Subcostal 4 chamber view
From Echocardiography in ICU
How to get the subcostal 4 chamber view?
The subcostal or subxyphoid echographic window is located medially, under the xyphoid. The notch is at 3 o'clock and the probe is oriented toward the patient's sternum. It will be easier to get the images if you put your probe vertically first, 3 to 4 centimeters below the xyphoid, and then angle upwards until you see the four chambers.
If you can't get any images, you can try to move your probe toward the right flanc of the patient, under the liver border. You have to correct the direction of the probe toward the left shoulder of the patient.
If the abdomen is very tense and you can't depress it, you can try to find the trans-hepatic window: between the last ribs on the patient's right side, the probe horizontal oriented toward the patient's nipple. This view is more difficult to get but can be very helpful.
What will you see?
Liver: on the top of the image. The liver structure transmits very well ultrasounds.
-Diaphragm: very echoic linear structure between the liver and the right heart. Moves with the respiration.
-RV: right ventricle. Lies on the diaphragm. Subcostal 4 chamber is a good view to estimate the size of the right ventricle compared to the size of the left ventricle.
-Tv: tricuspid valve. Between RV and RA. You can put color Doppler and look for a tricuspid regurgitation. The angle of the Doppler beam with the tricuspid regurgitation can be suited to the calculation of right ventricle systolic pressure.
-RA: right atrium and LA: left atrium. The interatrial septum is very well visualized in this view.
-Mv: mitral valve.
-LV: left ventricle. You will see the interventricular septum and lateral wall. You can get an idea of the LV systolic function.
In subcostal 4 chamber you have an overall view of the heart. It is a very good view to assess a pericardial effusion.