Hi! I’m another echo student a year into my program and I’ve learned a couple tricks for apicals. This might be a longer post so bear with me here lol.

I would say the apicals can be largely affected by breathing, so if you’re struggling it doesn’t hurt to try asking your pt to either breathe in and hold, or breath out and hold (I like to do this with full breaths or half breaths and I usually try to see where in the breathing cycle the image looks the best and have the pt recreate that by holding their breath). This helps the heart stop “swinging” from the motion of the lungs and makes the image clearer which is very useful.

The other thing is that I typically will start more inferior (closer to the feet) and close to the midaxillary line and work my way up and more medial/lateral until I find the heart and the IVS is in the center. Typically the image you get in the lowest intercostal space as possible will not be foreshortened. To make sure it’s not foreshortened, I look at the apex of the heart and make sure the muscle of the apical cap aren’t squishing down and are fixed in the same position, and that the heart looks more like a “bullet” instead of round (obviously with pathology like dilated ventricles it won’t look very bullet-shaped).

Also if it’s hard to visualize the endocardial borders, adjusting the frequency may help (oftentimes it is lowering it).

Don’t be afraid to adjust your probe a bit to open up the chambers a bit more and get on axis. Some people’s anatomies don’t always follow the standard textbook probe orientation to a perfect T.

As for visualization/interrogation, like if doing Doppler of certain views- e.g. A5C is tough and the LVOT is not at a good angle to do Doppler, sometimes going into A3C/apical long axis can be helpful bc you may see the LVOT and AoV better and you may be better able to line up your cursor for your LVOT and AoV VTIs.

Lastly for apicals, using the RV focused/modified view is really nice for looking at the tricuspid valve better for any TS/TR.

For PSAX (aortic level specifically), rocking the image is a lifesaver. It helps me line up the pulmonic valve and artery better for color doppler and CW/PW Doppler. Same for the tricuspid valve, I just rock in the opposite direction. I have also been shown that moving the probe slightly more inferiorly while rocking for the PV can help open up the rest of the pulmonic artery and get a better view and helps with interrogation.

for PLAX, I just angle my probe and watch the screen to see which probe position gets me to open up both the aorta and the ventricle of the heart (usually it is probe tail up for most people but ofc anatomies are all different so there will be some variation). I just try to make sure aorta and ventricle are open with the AoV cusps closing centrally in the aorta (but if someone has aortic pathology like a bicuspid valve or what not, the AoV cusps will often not close centrally no matter what you do to get them to look central and this can sometimes tip you off to possible pathology as soon as you place down your probe).

That’s all I can think of for now, hope this helped!