Dang, you were so close! But as you’ve probably realized, this is a zoom on the aortic valve with color flow, from the parasternal long axis view. It can be a little difficult to identify a zoomed image when its out of context, but you know there’s no other structure that would look like this. The color flow is normal, with no evidence of stenosis or regurgitation.

Sorry, I’m sure that was just a misfire on your mouse.  This is an apical 4 chamber (LV apex directly under the transducer) with color flow Doppler on the mitral valve.  The CFD box is set too large with color flow gain too high.  This can be seen as random color speckling, seen in this image near the interatrial septum.

You didn’t really mean to click that, did you?  Come back later and redeem yourself! As you know, this is a parasternal LV short axis at the basal level.  We clearly see the LV in short axis with the RV under the transducer.  We know we’re basal because we see the mitral subvalvular apparatus rather than the papillary muscles.  The arrow in indicating the basal inferior segment.  There is normal global and regional function of the LV in this view.

Don’t feel badly, this one was tough! This is the parasternal RV outflow view with the arrow on the main pulmonary artery.  This is a challenging view to identify sometimes.  You recognize it as parasternal because the right ventricle is seen under the transducer (notice the LV in pseudo-short axis below.)  Then you recognize that the valve is opening away from the RV, making it the pulmonic valve.  In some cases you can visualize the bifurcation of main PA into right and left.  Look here for a saddle pulmonary embolus!

Rats!  Try again next time, I’m sure you’ll get it. This is a parasternal RV inflow/outflow (or aortic valve short axis.)  It is the inverse of the midesophageal RV inflow/outflow view and shows similar information.  This image can be made by starting with the LV short axis and angling the probe to look more anterior (by tipping the tail more toward the floor.) The arrow is pointing at the right coronary cusp of the aortic valve.  Remember that the RCC will always be by the right ventricle, and the noncoronary cusp will always be by the interatrial septum.

Dang, you were so close! But, of course, this is actually an apical 2 chamber view. Clearly the apex is under the transducer. This can be identified as a 2 chamber both by what is seen and what is not seen. You do not see any of the LVOT or aortic valve as you would with a long axis, and you don’t see any of the RA or RV as you would with a 4 chamber. In addition you can just make out the coronary sinus (around 7 o’clock near the posterior mitral leaflet) and the opening of the left atrial appendage (around 5 o’clock.) In this view we see the anterior and inferior walls of the LV, and the arrow is pointing toward the apical inferior segment.

Come back and try this one again. Remember that the non-coronary cusp is by the interatrial septum and the right cusp will by the RV.

Ahhh, so close! But of course you now realize that this is a subcostal LV short axis.  See the liver at the top of the screen, under the transducer?  From this window we’re effectively looking from “below” the left ventricle.  As such the arrow is pointing to the mid inferoseptal segment.  To make this image you’ll start with the subcostal 4 chamber and rotate your probe clockwise until you see a short axis.  It is worth practicing, as you can sometimes see the LV better from this window than from any other.  Give it a try.

Come now, try that again later and make it happen. This is an apical long axis, with the apex seen under the transducer and the LVOT and aortic valve seen well.  The arrow is indicating the basal anteroseptal segment.  There is normal thickening of all segments of the anteroseptal and inferolateral walls in this view, along with normal appearing mitral and aortic valves.

Drat, you were wrong. But don’t get down on yourself, next time you’ll know that this is a parasternal LV short axis. You can see the RV at the top of the screen to orient yourself. The arrow is clearly pointing at a papillary muscle, and you know its the anterolateral because, well, its on the lateral side of the LV. The posteromedial pap is more inferior.

Ohhhh, so close, but actually we’re looking at a parasternal LV short axis at the apical level.  You can see the right ventricle at the top of the screen with the LV in short axis.  You know this is apical because you cannot identify papillary muscles or subvalvular apparatus, and the LV appears smaller.  While we name 6 segments at the basal and mid level of the LV, the apex (because it is smaller) only has 4 segments.  As such the arrow is pointing at the apical septal segment.

Oh, so close! But actually this is a parasternal long axis (RV at the top of the screen, MV, AV, LVOT, ascending aorta all seen well) with color flow across the LVOT and aortic valve. This is an excellent view to look for dynamic LVOT obstruction (seen as systolic anterior motion of the mitral leaflet with turbulent flow), aortic insufficiency (flow across the valve in diastole), and aortic stenosis (turbulent flow across a narrowed valve in systole.) There are none of those unfortunate findings here.

Oh, you nearly got it. But…this is an apical 4 chamber view, with the apex of the LV directly under the transducer.  In this view we assess global RV function by looking at the TAPSE (tricuspid annular plane systolic excursion) or descent of the base of the TV.  A normal excursion (motion of the TV annulus toward the apex in systole) is 1.6 cm.  It can be measured in M-mode or 2D, but in this case is clearly normal.

Come on now, you’re just messing with me right? This is an apical 2 chamber.  You see the LV apex under the transducer, and do not see the RV, RA, or aortic valve.  The arrow is indicating the left atrial appendage.  When you’re making this image ensure that you have your orientation correct by visualizing the orifice of the appendage on the right of the screen and the coronary sinus on the left of the screen.  Realize also that the appendage is visualized poorly with TTE and is seen much better with TEE.

Don’t sweat it, that was a tough one! This is a suprasternal aortic arch long axis, a view unique to TTE (there is no real transesophageal correlate) that is made with the transducer in the suprasternal notch with the indicator to the patient’s left.  We’re seeing the ascending aorta on the left of the screen with the great vessels coming off.  As such, the arrow is showing the left subclavian artery.

Whoops, you mean to say…This is an apical long axis (also referred to as an apical 3 chamber.)  You can see the apex of the LV under the transducer, and the mitral valve, LVOT, and aortic valve are all seen well.  The arrow is indicating the right coronary cusp of the aortic valve.  Just like in the midesophageal AV long axis, the right coronary cusp is seen reliably in this image.  The other cusp of the AV is likely the noncoronary cusp, but can sometimes be the left coronary cusp.

Whoops, not exactly. This is a zoom on the mitral valve from the parasternal long axis, with normal color flow showing no evidence of stenosis or regurgitation. There is actually a single puff of physiologic regurgitation seen right at the onset of systole, but this is totally normal. The mitral valve is kind of like a parachute, it only works when its full (of blood, not air) and a little bit squeaks through normally.

Whoops, you probably didn’t mean that, right? This image is identified as an apical long axis by the apex at the transducer and the aortic valve in long axis. The color flow Doppler shows normal flow through both the aortic and mitral valves (the small amount of MR is normal.) Ideally you’d make the color flow box smaller and focus on each valve separately. Remember that it isn’t normal to see flow convergence (PISA) on either side of any valve with a Nyquist limit set appropriately (50-60.)

Bzzzt! I’m sure you were close, and next time you’ll know that this is a normal parasternal RV inflow. Whenever you’re confused about an image start by asking yourself what window it is and what’s at the top of the screen. Does this look like the RV? the apex? the liver? Clearly RV, right? Knowing that this is RV and that you see a valve, and that the valve is opening…in…you know that this is an…RV inflow. See how easy?

Nope, come back to this question and have another go. This is a parasternal short axis of the LV.  This view is obtained by rotating 90 degrees clockwise from the parasternal long axis.  We see papillary muscles in the LV, so we know we’re looking at the mid segments.  The Z is on the infero-septal wall and the ZZ is on the antero-lateral wall.  In all our echocardiographic windows and cross-sections, the same walls will be opposite eachother in the same cross section.  A 4 chamber will show infero-septal and antero-lateral, a 2 chamber will show anterior and inferior, and a long axis will show anteroseptal and infero-lateral.  These walls are also opposite one another in the LV short axis views.

Drat, I’m sure you were very close but not quite there! This is an apical 2 chamber.  You know we’re at the apical window because the apex of the LV is under the transducer, and of course you can only see two chambers.  In addition you can see the coronary sinus (indicated by the arrow) and the orifice of the left atrial appendage (opposite the coronary sinus) both of which are characteristics of this view.  We see normal thickening of the anterior and inferior walls of the LV.

I know you know better, that must have been an accident. What you meant to say was…This is a subcostal IVC long axis with the patient sniffing.  Its pretty clear that the IVC is not dilated (it is less than 2.1 cm) and collapses more than 50% with a sniff.  That is consistent with relatively low right atrial pressures (it would be called 3 mmHg on an echo report.)  While a single image never tells the whole story, it is unlikely that this patient is currently suffering from intravascular volume overload or cardiac tamponade.

Now certainly you didn’t mean that, did you? This is an apical 4 chamber with the arrow on the posterior mitral leaflet.  As with every echo view the window is defined by the structure directly under the transducer (in this case the apex of the LV.)  The view is defined by a combination of the window and the cross section. While the surface of the two mitral leaflets is similar, the posterior mitral leaflet spreads across more of the mitral annulus but is shorter in length.

I’m sure you didn’t really mean that, right?  You were probably just kidding. This is an apical 4 chamber, focused on the right ventricle and tricuspid valve.  There is color flow on the tricuspid valve with appropriate Nyquist settings and color flow gain.  There is no evidence of tricuspid regurgitation or stenosis.

Dang, I’m sure you just clicked that by mistake. This is a subcostal 4 chamber.  To acquire this image your patient will be laying supine (ideally with their knees on a pillow to relax their abdominal muscles.)  The probe will be placed under the sternum, slightly off to the patient’s right, with the indicator pointing toward the patient’s left and the probe nearly horizontal.

