Evaluating the Inferior Vena Cava (IVC) with ultrasound is one of the most commonly used Point of Care Ultrasound (POCUS) applications. It is a great way to estimate central venous pressure (CVP) and fluid tolerance.
From the Subxiphoid view with the patient still in the supinated position with knees bent, keep the right atrium in view.
Locate the Inferior Vena Cava within the Liver and center it on the ultrasound screen.
Once the IVC is centered on the screen, rotate the transducer clockwise (to your right) to bring the indicator down toward the feet (play the instructional video).
This will give a longitudinal view of the Inferior Vena Cava entering the Right Atrium.
IVC Ultrasound Probe PositionIVC View – Going from Short Axis to the Long Axis View
Structures to identify in the Inferior Vena Cava (IVC) View:
IVC: Inferior Vena Cava
RA: Right atrium
HV: Hepatic Vein (sometimes seen)
IVC View
Assessing for IVC Collapsibility:
After you obtain the IVC view you will need to assess for IVC collapsibility in either your spontaneously breathing or ventilated patients.
For Spontaneously Breathing Patients: have them take a deep breath or have them sniff in. The maximum IVC diameter will be seen during expiration and the minimum IVC diameter will be seen during inspiration for these patients.
For Ventilated Patients: The positive pressure from the ventilator will have the opposite effect on the IVC compared to spontaneously breathing patients. The maximum IVC diameter will be seen during inspiration and the minimum IVC diameter will be seen during expiration for these patients.
The Subxiphoid or “Subcostal” view allows you to see similar structures as the Apical 4 Chamber view but just approached from a different angle. This Subxiphoid view is useful when you are having difficulty getting adequate parasternal views (i.e. COPD patients) or when you are evaluating a trauma patient when doing the eFAST scan.
With the patient’s knees bent, position the probe under the costal arch (beneath the xiphoid process) with the indicator pointing towards the patient’s left.
Since the plane of the heart is superficial, you need to use an overhand grip on the probe in order to be parallel with the skin
Hand and Probe position for the Subxiphoid (Subcostal) View
Structures to identify in the Subxiphoid (Subcostal) View:
RV: Right Ventricle
LV: Left Ventricle
TV: Tricuspid Valve
MV: Mitral Valve
LA: Left Atrium
RA: Right Atrium
Pericardium
Make sure to use the Liver as an acoustic window!
If you approach from the left side your view will be obstructed by the stomach or bowel gas.
If you are still having trouble getting a clear image, try applying gentle downward pressure on the probe.
The Apical Views are some of the most important views to be able to obtain when doing hemodynamic assessment of the heart. This includes looking at diastolic dysfunction, valvular regurgitation, cardiac output, etc.
Unfortunately, it can be one of the most challenging views to obtain when first starting out. In this section, we will show you exactly how to get the mail apical views including the apical 4 chamber view, 5 chamber view, and the coronary sinus view.
Apical 4 Chamber (A4C)View
From the Parasternal Short Axis View, slide the Transducer towards the apex of the heart keeping the indicator pointed towards the patient’s left side.
Once you reach the apex of the heart, as indicated by the left ventricle decreasing in size, tilt the tail of the probe down towards the patient’s foot.
For females, the Point of Maximal Impulse (PMI) is usually just under their left breast.
As you do this the Apical Four Chamber view should appear.
Hand and Probe position for the Apical 4 Chamber View
Structures to identify in the Apical 4 Chamber (A4C) View:
LV: Left Ventricle
RV: Right Ventricle
LA: Left Atrium
RA: Right Atrium
TV: Tricuspid Valve
MV: Mitral Valve
Apical 4 Chamber (A4C) View Illustration
Optimize the gain and depth to visualize the 4 chambers of the heart.
TIP: If you are having trouble getting the Apical 4 Chamber view, try placing the patient in the left lateral decubitus position. It will reduce lung artifact and bring the heart more proximal to your ultrasound probe, usually giving you an optimal view.
Cardiac Ultrasound -Apical 4 Chamber (A4C) View
Since the Apical 4 Chamber view can be a challenging view to obtain, you will most likely encounter variants of the apical view including the Apical 5 chamber view and the coronary sinus view. We will go over these views below.
Apical 5 Chamber (A5C)View
A common view produced when attempting to do the apical 4 chamber view is the “Apical 5 Chamber View.”
Of course, there are not really 5 chambers in the heart but in echocardiography, the “5th chamber” is when you can see the appearance of the aortic valve and the left ventricular outflow tract.
Sometimes you will want to intentionally obtain this view in order to calculate the cardiac output of the left heart.
From the Apical 4 Chamber view, slightly tilt the tail of your probe towards the patient’s feet to get the Apical 5 chamber view. If you want to go back to the Apical 4 chamber view just tilt the probe tail back towards the patient’s head. Often the difference between the two views is just a 5-10 degree tilt!
Another common view produced by novice sonographers when attempting to do the apical 4 chamber view is the Coronary Sinus View. You will rarely intentionally need to get this view and it is important to know what to do if you see this view.
The coronary sinus view will give the appearance of an atrial septal defect between the right and left atrium. Don’t be fooled by this.
The reason the Coronary Sinus view is coming into view and not the Apical 4 chamber is because the tail of your transducer is tilted too much towards the patient’s head. Tilt your probe tail slightly towards the patient’s feet and it should give you the apical 4 chamber view.
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 LongAxis view, the Left Ventricle is on the Left side of the screen.
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 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.
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 LevelAortic 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 – Aortic Valve Level (Mercedes Benz View)
