These important structures are seen in the parasternal long axis (PLAX) view:

These important structures are seen in the apical 4-chamber (AP4CH) view:

Remember: The OM should be pointed to the patient’s left side (not towards the left shoulder).

Get good images
If no image can be obtained: if possible, try moving the patient unto his/her left side and place the transducer more laterally.

If the right ventricle is in the center of the image: slide the transducer more laterally to visualise the left ventricle.

Remember: the OM should be pointed directly towards the right shoulder.

Get good images
Generally: stay close to the border of the sternum.

To

Focused ultrasonography of the heart is best performed withr a cardiac transducer. Alternatively a curved linear/abdominal transducer can be used

The cardiac transducer is a low frequency transducer permitting good penetration.

It has a small footprint that allows visualisation between the ribs.

If looking only for fluid in the pericardium from the subcostal view, an abdominal transducer (also low frequency) can also be used.

Tips and tricks

In order to obtain the subcostal acoustic window, sufficient pressure needs to be applied to the transducer so the ultrasound waves can travel under the rib cage as seen in the image below.

Asking the patient to bend his legs often helps as this causes relaxation of the abdominal muscles allowing for correct transducer placement.

Asking the patient to take a deep inspiration often improves image quality because the heart is displaced towards the abdomen and the transducer (remember to tilt the tail of the transducer upwards).

Once you have found an acoustic window, try optimizing the image (tilting and rotating) so the cavities are fully open. Often, a 10 degree counter-clockwise rotation is necessary.

If you get a lung-shadow across the apex, try sliding the transducer a little towards the patient’s right side.

The following important structures are seen in the subcostal 4-chamber view: