The Golden Rule for Obtaining an On-Axis Image

Imaging the heart on-axis is possibly the most important role of a cardiac sonographer. Foreshortened or off-axis images provide a false view of the heart which can result in wall motion (and function) looking more vigorous than it really is. We may miss something completely, all just because we aren’t slicing through the heart correctly. Knowing how to correct an off-axis image shouldn’t be guesswork for the sonographer.
The #1 secret to on-axis imaging can be found in the following mantra….
Angle for the center, rotate for the sides (and always in that order).

It is such an important point, that I want you to say it out loud 3 times before we move on!!!!!
Angle for the center, rotate for the sides!!
Angle for the center, rotate for the sides!!
Angle for the center, rotate for the sides!!
If we look at a standard, on-axis view… in this case, the PLAX view. Note the aortic and mitral valves are opening, the LV infero-lateral wall and ventricular septum are contracting as two parallel lines, the LV apex is not visible from this window, and the aorta is opened out nicely and forms two parallel lines.
On-axis PLAX image

On-axis PLAX image

Now, lets look at the process for how I got this image.
1. Place transducer on chest
When I first put the probe on chest the image looked like the one below. The probe is just to the left of the sternum, placed perpendicular to the chest wall in the 3rd or 4th intercostal space, with the image marker is rotated to around 11 o’clock. Sounds like a textbook description, but that is only a guide. Don’t lose any sleep over this, everyone’s heart is in a slightly different position in the chest. It doesn’t matter if your transducer needs to be rotated differently for a particular patient…we are all different, but we display the images in a standard layout. Sometimes if we place the transducer in the “textbook” position it will look like this…
Off-axis image. Note the valves are closed down and it appears like the apex is closing into the LV.

Off-axis image. Note the valves are closed down and it appears like the apex is closing into the LV.

This is a common scenario, where manipulation of the transducer is required to obtain the on-axis image. Experienced sonographers correct this without thinking, but often struggle to communicate to a trainee how to improve the image quickly. Trainees often just move around, adopting a “hope for the best” approach.


2. Mentally divide the image into thirds
This is where the Golden Rule comes into play. Divide the image into three rough zones – see image below. There will be a small section in the center of the image and a side-section on either side of the center.
Focus only on the center of the image initially.

Focus only on the center of the image initially.

 3. Tilt/Angle for the center
To then make adjustments to correct the image, angle for the center. Angle the transducer either way to open out the center region of the image. At this point, ignore the sides completely. Make sure that the AoV and MV are positioned within the center zone, and that the image is transecting through the center of both valves.
Here the center strip of the image is on-axis, but the apex still seems to be coming into the LV. The LV walls are not parallel with one another.

Here the center strip of the image is on-axis, but the apex still seems to be coming into the LV. The LV walls are not parallel with one another.

4. Rotate to open out the side thirds
 We are now happy that the center of the image is on-axis. It is important at this point that you hold the transducer very still and make sure you don’t slide, tilt or angle from this point. Very carefully rotate the transducer to open out the sides of the image. Often it will be a clockwise rotation, but if that doesn’t work, just rotate anti-clockwise instead. The important point is that you don’t tilt at this stage, and you limit your movements to a rotation. If you do slip…go back to the first step and tilt for the center – this MUST be the first movement, everytime.
On-axis PLAX image

Image is now tilted and rotated correctly.

It will seem like a slow process initially, but will become second nature very quickly… all of your imaging will become more efficient as you save time finding the correct image.
Additional thought exercise: 
Which structures are in the “center” and “side” zones for the PSAX view at the level of the AoV? What about the apical views??
What view do you routinely struggle with??
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  • Reply Susan Spell November 24, 2014 at 6:02 pm

    Oh thank you so much for your expertise !!!!! I have trained sonographers for years and have ( as you mentioned ) struggled to explain the strategy for obtaining what seasoned sonographers do without thinking ! Reading your method sent light bulbs off — that’s exactly what we do but I have NEVER known how to explain it so simply !!!! I can’t wait to get to work today to use it on my student !!!!!!!!!!

