ALAX…the tricky view??

The apical long axis (ALAX) can be a difficult view to master for many sonographers. A quality, on-axis image is obtained when the image transects the true apex and also needs to pass through the center of the mitral valve (commonly the middle scallops: P2 and A2). The aortic valve leaflets should also be seen to be opening well and the ascending aorta is opened out. It can sometimes be challenging to achieve all these aspects in the one image. Here are some tips  for imaging this view on-axis every time!

The ALAX view is one of my favorite views.


Optimized ALAX view. Note: 1. LV opened out 2. MV leaflets on axis 3. AoV / ascending aorta opened out

So, where do we go wrong??


Off-axis ALAX view. Note the aortic valve leaflets are not opening. There is movement, but no opening.

The #1 mistake made is over-rotation of the transducer. Sonographers often find that to visualize the aortic valve, they need to tilt the transducer anteriorly. This shuts down the MV and foreshortens the image. Usually when they tilt back to open out the LV/MV, part of the tricuspid valve is on view also. This is typical of an over-rotated image. Essentially the sonographer has rotated too far anti-clockwise and have obtained a “reverse A4C” view.

This is a "reverse A4C" view. The tricuspid valve leaflets are on view, but no aortic valve.

This is a “reverse A4C” view. The tricuspid valve leaflets are on view, but no aortic valve.


To visualize the aortic valve, the sonographer has tilted anteriorly. This has been at the expense of the mitral valve and closing off the left ventricle.

If you need to tilt anteriorly to see the AoV, you are over-rotated!!!


The image is usually salvaged very simply…  Remember the golden rule of obtaining an on-axis image…. Tilt for the center, rotate for the sides (always in that order).

Firstly tilt the transducer to open out the LV/MV. Don’t be concerned with the aortic valve at this stage. Just focus on tilting the transducer to optimize the ventricle. If the tilt is correct, the apex will be fixed (not foreshortened) and you will be passing through the center of the mitral valve.

Now “rotate for the sides”. Hold the image still…. Then rotate clockwise slowly until the aortic valve opens out (don’t’ tilt anteriorly to achieve this or you will drift off axis again). The index marker should be facing towards the patients right ear, but this is just a guide – use the echo image to give you an indication of how much rotation is needed. If you drift off-axis, go back to tilt for the center and optimize the LV. You will know when you have rotated correctly when the aortic valve is seen to be opening.



This view will become second nature in no time, and if you follow the steps of the Golden Rule, you will never struggle again!







Image courtesy of Master Isolated Images at

Previous Post Next Post

You Might Also Like


  • Reply ms December 14, 2014 at 6:41 pm

    thanks for sharing these wonderful tips. When you get a chance can you comment on LA measurement?? sometimes in parasternal view it is different, when compared to measuring from short axis view. Are we supposed to measure from short axis view as per ASE guidelines?/ Thanks

    • Reply echoguru December 14, 2014 at 7:48 pm

      Hi MS. Thanks for the question. I will try and get the images I need to explain this in the next couple of days.

  • Reply ms December 15, 2014 at 10:43 pm

    No problem. Take your time. thanks

  • Reply Karen Farrar January 28, 2015 at 12:18 pm

    I have always found the most challenging apical view to be the AP2 view. This is not just speaking for myself; I have seen it foreshortened in studies many times despite the AP4 & ALAX being well shown. Given the option, I now image the AP4 view, followed by the ALAX, then close out the aorta to come back to the AP2 in between. I find this way gives a much more reliable AP2 image, that is less likely to have a foreshortened LV or one that is not opened out properly.

  • Reply Phil Cannon June 6, 2016 at 10:00 am

    Any other tips for AP2 – I have always found this more difficult than AP4/ALAX?

    • Reply echoguru June 6, 2016 at 10:04 am

      Thanks Phil. Sounds like a good idea for a new post!

  • Reply Zoe May 16, 2018 at 10:55 am

    Thank you for this post! The tilt and rotate tip has made a huge difference in my ability to achieve this view on axis. I’m afraid my previous technique was tilt anteriorly and hope for the best, without really being aware of how foreshortened the view was. This is quickly becoming one of my favorite views too!

    • Reply echoguru May 16, 2018 at 12:14 pm

      Great to hear!!! Thanks Zoe.

    Leave a Reply

    This site uses Akismet to reduce spam. Learn how your comment data is processed.

    %d bloggers like this: