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Regional wall motion abnormalities and coronary territories on echo

An area that does not thicken, following a coronary territory. Watch the wall thickness, not the endocardial excursion: an akinetic segment next to normal segments is dragged inward (tethering) but stays the same thickness. Chronic infarcts are thin (<6 mm) and bright.

Watch it in the simulator →Practise random cases

Where to look

Apical 4-, 2- and 3-chamber views to place the abnormality on the 17-segment model, then PSAX to confirm. LAD: anterior wall, anteroseptum and apex. RCA: inferior wall, basal and mid inferoseptum and the apical inferior segment. LCx: inferolateral and anterolateral walls (and often the apical lateral segment). Territories vary with coronary dominance.

Typical wall-motion pattern

Example: RCA territory (acute)

Akinetic: basal inferior, mid inferoseptal, mid inferior · Hypokinetic: basal inferoseptal, apical inferior

EF in this example: 48% (Impaired (36–49%)).

1 Normal2 Hypokinetic3 Akinetic4 Dyskinetic5 Aneurysmal

Ejection fraction

Across 24 simulated cases of this pattern the true EF ranged from 33% to 59% (median 48%, Impaired (36–49%)). Every case in the simulator is different, so practise until your visual estimate lands in the right 5% range.

Variants you will see

Multivessel: LCx / obtuse marginal + RCA
Dominant RCA territory
LCx / obtuse marginal territory
Mid LAD territory
Multivessel: Distal / wrap-around LAD + Dominant RCA
Proximal LAD territory
Dominant LCx territory
Multivessel: Distal / wrap-around LAD + RCA

Teaching points

Chronic infarction: the akinetic segments are thinned (<6 mm) and brighter (fibrosis). Thin + bright = scar, unlikely to recover.
Ventricular ectopics: the premature beat is weak and dyssynchronous and the beat after the pause is stronger. Judge EF and wall motion on normal sinus beats only.
Acute pattern: wall thickness and brightness are preserved — the segment is stunned/ischaemic, not yet scarred.

Common pitfalls

Tethering: an akinetic segment next to normal myocardium is pulled inward and seems to move. Grade it by thickening, not motion. Hypokinesia at the border of a territory is common.

Try it now: open the Coronary-territory RWMA (ischaemia / infarction) example with the segment overlay, then test yourself in Practice where cases are random and graded against the exact answer.