‘The 20 Views’Annual Comprehensive

Review & Update of Perioperative Echo

LV axis model

17 segment model of the Left ventricle

ME four chamber

RA

TV

RV

LA

MV

LV

LV walls:

6 Basal Inferoseptal

12 Mid Inferoseptal

16 Apical Septal

3 Basal Anterolateral

9 Mid Anterolateral

14 Apical Lateral

17 Apical Cap

6

16

A2 P1S

12 9

14

A1

RV free wall

A or P(depending upon probe flexion)

3

17

ME two chamber

LA

LV

LAA

5

11

15

2

8

13

LV walls:

5 Basal Inferior

11 Mid Inferior

15 Apical Inferior

2 Basal Anterior

8 Mid Anterior

13 Apical Anterior

17 Apical Cap

Valve leaflets:

Carpentier Classification

Mitral- Anterior(A1, A2, A3)

Posterior(P3)

P3

Left Atrial Appendage (LAA)

A3

A2A1

17

ME LAX

LA

LV

P2 A2

AV

RV

4

10 7

1

LV walls:

4 Basal Inferolateral

10 Mid Inferolateral

1 Basal Anteroseptal

7 Mid Anteroseptal

15 Apical Inferior

13 Apical Anterior

14 Apical Lateral

16 Apical Septal

17 Apical Cap

Valve leaflets:

Carpentier Classification

Mitral- Anterior(A2)

Posterior(P2)

14 or 15 13 or 16

17

TG mid SAX

RV

LV

PM pap

AL pap

7

8

9

10

11

12

LV walls:

8 Mid Anterior

7 Mid Anteroseptal

12 Mid Inferoseptal

11 Mid Inferior

10 Mid Inferolateral

9 Mid Anterolateral

Papillary Muscles:

Anterolateral papillary muscle (AL pap)

Posteromedial papillary muscle (PM pap)

TG basal SAX

RV

LV

A2

P2

1

2

3

4

5

6

LV walls:

2 Basal Anterior

1 Basal Anteroseptal

6 Basal Inferoseptal

5 Basal Inferior

4 Basal Inferolateral

3 Basal Anterolateral

Valve leaflets:

Carpentier Classification

Mitral- Anterior

A1, A2, A3

and Posterior

P1, P2, P3

P3

P1

A1

A3

TG Apical SAX (Not part of original 20 views)

13

14

15

16

13 Apical Anterior14 Apical Lateral15 Apical Inferior16 Apical Septal

LV

RV

16 segment LV model

Older LV model nomenclature Replaced by 17 segment model

Regional Wall Model

Transthoracic imaging planes

Mitral valve axis model

Mitral Valve Anatomy

CarpentierClassification

ME mitral commissural

LA

LV

A2P1

PM pap AL pap

Valve leaflets:

Mitral- Anterior Scallops

(A2)

and Posterior Scallops

(P1, P3)

Papillary Muscles:

Anterolateral papillary muscle (AL pap)

Posteromedial papillary muscle (PM pap)

P3

TG two chamber

LV

LA

LAA

PL

AL

Valve leaflets:

Mitral- Anterior(AL)

and Posterior(PL)

Left Atrium (LA)Left Atrial Appendage (LAA)Left Ventricle (LV)

ME AV SAX

LA

RA

RVOT

PV

NCC LCC

RCC

IASAortic ValveNon coronary cusp (NCC)Left coronary cusp (LCC)Right coronary cusp (RCC)

Left Atrium (LA)Right Atrium (RA)Intra atrial septum (IAS)Pulmonic valve (PV)Right ventricular outflow tract (RVOT)

ME AV LAX

LA

LV

PL

AL

Asc Ao

AV

Valve leaflets:

Mitral- Anterior(AL)

and Posterior(PL)

Aortic Valve (AV)Right Coronary Cusp (RCC)Non Coronary Cusp(NCC)Left Coronary Cusp

(LCC)

RV

RCC

NCC or LCC

Ascending Aorta (Asc Ao)

TG LAX

RV

AV

Asc Ao

PL

ALLV

Right Ventricle (RV)Aortic Valve (AV)Ascending Aorta (Asc Ao)

Valve leaflets:

Mitral- Anterior(AL)

and Posterior(PL)

deep TG LAX

LV

PLAL

LA

RV

AVAo

Left Ventricle (LV)Right Ventricle (RV)Left Atrium (LA)

Aortic Valve (AV)Aorta (Ao)

Valve leaflets:

Mitral- Anterior(AL)

and Posterior(PL

ME bicaval

LA

RA

IAS

IVCSVC

Left Atrium (LA)Right Atrium (RA)Inferior Vena Cava (IVC)Superior Vena Cava (SVC)Intra atrial septum (IAS)

Fossa Ovalis

Right Atrial Appendage

Eustachian valve

ME RV inflow-outflow

LARA

TCV

RV

PV

AV

Left Atrium (LA)Right Atrium (RA)Tricuspid Valve (TCV)Pulmonic Valve (PV)Aortic Valve (AV)Right Ventricular Outflow Tract (RVOT)

ALPL

Valve leaflets:

Tricuspid- Anterior(AL)

and Posterior(PL)

Inferior RV free wall

RVOT

TG RV inflow

RARV

TCV

Right Atrium (RA)Right Ventricle (RV)Tricuspid Valve (TCV)

PL

AL

Valve leaflets:

Tricuspid- Anterior(AL)

and Posterior(PL)

ME asc aortic SAX

Rt PA

PASVC

Asc

Pulmonary Artery (PA)Right Pulmonary Artery (Rt PA)Superior Vena Cava (SVC)Ascending Aorta (Asc)

ME asc aortic LAX

Rt PA

Asc

Ascending Aorta (Asc)Right Pulmonary Artery(Rt PA)

Orientation:

DistalProximal

Aorta-esophageal position

As probe withdrawn from patient, TURN probe to the LEFT to keep aorta image in the center of the video screen

desc aortic SAX

Ao

Aorta (Ao)Orientation

desc aortic LAX

Ao

Aorta (Ao)

Caudad Cephalad

Orientation

UE aortic arch LAX

Aortic Arch

Distal

Proximal

Orientation

UE aortic arch SAX

PA

PV

RVOT

Aortic arch

L Subclavian artery

Left brachiocephalic vein

Pulmonary artery (PA)Pulmonic valve (PV)Right ventricular outflow tract (RVOT)

Orientation

• References:Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA Guidelines for Performing a Comprehensive Intraoperative Multiplane Transesophageal Echocardiography Examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999;89:870-74.