at the apex. Rotate the transducer clockwise with the tranducer marker at approximately 3 o’clock and angle the transducer or sound wave beam up through the apex of the heart or right shoulder

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Transducer angled laterally to image the apex of the RV, upper right side of screen, LV on the lower right side of screen, right atrium on the upper left side of screen, and left atrium on the lower right side of screen

The right and left apex will be at the top of the screen with the atria below

For IVC, angle the transducer medially or towards the patient’s right shoulder to view the right atrium. Slightly rotate the transducer counter clockwise. Tilt the transducer and soundwave beam slightly inferiorly or down to ‘open up’ or image the IVC in the long axis plane for measurements and IVC collapse/distensibility calculation. The measurement should be taken 1 to 2 cm in from the IVC/right atrium connection

The LV on the upper right side of the screen and the RV on the upper left side of the screen. If not sure which is the RV or LV, the tricuspid valve leaflets are always inserted closer to the apex than the mitral valve

If the apex is leftward on the screen, angle or slide the transducer and soundwave beam medially

If the apex is tilted rightward on the screen, angle or slide the transducer and soundwave beam laterally or rightward