Apical Views

Probe Position for the Apical Views

Probe position for typical Apical 4 chamber view. The probe is typically where the apex of the heart is expected. For the apical four-chamber (A4C) view, the ultrasound probe is positioned at the apex of the heart, which corresponds to the point of maximal impulse (PMI)—typically located at the left lower chest near the mid-axillary line in newborns, just below the nipple line in infants. The probe marker should be directed toward the left side of the patient (left shoulder in adults, often around the 3 o'clock position in neonates) to obtain a standard orientation. The imaging plane slices longitudinally through the heart, displaying the right and left atria and ventricles simultaneously, aligned from apex to base. This view is crucial for assessing chamber size, wall motion, septal integrity, and valvular function.

I have noticed that many trainees put the probe around the anterior axillary line, or even on the chest. It is often more posterior and near the mid- or posterior axillary line. One should slide the probe inferiorly until you are able to visualize nicely the apex. Often, the cavity is shortened and not at the apex because the probe is placed to high on the chest. The probe can be rotated with the marker at 12 o'clock for the A2C (marker 60 to 90 degrees - depending on patients - from the position in A4C). To obtain the A5C, the probe should be rotated 30 to 45 degrees from the A4C position with an anterior tilt (tilting towards the skin, rather than going deeper in the chest).

Review of the Anatomy and Apical 4 Chamber View

Apical 4 chamber view. Here we are at the level of the inflows (mitral valve and tricuspid valve in normal anatomy)

Segmentation of the left ventricle

2D-grayscale Apical 4 chamber view in 2D – LV focused with Left Atrium

In apical 4 chamber view, one may appreciate the RV, LV function and size. Here we see the free wall of the RV, the inter-ventricular septum and the lateral wall of the left ventricle. One can appreciate the size of the mitral and tricuspid valve. It is a view to also measure the RV basal, mid-cavity and longitudinal dimensions in diastole. EF by Simpsons may be calculated using the apical-4-chamber view. The biplane methods also evaluation in the Apical-2-chamber view. The apical 4 chamber view (A4C) is also useful to assess longitudinal function of the Right ventricle.

LV focused view: one may see the mitral valve having a longitudinal displacement towards the Apex in systole. All the walls should be clearly seen, inclusive of the apex. The endocardial border should be well delineated.

RV-focus view in the apical approach. The Tricuspid valve is seen having a longitudinal motion during systole, towards the apex.

A4C in B-Mode with a focus on the left ventricle. It is important to see all the walls of the left ventricle, the opening and closure of the mitral valve, and nicely delineate the endocardial border for tracing of the end diastolic and end systolic volumes.

A4C with colour over inflow (mitral valve) for mitral regurgitation or acceleration (restriction)

LV focus in A4C. We can see well the endocardial border (all the walls of septum and anterolateral wall of LV), the apex and the full left atrium. In this LV focused view (A4C), one may appreciate the systolic and diastolic dimensions of the left ventricle.

RV focus in A4C. We can see well the endocardial border, the apex and the full right atrium.

2D-colour over Mitral valve. Important to rule out mitral insufficiency or mitral stenosis (acceleration/aliasing, turbulence of flow).

2D-colour over Tricuspid valve. Important to rule out tricuspid insufficiency (blue jet) or tricuspid stenosis (acceleration/aliasing, turbulence of flow).

Here, one may see the apical-2-chamber (A2C) view, where we can appreciate the mitral valve, as well as the LV end-diastolic and end-systolic dimensions. One may use this view to calculate the biplane EF by Simpson's disc method. We can also appreciate the blood flow through the mitral valve by colour.

