4 chamber view, with demonstration of the A-V valves, both atria,
interatrial septum, right ventricular free wall, interventricular
septum, lateral wall of the LV. Some degree of anteflexion should
reveal the LVOT +/- the aortic valve. High resolution of the AV
valves should allow more detailed examination of the leaflets,
as well as annular measurements. Colour Doppler should be applied
to the AV valves, while withdrawing and advancing the probe to
intersect jets in different planes. (Shanewise fig 3a)
Rotation of the transducer to 30-60 degrees, and probe depth
adjustment should reveal the aortic valve in cross section. Colour
Doppler should be applied. The coronary ostia may be seen here.
(Shanewise fig 3h)
Rotation to 40-60 degrees and imaging of the mitral valve will
reveal the commisural view (Shanewise fig 8). Colour Doppler
should be applied to the mitral valves, while withdrawing and
advancing the probe to intersect jets in different planes. Remember
that if MR is present, 2 jets are the norm as the commissural
plane is intersected twice. (Shanewise fig 3g)
Rotation to 70-90 degrees will reveal the anterior and inferior
walls of the LV (2 chamber view) (Shanewise fig 3b)
Rotation to 120 degrees will reveal the posterior and anterior-septal
walls of the LV, the RVOT, the mitral valve, the aortic valve
long axis, and the ascending aorta. Colour should again be applied
to both valves. The aortic annulus is measured here; it is
essential that the aortic valve not be foreshortened, or else
the annular measurement will be inaccurate. (Shanewise fig
3c)
With the transducer at 90 degrees, and the probe rotated rightward,
the bicaval view is obtained. (Shanewise fig 3l) Advancing the
probe may allow imaging of the tricuspid valve, and as the probe
is advanced into the stomach, the IVC will be seen in long axis.
Withdrawing the probe back into the esophagus and rotating the
transducer back to 40-50 degrees allows the right sided inflow
outflow view to be obtained. (Shanewise fig 3m)
With the transducer again at 0 degrees, advancing the probe
allows visualization of the coronary sinus. Passing into the stomach,
the RV can be seen, as well as the short axis of the LV at basal
(mitral) levels, midpapillary, and apical views (Shanewise fig
3d+f). The corresponding LV segments should be examined as per
Shanewise. Deep entry and strong anteflexion should reveal the
LVOT and aortic valve. (Shanewise fig 3k) Rotating the probe rightward
the right side of the heart is imaged. Slowly rotating the transducer
should reveal the tricuspid valve in short axis. Further rotation
to about 90 degrees should reveal the long axis of the RA and
RV, as well as the tricuspid valve (Shanewise fig 3n).
Turning the probe posterior, the descending aorta is seen, and
should be followed up to the arch both at 0 degrees, and approximately
90 degrees. At 90 degrees as the descending aorta turns to the
arch, the left subclavian artery will be seen as well as the main
pulmonary artery and pulmonic valve. Rotating to 0 degrees should
reveal the pulmonary artery bifurcation and a cross section of
the ascending aorta and SVC. (Shanewise fig 3o)