Transthoracic Echocardiogram (TTE)

1. 1

   Position patient in left lateral decubitus. Select phased array probe.

2. 2

   Begin with PLAX: probe at 3rd–4th ICS left sternal border, marker to patient's right shoulder. Align with cardiac long axis. Measure EPSS, LV dimensions, aortic root, LA.

3. 3

   Rotate 90° clockwise to PSAX. Sweep from mitral valve (fish mouth) down to papillary level to apex. Assess for wall motion abnormalities and D-sign.

4. 4

   Move to cardiac apex for A4C: probe at point of maximal impulse, marker toward left shoulder. Assess all four chambers, EF, MV and TV.

5. 5

   Tilt anteriorly from A4C for A5C (LVOT/aortic valve). Rotate to A2C (marker down) then to APLAX.

6. 6

   Subcostal window: patient supine, probe subxiphoid, marker to patient's left. Assess all chambers and measure IVC.

7. 7

   Suprasternal notch: probe in suprasternal notch for aortic arch. Document all measurements per lab protocol.

• Parasternal Long Axis (PLAX)
• Parasternal Short Axis — MV level
• Parasternal Short Axis — Papillary level
• Apical 4-Chamber (A4C)
• Apical 5-Chamber (A5C)
• Apical 2-Chamber (A2C)
• Apical Long Axis (A3C/APLAX)
• Subcostal 4-Chamber
• Subcostal IVC
• Suprasternal Notch (aortic arch)

• LV systolic function (EF)
• Wall motion abnormality
• Pericardial effusion
• Valve pathology (regurgitation/stenosis)
• RV size and function
• LA/RA size

• Foreshortened apical views overestimate EF
• Epicardial fat mistaken for pericardial effusion
• Lateral wall dropout in A4C
• Subcostal window limited by bowel gas

Start with PLAX to align cardiac axis, then rotate to PSAX. Left lateral decubitus position improves apical window dramatically.