Apical Long Axis-Apical 3-Chamber View
©Walter Rasmussen, R.D.C.S.
The apical long axis looks similar to the parasternal long axis view and is found by rotating the transducer about 20-30 degrees counter-clockwise from the apical two- chamber view to the point where the left ventricle, left atrium, mitral and aortic valves are visualized
The apical long axis has advantages over the parasternal long axis including: better visualizes the cardiac apex and an alternate view of the mitral and aortic valves, thus enabling a more comprehensive assessment of valvular lesions. When the parasternal long axis view is sub-optimal, the apical long axis serves as a good back-up view to it.
When the apical long axis image is of poor quality, respiratory maneuvers, (sustained inhalation or exhalation), can aid in creating images with greater clarity and also helps to avoid a foreshortened view or having to move up the chest wall to what is actually a low parasternal view. As with all respiratory maneuvers, it may be necessary to move the transducer medially or laterally as the heart is pushed or pulled by the lungs.
Two-dimensional echo in the apical long axis view should demonstrate left ventricular wall motion, outflow tract anatomy, and the systolic and diastolic motion of the aortic and mitral valves. The apical long axis is particularly valuable in demonstrating a prolapsed or flail mitral valve leaflet and narrow anteriorly or posteriorly directed regurgitant jets. Color Doppler of mitral diastolic flow and regurgitation as well as systolic and diastolic blood flow of both the left ventricular outflow tract and aortic valve can be clearly demonstrated in this view, aiding in determination of the severity of aortic stenosis and insufficiency, mitral stenosis and regurgitation and left ventricular outflow tract obstruction.
For the evaluation of an AR jet, adjust the color Doppler box to show its width and full extension into the left ventricle. The color Doppler box width should be kept to only what is necessary in order to keep the frame rate above 17 Hz and the color Doppler scale should not be set between 50-60 cm/sec in order to ensure that the degree of regurgitation will not be diminished, nor exaggerated.
In patients who are being investigated for hypertrophic obstructive cardiomyopathy, aka, HOCM, the sonographer has the option to perform the same detailed Doppler evaluation as described earlier in this guide in the section covering the apical five chamber view. Zooming-in, (preferably with write zoom rather than read zoom), on the mitral and aortic valves helps to obtain a more complete assessment of valvular morphology and function.