ECHO in Context
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The Changing Left Ventricle

Aortic Valve Disease: New Dimensions in Evaluation and Management

Heart Failure: Echo's Role in and Emerging Health Crisis

Chest Pain in Children & Adults: The Role of Echo

Mitral Regurgitation: New Concept

The Falling Left Ventricle: Diastolic & Systolic Function

Changing the Outcome of Coronary Artery Disease
Digital Integration
Doppler Echo

Chest Pain in Children and Adults

Mitral Regurgitation: New Concepts

Diastolic and Systolic Function

Changing the Outcome of CAD

2000 MV
2001 Chest Pain
2002 Heart Failure

Subcostal Four-Chamber Plane
skillB_fig. 51  The four-chamber plane with the subcostal transducer position indicated.
Fig. 51 The four-chamber plane with the subcostal transducer position indicated.

The anatomy of the four-chamber plane seen from the subcostal views is identical to that already described in the apical view, but with orientation as shown in Fig. 52. In the body, the inferior surface of the right ventricle, seen at the top (Fig. 52), rests on the diaphragm, and the ultrasound beam approaches the heart through a corner of the liver and across the diaphragm.

The echocardiographic image of the subcostal four-chamber plane is shown in Fig. 53 and 54. Although the apical region is not seen as well as from the apex, more of the atria are visualized. In addition, clearer echoes are generated by the interatrial and interventricular septa because the ultrasound beam approaches them more nearly at right angles. Thus, while dropout of the echo signals from the septa in the apical view is most likely to be artifactual, consistent absence of echoes from a region of either the interatrial or interventricular septum in the subcostal view suggests the presence of a defect. Two-dimensional echocardiography is helpful for diagnosing these lesions and, in the case of the interatrial septum, it is usually possible to differentiate a defect in the area of the fossa ovalis (secundum type) from a low defect extending down to the mitral annulus (primum) or a sinus venous defect high in the roof of the atria.

Fig. 52

The subcostal four-chamber view is the only satisfactory way to visualize the right atrium, and it also affords the best view of the right ventricle, since these chambers like nearest to the transducer. Right atrial morphology can be confirmed by tilting the scan plane inferiorly so that the entrance of the inferior vena cava is seen. In addition to the identification of the atrioventricular valves by their relative levels of attachment to the septum, it is frequently possible to determine ventricular morphology by locating the moderator band within the right ventricle. To a certain extent it is also possible to assess the thickness of the right ventricular walls, and in some patients to diagnose right ventricular hypertrophy.

Figs. 53-54

If a pericardial effusion is present, its extent and the degree of separation of the heart from the pericardium should be determined in the subcostal view if pericardiocentesis is contemplated.

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