What am I Looking at?

The subxiphoid 4 Chamber view can be used to assess ventricular function, particularly during emergent situations, when access to the other windows is limited.

The left ventricle is seen in the far field with the septal and lateral walls in view. The RV is seen more anteriorly.

 

Figure 25. Subxiphoid 4 chamber with the LV walls labeled

What is Normal

Contractility:

All visible LV walls should demonstrate symmetric inward motion and thickening, moving toward the center of the ventricle in a coordinated fashion.

Figure 26. Subxiphoid 4 chamber view with normal LV function

 

What is NOT Normal

Decreased global function:

The LV walls will fail to contract effectively toward the center of the cavity during systole. Wall motion appears sluggish or diminished, and the overall inward movement and thickening are reduced (figure 27).

Figure 27: Subxiphoid 4 Chamber demonstrating reduced LV systolic function. Video courtesy of Dave Kirschner

What am I Looking at?

In A4C view, you can assess LV wall motion at the basal, mid, and apical levels of the inferoseptal and anterolateral walls (figure 19). This view is also useful for visual estimation of overall contractility and evaluation of the LV’s size and shape throughout systole and diastole.

It is important to avoid foreshortening in the A4C view, as this can underestimate LV length and overestimate function. If the LV appears round or blunt at the apex, the image is likely foreshortened—slide the probe laterally and slightly inferiorly to better align with the cardiac apex, and angle it more anteriorly (toward the face) to bring the true apex into view and ensure a full-length chamber.

Formal echocardiography uses apical views to calculate EF using Simpson’s biplane methods; however, this is beyond the scope of PoCUS practice

 

Figure 19: Apical 4 Chamber view in cardiology convention with the labeled left ventricular walls

 

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What is Normal

Contractility:

The apex and visible LV walls (inferoseptal and anterolateral) should move inward toward the center, with the base also moving toward the apex. All walls should demonstrate coordinated inward motion and uniform thickening.

Eyeballing Ejection Fraction:

When qualitatively assessing LV function in the A4C view, the EF can often be ‘eyeballed’. The LV cavity should visibly reduce its volume by more than half with each contraction. Longitudinal shortening will also contribute to overall cavity reduction.

Figure 20: A4C demonstrating adequate contractility despite poor window

 

Figure 21. A4C demonstrating adequate contractility and clear wall thickening

 

What is NOT Normal

Decreased global function:

LVfx is considered reduced if the visible walls fail to contract effectively toward the center of the cavity during systole. Wall motion appears sluggish or diminished, and the overall inward movement and thickening are reduced.

 

Figure 22. A4C view in a child with severe, globally reduced systolic function

 

RWMAs:

RWMAs may be observed in the inferoseptal wall, anterolateral wall, or apex, with segments showing hypokinesis, paradoxical motion, dyskinesis or akinesis while other segments contract normally (figure 23). The segments may also be reduced in a global fashion.

Figure 23: A4C view demonstrating moderately reduced LF systolic function and RWMAs of the inferoseptal and anterolateral walls.

 

 

Hyperdynamic function:

The inferoseptal and anterolateral walls may nearly or completely touch during systole, leading to near obliteration of the ventricular cavity (figure 24). This effect is often more pronounced at the apex, while the basal segments may not completely obliterate.

Figure 24. A4C view demonstrating hyperdynamic LV systolic function.

What am I Looking at?

The PSAX view provides a cross-sectional image of the LV, allowing simultaneous visualization of multiple walls. It is the preferred view for global assessment of LVfx and RWMAs. This view is useful for assessing wall motion across the anterior, lateral, posterior, inferior, and septal segments, all seen in a single plane at multiple levels (basal, mid, apical) (figure 11).

A circular LV cavity indicates you’re on-axis, while an oval or elliptical shape suggests you’re off-axis and should adjust your probe angle for a true short-axis view.

 

Figure 11. PSAX at the mid-papillary level with left ventricular walls labeled.