At the top of the screen is several centimeters of liver tissue.  In this view we see the free wall of the right ventricle very well.  The right ventricle has normal function, as evidenced by a normal (>1.6 cm) excursion of the lateral annulus of the tricuspid valve (also called “TAPSE” or tricuspid annular plane systolic excursion).  There is no pericardial effusion seen in this view (hope it isn’t too early for trick questions), though it is a good view to assess for the presence and severity of effusion.

Rats, I was sure you were going to get it. But this is another excellent parasternal long axis. In this case the arrow is pointing to a portion of the aortic valve, in particularly the right coronary cusp. The RCC will always be anterior (at the “top” in this image.) The other cusp will usually be the non-coronary but may be the left coronary.

Whoops, come back and try that one again!

Sorry, my friend, you didn’t quite nail this one. Don’t sweat it. Next time you’ll know that we’re seeing the LV short axis from the parasternal window. The arrow here is pointing at the mid inferolateral segment. Take a moment to orient yourself to the walls in this view again. If you thought this was just inferior, you’re not totally crazy – it is close. But notice how this segment is across from the anteroseptal segment (rather than the anterior segment.) Does that help?

Rats, you were so close! This is an apical 4 chamber.  You would create this image with your patient lying on their left side with their left arm under their head.  Your probe would be located on the apex with the indicator pointing toward the floor.  The arrow in this image is pointing at the right upper pulmonary vein.  This is generally the only pulmonary vein that is easily visualized with TTE.

Oops! I’m sure you didn’t mean to click that.  Try again next time. This is an apical 4 chamber with the arrow pointing at the anterior mitral leaflet.  The AML is always located near the aortic valve, which is an anterior structure.  In most views the AML also appears longer than the posterior leaflet. Notice how the apex of the LV is directly under the transducer.  That is how you want this image to look.  You’ll also notice that the right ventricle is slightly cut off.  If you want to see more RV size and function you’ll have to either angle your probe more anteriorly (by tipping the tail toward the floor) or slide slightly up the chest wall.

Close, but no cigar! This is an apical 4 chamber with the arrow on the apical inferoseptal segment.  There is normal chamber size with normal global and regional biventricular systolic function.  Both AV valves open normally in diastole and there is no evidence of valvular prolapse in systole.

Ahh, so close!  By now you probably realize that this is a parasternal LV short axis, at the basal level of the LV.  The RV is under the transducer and the LV is clearly in short axis.  We know we’re basal because we see mitral subvalvular apparatus in the LV rather than papillary muscles.  The arrow is pointing to something in the RV.  Is it a thrombus?  No, it is the moderator band (a normal structure that traverses the right ventricle from the septum to the free wall.)

Wow, you were close.  I’ll be you get it next time! This, of course, is an apical 2 chamber.  The apex of the LV is seen under the transducer, with the coronary sinus on the left and the orifice of the left atrial appendage on the right.  The arrow is indicating the mid-anterior segment of the LV.  There is normal global and regional function of the LV in this image.

I’m sure you’ll get it next time! This is a beautiful, normal parasternal long axis. All parasternal images will have the RV at the top of the screen, and you should see the AV in long axis as you do here. This view shows us the basal and mid anteroseptal and inferolateral segments, and the arrow is pointing towards the basal inferolateral.

Nope, nice try though! This is an apical 4 chamber (LV apex directly under the transducer) with color flow on the tricuspid valve.  The Nyquist limit is set appropriately and we can see mild tricuspid regurgitation.  While there is one frame with a moderate-size vena contracta, notice that the regurgitation does not begin until approximately half way through systole.  This is definitely a small volume of regurgitation with a normal valve.

Nope, try again slick! The parasternal window is usually at the 4th intercostal space just off the sternum (to the left.)  The long axis image is made with the arrow on the TTE probe pointing generally toward the patient’s right shoulder.  The patient will by lying on their left side with their left arm under their head.  The arrow in this case indicates the anterior leaflet of the mitral valve.  The aortic valve is an anterior structure, and the leaflet of the mitral valve associated with it will always be the anterior leaflet.

Well…not exactly. You can see the right ventricle just fine, and you can tell that the function is relatively normal. Take another look if you’re confused, you’ll get there!

Whoops! You certainly intended to say…This is a parasternal LV short axis at the mid-papillary level.  The LV is clearly seen in the short axis (transected like a loaf of bread) with the RV under the transducer like in all parasternal images.  The arrow is indicating the mid anterior segment.

Ah, rats, I’ll be you almost got it! But this is a nice, normal parasternal (RV’s at the top) right ventricular inflow-outflow with the arrow on the pulmonic valve. If you’re used to TEE you’ll recognize that this is an inverted version of the midesophageal RV inflow-outflow. You see the aortic valve in short axis, function of the tricuspid and pulmonic valves, and function of the right ventricle.