Apical 2 Chamber View

B-Mode (2D) and Colour Mode to visualize the A2C

In the apical two-chamber (A2C) view of the left ventricle (LV), the ultrasound probe is positioned at the cardiac apex (similar to the A4C), but rotated approximately 60 degrees (up to 90 degrees in some patients) counterclockwise from the A4C orientation. This view displays: The left atrium (LA) and left ventricle (LV) in longitudinal section. The anterior and inferior walls of the LV. The mitral valve (particularly the anterior leaflet). The apex of the LV. Notably, the right-sided structures (RV and RA) are not visualized in this view. The A2C view is useful for assessing regional wall motion, LV size and function, mitral valve morphology, and segmental contraction of the anterior and inferior LV walls. It also serves as a key imaging plane in LV quantification and strain analysis.

A2C - the inferior ("posterior") wall of the LV is seen just above the liver echotexture. The left atrial appendage (finger like) is seen anteriorly going downward from the LA. We see the anterior and posterior leaflet of MV

LV-Ejection fraction (EF) by Simpson's disc method

EF(%) = (LVEDV − LVESV)/LVEDV × 100

Assumes a bullet shape geometry of the LV
May not be true if high PVR; abnormal septal geometry; LV hypoplasia
EF preserved despite abnormal regional subclinical disease
Decreased areas of contractility tethered by more healthy myocardium
Multiple methods based on mathematical models assuming a bullet shape appearance
Limitation of this assumption in the context of high PVR or Pulmonary Hypertension (flattening or dyskinesia of septum)
Variability of measurements is within the 10–15% range. A reduction in EF of >10% in the normal range (>55%) and >5% if <55% is clinically significant.
More in the LV function section.

Ref: Lai, W. W., Mertens, L. L., Cohen, M. S., & Geva, T. (2015). Echocardiography in pediatric and congenital heart disease: from fetus to adult. John Wiley & Sons.

A2C Disc Method for EDV at peak of diastole - mitral valve closed (QRS)

A2C Disc Method for ESV at peak of systole - mitral valve closed

A4C Disc Method for EDV at peak of diastole - mitral valve closed (QRS)

A4C Disc Method for ESV at peak of systole - mitral valve closed

It is important to note that the EF is simply a fraction of volumes (EDV and ESV). If there is significant/severe mitral insufficiency, the EF may be within normal range, but a large portion of the EF is towards the left atrium. Also, the EF can be calculated if you can estimate the EDV and the ESV of the LV. There are many methods for that. Here we are showing the Simpson's biplane disc method. However, you can segment the volumetry of the LV at peak of systole or diastole using other methods (5/6 bullet; Speckle-Tracking; 3D-Echo; assumptions from the M-Mode or Diameters using the Teichholz - which is discouraged as it does not truly reflect the LV volumes). More in the LV functional section.

Simpson’s Biplane Disc Method: The method involves approximating the left ventricular (LV) cavity by dividing it into a series of parallel elliptical discs from two orthogonal views, typically the apical 4-chamber (A4C) and apical 2-chamber (A2C) views.

1. Acquire Necessary Apical Views

Apical 4-chamber (A4C) view and Apical 2-chamber (A2C) view
Both views should be: non-foreshortened and optimally aligned to visualize true LV apex and endocardial borders

2. Trace the Endocardial Borders

At end-diastole (largest LV size) and end-systole (smallest LV size)
Trace from mitral annulus → apex → back to annulus
Exclude trabeculations/papillary muscles (follow ASE guidelines). This provides the long-axis length (L) and diameters at intervals from base to apex.

The software divides the ventricle into 20 slices (disks) of equal height (h = L/20), and calculates volume using formula

After computing the End-Diastolic Volume (EDV) and End-Systolic Volume (ESV), the EF is calculated as: EF(%)=(EDV−ESV)/EDV×100

Tricuspid Regurgitant Jet (TRJ) Velocity

During systole, tricuspid valve is closed (prevents backflow in RA)
As RV afterload starts rising - RV dilates, tricuspid annulus dilates and coaptation of valve becomes less competent
TR appears: blood flow from high pressure RV to low pressure RA generates a velocity of flow
Measuring speed using Doppler allows to estimate the “gradient” (difference) between RV and RA chamber at peak of systole
Simplified Bernouilli equation tells you that :
- Pressure difference between the 2 cavities = 4 x velocity2
- True if the opening of jet is a narrow point.
- Assuming RA pressure – 0-5mmHg (will increase with diastolic RV dysfunction)
- TR = 5.45 m/s à 4v2 = 119 mmHg at peak of systole à RV-RA gradient of 119 mmHg
- Assuming RA pressure about 5 mmHg: estimate of systolic PAP = 119+5 = 124 mmHg

