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Updated: May 8, 2026
Echocardiographic Assessment Using Subxiphoid-Only Examination for Hypotensive Patients
Published on: April 18, 2025
The subxiphoid view cannot replace the apical view for transthoracic echocardiographic assessment of hemodynamic
Insights
The subxiphoid window in transthoracic echocardiography (TTE) can assess cardiac structure and function, but it does not accurately measure hemodynamic parameters. Both apical and subxiphoid views are recommended for comprehensive cardiac assessment in the ICU.
Area of Science:
- Cardiology
- Critical Care Medicine
- Medical Imaging
Background:
- Transthoracic echocardiography (TTE) is vital in intensive care units (ICUs).
- The subxiphoid acoustic window is an alternative view in TTE, particularly when the apical view is unavailable.
- Assessing the utility of the subxiphoid window for hemodynamic evaluation is crucial.
Purpose of the Study:
- To evaluate the subxiphoid acoustic window as an alternative to the apical view in TTE for assessing hemodynamic parameters.
- To compare measurements of cardiac function and morphology obtained from both apical and subxiphoid views.
Main Methods:
- A prospective study was conducted in a medical ICU over 4 months.
- Transthoracic echocardiography (TTE) was performed on 107 patients.
- Quality of parasternal, apical, and subxiphoid windows was rated; key hemodynamic parameters (LVEF, RVEDA/LVEDA, E/A, Ao VTI, E/Ea) were compared between adequate apical and subxiphoid views.
Main Results:
- Adequate apical views were obtained in 80% and subxiphoid views in 63% of patients.
- Left ventricular ejection fraction (LVEF), E/A ratio, and RVEDA/LVEDA were comparable and strongly correlated between views (r > 0.80).
- Aortic velocity time integral (Ao VTI) and E/Ea ratio were significantly lower with the subxiphoid view, indicating less accurate hemodynamic Doppler information.
Conclusions:
- The subxiphoid window is useful for assessing cardiac morphology and function, complementing the apical view.
- Hemodynamic Doppler measurements (Ao VTI, E/Ea) using the subxiphoid window are not accurate.
- ICU echocardiographers should obtain both apical and subxiphoid views for comprehensive cardiac assessment.
Introduction:
This prospective study aimed to assess whether use of the subxiphoid acoustic window in transthoracic echocardiography (TTE) can be an accurate alternative in the absence of an apical view to assess hemodynamic parameters.
Methods:
This prospective study took place in a teaching hospital medical ICU. Over a 4-month period, TTE was performed in patients admitted for more than 24 hours. Two operators rated the quality of parasternal, apical, and subxiphoid acoustic windows as Excellent, Good, Acceptable, Poor, or No image. In the subpopulation presenting adequate (rated as acceptable or higher) apical and subxiphoid views, we compared the left ventricular ejection fraction (LVEF), the ratio between right and left ventricular end-diastolic areas (RVEDA/LVEDA), the ratio between early and late mitral inflow on pulsed Doppler (E/A ratio), the aortic velocity time integral (Ao VTI), and the ratio between early mitral inflow and displacement of the mitral annulus on tissue Doppler imaging (E/Ea ratio).
Results:
An adequate apical view was obtained in 80%, and an adequate subxiphoid view was obtained in 63% of the 107 patients included. Only 5% of patients presented an adequate subxiphoid view without an adequate apical view. In the subpopulation of patients with adequate apical and subxiphoid windows (n = 65), LVEF, E/A, and RVEDA/LVEDA were comparable on both views, and were strongly correlated (r > 0.80) with acceptable biases and precision. However, the Ao VTI and the E/Ea ratio were lower on the subxiphoid view than on the apical view (18 ± 5 versus 16 ± 5 cm and 9.6 ± 4.6 versus 7.6 ± 4 cm, respectively, P = 0.001 for both).
Conclusions:
An adequate TTE subxiphoid window was obtained in fewer than two thirds of ICU patients. In addition to the classic indication for the subxiphoid window to study the vena cava and pericardium, this view can be used to study right and left ventricular morphology and function, but does not provide accurate hemodynamic Doppler information. ICU echocardiographers should therefore record both apical and subxiphoid views to assess comprehensively the cardiac function and hemodynamic status.
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