 

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What is Normal

Contractility:

At each PSAX level, all LV walls should contract symmetrically, moving inward toward the center of the circular cavity and thickening evenly during systole. All walls should demonstrate coordinated inward motion and uniform thickening.

At the apical level, you may also notice a subtle twisting or rotational motion during systole, reflecting the normal torsional mechanics of the LV.

 

Eyeballing Ejection Fraction:

When qualitatively assessing LV function in PSAX, the EF can often be ‘eyeballed.’ From the circular ‘donut’ view at the mid-papillary level, a normal EF should look like the LV cavity volume is shrinking by more than half.

 

Figure 12: 2D PSAX demonstrating normal contractility and uniform wall motion

 

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What is Not Normal

Decreased global function:

LVfx is considered reduced if the LV walls fail to contract effectively toward the center of the circular cavity during systole (figure 13).

 

RWMAs 

RWMAs may be observed at any PSAX level (basal, mid or apical). One or more LV wall segments will fail to contract normally.  Segments may appear hypokinetic, dyskinetic, akinetic or move paradoxically while surrounding segments contract normally. The LV segments may also be reduced in a global fashion.

 

 

Figure 13: PSAX view demonstrating a dilated LV with reduced systolic function. Video courtesy of Dave Kirschner

Figure 14. PSAX mid papillary level exhibiting decreased function with hypokinesis of the lateral segment and akinesis of the posterior, inferior and septal segments. The anterior segment is not well seen in this clip. Note the pericardial effusion present laterally.

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PSAX M-Mode

At the mid-papillary level, placing M-mode across the LV walls produces a motion trace of the septal and posterior walls throughout the cardiac cycle with distance displayed on the y-axis and time on the x-axis. The tracing shows the walls coming toward each other during systole and moving apart during diastole, with the LV cavity changing width in between (figure 15).

 

Figure 15: M-mode of the PSAX mid-papillary level

 

This pattern forms the basis for calculating fractional shortening (FS), which describes how much the LV diameter decreases during contraction, and linear EF, which measures volumetric change(figure 16). The FS and EF can be used to semi-quantify LVfx.

Measurements for FS and linear EF should be obtained at a single timepoint along the x axis corresponding to end-diastole and end-systole, rather than by selecting maximal wall excursion at different timepoints. Measuring the septum and posterior wall at different points of maximal excursion can result in inaccurate LV dimensions and overestimation of systolic function. It is also imperative to avoid placing the M-mode cursor through the papillary muscles, to ensure the true endocardial excursion is captured.

 

FS: percentage decrease in the LV diameter during contraction

 

**Key Consideration**
FS assumes normal heart shape, absence of valvular pathology and normal global LV function without RWMAs. In the presence of arrhythmias (e.g. bundle branch blocks), RWMAs, variation in heart shape, or structural/valvular abnormalities (e.g., congenital heart disease, shunts), FS may not accurately reflect true LVFx.  Even if FS appears normal, the heart may still fail to provide adequate forward systemic output.

 

Figure 16. LVIDd and LVIDs caliper placement for FS/EF calculation in PSAX M-mode

 

 

PSAX M-Mode Technique

1. At the mid-papillary level, place the M-mode curser perpendicularly through the centre of the LV cavity, between the papillary muscles
2. Measure the FS if findings appear grossly abnormal, when a quantitative baseline is useful for follow-up or clinical reassessment, or consultation with cardiology is anticipated.

– Select the FS calculation package and measure the left ventricular internal diameter in diastole (LVIDd) and in systole (LVIDs)

3. Save the M-mode image, and include the measurement if performed.

 

Note: FS M-mode can also be done in the PLAX view, by placing the M-mode cursor just past the MV leaflet tips; however, it is simpler and preferred in the PSAX view due to better alignment of the M-mode cursor perpendicular to the LV walls, which ensures more accurate and reproducible measurements.

