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Parasternal Long-Axis View
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The transducer is placed in the left 3rd or 4th intercostal space adjacent to the sternum with the orientation marker pointing towards the patient’s right shoulder (Figure 95–1) (Table 95–3). The probe position is adjusted in order to line up the aortic valve (AV), mitral valve (MV), and the largest left ventricular (LV) areas (Figure 95–2).
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This view allows for assessment for pericardial effusion, LV/RV size and function, septal kinetics, and valve anatomy. Pitfalls inherent to this view include underestimation of RV size, inaccurate assessment of LV size and function with off-axis views (false end-systolic effacement), and underestimation of regurgitant jets with color Doppler.
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Parasternal Short-Axis at the Mid-Ventricular Level
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From the parasternal long-axis view, the transducer is rotated 90° clockwise without angulation or tilting (Figure 95–3), resulting in a cross-sectional view of the heart at the midventricular/papillary muscle level with the orientation marker pointing towards the patient’s left shoulder (Figure 95–4).
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This view allows for assessment for pericardial effusion, LV/RV size and function, and septal kinetics. Pitfalls inherent to this view include inaccurate assessment of the LV if off-axis views are obtained (ie, imaging the apex of the LV can create false end-systolic effacement and overrotation of the transducer may result in septal flattening).
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Apical Four-Chamber View
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The transducer is placed on the lower lateral chest with the orientation marker pointed towards the patient’s left shoulder and the tomographic plane adjusted to bisect the anatomic apex of the LV and the two atria (Figures 95–5 and 95–6). This view is best achieved with the patient in the left lateral decubitus position.
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This view allows for assessment of LV/RV size and function, particularly identifying RV enlargement by the RV/LV ratio, and for assessment for pericardial effusion. Pitfalls inherent to this view include difficulty obtaining an on-axis image, which can result in inaccurate assessment of LV/RV size and function and an incorrect RV/LV ratio.
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Subcostal Long-Axis View
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The transducer is placed just below the xiphoid process with the orientation marker pointing towards the 3 to 4 o’clock position and the tomographic plane adjusted to bisect the LV and left atrium (LA). The transducer must be held at the top of its surface in order to allow it to lay as flat as possible on the patient’s abdomen (Figures 95–7 and 95–8).
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This is often the best view on a mechanically ventilated patient as the liver serves as an acoustic window to the heart and the ultrasound is not blocked by an aerated lung. This view allows for assessment for pericardial effusion, LV/RV size and function, and the RV/LV ratio. This view is the best for a rapid assessment of cardiac function during pulse checks when performing cardiopulmonary resuscitation. Pitfalls include inaccurate assessment of cardiac structures when the view is off-axis.
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Inferior Vena Cava Longitudinal View
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From the SCL view, the transducer is rotated counterclockwise 90°, tilted inferiorly, and angled laterally to visualize the IVC in the longitudinal axis (Figures 95–9 and 95–10).
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This view allows for assessment of preload sensitivity in a hypotensive patient and when assessing a patient for the presence of pericardial tamponade. Pitfalls inherent to this view include the misidentification of the aorta for the IVC, off-axis view of the IVC, and translational artifact mimicking respiratory variation of the IVC.