SonoTip&Trick: “I can’t get a good apical 4-chamber view.” Really? well try this…

It can be one of the most difficult views to obtain. Why? Well, you may need to go through some lung tissue, you dont really know where the apex is, and it’s never where it’s supposed to be…. among others. Well I’m hoping to make it a bit easier for you.

 (Long Live Netter!)

The apical 4-chamber view is an excellent cross-longitudinal section of the heart, where you can see the right ventricle size compared to left ventricle size, the contractility of each chamber well, the tricuspid and mitral valves well (and throw on color doppler to assess for valvular dysfunction should you be so inclined), and the descending thoracic aorta in cross section next to the left atrium.

It can give loads of information that can lead to evaluating for hemodynamically unstable pulmonary embolism, CHF, acute MI (should you know what it looked like before), tamponade, and valvular disease. So, how can we get it on your screen better? Try these steps:

1. Have the patient lean or turn onto the left side – this brings the heart closer to the probe, minimizing the air that can get in the way obstructing the view (air is the enemy of ultrasound!)

2. Feel for the PMI – some people are really good at this. I, for one, am not. If you’re one of those who are good at it – go for it. Where you feel it, is where you want to place your probe since it corresponds to the apex.

 from UCSD

3. If you’re not good at feeling for the PMI, then start with the parasternal long/short views, stay in that intercostal space, and slide your probe laterally after you adjust the direction of your indicator (to be to the patient’s right if your screen dot is on your left (EM way); to the patient’s left if screen dot on your right (cardiology way)). As you slide laterally, you’ll see the heart stay on your screen (which is the first step in getting your image). If you are cutting off the apex, just slide down a rib space.

PSL (finger corresponds to indicator to left hip) AP4 (finger corresponds to indicator to right side)

4. Change the angle of your probe so that your pointing through the body and into the vertebral body of the spine (and also upward toward the right shoulder). Another thing you can do to help understand this concept for angling: place your left hand in a cupped position on the chest wall in the direction of how the heart lies (your fingers are the ventricles, your hand being the atria). Knowing you have to cut the heart longitudinally, angle your probe in line with your hand.

Here’s a great SonoSite youtube clip for the how-to for AP4:

If all else fails, you can have the patient on their left side and just underneath the nipple you can circle your probe on the chest wall until you find the heart and adjust your angling once you get your heart on the screen: Here’s a video by Echo V-Torials showing this, as well as describing the details of the AP4 view:


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