 

 

 

What is Normal & Not Normal

• Normal values for FS in infants and children are typically between 28% and 46% [18,22] (figure 17).
• A FS <28% is generally considered abnormal. This can be further categorized into mild, moderate and severe systolic dysfunction (table 3) [22] (Figure 18).
• In pediatrics, normal EF is ≥ 55% (figure 17)[23].

 

Table 3: Categorization of FS in Children

28-48%	Normal
20-25%	Mild Dysfunction
15-19%	Moderate dysfunction
<14%	Severe dysfunction

 

Table 4: EF categorization [22]

≥ 55%	Normal
41-55%	Mildly reduced
31-40%	Moderately reduced
≤ 30%	Severely reduced function

 

Figure 17. PSAX M-mode normal FS and EF

 

Figure 18. PSAX M-mode abnormal FS

What am I Looking at?

In the PLAX view, we see the interventricular septum (IVS), LV cavity, and the posterior wall of the LV (Figure 3). You should see the mitral valve, LV outflow tract, and AOV in one continuous plane. Most often, you will not see the distal ventricle/apex in the same window as your AOV/MV.

Foreshortening is a common limitation to the PLAX view, and recognizing when you are foreshortened is important to avoid overestimating systolic function. Signs of foreshortening include a LV cavity that seems unusually short and truncated, rather than elongated (figure 4). Remember to ensure that you have the AMVL as well as the point of coaptation of the AOV cusps clearly visible in the same plane and the ventricle looks elongated an bullet shaped as this will ensure that you are in the true long-axis position and will avoid the risk of foreshortening.

 

 

Figure 3: Parasternal long axis view in cardiology convention anatomically labeled.

 

Figure 4ab: Comparison of PLAX foreshortened (a) VS not foreshortened (b)

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What is Normal

 

Contractility:

The IVS and posterior LV wall should both thicken and move inward toward each other during systole, with coordinated and symmetric motion.

AMVL motion:

When the AMVL nearly contacts the IVS during diastole, it is generally indicative of normal LV systolic function. The closer the leaflet comes to the septum, the better the presumed function.

 

**Key Consideration: Assessing LV function based on AMVL motion assumes a structurally and functionally normal mitral valve and absence of other pathology such as aortic regurgitation, LV dilation, and IVS motion abnormality/arrythmia. In the presence of such pathology, this method is an unreliable correlate of LV systolic function.

 

Figure 5: 2D PLAX demonstrating normal contractility and function with minimal distance between the AMVL and IVS during diastole.

 

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What is NOT Normal

Decreased global function:

If the IVS and the posterior LV wall fail to move effectively toward each other during systole it suggests reduced LVfx. Wall motion may appear sluggish, and thickening may be diminished.

AMVL motion

If the AMVL does not move close to the IVS, but rather creates a visibly large gap, this could suggest reduced systolic function (figure 6).

 

Figure 6: 2D PLAX view demonstrating markedly reduced LV systolic function, evidenced by poor inward motion of the LV walls during systole and a large gap between the IVS and AMVL.

 

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PLAX M-Mode

In the PLAX view, M-mode is commonly used to assess LVfx by placing the cursor perpendicular to the IVS and posterior wall at the level of the MV tips. This provides a time-motion trace of LV wall motion and cavity size throughout the cardiac cycle, with distance displayed on the y-axis and time on the x-axis allowing evaluation of systolic function.

You’ll see a wave-like motion tracing of the MV leaflets movement across the cardiac cycle. In early diastole, the AMVL rapidly opens toward the IVS, creating the tall E-wave, followed by a smaller A-wave from atrial contraction (figure 7,8).

 

Figure 7. M-mode

 

Figure 8. Zoomed-in view of the PLAX M-mode tracing at the level of the mitral valve tips.

 

End Point Septal Separation

The EPSS is a measure of AMVL motion and is used as a way to semi-quantify LVfx. It refers to the minimal distance between the peak of the E-wave and the IVS at the same X-axis time point (figure 8).

Technique – EPSS
1. Activate M-mode and place the cursor line through the tip of the AMVL and the septum.
2. Measure EPSS if findings appear grossly abnormal, when a semi-quantitative baseline is useful for follow-up or clinical reassessment, or consultation with cardiology is anticipated.

· The EPSS is measured at the minimum distance between the AMVL and the septum in early diastole.

3. Save the M-mode image, and include the measurement if performed.

 

 

In a normally functioning LV, the E-point comes close to the septum (figure 9).  In pediatric patients, there is limited validated evidence for normal EPSS values. A 1983 study provided guidelines for the use of EPSS in infants and children and found that normal EPSS was ≤ to 6mm, with 7-8mm being tail end of normal [21]. This was confirmed in a more recent study where an EPSS of 6.17 mm optimally distinguished normal from depressed LV systolic function, with a sensitivity of 86% and specificity of 92% [12].

The larger the EPSS distance the worse the function. Similar to the AMVL visual assessment, if the E-point is not close to the IVS during the M-mode tracing, this could suggest reduced systolic function. Specific cutoff values are available to guide interpretation (table 3) (Figure 10).

Table 2: EPSS value ranges for pediatric populations [12,21]

≤7mm	Normal
≥ 8	Reduced function

 

Key Consideration: The EPSS should never be used as a single measure of LV systolic function as it can be influenced by many factors such as valvular dysfunction in mitral stenosis or aortic insufficiency. EPSS should always be considered in a larger evaluation of LV function including visual assessment of LV contractility. EPSS alone is insufficient to guide decisions regarding cardiology referral or formal echocardiography without corroborating functional findings.

 

Figure 9: PLAX M-mode with normal EPSS measurement

 

Figure 10: PLAX M-mode abnormal EPSS

 

Each cardiac view offers a different perspective of the LV, displaying various walls and myocardial segments. The LV is typically divided into three levels: basal, mid, and apical. The basal segments are located closest to the atrioventricular valves and represent the upper portion of the LV; the mid segments are situated in the middle, at or around the level of the papillary muscles, and the apical segments are near the apex of the ventricle. Understanding which walls are visualized in each view is key to assessing LVfx.

Figure 1ab: LV levels in the PLAX view (a) and A4C (b) in cardiology convention

 

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At a Glance: Normal VS Not Normal

The findings below outline the broad features of what is considered normal and not normal for pediatric LVfx; the specifics for each individual view will be described in the following sections.

 

What is Normal

Contractility:

The contraction of the LV occurs in a complex but coordinated manner, combining longitudinal shortening, radial thickening, and circumferential constriction [20]. The base of the heart moves toward the apex as the ventricle shortens, while the cavity simultaneously decreases in diameter due to inward wall motion. This multidirectional contraction pattern efficiently ejects blood into the aorta and gives the ventricle its characteristic torsional motion, where the apex rotates slightly counterclockwise and the base clockwise during systole [20].

In normal systolic function, the LV walls should thicken visibly and move inward symmetrically, coming close to one another during systole. All walls should demonstrate coordinated inward motion and uniform thickening (radial contraction). You should also see the base move toward the apex (longitudinal shortening). Although circumferential shortening contributes to the overall narrowing of the cavity, this is not directly distinguishable on standard PoCUS imaging.

 

Size and Shape:

The LV should be ellipsoid or bullet-shape. It is typically larger than the right ventricle, assuming the RV is normal, usually about one and a half times the size of the RV.

 

What is NOT normal

Decreased global function:

LVfx is considered reduced if the LV walls fail to contract effectively toward the center of the cavity during systole. Wall motion will appear sluggish or diminished, and the overall inward movement and thickening will be reduced.

 

Size and Shape:

Decreased LV systolic function is often accompanied by dilation, such as in dilated cardiomyopathy. The LV loses its normal ellipsoid or bullet shape, appearing globular or rounded, and is much larger than the right ventricle.

 

RWMAs:

Segmental dysfunction may be observed when one or more LV wall segments move less than expected (hypokinesis), move opposite direction as normal (dyskinetic), or do not move at all (akinesis), while other segments contract normally. These findings often suggest ischemia or myocardial injury. Akinetic segments will also often appear thinner and more hyperechoic than normal myocardium reflecting myocardial fibrosis or scarring that reduce contractility and alter tissue characteristics.

 

Hyperdynamic function:

In cases of increased contractility, the LV walls may nearly or completely touch during systole, leading to near obliteration of the ventricular cavity. This is often most pronounced at the apex, while the basal segments may not completely obliterate. Hyperdynamic function can occur in states of low preload, hypovolemia, or compensatory hypercontractility. Of note, tachycardia can create the illusion of hyperdynamic function, therefore it is important to look at the wall motion and cavity itself and not just the rate at which the heart is contracting. Saving and slowing down a clip can be helpful in cases of significant tachycardia

 

 

Figure 2a. Normal function seen in the A4C view

 

 

Figure 2b. Severely decreased function, globally seen in the A4C view

 

** For detailed instructions on obtaining the cardiac windows, please revisit the prerequisite KidSONO Introduction to Cardiac Windows Module

Stepwise Technique

1.  Parasternal long axis: Visual assessment of LVfx

i. Assess the overall movement of the LV walls

ii. Observe the anterior mitral valve leaflet (AMVL) and evaluate if it approaches the interventricular septum during diastole

iii. M-Mode: Activate M-mode and place the cursor line through the tip of the AMVL and the septum. Measure EPSS

 

2.  Parasternal Short Axis: Visual assessment of global LVfx & regional wall motion abnormalities 

i. From the MV level sweep the probe all the way to the apex, assessing LVFx and wall motion at each level

– Obtain a representative clip at the mid-papillary level and/or where contractility changes are observed

ii. M-Mode: At the mid-papillary level, place the M-mode curser perpendicularly through the centre of the LV cavity, between the papillary muscles. Calculate fractional shortening

 

3. Apical 4 Chamber: Visual assessment of global LVfx & size

i. Assess the overall movement of the LV walls

ii. Assess which ventricle is making up the apex of the heart (as should be the LV) and compare general size of RV to LV

 

4. Subxiphoid 4 Chamber: Visual assessment of global LVfx & size

i. Assess the overall movement of the LV walls

 

5. Documentation: Store representative clips for each standard view

 

Indications

Cardiopulmonary Symptoms

• Chest pain
• Dyspnea or unexplained shortness of breath
• Tachycardia or new arrhythmia or palpitations
• Pre-syncope or syncope
• Hypotension

 

Signs of Shock or Poor Perfusion

• Altered mental status
• Delayed capillary refill, cool extremities, or weak pulses
• Unexplained lactic acidosis or elevated lactate
• Hypotension or narrow pulse pressure
• Signs of hypoxia or cyanosis

 

Critical Illness / Resuscitation Scenarios

• Unexplained hemodynamic instability or acute respiratory distress
• Cardiac arrest or peri-arrest evaluation
• Sepsis or septic shock (to differentiate distributive vs cardiogenic components)
• Trauma patients with suspected cardiac dysfunction (e.g., contusion, or tamponade physiology)

 

Therapy Response and Monitoring

• Assessment of cardiac function before and after fluid resuscitation or inotropic support
• Ongoing monitoring of LV function in PICU or ED settings

 

Risk or Treatment-Related

• Patients exposed to cardiotoxic medications (e.g. overdose)

 

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Equipment

• Ultrasound machine
• Phased array ultrasound probe
• Gel

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Patient Position

Supine or left lateral decubitus position

 

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Emergency Medicine VS Cardiology/ICU Probe Convention

While cardiac function can be assessed in either the Emergency Medicine or Cardiology/IUC probe conventions, this module will present images and guidance using the Cardiology/ICU convention to align with standard echocardiography practices.

 

A wide range of etiologies can lead to reduced left ventricular function (LVfx) in children, including cardiomyopathies, myocarditis, congenital heart defects (CHDs), sepsis, tachyarrhythmias, and chemotherapy-related toxicity, among others.  These wide-ranging and clinically significant conditions highlight the importance of assessing cardiac function in pediatric patients.

