Transthoracic echocardiography: Normal cardiac anatomy and tomographic views
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
Transthoracic echocardiography (TTE) is the primary noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function [1,2]. Two-dimensional (2D) echocardiography provides tomographic or "thin slice" imaging. Comprehensive echocardiographic examination typically involves imaging the heart from multiple "viewing" orientations. A three-dimensional (3D) appreciation of cardiac anatomy is needed to integrate 2D (and M-mode) echocardiographic information.
Echocardiographs equipped with 3D capability have been developed to overcome the disadvantages of tomography [3-5]. These devices generally acquire a volumetric data set which can then be displayed in custom orientations. The specific clinical advantages of 3D echocardiography are being defined and gaining increasing clinical importance. (See "Three-dimensional echocardiography".)
The nomenclature, standard protocol, and normal views associated with TTE are reviewed here. The instrumentation and physics associated with echocardiography, along with discussions of various echocardiographic techniques, are presented separately. (See "Echocardiography essentials: Physics and instrumentation" and "Principles of Doppler echocardiography" and "Tissue Doppler echocardiography".)
Each tomographic view is defined by the transducer position (parasternal, apical, subcostal, suprasternal) and view (long axis, short axis, four-chamber, five-chamber). Transducer position is altered by placing the transducer at various locations on the thorax, while the view is manipulated by a combination of angulation and rotation. Due to limitations imposed by the thoracic skeleton and lungs, not all permutations of both variables result in clinically useful images.
Orientation — While acceptance is not universal, most labs follow the recommendations of the American Society of Echocardiography with respect to image display. With this convention, the transducer position is depicted at the top of the screen, with anatomy more distant from the transducer depicted at progressively lower regions of the display, the lateral/left structures to the right, and medial/right structures to the left. A linear calibration scale is provided for all two-dimensional (2D) and M-mode measurements.
- Pearlman JD, Triulzi MO, King ME, et al. Limits of normal left ventricular dimensions in growth and development: analysis of dimensions and variance in the two-dimensional echocardiograms of 268 normal healthy subjects. J Am Coll Cardiol 1988; 12:1432.
- Otto CM. Textbook of Clinical Echocardiography, 4th edition, Saunders Elsevier, 2009.
- Wang XF, Deng YB, Nanda NC, et al. Live three-dimensional echocardiography: imaging principles and clinical application. Echocardiography 2003; 20:593.
- Panza JA. Real-time three-dimensional echocardiography: an overview. Int J Cardiovasc Imaging 2001; 17:227.
- Lange A, Palka P, Burstow DJ, Godman MJ. Three-dimensional echocardiography: historical development and current applications. J Am Soc Echocardiogr 2001; 14:403.
- Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002; 105:539.
- Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18:1440.
- Parmley WW. Pathophysiology of heart failure. In: Cardiology, Parmley WW, Chatterjee K (Eds), J.B. Lippincott Co, Philadelphia 1994. Vol 3, p.1.
- Silverman NH, Schiller NB. Apex echocardiography. A two-dimensional technique for evaluating congenital heart disease. Circulation 1978; 57:503.
- Tomographic views
- TRANSDUCER POSITIONS
- Parasternal long axis
- - M-mode recordings
- - Right ventricular inflow and outflow
- Parasternal short axis
- Apical four-chamber
- Apical five-chamber
- Apical two-chamber
- Apical long axis
- Subcostal four-chamber
- Subcostal short axis
- Suprasternal notch
- Right parasternal
- Posterior orientations
- INFORMATION FOR PATIENTS