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

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

standard acquisition sequence