Echocardiographic Imaging Techniques, Views, and Protocols
The standard windows
A complete adult study moves through parasternal, apical, subcostal, and suprasternal windows, acquiring two-dimensional, M-mode, color, and spectral Doppler at each relevant level. Parasternal long axis shows the aortic root, LV outflow tract, mitral valve, and posterolateral wall. Parasternal short axis sweeps aortic valve (Mercedes-Benz sign), mitral valve (fish-mouth), and papillary muscle levels. Apical four-chamber gives all four chambers and the septal and lateral walls; five-chamber adds the LVOT and aortic valve; two-chamber shows anterior and inferior walls; three-chamber shows anteroseptal and inferolateral walls with the aortic valve.
Measurement conventions
Measure leading edge to leading edge, perpendicular to the long axis, at the chordal level in parasternal long axis. LV internal dimension, septum, and posterior wall are taken at end-diastole and end-systole; the aortic root and ascending aorta are measured at end-diastole; LA volume uses the biplane Simpson method. Right ventricular size is measured at the base in the apical four-chamber view, and TAPSE is obtained with an M-mode cursor through the lateral tricuspid annulus.
Traps
Display orientation trips candidates: in the apical four-chamber view the right ventricle appears on the left of the screen. The parasternal long axis is not the true long axis and foreshortens the true apex. Foreshortening in apical views underestimates volumes and hides apical thrombus - pull back until the apex is at the top of the sector. Subcostal is the window of choice for pericardial effusion and IVC assessment; suprasternal for the arch and descending aorta.
Rule of thumb
If the LV apex is not at the narrowest part of the sector and does not contract, you are foreshortened - reposition before measuring.