    Thank you so much! You are the BEST !!

    Susan Spell

    • Reply November 25, 2014 at 8:49 am

      Thanks Susan for your support and really kind words. I would love to hear how you get on with trying some of the tips out. Especially let me know if you find something is still a struggle with the students, I am always looking to tweak my techniques!

  • Reply Carlos Ochoa November 24, 2014 at 10:37 pm

    Thanks you!

  • Reply Ken Spencer November 25, 2014 at 12:50 am


  • Reply MS November 25, 2014 at 8:43 am

    Nicely explained. When will you be posting your suggestions on apical views ??

    • Reply November 25, 2014 at 8:47 am

      Hi MS. Maybe late next week for apical views. I will prob post one more PLAX tip post, then I want to post a diastology post… SO many great suggestions for posts and so little time… I will get to it all eventually though.

      • Reply MS November 25, 2014 at 8:49 am

        No problem. thanks so much.

      • Reply Mark May 8, 2019 at 10:35 am

        Do you still manage this page and send replies?

        • Reply echoguru May 8, 2019 at 10:39 am

          Yes I do. Have been busy with two young kids, but new posts are coming soon!!!

  • Reply Sophie Dritsas, BS, RVT, RDCS November 27, 2014 at 3:25 pm

    Thank you! So simple and elegantly explained! Not once did I hear it described in this way during my Echo cross-training or clinical Rotation. Way to pay it forward! Passing website on to my fellow classmates and recent Echo graduates.

  • Reply Faizal Amri Hamzah August 25, 2015 at 2:20 am

    Excellente! Concise and easily understandable….

  • Reply RSE - The fifth acoustic window - Echo.Guru December 21, 2015 at 6:26 am

    […] older patients are rotated anticlockwise back to ~ 10 o’clock). And always remember the Golden Rule for obtaining an on-axis image: tilt for the center and rotate for the sides (and always in that order). You will need to rotate […]

  • Reply Elton Aguilar, BS RDCS October 7, 2016 at 3:36 am

    As usual… Great stuff Tony!

    May I add a comment regarding “sliding”. To minimize probe-slide, it is imperative that you anchor your hand or fingers on the body of the patient. It is the sensory information you receive on your hand that will tell you if you are sliding. You can’t hold the probe at the back end close to the cable and expect not to slide. You need to touch the patient. It may be as little as the tip of your pinky finger touching the patient that can tell you if you slide. Happy scanning!

    • Reply echoguru October 7, 2016 at 3:37 am

      Elton, Thankyou!! That is great advice!

  • Reply Milnium January 8, 2018 at 3:23 am

    you don’t know what you just accomplished to my career. I am student and I was thinking to drop because It seemed to me like magic.As you said above, ” trainee often just move around, and adopting hope to get the best approach”. You exactly described me, I have researched online who could you keep me to stay to this career? You are my answer. You are the only one in the world who know what echo trainees are suffering from. Thank you to keep me to this program which will be my life career. Thank you again. please I can’t wait anything (RVIT, RVOT, SAX, APICAL,..) more you have beside this.

    • Reply echoguru January 8, 2018 at 4:53 am

      Thanks for the comment. Glad you found it useful. Echo training is really hard work, and I still have days (most days) that I struggle with some aspect of our craft. Stay positive knowing that everyone of us went through how you are feeling. I am hoping to have a lot more content coming in 2018- hopefully it helps.

  • Reply Mark May 8, 2019 at 10:27 am

    Hi, I’d like to place here one case – the echo with explanations and description, to have your opinion on it’s quality and the rightness of interpretations. Could I?

    • Reply echoguru May 8, 2019 at 10:30 am

      Hi Mark. Happy for you to post the images (anonymized) on the Facebook group….or you can share a google drive link for me to look at.

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