of the last rib to avoid the acoustic artifacts caused by air in the stomach, using the liver as an acoustic window As the ultrasound beam moves toward the left shoulder from the subxiphoid space, it will encounter the liver first, then right ventricle (RV) and right atrium (RA), followed by the left ventricle (LV) and left atrium (LA) The image obtained will correlate such that the liver is at the top of the screen and the left ventricle is near the bottom of the screen (Fig 131.7 ) Normally, the bright white pericardium abuts the gray myocardium When a pericardial effusion is present, a hypoechoic or anechoic (dark) stripe will appear between the two (Fig 131.9 , Video 131.8 ) The left parasternal long view is obtained by placing the probe in the third or fourth intercostal space, immediately left of the sternum, with the marker pointed toward the left hip Unlike the subxiphoid view in which the probe lies almost flat against the chest, it should instead be placed perpendicular to the chest wall in the parasternal long view (Fig 131.10 ) The image acquired should cut across the long axis of the heart, from the atria (right shoulder) to apex (left hip) This view can be quite useful in obese patients, in whom the subxiphoid view is often difficult to obtain Just as in the subxiphoid view, the right ventricle is the first cardiac structure encountered by the ultrasound beam, as it lies most anterior and closest to the probe (Fig 131.11 , Video 131.9 )