How to assess the left ventricle using handheld ECHO

26th Nov 2020

Left ventricular (LV) dimensions and function can be assessed qualitatively with a handheld echocardiography (HHE) device. 


Assessing left ventricular dimensions with handheld echocardiography

Left ventricular size is reduced when the ventricular cavity appears small in an under-filled patient. On the other hand, LV dimensions may be increased when there is LV dysfunction or volume overload, such as severe mitral or aortic regurgitation. 

Multi-component video of left ventricle echocardiograms for a small and dilated LV cavity.

Figure 1. Signs of reduced left ventricle (LV) dimensions include a small LV cavity in an underfilled patient and a dilated LV cavity in a patient with severe mitral or aortic regurgitation. 


Assessing left ventricular function with handheld echocardiography

Left ventricular function is described qualitatively by assessing myocardial wall thickening, inward motion of the LV cavity in systole, and outward motion in diastole. 

Each myocardial segment should be assessed, and the presence of regional wall motion abnormalities described. In the parasternal long-axis (PLAX) view, regional wall motion abnormalities can be seen affecting the anteroseptal wall. 

Left ventricular echocardiogram with anteroseptal wall highlighted. Parasternal long-axis (PLAX) view.

Figure 2. Signs of left ventricular dysfunction in the parasternal long-axis (PLAX) view include regional wall motion abnormalities affecting the anteroseptal wall. 

To see a great example of left ventricular dysfunction (regional wall abnormalities in the anteroseptal wall), check out this short video clip from our COVID Mini: Handheld ECHO Course:


Ventricular function should be described as normal or impaired (mild, moderate, or severe). In cases where myocardial contraction is more pronounced than normal (as seen in pathological states such as sepsis or hypovolemia), the term ‘hyperdynamic’ is applied.


Clickable call to action, "Start learning for free", with direct link to sign up for a free Medmastery trial account.


Assessing left ventricle function in patients with COVID-19

Case reports of patients with COVID-19 have shown evidence of myocarditis. In an echocardiogram, there may be evidence of reduced myocardial wall thickness and a reduction in LV systolic function in patients with COVID-19. 

Myocarditis after a SARS-CoV-2 infection may cause global or regional ventricular impairments, which typically do not correspond to coronary territory. 

Echocardiogram showing global ventricular impairments with myocarditis from the parasternal long-axis (PLAX) view.

Figure 3. Parasternal long-axis (PLAX) view of global ventricular impairments in a patient with myocarditis after infection with SARS-CoV-2. 

Check out this short video clip from our COVID Mini: Handheld ECHO Course to see an example of myocarditis in a patient with COVID-19:


There are also documented cases of acute Takotsubo—or stress-induced—cardiomyopathy after a SARS-CoV-2 infection. 

Typically, there is transient LV dysfunction with a characteristic pattern of apical and midsegment hypokinesia which gives rise to the classical apical ballooning appearance. There are also widespread electrocardiogram (ECG) changes with raised troponin levels. 

Echocardiograms showing Takotsubo cardiomyopathy features. Apical views.

Figure 4. Signs of acute Takotsubo cardiomyopathy include transient LV dysfunction with a characteristic pattern of apical and midsegment hypokinesia, which gives rise to the apical ballooning appearance seen here.

To see an example of the apical and midsegment hypokinesia, characteristic of Takotsubo cardiomyopathy in a patient with COVID-19, check out this short video clip from our COVID Mini: Handheld ECHO Course:


Where doubt remains and infection control measures allow, cardiac magnetic resonance (CMR) imaging can provide incremental information that allows for the detection of relevant functional and tissue changes useful in differentiating Takotsubo cardiomyopathy from acute coronary syndromes. 


That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

  • Chamsi-Pasha, MA, Sengupta, PP, and Zoghbi, WA. 2017. Handheld echocardiography: Current state and future perspectives. Circulation136: 2178–2188. PMID: 29180495
  • Clerkin, KJ, Fried, JA, Raikhelkar, J, et al. 2020. COVID-19 and cardiovascular disease. Circulation141: 1648–1655. PMID: 32200663
  • Doyen, D, Moceri, P, Ducreux, D, et al. 2020. Myocarditis in a patient with COVID-19: A cause of raised troponin and ECG changes. Lancet395: 1516. PMID: 32334650
  • Drake, DH, De Bonis, M, Covella, M, et al. 2020. Echocardiography in pandemic: Front-line perspective, expanding role of ultrasound and ethics of resource allocation. J Am Soc Echocardiogr33: 683–689. PMID: 32503707
  • Fukuhara, S, Rosati, CM, and El-Dalati, S. 2020. Acute type A aortic dissection during the COVID-19 outbreak. Ann Thorac Surg. 110: e405–e407. PMID: 32333849
  • Haji, K, Wong, C, Neil, C, et al. 2019. Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE). Echo Res Pract6: 91–96. PMID: 31516721
  • Hua, A, O’Gallagher, K, Sado, D, et al. 2020. Life-threatening cardiac tamponade complicating myo-pericarditis in COVID-19. Eur Heart J41: 2130. PMID: 32227076
  • Johri, AM, Galen, B, Kirkpatrick, JN, et al. 2020. ASE statement on point-of-care ultrasound during the 2019 novel coronavirus pandemic. J Am Soc Echocardiogr33: 670–673. PMID: 32503704
  • Meyer, P, Degrauwe, S, Van Delden, C, et al. 2020. Typical takotsubo syndrome triggered by SARS-CoV-2 infection. Eur Heart J41: 1860. PMID: 32285915
  • Neskovic, AN, Hagendorff, A, Lancellotti, P, et al. 2013. Emergency echocardiography: The European association of cardiovascular imaging recommendations. Eur Heart J Cardiovasc Imaging14: 1–11. PMID: 23239795
  • Nguyen, VTQ, Ho, JE, Ho, CY, et al. 2008. Handheld echocardiography offers rapid assessment of clinical volume status. Am Heart J156: 537–542. PMID: 18760138
  • Poissy, J, Goutay, J, Caplan, M, et al. 2020. Pulmonary embolism in patients with COVID-19: Awareness of an increased prevalence. Circulation142: 184–186. PMID: 32330083
  • Shi, S, Qin, M, Shen, B, et al. 2020. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol5: 802–810. PMID: 32211816
  • The American Society of Echocardiography. ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. 2020.  
  • The American Society of Echocardiography. Cleaning recommendations from ultrasound manufacturers. 2020.
  • The Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England. COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0. 2020. 
  • Zeng, JH, Liu, YX, Yuan, J, et al. 2020. First case of COVID-19 complicated with fulminant myocarditis: A case report and insights. Infection48: 773–777. PMID: 32277408