This is the TEE equivalent of your favorite lounging spot in your house. It is often the first image sought when the probe is introduced, and it is a stellar place to return if you ever become lost.

*Pearls*

Gentle retroflexion of the probe tip is often required to avoid foreshortening this view, which will make the LV look smaller and more robust than it actually may be.

Sometimes image optimization is difficult due to patient anatomy and it is easier to split this into an "LV-focused" view and an "RV-focused" view by simply rotating to the left and right.

Often at 0 degrees of omniplane, a 5 chamber view will be obtained with the LVOT and part of the aortic valve imaged. In this scenario the omniplane can be increased slightly (usually no more than 20-30 degrees) to obtain a more true 4 chamber view.

From the ME 4 chamber, center the left atrium and ventricle in the image and increase the omniplane to 90 degrees.

*Pearls*

The left atrial appendage is often viewed best from this view (though sometimes with slightly less omniplane and can be interrogated for clot presence.

At 90 degrees of omniplane, the anterior wall of the LV will be displayed on screen right and the inferior wall on screen left.

From the same location as the ME4 and ME2 chamber views, spin the omniplane up to ~120 degrees to produce the image on the right.

*Pearls*

Frequently this image will be obtained best at a higher angle than 120 (often 130-150). The trick is to optimize the cavity size of the LV as well as the LVOT and aortic root.

From the ME Long Axis view, focus on the aortic root and begin slowly withdrawing the probe to image the more superior ascending aorta. The right pulmonary artery will be seen in cross section between the ultrasound transducer and the aorta.

*Pearls*

Careful counter-clockwise rotation from this view will allow imaging of the main pulmonary artery and pulmonic valve, often with good alignment for doppler interrogation.

This view is named after the ascending aorta, but the pulmonary arteries are the main stars. It can be found from the UE ascending aortic long axis view by decreasing to the omniplane to ~30. To image the main PA often requires a fair bit of retroflexion.

*Pearls*

If simply looking for the MPA, I find this view easier to obtain by starting with a ME aortic valve short axis view (below), slowly retracting the probe until the valve disappears and all that is imaged is the ascending aorta, and then gently retroflexing until the RPA and MPA are seen.

From the ME 4 chamber view,  increase the omniplane slightly to ~30 degrees and gently withdraw the probe, centering the aortic valve on the screen, until the valve leaflets become clear.

*Pearls*

The three cusps are labeled to the left. The non-coronary cusp is always adjacent to the interatrial septum and the right-coronary cusp is at the bottom of the screen adjacent to the RVOT as imaged. The left-cusp is usually identified as "last-but-not-least".

Not infrequently the left main coronary artery and sometimes the right coronary can be seen originating from their respective cusps (L and R respectively).

From the ME aortic valve short axis view, advance the probe ever so slightly and increase the omniplane to ~60 degrees.

*Pearls*

If present, a tricuspid regurgitation jet may align better for doppler interrogation in this view (or a close variant) than in the ME 4 chamber view.

This view is especially useful when floating a PA catheter or, in conjunction with the UE ascending aortic short axis view, querying the position of one that may already be in place.

While focusing on the interatrial septum from the ME 4 chamber view, increase the omniplane to 90 degrees and rotate the probe to the right until the SVC and IVC are opened in the image.

*Pearls*

This view is ideal for confirming wire location during central line placement (with a careful spin of the wire you can even see the "J" which can help differentiate your wire from other pacemaker leads, lines, or wires that may already be present).

This is also the best view for examining the fossa ovalis (FO) and querying the presence of a PFO.

From the ME 4 chamber view, advance the prove gently into the stomach and, after the image degrades, anteflex the probe to maintain good contact with the stomach wall. This image is optimized when both papillary muscles are visualized in cross-section, which may require some fine tuning of the depth and degree of anteflexion. The "mid-papillary" part of the name truly is key for correct image interpretation.

*Pearls*

This view is ideal for rapid assessment of:

• Global left ventricular function

• Regional wall motion abnormalities (all coronary distributions can be examined from this same imaging location)

• Interventricular septum for presence of a "D" sign such as in cases of RV pressure-overload (though caution in interpretation as the septum can be made to look flat in a foreshortened or otherwise off-axis image)

From the transgastric view, rotate the probe ~180 degrees to visualize the aorta in short axis.

*Pearls*

If the aorta is not initially seen, try withdrawing the probe slightly and continue searching. As it becomes more distal, the stomach will course away from the aorta and you will no longer be able to visualize it with TEE.

Decreasing the imaging depth will help optimize your imaging of the aorta, given its small diameter in relation to the heart.

The probe can be slowly withdrawn while keeping the aorta in the center of the image display to image the length of the descending thoracic aorta all the way back up to the aortic arch.

From the same descending aortic short axis view, increase the omniplane to 90 degrees to image the aorta in long axis.

*Pearls*

If the TEE machine has an x-plane feature, this can be used to simulataneously image the full length of the descending thoracic aorta in both short and long axis as the probe is slowly withdrawn. This will save you multiple trips into the stomach.