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Table 1 Subcostal and apical four-chamber view

From: A practical approach to goal-directed echocardiography in the critical care setting

  Subcostal view 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
Search for the best window 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
  1. IVC, inferior vena cava; LV, left ventricle; RV, right ventricle.