## **Clinical imaging and techniques** ## The utility of the trans-splenic retrocardiac view in supine critically ill patients Issac Cheong^1,2, Pablo Martín Merlo², Francisco Marcelo Tamagnone² Corresponding Author: Issac Cheong, Email: issac cheong@hotmail.com World J Emerg Med 2026;17(2):000-000 DOI: 10.5847/wjem.j.1920-8642.2026.018 Monitoring cardiac function is a fundamental component of the diagnosis and management of critically ill patients. While pulmonary artery catheterization has long served as the standard for hemodynamic assessment, its invasive nature and associated risks have shifted clinical practice toward non-invasive modalities. [1] Among these methods, point-of-care ultrasound (POCUS) has gained widespread acceptance, offering real-time bedside evaluation of cardiac function. [2] Traditionally, echocardiographic assessment relies on three standard windows: parasternal, apical, and subxiphoid windows. However, in critically ill patients—especially those requiring mechanical ventilation—these windows may be difficult or impossible to obtain due to factors like lung hyperinflation, patient positioning, or the presence of bandages and drains.^[3] In this context, the trans-splenic view has emerged as a valuable alternative.^[1] Originally described in prone patients, this approach can also be utilized in the supine position, expanding its applicability.^[1,4] It involves placing a phased array transducer (ranging from 2 to 4 MHz) at the intersection of the posterior axillary line and the fifth intercostal space, with the transducer index mark oriented toward the bed. This orientation directs the ultrasound beam through the splenic parenchyma toward the heart, offering a posterior-lateral retrocardiac view. We describe the case of a 44-year-old male patient who required orotracheal intubation and mechanical ventilation due to pneumonia. At examination, his mean arterial pressure was 75 mmHg (1 mmHg=0.133 kPa), heart rate was 78 beats/min, and he required norepinephrine infusion to maintain adequate perfusion. Key laboratory values included a white blood cell count of 7,250/mm³, pH 7.45, partial pressure of oxygen (PaO₂) 107 mmHg, partial pressure of carbon dioxide (PaCO₂) 44 mmHg, HCO₃^- 30 mEq/L, and lactate 18 mg/dL, with a PaO₂/FiO₂ ratio of 267, reflecting moderate oxygenation. In this case, the patient also presented with left pleural effusion and lower lobe consolidation, which enhanced the transmission of ultrasound waves and improved visualization of cardiac structures through the trans-splenic window. The patient was positioned completely supine and semirecumbent, with the left arm slightly abducted from the torso to facilitate transducer placement for the trans-splenic window. The examination was performed using a Philips Sparq ultrasound machine with a phased array probe. This window enabled qualitative evaluation of the cardiac chambers, including assessment of global systolic function, and chamber size. Notably, by tilting the probe's tail slightly downward to obtain an apical five-chamber alignment, we were able to record a measurable left ventricular outflow tract velocity time integral (LVOT VTI) using pulsed-wave Doppler (Figure 1 and Supplementary Video). This finding indicates that the trans-splenic view can support both anatomical assessment and hemodynamic monitoring—using LVOT VTI as a surrogate for stroke volume—when adequate alignment is achieved. [1] Importantly, while pleural effusion and lung consolidation may improve acoustic transmission and image quality, they are not strictly necessary to obtain a trans-splenic view.^[2,4] The spleen itself often provides a suitable acoustic window, and this approach can be considered even in the absence of additional fluid collection or lung pathology.^[4] However, several limitations should be acknowledged. The acoustic window may be restricted in patients with small spleens, ^<sup>1 Department of Critical Care Medicine, Sanatorio de Los Arcos, Buenos Aires C1174ABH, Argentina ^<sup>2 Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires 1436, Argentina ![](https://assets.reachrx.ai/images/10.5847%E2%98%8Dwjem.j.1920-8642.2026.018/_page_1_Figure_2.jpeg) **Figure 1.** The ultrasound imaging findings. A: B-mode image of the trans-splenic retrocardiac view showing the four cardiac chambers (S: spleen; P: pleural effusion; C: lung consolidation). B: pulsed-wave Doppler at the LVOT in the trans-splenic retrocardiac view demonstrating VTI measurement. LVOT: left ventricular outflow tract; VTI: velocity time integral. a high body mass index, or significant bowel gas. In summary, the trans-splenic view represents a practical and underutilized alternative for cardiac imaging in critically ill patients in the supine position, especially when standard echocardiographic windows are not obtainable. With proper technique and anatomical orientation, this window can expand the toolkit of clinicians using POCUS in challenging scenarios. This report serves as an initial feasibility description and was not designed to compare measurements with conventional windows. Therefore, prospective studies comparing LVOT VTI and other hemodynamic parameters between trans-splenic and standard views are warranted to validate the reliability of this technique ## Funding: None. Ethical approval: Approval for this study was waived in accordance with the local regulations because this study is a case report of a single patient and did not include protected health information, data analysis, or testing of a hypothesis, and was deidentified. Written consent was obtained from the patient before the publication of this case report. **Conflicts of interest:** The authors have no relevant financial or non/financial interests to disclose. **Author contributions:** Conceptualization: IC; Methodology: IC; Formal analysis and investigation: IC; Writing – original draft preparation: IC; Writing – review and editing: IC; Supervision: IC, PMM, FMT. All the supplementary files in this paper are available at http://wjem.com.cn. ## **REFERENCES** - 1 Cheong I. Unconventional echocardiographic techniques for LVOT VTI measurement in critical care settings. J Clin Ultrasound. 2025;53(6): 1418-24. - 2 Cheong I, Merlo PM, Tamagnone FM. POCUS use in the critical care areas: The use of posterior view for heart assessment. Sonography. 2025;12(1): 88-9. - 3 Cheong I, Bermeo M, Merlo PM, Tamagnone FM. A new approach of non-invasive hemodynamic assessment by echocardiography in the intensive care unit: The right intercostal transhepatic window. Echocardiography. 2022;39(5): 752-4. - 4 Catena E, Rizzuto C, Borghi B, Bergomi P, Guglielmetti L, Gambarini M, et al. The usefulness of trans-splenic retrocardiac imaging in prone positioned critically ill patients. J Clin Ultrasound. 2024;52(7): 973-5. Received May 11, 2025 Accepted after revision October 6, 2025