standard acquisition sequence

Technicians in the echo lab follow a prescriptive sequence in obtaining echo clips/images and making measurements. Here we provide a gross outline of the imaging sequence for the purposes of critical care and other sub-specialty trainees.

Enter data

STEP 1- Enter demographic info for image capture and storage: Pt name, ULI, and your user ID

STEP 2- Select low-frequency, phased-array transducer. Ensure cardiac setting is selected (marker to screen right).

​STEP 3- Connect ECG leads to patient


Parasternal views

step 1. Parasternal views

Start at 2nd ICS with parasternal long axis view, depth of field ~15cm.

  • Angle probe marker toward patient’s right shoulder, slight inferior tilt (over the rib).
  • Slide probe down chest until cardiac structures come into view. Capture this image.
  • Deep initial view will prevent missing a pericardial/pleural effusion

Parasternal long axis

Decrease depth so that the heart fills as much of the screen as possible without cutting off structures.
  • Capture 1-2 loops in B-mode to assess wall motion
  • Visually inspect mitral/aortic valve appearance and opening
  • Place M-mode cursor just past MV leaflets to assess fractional shortening of LV cavity

STep 3. PLAX valves

Capture loops with color doppler over MV/AV
  • Adjust sector width (medium) to optimize frame rate if needed
  • Place color box over individual valve (aortic/mitral)
  • Zoom in on valves if any abnormality suspected

STep 4. RV inflow

Tilt transducer over rib to bring right-sided (anterior) structures into view
  • Color doppler through tricuspid valve
Measure: CW Doppler through TR jet, TR Vmax to estimate RVSP

STep 5. PSSAX valves

Keep probe on same “footprint”: rotate transducer so that marker now points toward left shoulder

  • Tilt transducer toward sternum so that AV comes into view end-on
  • Assess valve structure and opening
  • Capture a loop of best possible view
  • Color Doppler over AV (En Face)
  • Color Doppler over TV
  • Color Doppler over PV

Measure– CW Doppler through TR jet, TR Vmax to estimate RVSP: Color doppler over PV

Step 6. PSSAX function​

  1. Tilt transducer toward cardiac apex to bring LV/RV cavities into view
  • Optimize image to make LV as round as possible (rotate and tilt)
  • Capture loop at mitral-valve level (“fish-mouth” view)
  • Capture loop at the level of the LV pap muscles
  • Tilt transducer further toward cardiac apex and capture a loop of the apex

mitral-valve level

mid-papillary level

apex level

Apical views

step 7. APical 4-chamber

Place transducer over cardiac apex- roughly 4-5th ICS, just lateral to mid-clavicular line. Probe marker toward the ground in a supine patient

  • Center the septum and rock probe to get septum as vertical as possible
  • Rotate and tilt probe to bring cardiac chambers into best possible view. Capture loop
  • Color doppler over MV
  • Color doppler over TV
  • Place M-mode cursor over lateral tricuspid annulus

Measure– TAPSE (>1.6cm normal): CW through TR jet, TR Vmax to estimate RVSP

Step 8. Diastology

In an apical 4-chamber view place the PW Doppler sample volume box at the tips of the leaflets in diastole–as shown here. If the patient is in sinus rhythm the E and A-wave height can be measured, alongside the deceleration time of the E-wave.

Step 9. Pulse wave Doppler in the left ventricular outflow tract

Place the PW Doppler sample volume box roughly within 1 cm of the aortic valve. Trace the spectral waveform below the baseline in systole to measure the LVOT VTI.

Measurement of RV function

Step 10. Measure RV function

M-mode should be used to assess the lateral tricuspid annulus.  A normal RV moves >1.6 cm from base to apex.

SUbcostal views

STep 11. Subcostal 4-chamber

Slide probe upwards toward xiphoid from just above umbilicus. Rock probe to bring entirety of heart including apex into view
  • Capture loop of best possible view
  • Fan (or tilt) transducer antero-posterior to ‘sweep’ through pericardial space looking for effusion

Subcostal short axis

Rotate transducer 90 degrees so that probe marker is pointed toward the ceiling
  • Tilt transducer to bring LV in short axis into view. Rotate probe to make LV cavity as circular as possible
  • Capture loop at level of pap muscles

Inferior vena cava

Step 12. Inferior vena cava​

Place transducer directed posteriorly just to the right of the xiphoid with probe marker toward patient’s head.
  • Bring IVC into view, imaging at the level that the hepatic vein merges with the IVC
  • Rock probe so that the IVC is imaged at the widest possible point (avoid cylinfer effect)
  • Capture loop of IVC for 1-2 resp cycles
  • M-mode cursor over IVC ~1cm distal to hepatic vein
Measure IVCd and compressibility

PW over hepatic vein