Mastering the apical four-chamber view (4CV) on transthoracic echo

In this video, you’ll learn how to display an optimized four-chamber view image on transthoracic echo, and how to recognize the structures, assess them, and know when something's wrong.

After completing this course, you’ll be able to perform a basic transthoracic echo (TTE) exam without the help of a more senior colleague. Using practical demos, we’ll teach you echo anatomy and show you how to operate the machine, obtain the standard TTE views, differentiate normal from abnormal, and confidently assess and report anything you find!

[00:00:00] This is where the apical four-chamber view cuts through the heart. So, the probe is now down here, scanning from the apex. The first structure it's going to encounter will be the apex of the heart, as its name describes. In this view, the imaging sector passes through all four cardiac chambers, with the atria furthest away from the probe. So, now we're going to move on to a completely different echo window. We're going to the apical window to get a series of apical views. So,

[00:00:30] this means putting the probe on the apex beat, with the notch angled towards the left shoulder. And the trick is to get the view, as well as you can, as far down the chest as possible so you're not foreshortening. Just move a tiny bit forwards, that’s it. If you got a cutout on your bed, it's really useful to get the angle of the probe here, against the chest, so you can get an apical four-chamber view, like this. And this is a diagram of the apical four-chamber view.

[00:01:00] As ever, our probe is positioned to the top of the screen. First structure we're going to image is the LV apex and then the cavity of the left ventricle. We have the right ventricle, here, the right atrium, and the left atrium. This is the mitral valve. This is the tricuspid valve. In a normal heart, the left ventricular apex forms the apex of the heart. If the right ventricle becomes dilated, it can push it over but this is a normal situation we're looking at, here. We've got three of the four pulmonary veins,

[00:01:30] coming into the left atrium. And then the circular structure outside of the heart, it is outside of the pericardium, is the descending aorta. So, this is my apical four-chamber view. It's a really nice view for seeing all the chambers laid out side by side, so you can see their relative sizes. So, we can see that the right ventricle is about two-thirds of the size of the left ventricle. We can see that the atria are very similar sizes and they're considerably

[00:02:00] smaller than the two ventricles. So, if we move slightly to focus on the right ventricle. So, I've just moved my probe very slightly inwards ready towards the spine. You can see how trabeculated, so all these ins and outs of the right ventricle free wall and we can see there are, sort of cords going across the cavity of the ventricle. One of these is probably the moderator band.

[00:02:30] So, this is what a normal right ventricle looks like. Another thing I'll be checking, whilst I'm on the right side, is the relative positions of the two valves, so the tricuspid, which is here and the mitral valve. And we expect the tricuspid to be near the apex, near the heart's apex than the mitral, which you can see here. There's only a small offset and that's fine. It's usually sort of around 5 mm. If there's no offset and the valves look like they're in a line together,

[00:03:00] that would make you start wondering whether there was congenital heart disease. So, having looked at the right ventricle, I'll slightly move my probe to bring the left into view. So, it's a nice view to look at the function of the ventricles, at how the walls are all moving in and whether they're moving in similarly. I can assess the valves really well here. So, the tricuspid and the mitral valve, so I'll be putting some color on, like this. So, this is the red, is forward flow

[00:03:30] through the tricuspid valve. I can't see any tricuspid regurgitation and then I'll do exactly the same thing over on the mitral valve. I can see the interatrial septum quite well, which is here but I'm not very well lined up for flow across it. So, whilst I could put color across, I'll probably want to go on a subcostal view to check if there is any ASD or PFO flow. So, we can

[00:04:00] measure cavity sizes, we can measure diameters, we can do areas or volumes of the atria in this view. It's also nice for looking for pericardial effusion and again, I will be moving my view around a bit. If I wanted to see if there was any fluid around the heart, I could pull the LV over, like that and then can pull the RV over, like that. I'm just checking whether there's any fluid all around the heart. No, there isn't. This is a nice normal echo.