Physical exam findings of cardiac dysfunction are often subtle or non-specific. The standard of care typically involves physical exam combined with the ordering of indirect tests such as EKG, CXR and troponins in the case of suspected LV dysfunction. A formal cardiology echocardiogram, interpreted by a cardiologist, is recommended if the index of suspicion is high. The reliance on formal echo is expensive and can delay diagnosis and compromise patient care, particularly during overnight or weekend hours when cardiology services may be limited.

Point-of-care ultrasound (PoCUS) has emerged as an important tool in the assessment of cardiac function, offering more timely and focused clinical insights than physical exam alone. Additionally, PoCUS findings can provide cardiologists with relevant preliminary information that helps streamline decision-making and enhance patient care.

This module focuses on guiding learners through a preliminary assessment of LVfx using PoCUS. While the evaluation of CHDs and valvular abnormalities is common in pediatric cardiology, these are beyond the scope of of this module. By course completion, learners should feel confident assessing global LVFx using the five standard PoCUS cardiac views.

 

Why Ultrasound?

Ultrasound’s advantages include being low cost, portable, and free from ionizing radiation. This, in addition to its ability to visualize the heart and its function in real time, makes it the diagnostic modality of choice for cardiac evaluation [1]. PoCUS is now widely available in most emergency departments (EDs), intensive care units (PICUs) and hospital wards, providing rapid, real-time evaluation of cardiac function in critically ill patients.

When managing patients with respiratory or circulatory compromise, prompt and accurate diagnosis is crucial. Adult studies have demonstrated that PoCUS enables clinicians to diagnose more quickly and accurately than clinical assessment alone, facilitating more targeted and timely interventions [2,3] and in some cases, improving mortality outcomes [4,5].

Several studies have shown that pediatric physicians without cardiology specialization can reliably assess left ventricular (LV) systolic function using cardiac PoCUS following appropriate training [6-10], including hypotensive patients [11]. Reported diagnostic performance has been high, with studies demonstrating excellent agreement with formal echocardiography (κ = 0.87–0.89) [6,9].

 

Table 1: Diagnostic Accuracy of POCUS for LVfx assessment in pediatric populations

 

Cardiac function PoCUS generally utilizes an impression-based, qualitative approach, whereas formal echocardiography relies more on quantitative measures. That said, PoCUS is supported by one or two key semi-quantitative measures, such as the E-Point Septal Separation (EPSS), which has demonstrated high negative predictive value in ruling out systolic dysfunction in pediatric patients [12], highlighting its utility as a screening tool.

PoCUS is also repeatable, allowing practitioners to monitor the effectiveness of interventions and changes in LVfx over time. PoCUS is a skill that can be learned and acquired through training, including both didactic and hands-on practice. Research supports that once undergoing short training, PoCUS can safely and accurately be used by practitioners at the bedside in both adult and pediatric populations [2, 13-17]. Given these benefits, PoCUS use for cardiac assessments is now endorsed by multiple professional societies [18,19].

 

Author: Julia Stiz, MSc, RDCS

Secondary Author: Melanie Willimann, MD, FRCPC

Reviewer(s): Jackie Harrison, M.D., FRCPC; Mark Bromley, M.D., FRCPC; Nicholas Packer, M.D., FRCPC; Kim Myers, M.D., FRCPC

 

*To continue through to the course, make sure to select the “Mark as Completed” button below.

 

By selecting the “Mark as Complete” button below, I acknowledge that:

• This activity is educational only.
• Completion does not grant certification, credentialing, privileging, or independent authorization to perform point-of-care ultrasound.
• I am responsible for practicing within my professional scope, training, local institutional policies, supervision requirements, and regulatory requirements.
• I will not rely on point-of-care ultrasound findings in isolation when making clinical decisions.
• Any clinical use of point-of-care ultrasound remains subject to local governance, quality assurance, documentation, and patient safety processes.