Colour box may be applied on the tricuspid valve of the A4C - as such, in this clip, we can appreciate some tricuspid regurgitant jet (blue - away) when the tricuspid valve is closed. One may interrogate the TRJ to evaluate the RV-RA velocity gradient. This gradient may allow to estimate end-systolic RV pressures. If there is no RVOT obstruction, this can be used as a surrogate of systolic MPA pressure.

2D-colour over Tricuspid valve. One my appreciate the TR jet.

One may also use the enveloppe of the tricuspid regurgitant jet (CW) to calculate the systolic to diastolic time ratio, an indicator of ventricular function. Indeed, the S/D ratio is increased in ventricular dysfunction since there is prolongation of the systolic duration and a reduction in the diastolic time period. Similarly, the enveloppe may be used to calculate the dp/dt of the RV (especially useful in the context of single RV - such as in HLHS). As per Csecho.ca: "The RV contractility dP/dt can be estimated by using time interval between 1 and 2 m/sec on TR velocity CW spectrum during isovolumetric contraction. (...) Although the time from 1 to 2 m/s is most commonly used, the best correlation between echocardiographic and invasive measures was found by using the time for the TR velocity to increase from 0.5 to 2 m/s. In this case the numerator for the calculation is 15 mmHg."

Example of a TRJ with RV-RA gradient of 5.45 m/s, which gives 119 mmHg of RV-RA gradient. This can be seen in significant RV hypertension, such as in pulmonary hypertension or pulmonary embolus. More examples are provided in the pulmonary hypertension section.

The TRJ must be obtained with the line of interrogation aligned with the jet. Indeed, the jet may be eccentric, and it may be necessary to orient the probe in various directions in the apical view (or other views) to achieve the best alignment and obtain a full envelope, thereby avoiding underestimation of the RV-RA gradient. The example here outlines that there is a RV-focus view, with the RV slightly tilted. Below, another example with the Jet being significant. Typically, when there is significant RA dilatation, we consider the TR to be severe. Further, severe TR often has the jet extending to the roof of the RA.

Pulmonary veins and Mitral Inflow

The colour box indicates some mitral regurgitation (blue flow when mitral valve is closed). In this case, the patient had hypoxic ischemic encephalopathy and some signs of LV dysfunction. Papillary muscles are often the watershed part of the myocardium and MR may appear in patients with LV dysfunction. Furthermore, when facing moderate to severe MR, assessment of LV function by echocardiography is very challenging. Indeed, the LV contracts against the lower pressure chamber (left atrium) and as such, the use of markers such as ejection fraction or shortening fraction may not reflect adequately underlying performance. In this case, the MR was judged as mild.

Pulmonary venous flow visualized by colour Doppler. Often, it requires to decrease the Nyquist (velocity) in order to visualize by colour the flow.

Examples of B-Mode and Colour over the Apical 4-Chamber view, at the level of the inflow (mitral valve) and at the level of the left atrium (for pulmonary veins)

Doppler of the left lower pulmonary vein (PW-Doppler). One may appreciate a short Ar duration (during atrial contraction).

The best view in newborns to visualize pulmonary venous flow is in the "crab view" (suprasternal with a posterior angulation to visualize the left atrium). However, one may appreciate some of the pulmonary venous flow in the A4C. As such, colour velocity ("Nyquist") may need to be decrease din order to capture the low velocity pulmonary venous flow as it enters the left atrium. Typically, the PW Doppler is used to probe the pulmonary veins at their osteum. High velocity may occur in the context of increased pulmonary venous flow (example: left to right ductus arteriosus with significant Qp:Qs) or secondary to obstruction with flow acceleration (example: pulmonary venous stenosis). A pulmonary venous atresia may be difficult to diagnose by echocardiography, since it is associated with interruption of flow.

