Two Dimensional Image Acquisition

Patient Positioning
The patient should be in the left lateral position as this brings the heart into contact with chest wall. The left arm is extended behind the head to permit access to the apical and parasternal windows.

Probe Positioning
There are four standbrd transducer positions-pmsternal, apical, subcostal and suprasternal which id utilized to visualize heart and great vessels.

 Fig.  (a): Four standard transducer position with parasternal, apical, subcostal and su- prasternal views
 

Fig.  (b): Also shows right parasternal view used to take aortic gradient in patient of aortic stenosis

A) Parasternal Po$ition

Examination is begun by placing the transducer in left parasternal region, usually in the third or fourth left intercostal space. From this position, a sector image of the heart along its lcbng and short axis can be obtained.

Parasternal Long Akis View

The parasternal lona axis view is acquired with the ridge of the transducer pointing towards tht$ patient's right shoulder. Angling the beam, toward the righthip brings the right ventricular inflow into view. Angling the beam towards the right shoulder allows evaluation of right ventricular outflow tract.

Plax view-schematic diagram and Two-dimensional echocardiographic image showing
various structures visualized

Various structures visualized are LV, LA, MV, RV, LVOT and AV, ascending aorta.

Parasteranl Short Axis Vim With the transducer placed in the parasternal position (third or fourth left intercostals space), the probe is then turned 90" clockwise from parasternal long axis view to obtain short axis view. The ridge now points towards left shoulder and observation is made at four levels:

1) At the level of great vessels

2) Mitral valve

3) Papillary muscles

4) Apex

Various structure visualized are apex, MV, Papillary muscles, AV, TV, PV,pulmonary artery and bihrcation, LA, RA and RV.

Schematic diagram and Two-dimensional echocardiographic image of
the parasternal short axis view at the aortic level

Schemltic diagram and Two-dimensional echocardiographic image of
short $xis view at level of papillary muscles

B) Apical Window

The transducer is placed in the mid axillary line with the transducer ridge pointing towards the patients left to obtain the four-chamber view. The left ventricular apex is aligned in the middle of the screen sector by sliding the transducer mediallp. The ultrasound beam is angled anteriorly to obtain five-chamber view or posteriorly to visualize the coronary sinus. From the four chamber view, the probe is rotated counter clockwise to acquire the two chamber view and further cbunter clockwise to the apical long axis view.

Schematic diagram and Two-dimensional echocardiographic image of
apical four-chamber view
Inferior
Wall
erior

Schemltic diagram and Two-dimensional echocardiographic image of
short $xis view at level of papillary muscles

C ) Subcostal Mewsf
In addition to parasternal and apical transducer position. Subcostal view also provides imaging window in adult patients. The patient is supine with knees flexed to relax the abdominal muscles. The transducer is moved to the subxiphoid position with the ridge pointing towards the patients left. The subcostal transducer position can be very effective in-patient with chronic lung diseases in whom parasternal and apical view are obscured by intervening lung tissue. The subcostal views also provide excellent visualization of the atria septum and the connections between IVC and right atrium.

Schematic diagram and Two-dimensional echocardiographic image of
subcostal four-chamber view

D ) Suprasternal Eews
These views are obtained by placing the transducer in the suprasternal notch with the ridge pointing cephalad. The neck is extended during the suprasternal notch examination. This position may be uncomfortable for many patients.It provides a view of the arch of the aorta and includes the great vessels in the majority of patients and positions of the main pulmonary artery.

Schematic diagram of the aorta and right pulmonary artery from the
suprasternal notch window

E ) Right Parasterdal Windows It is a view obtaineld in right lateral decubitus position with the transducer in the right parasternal arda and can be helpful in evaluating the ascending aorta and the interatrial septum.