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2019 GUIDELINES Source

  • Mitchell C, Rahko PS, Blauwet LA, et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2019;32:1–64.

  • This comprehensive document is the starting point for learning and performing an echocardiographic examination in the adult.

  • It is beautifully illustrated and comprehensive, and it includes an appendix with additional alternative views.

  • Find and learn the highlighted key scanning points.

  • Go to to download the latest version.


  • The quality of echocardiographic images can vary widely from patient to patient.

  • It is both operator and patient dependent.

  • A standardized imaging approach is important to achieve study to study reproducibility.

  • In order to obtain proper images, ultrasound must get around bone and lung tissue, and reach the heart.


  • Tajik AJ, Seward JB, Hagler DJ, et al. Two-dimensional real-time ultrasonic imaging of the heart and great vessels. Technique, image orientation, structure identification, and validation. Mayo Clin Proc. 1978;53:271–303.


  • Parasternal images are best obtained with the patient in the left lateral decubitus position.

  • Imaging advantages of the lateral decubitus position:

    • - The heart moves away from under the sternum.

    • - The rib interspaces separate more.

    • - An ultrasound pathway around lung tissue becomes available.

    • - The long axis view is parallel to the long axis of the heart.

  • The major cardiac structures (possible abnormal findings in parentheses) in this view are:

    • - The proximal ascending aorta, and a peephole view of the descending aorta behind the heart (aneurysm, dissection flap, atherosclerotic plaque).

    • - The aortic valve (bicuspid valve, aortic valve endocarditis, calcification or thickening).

    • - The left atrium (dilatation, sphericity, elongation, systolic expansion, myxomas).

    • - The mitral valve, chordae, and papillary tips (prolapse, systolic anterior motion, rheumatic doming, endocarditis, annular calcification).

    • - The basal and mid-left ventricular septum and inferolateral wall (basal septal hypertrophy, wall motion abnormalities).

    • - Pericardium and pericardial space (effusion, pleuro/pericardial thickening is only rarely measurable when there is fluid on both sides of the pericardium).

    • - Coronary sinus (dilates when there is a left superior vena cava).


  • Reynolds T, Abate K, Abate J. “Rib-hooks,” “pressure points,” and “hugs”: technical hints for improving two-dimensional echocardiographic imaging. J Am Soc Echocardiogr. 1993;6:312–318.


  • The right ventricular focused apical four-chamber view is used to perform linear measurements of the right ventricle.

  • Technique:

    • - Transducer is pointed medially toward the tricuspid valve.

    • - Left ventricular apex is kept in the same position.

    • - Mitral annulus is moved over to the side.

    • - Tricuspid annulus is moved toward the center of the image.

  • Measurements:

    • - Basal right ventricular cavity diameter (maximum short-axis length of the basal right ventricular cavity, in the mid portion ...

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