Color on left atrium with low-velocity filter for pulmonary vein

PW-Doppler in right upper pulmonary vein

Pulmonary venous flow typically shows a triphasic pattern: the S1 and S2 waves represent systolic forward flow into the left atrium, with S1 occurring during early systole and S2 during late systole. You can appreciate here relative to the relationship of the QRS. The D wave reflects diastolic forward flow during early ventricular filling when the mitral valve is open. The AR wave (atrial reversal) is a brief retrograde flow occurring during atrial contraction, just before mitral valve closure. This pattern provides insight into left atrial and ventricular diastolic properties.

These waveforms are influenced by the dynamic pressure relationships between the pulmonary veins, LA, and LV. The S waves reflect LA compliance and downstream LV systolic function; diminished S waves may indicate elevated LA pressures or impaired atrial relaxation. The D wave is primarily dependent on LV diastolic compliance and suction, and becomes more prominent with increased preload or restrictive physiology. The AR wave amplitude increases with reduced LA compliance or elevated LV end-diastolic pressure, as atrial contraction must overcome higher resistance. Altogether, analysis of pulmonary venous flow provides valuable insight into left-sided filling pressures, diastolic function, and atrial mechanics. More information on the website of NephroPOCUS.

E/A velocities ratio

A PW Doppler may be sampled at the inflow of the right or the left ventricle. Filling of the ventricle typically occurs during 2 phases - mostly in early diastole (passive early phase - E phase), and in late diastole by the atrial contraction (late diastolic atrial phase - A phase). These phases may fuse in the context of fast heart rate (such as in newborns). The early peak velocity is typically higher than the atrial velocity in compliant ventricles. In patients with restricted filling (diastolic dysfunction), the ratio of these velocity may become inverted. It is not uncommon for newborns to have a reversed profile, especially in the first few days of life. Indeed, in the context of post-natal adaptation, the ventricles are less compliant compared to the expected compliance of the pediatric/adult ventricles. Hence, the RV is more muscular than the thin walled RV found later in life.

Another example of PW-Doppler of mitral inflow for velocities. E-A velocities seen with B-Mode on top.

Another example of PW-Doppler of mitral inflow for velocities. E-A velocities seen with B-Mode+Colour on top.

Example here of some of the cycles with fusion of the E and A wave and some cycles with E < A velocity from the tricuspid valve inflow.

Example of E<A velocities of a left ventricle in a premature newborn with some degree of LV hypertrophy.

Other examples of E/A of the inflow velocities for the left and the right ventricles.

E/A = 0.97/1.08 = 0.90 (left ventricle)

E/A = 0.86/0.95 = 0.91 (right ventricle)

E and A velocity of LV. Here 0.61/0.38 = 1.61

E and A velocity of RV. Here 0.45/0.30 = 1.5.

Left Ventricular Velocity of Propagation as a marker of LV diastolic assessment has been described, mostly in the adult population, but not well studied in the pediatric population. As per the ASE: "Color M-mode measurements of the early diastolic flow propagation velocity from the MV to the apex correlate well with t and provide another means by which to evaluate LV filling; as LV relaxation becomes abnormal, the rate of early diastolic flow propagation into the left ventricle decreases."

Ref: Lopez L. et al. Recommendations for Quantification Methods During the Performance of a Pediatric Echocardiogram: A Report From the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr 2010;23:465-95.

LV inflow velocities may also be assessed in the A2C.

