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3. Echocardiography Protocol

Cardiac Ultrasound Views

The 5 main/basic cardiac ultrasound views of the heart are the Parasternal Long Axis, Parasternal Short Axis, Apical 4 Chamber, Subxiphoid (Subcostal), and IVC Views.

Step 1: Parasternal Long Axis (PSLA) View

The Parasternal Long Axis View is often abbreviated as PSLA or PLAX.

It is usually the first cardiac ultrasound view obtained and will give you an immediate assessment of the general condition of the heart including ejection fraction and overall left and right ventricular sizes.

  • Point the probe indicator toward the patient’s right shoulder
  • Place the probe at the 4th intercostal space which is approximately the nipple line for males or the inframammary fold to the sternum (females).

Structures to identify in the Parasternal Long Axis (PSLA) View:

  • RV: Right Ventricle
  • LV: Left Ventricle
  • LA: Left Atrium
  • AV: Aortic Valve
  • MV: Mitral Valve
  • AO: Aorta
  • DA: Descending Aorta
  • Pericardium
Parasternal Long Axis View Structures – Illustration
  • Optimize the gain to visualize the different chambers of the heart in view
  • Optimize the depth to makes sure you can see the Descending Aorta.
  • POCUS 101 TIP: If you are having trouble orienting yourself, just remember “the 3 L‘s“: For the Parasternal Long Axis view, the Left Ventricle is on the Left side of the screen.
Parasternal Long Axis View Ultrasound Echocardiography Video eFAST FAST scan POCUS
Cardiac Ultrasound – Parasternal Long Axis View

Parasternal Short Axis – Mid-Papillary Level

The first Parasternal Short Axis view on echocardiography you should focus on is the Mid-Papillary level. The Mid-Papillary level gives you information regarding overall ejection fraction, right ventricular dysfunction, and left ventricular regional wall motion abnormalities.

Probe placement for Mid-Papillary View.
Mid-Papillary Level Illustration

Structures to identify in the Parasternal Short Axis (PSSA) Mid-Papillary Level:

  • RV: Right Ventricle
  • LV: Left Ventricle 
  • Papillary Muscles
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Mid Papillary Video
Cardiac Ultrasound of Mid-Papillary Level

Parasternal Short Axis – Mitral Valve Level (Fish Mouth View)

The Mitral Valve level is common view seen and allows you to view the anterior and posterior valves of the mitral valve.

  • To get the Mitral Valve level from the Mid-Papillary level, slide the Transducer towards the sternum towards the mitral valve (base of the heart).
  • The Anterior and Posterior leaflets of the Mitral Valve should come into view.
Probe placement for Mitral Valve Level
Mitral Valve Level (Fish Mouth View) Illustration

Structures to identify in the Parasternal Short Axis (PSSA) Mitral Valve Level:

  • RV: Right Ventricle
  • LV: Left Ventricle 
  • MV: Mitral Valve (Anterior and Posterior leaflets)
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Mitral Valve Fish Mouth Ultrasound Video
Cardiac Ultrasound – Mitral Valve Level (Fish Mouth View)

Parasternal Short Axis – Aortic Valve Level (Mercedes Benz View)

The aortic valve level of the parasternal short axis view allows you to visualize the right ventricle, right atrium, left atrium, aortic valve, tricuspid valve, and pulmonic valve. You can use this view to perform some advanced Point of Care Ultrasound (POCUS) applications such as evaluation of a bicuspid aortic valve, the severity of aortic stenosis, tricuspid regurgitation, and measuring of pulmonary pressures.

  • To get the Aortic Valve level from the Mitral Valve level, tilt the tail of the probe inferiorly and point it towards the Aortic Valve.
  • As you do so the Aortic Valve should come into view with its leaflets representing the “Mercedes Benz Sign.”
Probe placement for Aortic Valve Level
Aortic Valve Level (Mercedes Benz View) Illustration

Structures to identify in the Parasternal Short Axis (PSSA) Aortic Valve Level:

  • RV: Right Ventricle 
  • TV: Tricuspid Valve
  • AV: Aortic Valve
  • PV: Pulmonic Valve
  • RVOT: Right Ventricular Outflow Tract
  • RA: Right Atrium
  • LA: Left Atrium
Cardiac Ultrasound Echocardiography Parasternal Short Axis View PSSA PSAX Aortic Valve Level Mercedes Benz Sign Ultrasound Video
Cardiac Ultrasound – Aortic Valve Level (Mercedes Benz View)

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