Basic Cardiac Views

Parasternal long axis (PSL)

Point the probe indicator toward the patient’s right shoulder
Place the probe at the 4th intercostal space which is around the nipple line in males or the inframammary fold to the sternum in females

Rotate the probe to maximize visualization of the LVOT, and sweep medially/laterally to center and widen the LV cavity.
Indicators of Normal LV Function:
- Fractional shortening > 30% at the mid-LV level
- EPSS (E-point septal separation) < 1 cm (The anterior mitral valve leaflet should come within 1 cm of the interventricular septum during early diastole)
- Mid-LV diameter < 5 cm at end-diastole
- LV free wall > 1 cm thick and shows visible thickening during systole

From the PSL, rotate your probe 90 degrees clockwise so the indicator is pointing towards the patient’s left shoulder
Visualize the following 3 levels:
1. Mid-papillary level
2. Mitral valve level (known as Fish mouth view, showing the anterior and posterior leaflets)
3. Aortic valve level (known as the Mercedes Benz view, tilt the tail of the probe inferiorly and point it towards the aortic Valve)

Evaluate for normal LV Function:
- Look for concentric contraction of the LV throughout systole.
- The LV cavity should visibly shrink in a circular, symmetric manner.
Indicators of Normal Function:
- Fractional Shortening > 30% (i.e., the difference in LV diameter between diastole and systole should be significant)
- Mid-LV diameter < 5 cm at end-diastole
- LV free wall thickness > 1 cm, with visible thickening during systole
Hyperdynamic LV Clue:
- Presence of “kissing ventricles” during systole (i.e., near-complete collapse of the LV cavity) suggests hyperdynamic function which often indicates the patient is volume-depleted (dry)

From PSS, slide the transducer towards apex of the heart, keeping the indicator pointed towards the patient’s left side. You can recognize the apex by observing the left ventricle decrease in size
Tilt the tail of the probe down towards the patient’s foot. For females, Point of Maximal Impulse (PMI) is typically just under their left breast.
As you do this, the A4C view should appear. If you are having trouble with the A4C view, reposition the patient in the left lateral decubitus position. It reduces lung artifact and brings the heart closer to the ultrasound probe, usually giving a better view.
From A4C, slightly tilt the tail of your probe towards the patient’s feet to get the A5C. This allows visualziation of the aortic valve and the left ventricular outflow tract.