Apical Views

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. 

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

In this LV focused view (A4C), one may appreciate the systolic and diastolic dimensions of the left ventricle. 

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. 

Ejection fraction (EF)

EF(%) = (LVEDV − LVESV)/LVEDV × 100

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.

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.

Tricuspid Regurgitant Jet (TRJ) Velocity

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.

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. 

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)

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 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. 

Isovolumetric relaxation time of the left ventricle may also be measured in the Apical-3-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.

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.

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. 

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. 

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). 

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


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. 

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. 

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.

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

TDI is here obtained at the LV free wall

Sampling is here obtained at the septal area (for the LV). 

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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