Whoops, you probably clicked that one by accident, right? Since you can identify this as an apical long axis image by the location of the apex under the probe and the cross-section that shows the aortic valve in long axis with no right atrium. The appropriate orientation of this image is as shown, with the aortic valve on the right of the screen. This, along with the apical 5 chamber, is a nice view to use for spectral doppler evaluation of the aortic valve. The arrow is pointing to the anterior mitral leaflet, which will always be seen by the aortic valve.

Ah, just missed it! This is an apical 4 chamber (notice the LV apex directly under the transducer.)  The color flow box is too large, but the Nyquist limit and gain appear appropriate.  When you’re screening valves with color flow, you should never see flow acceleration on either side of any valve.  Flow acceleration suggests either stenosis or regurgitation that requires more detailed evaluation.  It won’t necessariliy be severe, but should receive more attention.

Almost, but not quite…This is a classic parasternal long axis.  The RV is seen under the transducer and we transect the aortic and mitral valves perfectly.  Every long axis view, from every window, will show the anteroseptal and inferolateral walls.

Close, but no cigar! This is a parasternal long axis.  Notice that the right ventricle is seen under the transducer, and the mitral valve, LVOT, and AV are all seen well.  The arrow is indicating the anterior mitral leaflet.  The anterior leaflet will always be seen next to the aortic valve.

No, but thanks for playing. This is a parasternal long axis, with the RV under the transducer and the mitral valve, LV, and aortic valve seen well.  The arrow is indicating the descending thoracic aorta, which is an important landmark when attempting to distinguish between a left pleural effusion and a pericardial effusion.

Whoops! You probably didn’t mean that, did you? This is a parasternal long axis with color flow doppler on the mitral valve.  The ‘Nyquist limit’ is seen in the upper left corner near the ‘rainbow bar’.  The Nyquist limit is also called the aliasing limit, and affects the appearance of the color flow signal.  It should ideally be set between 0.5 and 0.6 m/s for valvular evaluation, though 0.64 will not be likely to make a significant difference.  There is a trivial amount of mitral regurgitation seen just at the beginning of systole – a normal finding for the mitral and tricuspid valves.

Whoops, I’m sure you didn’t really mean that. This is a subcostal 4 chamber, see the liver at the top of the screen? And both ventricles look good (even though admittedly you can’t see the entire heart in one image.)

Nope, you’ll have to come back and try this one again, my friend! This is an apical 4 chamber view.  The LV is on the right side of the screen and the RV is on the left.  The sonographer has slightly cut off the atria, as they’re focusing on the LV.  The Z is in the basal infero-septal segment, the ZZ is in the mid antero-lateral segment.  We name the segments of the left ventricle based on the wall (around the circumference of the LV) and the position along the length of the LV (basal, mid, or apical.)  The LV in this view has normal global and regional function.

Back to the drawing board! This is a parasternal long axis, with color flow on the mitral and aortic valves.  Ideally we would focus on each valve separately to maximize resolution.  In addition the color flow gain appears slightly too high (see random speckling.)  That being said there is no evidence of mitral or aortic regurgitation or stenosis.

Dang, not quite right! This is a parasternal long axis view, and we’re seeing the posteromedial papillary muscle. I suspect you recognize the parasternal (RV on top) long axis (MV and AV) view. You can see the subvalvular apparatus of the mitral valve with chords attaching to the papillary muscle. You would expect the PM papillarly muscle to be closer to the back than the front of the heart.

Ohhh, so close! But next time you’ll know that this is an apical 4 chamber showing the septal leaflet of the TV. The septal leaflet is seen by…the interventricular septum.

Yeah, this was a tough one.  Don’t feel badly, just come back around again. This would be called an apical 5 chamber.  The apex of the LV is seen under the transducer, and the LV, RV, and aortic valve are seen.  You might want to make this image to assess the aortic valve with spectral Doppler (in the setting of AS, AI, or dynamic outflow obstruction) but you will also see this image when you’re trying to make an apical 4 chamber.  To turn this to a 4 chamber remember that the aortic valve is more anterior than the classic 4 chamber image, and tip the tail of your probe slightly upward or toward the patient’s right shoulder (to angle more posteriorly.)

Rats, I’m sure you were so close! But this is actually a nice parasternal long axis. Remember that the RV will always be on top for parasternal images. The arrow is indicating the posterior mitral leaflet (the anterior leaflet will always be by the aortic valve.)

Rats, I really thought you had it. Next time, right? This is a subcostal 4 chamber, which means we’re looking through the liver at the heart. The probe will be positioned under the sternum, slightly to the patient’s right, very horizontal, with the indicator pointing to the patient’s left.