Chapter: Segmental Anatomy and Perfusion

Parasternal Segments Apical Segments WMA categories Coronary Perfusion

LV Segmental Anatomy

An overview of the general segmental anatomy of the left ventricle and the associated coronary perfusion

Missing a wall motion abnormality in a patient with globally preserved LV systolic function could miss an important sign of ischemic disease. Some forms of non-ischemic cardiomyopathy can also have regional wall motion abnormalities but global LV function would not be normal in these patients. Some of the images in this chapter were taken from other sources.

The LV is divided into longitudinal thirds from the mitral valve annulus out to the tip of the apex; BASE (to the papillary muscles), MID VENTRICLE (to the distal third), and APEX (distal third). This image is from 123sonography.com.

There is then a circumferential division of the LV into six zones (only four out at the apex). These can be nicely labeled on the following PSAX view taken at the MV level.

Going around the circle starting with the upper right are the Anterior, Anterolateral, Inferolateral, Inferior, Inferoseptal, and Anteroseptal segments.

The two terminologies are combined to describe the location of a wall motion abnormality (e.g. basal inferolateral). This terminology is only learned through repetition. A learner must frequently and routinely get all the  cardiac views and specifically note, and name, the major wall segments.

The routine PLAX view of the heart is a section through the anteroseptal and inferolateral segments, as shown on the following image. The apical3 view shows these same walls (with everything tipped up), but the apical region is better seen.

A typical PLAX shows only 2 of the 6 segments of the LV and only the basal and mid-LV portions of these. A typical PSAX shows maybe 4 or 5 segments, because often the more lateral LV wall is difficult to see and again, the apex is often obscured. Thus, the apical views are usually required to have a better view of all the LV segments.

The standard apical4 view shows the inferoseptal and the anterolateral LV as shown on the following image. Thus, the parasternal window and the apical4 usually show 4 of the 6 circumferential sections of the LV.

The missing 2 segments of the LV are the true inferior and anterior walls and these are seen with the apical 2 view as shown in the next image from 123sonography.com.

Wall motion abnormalities vary from an area that thickens less with systole and doesn’t move quite as well (hypokinesia) to more obvious abnormalities of thinned myocardium that doesn’t move at all (akinesia) and myocardium that bulges the wrong way with systole (dyskinesia). This image is from 123sonography.

When abnormal wall segments are identified, the next image identifies the coronary perfusion of the different regions of the heart. This image was taken from the American and European echocardiography societies publication on cardiac chamber quantification in J Am Soc Echocardiogr 2015;24:1-39.

It takes much repetition to learn this organization. Notice particularly that over half the heart has two different ways that it can be perfused.