‘The 20 Views’ Annual Comprehensive Review & Update of Perioperative Echo

LV axis model

17 segment model of the Left ventricle

ME four chamber LV walls: 6 Basal Inferoseptal 12 Mid Inferoseptal 16 Apical Septal 3 Basal Anterolateral 9 Mid Anterolateral 14 Apical Lateral 17 Apical Cap Valve leaflets: Mitral- Anterior(A1, A2) and Posterior(P1) Tricuspid- Septal(S) Anterior (A), Posterior (P) RA LA A2 P1 S A1 TV 3 6 MV 12 9 RV LV 16 14 17 A or P (depending upon probe flexion) RV free wall

ME two chamber Valve leaflets: Carpentier Classification Mitral- Anterior(A1, A2, A3) Posterior(P3) LV walls: 5 Basal Inferior 11 Mid Inferior 15 Apical Inferior 2 Basal Anterior 8 Mid Anterior 13 Apical Anterior 17 Apical Cap LA LAA A1 A2 P3 5 A3 2 11 8 LV 15 13 Left Atrial Appendage (LAA) 17

ME LAX LV walls: 4 Basal Inferolateral Valve leaflets: 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) LA AV A2 P2 4 1 10 7 RV LV 14 or 15 13 or 16 17

TG mid SAX LV walls: 8 Mid Anterior 7 Mid Anteroseptal 12 Mid Inferoseptal 11 Mid Inferior 10 Mid Inferolateral 9 Mid Anterolateral PM pap 11 12 10 RV AL pap 7 9 8 LV Papillary Muscles: Anterolateral papillary muscle (AL pap) Posteromedial papillary muscle (PM pap)

TG basal SAX 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 5 P3 6 4 A3 P2 A2 P1 1 A1 3 RV 2 LV

TG Apical SAX (Not part of original 20 views) 13 Apical Anterior 14 Apical Lateral 15 Apical Inferior 16 Apical Septal 15 16 14 LV 13 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 Carpentier Classification

ME mitral commissural Valve leaflets: Mitral- Anterior Scallops (A2) and Posterior Scallops (P1, P3) LA P3 P1 A2 PM pap AL pap LV Papillary Muscles: Anterolateral papillary muscle (AL pap) Posteromedial papillary muscle (PM pap)

TG two chamber Valve leaflets: Mitral- Anterior(AL) and Posterior(PL) LAA Left Atrium (LA) Left Atrial Appendage (LAA) Left Ventricle (LV)

ME AV SAX Aortic Valve Non coronary cusp (NCC) IAS Left coronary cusp (LCC) Right coronary cusp (RCC) IAS LA PV NCC LCC RA RCC RVOT Left Atrium (LA) Right Atrium (RA) Intra atrial septum (IAS) Pulmonic valve (PV) Right ventricular outflow tract (RVOT)

ME AV LAX Aortic Valve (AV) Valve leaflets: Mitral- Anterior(AL) Right Coronary Cusp (RCC) Non Coronary Cusp (NCC) Left Coronary Cusp (LCC) Valve leaflets: Mitral- Anterior(AL) and Posterior(PL) LA PL AL NCC or LCC RCC Asc Ao LV RV AV Ascending Aorta (Asc Ao)

TG LAX Valve leaflets: Mitral- Anterior(AL) and Posterior(PL) AV LV Asc Ao RV Right Ventricle (RV) Aortic Valve (AV) Ascending Aorta (Asc Ao)

deep TG LAX Valve leaflets: Mitral- Anterior(AL) Left Ventricle (LV) and Posterior(PL Left Ventricle (LV) Right Ventricle (RV) Left Atrium (LA) LV RV AL PL LA AV Ao Aortic Valve (AV) Aorta (Ao)

ME bicaval IAS LA IVC SVC Left Atrium (LA) Right Atrium (RA) Eustachian valve Left Atrium (LA) Right Atrium (RA) Inferior Vena Cava (IVC) Superior Vena Cava (SVC) Intra atrial septum (IAS) Right Atrial Appendage Fossa Ovalis RA

ME RV inflow-outflow Valve leaflets: Tricuspid- Anterior(AL) LA and Posterior(PL) LA RA AV TCV PL AL PV RV RVOT Left Atrium (LA) Right Atrium (RA) Tricuspid Valve (TCV) Pulmonic Valve (PV) Aortic Valve (AV) Right Ventricular Outflow Tract (RVOT) Inferior RV free wall

TG RV inflow TCV Valve leaflets: Tricuspid- Anterior(AL) and Posterior(PL) RA RV PL AL Right Atrium (RA) Right Ventricle (RV) Tricuspid Valve (TCV)

ME asc aortic SAX Rt PA SVC PA Asc Pulmonary Artery (PA) Right Pulmonary Artery (Rt PA) Superior Vena Cava (SVC) Ascending Aorta (Asc)

ME asc aortic LAX Orientation: Ascending Aorta (Asc) Right Pulmonary Artery (Rt PA) Rt PA Asc Proximal Distal

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 Orientation Aorta (Ao)

desc aortic LAX Ao Caudad Cephalad Aorta (Ao) Orientation

UE aortic arch LAX Distal Aortic Arch Proximal Orientation

UE aortic arch SAX Aortic arch PA L Subclavian artery PV Orientation RVOT Left brachiocephalic vein Pulmonary artery (PA) Pulmonic valve (PV) Right ventricular outflow tract (RVOT)

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.