Apical 5 Chamber View

The apical five-chamber (A5C) view is obtained by starting from the standard apical four-chamber (A4C) position and gently tilting the ultrasound probe anteriorly toward the patient’s right shoulder. In newborns, this is often accompanied with a slight clockwise rotation of 20 to 30 degrees. This maneuver brings the left ventricular outflow tract (LVOT) and the aortic valve into view, effectively adding a "fifth chamber" to the image—the proximal ascending aorta. In this view, the left and right atria, left and right ventricles, aortic valve, LVOT, and ascending aorta can be visualized. The A5C view is particularly valuable for Doppler interrogation of the LVOT and aortic valve, allowing for measurement of aortic velocities, LVOT velocity time integral (VTI), and the calculation of stroke volume and cardiac output. It plays a key role in the assessment of aortic stenosis, left ventricular systolic function, and overall cardiac hemodynamics.

Apical 5 Chamber view of LV in 2D-grayscale

Apical 5 chamber view in 2D-Color to see flow from mitral through Aortic Valve

Apical 5 chamber view in 2D. This view is essential to evaluate LVOT and rule out sub-aortic obstruction. It is the view in which we also obtain PW-Doppler at the level of the tip of the aortic valve.

In this view, one may appreciate the flow from the left atrium to the left ventricle, as well as from the LV to the aorta.

In this view (apical 5 chamber view), one may apply the colour Doppler and see the flow through the LVOT. Presence of aortic insufficiency or stenosis can be appreciated in this view, if present. As well, presence of sub-aortic stenosis (such as in infants of diabetic mother with septal hypertrophy) can lead to flow acceleration that may be noticed in this view

Examples of the Apical 5 Chamber view with B-Mode and Colour.

Isovolumic relaxation time (IVRT)

In the apical five-chamber (A5C) view, isovolumic relaxation time (IVRT) of the LV can be measured using the pulsed-wave Doppler placed just below the aortic valve in the left ventricular outflow tract (LVOT). IVRT represents the interval between aortic valve closure and mitral valve opening, during which the left ventricle is relaxing but not yet filling. This Doppler tracing shows cessation of forward flow in the aorta followed by the onset of mitral inflow, with IVRT measured as the time between these events. Physiologically, IVRT is a key marker of diastolic performance, reflecting the rate and completeness of active myocardial relaxation. A prolonged IVRT suggests impaired relaxation (as in early diastolic dysfunction), while a shortened IVRT may reflect elevated left atrial pressures or restrictive filling. Because IVRT is influenced by loading conditions, heart rate, and myocardial compliance, it serves as a sensitive—though load-dependent—indicator of early diastolic abnormalities and is particularly valuable when interpreted alongside mitral inflow and tissue Doppler parameters.

A large left-to-right patent ductus arteriosus (PDA) significantly affects isovolumic relaxation time (IVRT) by shortening it. This occurs because the continuous left-to-right shunt increases left atrial (LA) pressure and volume, leading to elevated left atrial preload. This is true if the LA does not decompress a lot into the RA via a significant inter-atrial shunt. The left ventricular (LV) diastolic pressure rises with increased LA preload (again, this is true if the compliace of the LV is relatively appropriate for the age), and the pressure gradient between the left atrium and the left ventricle equalizes more quickly after aortic valve closure. Since IVRT is defined as the time between aortic valve closure and mitral valve opening, this faster equilibration shortens the IVRT—sometimes making it unmeasurably brief or even causing mitral inflow to begin while the aortic valve is still closing. Physiologically, a short IVRT in this context is a marker of elevated LA pressure and diastolic constraint, not necessarily enhanced relaxation. In large PDAs, this alteration of the LV filling dynamics may mimic or mask true diastolic dysfunction and must be interpreted in the context of the overall hemodynamic picture.

Isovolumetric relaxation time of the left ventricle may also be measured in the Apical-5-Chamber view by capturing a Pulse Wave Doppler of the inflow-outflow. The IVRT is indicated by the red arrow. Below, the IVRT is 66.02 msec.

Cursor is placed at the inflow-outflow junction.

IVRT of 52.80 msec.

