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Focused Cardiac Ultrasound

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  1. Welcome

    Introduction to FoCUS
    2 Topics
  2. Section 1
    Video: Cardiac Anatomy
  3. Cardiac Anatomy
    3 Topics
  4. Section 2
    Key Video: Obtaining the 5 Views
  5. Acquisition & the 4Ps
    4 Topics
    |
    1 Quiz
  6. Acquiring The 5 Views
    5 Topics
    |
    1 Quiz
  7. Clinical Case Scenario
  8. Section 3
    Interpretation
    11 Topics
    |
    2 Quizzes
  9. Interpretation: The RUSH Protocol
    1 Quiz
  10. Section 4
    Medical Management
  11. Foundations of Echocardiography
  12. References
    References & Further Reading

Quizzes

Lesson Progress
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APICAL 4 CHAMBER

How To Obtain This View:

From the PSAX view, slide the transducer towards the apex of the heart. The apical 4 chamber view is obtained at the point of maximal impulse of the heart. The probe marker should face the patients left flank or 3 o’clock position.

The patient is best placed in the left lateral decubitus position, but probe positioning may be difficult with the surface of the bed causing obstruction. A cut out bed is ideal, otherwise the supine position can be used.

Anatomical view of the apical 4 chamber. Image by Patrick J. Lynch and C. Carl Jaffe – Creative Commons CC BY 2.5
Probe position for apical 4 chamber.

Useful For Assessment Of:

Left Ventricle:

LV cavity size and systolic function can be determined qualitatively. This view is also used for determining LV ejection fraction by the Simpson’s method.

Bothe the anterolateral and inferoseptal LV walls are seen. The basal, mid and apical segments of the LV are visualized.

Right Ventricle:

RV size should be 1/3 the size of the LV in the normal heart. As the RV enlarges, it gradually comes to form the apex of the heart. This view is useful for obtaining the tricuspid annular plane systolic excursion (TAPSE) measurement. M-mode is used, with the cursor placed across the lateral annulus of the tricuspid valve. TAPSE is an indicator of RV systolic function.

Left Atrium & Right Atrium:

The atrial size and presence of thrombus or masses can be evaluated.

Tricuspid Valve & Mitral Valve:

This view is useful for 2D imaging of the valves, looking at leaflet thickening, calcification, vegetations and mobility. MAPSE, a similar measurement to TAPSE can be obtained with M-Mode by placing the cursor across the lateral annulus of the mitral valve.

Pericardial Space:

Look for effusions and signs of pericardial tamponade.

Features of a Normal RV:

RV size is best assessed in the apical 4-chamber (A4C) view.  In a normal A4C view, the RV should have the following features:

  1. RV size should be about 2/3rds the size of the LV;
  2. RV shape should be triangular (rather than sail-shaped); and
  3. The RV should not contribute to the apex of the heart (which is normally formed exclusively by the LV).
  4. The RV has a moderator band
  5. The tricuspid valve has a more apical position when compared to the mitral valve.
Apical 4 Chamber

Apical view (Illustration by Angélica Ortiz ©2019, provided under CC-BY–NC–ND

Pitfalls when scanning the Apical 4C:

  1. Foreshortening occurs when the ultrasound beam does not cut through the true apex of the LV.
  2. Foreshortening in the apical 4 chamber view may lead to underestimation of chamber sizes of the heart.
  3. Foreshortening can be corrected by moving the probe to the apex of the heart. Try scanning one intercostal space lower.
Foreshortening

Foreshortening – (b) ; Correct angle for apical 4 chamber view in (c). Image from: Hall et al. Academy of Emergency Medicine, 2015

How to tell if the apical 4 chamber view is foreshortened:

  1. Apex will move rapidly rather than appear stationary compared to other segments.
  2. Apex appears globular rather than bullet or tapered.
  3. Apical 4 & 2 chamber views will be different lengths or size.
  4. Apex looks thick (should look thin)
Apical 4 Chamber & Foreshortening