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.

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

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.

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 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. 

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. 

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

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.

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. 

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.

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).