LVOT Dopplers

CW-Doppler through the LVOT outlining there is no signs of LVOT obstruction with a minimal graident of 2.6 mmHg. Gradient will increase with obstruction (either fixed or dynamic). It will also increase with increased output - since the aortic annulus is relatively fibrous and will act as restrictive if there is torrential flow through it. In the context of atresia or extremely low LV output, the gradient/velocity may be inexistend (atresia) or very low (low output due to LV dysfunction for example). As such, the extreme of an obstruction is the absence of a gradient.

PW-Doppler with appropriate alignement with the LVOT. The cursor is placed at the LVOT. The VTI is 0.089 meter and the heart rate for this cycle is 128 bpm.

At the tip of the aortic valve, one may probe with PW-Doppler the LVOT in order to estimate the LVOT-VTI (stroke distance). The VTI can also be used to estimate stroke volume and resultant cardiac output. In the presence of poor LV performance, or significantly increased LV afterload, one may appreciate a decrease in the stroke distance by VTI. More on Output estimation here.

Output Calculator here
LV: Velocity time integral of the LVOT
Cardiac Output (CO) = SV × HR = VTI × CSA × Heart Rate
The normal values are 150–400 ml/kg/day in infants and children.
Important to assess output in situations of poor cardiac contractility, abnormal excessive preload (PDA), or underfilling (pulmonary hypertension) or risk of LVOT obstruction (infant of diabetic mother, intracardiac mass, etc).

Ref: Tissot, C., Singh, Y., & Sekarski, N. (2018). echocardiographic evaluation of ventricular Function—For the Neonatologist and Pediatric intensivist. Frontiers in pediatrics, 6, 79.

Examples of a decreased LVOT-VTI in patients with significant LV dysfunction secondary to birth asphyxia.

Here the VTI is decreased at 0.043 meter. However, there is a high angle of insonation and the PW-Doppler should be obtained with the least amount of angle (less than 30 degrees), as this may underestimate output.

Here the VTI is decreased at 0.055 to 0.057 meter.

VTI and heart rate for LVO estimation. Appropriate angle of insonation.

Apical 5 chamber view in 2D-Color to see flow from mitral through Aortic Valve

Aprical 3 Chamber View

The apical 3-chamber view (A3C), also known as the apical long axis view, provides a focused image of the left atrium, left ventricle, mitral valve, aortic valve, and proximal ascending aorta. It is particularly useful for assessing left ventricular systolic function and the structure and function of the mitral and aortic valves, as well as for obtaining spectral Doppler measurements across the left ventricular outflow tract (LVOT) and aortic valve. This view is particularly important to rule out any segmental anormalies of motion of the left ventricle. The apical three-chamber (A3C) view is obtained by rotating the probe counterclockwise from the apical two-chamber (A2C) view. Specifically, rotate the probe approximately 60 degrees counterclockwise from the A2C view, with the probe marker pointing towards the patient's right shoulder. This view allows for visualization of the left ventricle, mitral valve, and aortic valve.

In contrast, the apical 5-chamber view (A5C) is obtained by anteriorly angling the probe from the standard apical 4-chamber view to include the LVOT and aortic valve. While it retains visualization of the four chambers and both atrioventricular valves, it adds the “fifth chamber”—the LVOT and aortic valve—enabling functional assessment through Doppler without losing the context of right heart structures. Compared to A3C, the A5C may offer slightly less anatomic detail of the aortic root but better integrates right heart views. Both views allow Doppler interrogation of the LVOT and aortic valve, but A3C offers superior alignment for anatomical evaluation, whereas A5C is more commonly used in functional studies, such as calculating stroke volume or detecting outflow tract obstruction.

Right ventricle

From the apical 2 chamber view, one may slide the probe to obtain a RV-focus view. In this Inflow-Outflow view of the RV, one may also attempt to interrogate for TR or PI. It is also a good view to observe the posterior and anterior wall of the RV and appreciate the fibrous discontinuity between the tricuspid and pulmonary valve.

One may attempt to obtain the TR jet in the RV-3C view.

