Welcome back to our fourth lecture, the basic TT echo views. In the previous lecture we mentioned how ultrasound waves are affected by solid structures like ribs, and how therefore, we have to look at the heart through certain windows in the chest wall. Each window allows us to visualize the heart from a different viewpoint. And by changing the probes orientation, we can get a number of views from each window. There are a number of standard views that you need to be familiar with in order to be able to perform an adequate echo study. And learning to get the views is actually the hardest part of learning echo.
Okay, first, before we get go onto the views, I want to teach you a little about the Pro. This is an example of an echo probe and this is the way to hold an echo probe. You you hold it kind of like a paintbrush. This this pad here is the surface that gets in contact with the patient's skin. And this marker here is called the knob. On some probes it's going to be a lamp instead of a marker and This is used to orient the probe as we'll explain later on, we have three types of probe motion.
The first kind is translation, which is simply sliding the probe across the face into the patient's chest. The second kind is rotation which can be clockwise or anti clockwise. Third Kind is tilt. Lateral tilt can be a lateral, right or left, or it can be cranial towards the head, or caudal tilt towards the patient's feet. These tilts happen relative to the axis of the probe and not the patient. So as you see, in this example, a caudal tilt happens relative to the long axis of the probe, and and not in the direction of the patient's feet or forehead, per se.
Okay, now on to the views. The first window we'll be using is called the left pair of sternal window, and we get that at second or third intercostal space just to the left To the sternum. And we can get five views from these from this window. The first view is called the left pair of sternal. Long acts Start by placing your probe in the left personal window and point the knob towards the patient's right shoulder. You're now roughly cutting the heart along its long axis.
And the view sheet you see should look something like this. This here is where the probe is. So this is the chest wall and the bottom of the image is the area for this from the probe. Not it? Probably not. In fact, I'd be surprised if you did, chances are you're going to place the probe exactly what I showed you and see absolutely nothing.
That's okay, that's that's normal. It takes some maneuvering to find the right spot and it takes a lot of practice before your hand starts finding it automatically. Just Just try some more, try moving the program until you at least see something moving and then we'll try to fix your view together. Now what you should be seeing if you Got the view right is the following. This is the left atrium and this is the left ventricle, and they're separated by the mitral valve you can see both leaflets of the mitral valve opening and closing. This is the aortic valve separating left ventricle from the aorta.
This year is the intro ventricular septum and this is part of the RV. The next view is called the left pair sternal short axis. You get this view by keeping your hand at the same spot where it is, but rotating the probe clockwise about 90 degrees so that the knob now points toward the patient's left shoulder instead of the right choice. If you manage not to move your hand at all, you'll probably be cutting the heart at the level of the mitral valve which is what we call the bezel bezel Lv level. In this view, you can see the Lv and cross section at the level of the mitral valve so you can also see the two mitral valve leaflets opening and closing. You can also see the RV which has a crescent or cross section attached to the Lv.
If you tilt the probe quarterly a little bit, you'll now cut the Lv at its mid level, called the mid cavity level or the papillary muscle level because you can see the papillary muscles in this level. And again, you can see the Lv and cross section with both papillary muscles visible. If you tilt the probe quarterly, a little bit further, you'll be cutting the heart still in cross section, but at the ethical level of the Lv. So this is called short axis a typical level, you can still see a cross section of the apex of the Lv, and a cross section of the apex of the RV. If you tilt the probe crania Li, that's the opposite direction all the way up past the basal level that we started with initially You'll reach a level that we call the great vessel level in which we cut the heart at the level of the aortic valve.
This is the aortic valve in the middle. Opening and closing, you can clearly see the three leaflets, opening the form of triangle and closing in the form of Mercedes Benz sign, an inverted Mercedes Benz sign. This is the LA left atrium. This is the right atrium, and this is the tricuspid valve separating it from the right ventricle. This is the pulmonary Vives valve separating the right ventricle from the pulmonary artery. That's it for the persona window.
The next window is called the typical window and we get this window by placing the probe at the apex which usually lies at the fifth intercostal space, mid clavicular line. We get four views from this window. The first view is called the atypical for chamber view. We get this by placing the probe at the typical window at the apex tilted cranial Lee at a steep angle and with the knob Pointing laterally. The view you get should be like this. And it shows the two atria separated from the two ventricles by the mitral and tricuspid valves.
This is kind of a classic textbook view of the heart with the two ventricles and atrial lying side by side. The next use called the typical five chamber and we get it by emulating the probe or tilting the probe cranial Lee a little bit further. And what happens in this view that is that the aorta opens and the aortic valve becomes visible. Again, these are the two atria. These are the two ventricles. But now we can see an additional valve, which is the aortic valve.
And this is why it's called a five chamber because the aorta is now visible and it's being considered a fifth chamber. The next few is called the typical two chamber view. To get the typical two chamber view go back to the atypical four chamber then rotate the pro counterclockwise by about 90 degrees. And you should get a view similar to this, with only the left atrium and the left ventricle visible, being separated by the mitral valve. If you rotate the probe counterclockwise a little bit more 30 to 60 degrees with the knob now pointing roughly toward the patient's right shoulder again, you'll get the typical three chamber view, which is basically the same as the left long pair sternal. Because the aorta is now visible, together with the aortic valve, that's it for the atypical window.
Now let's move on to the sub costal window. The subclass the window is achieved by placing the probe in the epigastric region and we get two views from the subclass terminal. The first view is called the subclass to fight for chamber view. And we get this by placing the probe in the epigastric almost parallel to the abdominal wall parallel to the skin. So extreme cranial tilt, with the knob pointing laterally. And what we get is a view similar to this, which kind of looks like the typical for chamber view, but with the heart kind of tilted sideways a little bit instead of vertical.
And we see the same structures, which are the two atria and the two ventricles, separated by the mitral and tricuspid valves. Keeping the probe in the same place, rotate the probe counterclockwise about 90 degrees so that the knob now points upwards, and you get this view which is called the sub costal IVC view. This is the right atrium, and this is the IVC or the inferior vena cava and this up here is the liver. This was our last view, you do Echo, you always have to try and look at all of these views in this order. As we move along the course you'll learn what we're supposed to look for in each of these views. Just so that you know, these views aren't all the standard views and echo, I've left out a couple for the sake of simplicity, because you don't want to overwhelm yourself with too much information at this stage.
Just practice these views until you're comfortable getting them first before moving on. It'll take some time. Again, I recommend using a simulator like virtual echo first, and I recommend you check my other free course. Once you're ready, I'll see you in the next lecture assessing Lv sizing function. See you there