Echocardiography: the standard views and the coronary territories

1. Parasternal long axis

Probe at the left sternal edge (3rd–4th intercostal space), marker towards the right shoulder. The beam slices the heart along its long axis: right ventricular outflow at the top, then the septum, the left ventricular cavity and the inferolateral wall; the aortic root and mitral valve at the base, the left atrium behind.

Surgeon’s corner: The first view of every echo: aortic root size, valve opening, wall thickness and a quick look for pericardial fluid — which collects behind the left ventricle, in front of the descending aorta.

2. Parasternal short axis

From the same window, the probe turned 90° clockwise cuts the left ventricle across, like a doughnut: here at the level of the papillary muscles. The right ventricle wraps round it in front. All three coronary territories are seen in one ring.

Surgeon’s corner: A right ventricle under pressure (pulmonary embolism, pulmonary hypertension) flattens the septum into a "D" in this view.

3. Apical four-chamber

Probe at the apex beat (usually 5th intercostal space, midclavicular to anterior axillary line), pointing to the right shoulder. All four chambers appear with the apex at the top: the septum in the middle, the lateral wall of the left ventricle on one side, the right ventricle on the other, the atria and the mitral and tricuspid valves below.

Surgeon’s corner: The tricuspid valve inserts slightly closer to the apex than the mitral valve — this offset identifies the right side; an exaggerated offset is Ebstein anomaly.

4. Apical two-chamber

From the apex, the probe turned about 60° anticlockwise drops the right heart out of the image: only the left ventricle and left atrium remain, showing the anterior wall on one side and the inferior wall on the other.

Surgeon’s corner: The four- and two-chamber views together give the biplane (Simpson) ejection fraction: normal about 50–55% or more.

5. Which wall, which artery?

A wall that moves poorly (hypokinetic) or not at all (akinetic) points to its artery: anterior wall, anterior septum and apex — LAD; anterolateral and inferolateral walls — circumflex; inferior wall and inferior septum — right coronary artery. Tap the views in the panel to see the walls each one shows.

Surgeon’s corner: A new regional wall-motion abnormality in a patient with chest pain and a non-diagnostic ECG supports acute ischaemia; normal wall motion during ongoing pain makes extensive ischaemia less likely but does not exclude it (small or circumflex-territory infarcts can be missed). The inferolateral and inferior walls vary with dominance; the apex varies with how far the LAD wraps around it, and anterolateral segments may be fed by LAD diagonals.