You can also visualize colour flow from the RV to the RVOT and to the Pulmonary Artery in the RV-3C view. You can also obtain the PW-Doppler of the RVOT for the RVO in this view when you are appropriately aligned. Here we are in direct alignment. It is often a good view when there is a left to right PDA which may contaminate the estimation in the PLAX or PSAX for the RVOT.

Here the cursor is aligned with the tricuspid valve in order to evaluate for TR jet velocity in the RV-3C view. This is currently in B-mode to appreciate the function of the RV posterior and anterior walls, as well as the tripartite anatomy of the RV (better visualized in the sweeps in the subcostal view.

Velocity time integral from the RVOT PW-Doppler. Here it is at 0.143 meter (stroke distance). This metric can be used to estimate RV output. The Pulmonary artery acceleration time is 92.43 msec and the RV ejection time is 227.11 msec. The shape is parabolic (with normal PVR setting).

Sweep from the Apical 2 Chamber view of the LV towards the Apical 3 Chamber view of the RV (occasionally termed "Tet view" of the RV).

Fractional Area Change of the RV

The fractional area change of the RV is calculated with: (RV-end diastolic area - RV-end systolic area)/RV-end diastolic area.

Usually FAC > 35% normal, correlates with RV-EF by MRI.

Ref: Lang, R et al. J Am Soc Echocardiogr 2005.18; 12:443-7

RV-End Systolic Area at A4C - closed valve. Hinge of tricuspid valve connected by straight line (ASE method). For RV-FAC calculation. ESA = 2.61 cm2.

RV-End Diastolic Area at A4C (at QRS) - closed valve. Hinge of tricuspid valve connected by straight line (ASE method). For RV-FAC calculation. EDA = 4.56 cm2.

Here the FAC is (4.56 - 2.61)/4.56 = 43%

RV-Apical 3 Chamber view in 2D grayscale (make sure to have all the RV walls). RV "Tet" view.

RV-A3C for TRJ for best angle if not obtained in previous views, and for PW-Doppler of RVOT if not obtainable in PLAX/PSAX.

RV-End Systolic Area at RV-A3C - peak of contraction valves closed. For RV-FAC calculation.

RV-End Diastolic Area at RV-A3C - peak of dilatation valves closed (at QRS). For RV-FAC calculation.

TAPSE

Tricuspid annular plane systolic excursion (TAPSE) can estimate the longitudinal movement of the tricuspid valve in the RV cavity during systole. The RV is a ventricle that contracts with a longitudinal movement (like a bellow). The Tricuspid valve goes towards the outflow tract, the inter-ventricular septum contracts towards the RV cavity and the free wall contracts towards the septum. TAPSE attempts to capture this longitudinal component of the RV function. Normative values have been published for newborns and are presented below, as well as in the normative section.

If M-mode not obtained during echocardiography, one may use the FAC tracing and connect the hinge point of the tricuspid valve at end of systole and end of diastole, as a surrogate indicator of the TAPSE. There is high correlation between the 2.

One may also use tissue doppler imaging in order to trace the phases of the cardiac cycle for the measurement of the TAPSE (on top of the M-Mode). The "red" outlines when there is motion towards the probe. The "blue" outlines when there is motion away from the probe. As such, the interface between the 2 colours outline the different portion of the mechanical cardiac cycle. The line of interrogation goes through the apex and towards the junction between the annulus of the tricuspid valve and the free wall of the right ventricle. The distance that is travelled from the peak of diastole to the peak of systole represents the TAPSE, as a marker of RV longitudinal function. Here the values is 0.84 cm in a preterm neonate (normal for this corresponding gestational age). One must follow the line of the tricuspid valve attachment as represented on the M-Mode, to accurately derive its complete displacement.

Another example of Tissue Doppler Imaging superimposed on the M-Mode when acquiring TAPSE. TAPSE represents the movement of the base of the tricuspid annulus towards the apex of the heart during systole. TDI allows to outline the directionality of the motion of the myocardial wall, outlining systole and motion towards the probe and diastole with motion away from the probe. This allows delineation for measurement of TAPSE from the onset of the "blue-red" junction to the other "red-blue" junction.

It is important to follow the line corresponding to the attachment of the triscuspid valve to the free wall and follow from the peak of diastole (corresponds to the QRS) to the peak of systole (lowest displacement point). Follow the same line for the measurement of this distance.

Other examples of TAPSE estimation:

TAPSE be also be indirectly derived and estimated from the Apical view (in the absence of a M-Mode), although the temporal resolution is not as rich as with M-Mode. Here we track the motion of the tricuspid valve from peak of diastole to peak of systole, ideally in the direction of the Apex.

Example of TAPSE in a pediatric subject (1.73 cm). One must follow the line from diastole to peak of systole.

Recap: Right ventricular focused views

Lateral and septal walls.

Tricuspid Regurgitation

"Tet view". Anterior and posterior walls.

Apical view in B-Mode and with colour, with a focus on the RVOT. The probe is angulated anteriorly in order to evaluate the right ventricular outflow tract. One may be well alligned to interrogate for signs of RVOT obstruction by CW-Doppler. One may also be able to obtain a PW-Doppler at the RVOT for estimation of the output, considering that the line of interrogation may be well aligned in this view.

Images from the J Am Soc Echocardiogr 2010;23:465.

Indications on how to measure the RV basal diameter, length and mid-cavity diameter. Similarly, RA planimetry and RVOT measurements are indicated here.

Tissue Doppler Imaging

Tissue Doppler Imaging (TDI) allow for the evaluation of myocardial velocities during systole and diastole. TDI are highly angle-dependent and influenced by tethering of myocardium. The measurements are heart rate and load-dependent (like most measure). TDI profile may be used to calculate the Tei index (Myocardial Performance Index – MPI) – a measure of diastolic and systolic performance - MPI = (IVCT+IVRT)/LVET

Normative values of velocities and MPI in newborn period have been published. Peak systolic velocity (s'), peak early (e') diastolic velocity and late (a') diastolic velocity represents velocity of myocardial movement. Typically, the sampled area is right under the attachement of the mitral (free wall and/or septum) or tricuspid valve.

To avoid inaccuracies related to measurements, the MPI is often calculated by taking a measurement of the entire "a" (IVCT+ET+IVRT) or MCO (mitral closure to opening). The MPI is then derived as: (a-ET)/ET.

s' = systolic velocity / vitesse systolique

e' = early diastolic velocity / vitesse diastolique précoce

a' = late (atrial) diastolic velocity / vitesse diastolique tardive

Myocardial performance index (rarely used) = (a-b)/b = (isovolumetric contraction time + isovolumetric relaxation time) / ejection time

Indice de performance myocardique (rarement utilisé) = (a-b)/b = (temps de contraction isovolumétrique + temps de relaxation isovolumétrique) / temps d'éjection

a = ejection time / temps d'éjection

c = isovolumetric contraction time / temps de contraction isovolumétrique

d = isovolumetric relaxation time / temps de relaxation isovolumétrique

Example of s', e' and a' at the RV free wall

TDI is here obtained at the LV free wall

TDI at the RV free wall (below tricuspid valve attachement. One may nicely see the systolic (positive) wave of tissue velocities. We can also appreciate the first negative deflection (early velocity of RV filling, when the RV expands and the wall gets away from the probe), as well as the second negative deflection representing the atrial contraction creating a second wave of tissue expansion of the RV.

Septal TDI just below insertion of the mitral valve at the septal level. For TDI, one should pay attention to have the least amount of angle of insonation with the structure being probed.

Recap: Recommendations for Quantification Methods of the RV

From: Recommendations for Quantification Methods During the Performance of a Pediatric Echocardiogram: A Report From the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. Lopez L. et al. J Am Soc Echocardiogr 2010;23:465-95.

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