Eyeballing LV function : Test yourself

Gollum, Wellington Airport, Weta Studios

Estimating ejection fraction (EF) can be done by eyeballing LV contraction on ECHO. This requires some skill and expertise. A very basic assessment in the Emergency department requires a parasternal long axis (PLAX), a parasternal short axis (PSAX) and a 4 chamber view (4CV).

What are we looking for ?

  • Reduced motion of the anterior mitral valve  leaflet  in the parasternal long axis view. The anterior mitral valve leaflet should come within 8mm of the septal wall in the PLAX view in systole.  Normal  motion < 8mm, moderately reduced motion 8 -18mm, severely reduced motion > 18mm
  • Inward movement of the endocardium
  • Thickening of the myocardium
  • Longitudinal motion of the mitral annulus
  • Geometry of the left ventricle (size, aneurysms)

Example

Have a look at the cineloops below and assess LV function as severely reduced, moderately reduced, normal or hyperkinetic.

Answer : Moderately to  severely reduced ejection fraction (EF)

By reviewing the above images again below, note the poor inward motion of the endocardium, the poor thickening of the myocardium and the poor motion of the anterior leaflet of the mitral valve in the PLAX view.

In the PSAX  view below note the poor circumferential inward movement of the endocardium and the poor thickening of the myocardium.

In the 4CV below note the poor longitudinal movement of the mitral annulus. The left ventricle contracts circumferentially, radially, and longitudinally. The longitudinal contraction can be assessed by looking at how far the mitral annulus moves up in systole. There should be a brisk upwards movement of the mitral annulus in normal LV longitudinal contraction.

Compare the above cineloops with those below. This patient has normal LV function

Caveats when assessing LV function using 3 views only.

  1. You are looking at 3 views only and may not be properly assessing all the walls of the LV. This means that you may overestimate LV function if dyskinetic, akinetic or hypokinetic segments are not taken into account.
  2. If there is akinesis at the apex, from a previous LAD infarct for example, there may be  hypercontractile basal segments which, if assessed in isolation, will cause an overestimation of  the EF
  3. Filling volumes will affect estimation of the EF. If the LV is underfilled, the EF may be overestimated. If the LV is overfilled the EF may be underestimated.
  4. Assessment of EF in patients with tachycardia and dysrrythmias such as AF may be difficult to assess correctly.
  5. Preservation of LVEF does not exclude heart failure. Patient with heart failure preserved ejection fraction (HFpEF) will, in most cases, have diastolic dysfunction. They will mainly  present with a normal LV cavity size, and with an increase in LV wall thickness and /or increased left atrial size as a sign of increased filling pressures.

Your turn now!

Assess the following clips for overall LV function : severely reduced, moderately reduced, normal or hyperkinetic

Case 1

Moderately reduced EF

Case 2

Severely reduced EF with dilated RV. Note thickened LV wall

Case 3

Hyperkinetic contraction with normal EF. It is difficult to estimate EF however in a patient like this who has atrial fibrillation.
Case 4

Moderately reduced EF. Poor inward movement of endocardium and thickening of myocardium. Poor anterior mitral valve leaflet motion. Reduced mitral annular longitudinal excursion.

Case 5

Normal LV function and EF

Case 6

Severely reduced LV function.

Case 7

Moderately reduced EF. The thickening of the myocardium in the PLAX view and the PSAX view is reduced and there is reduced longitudinal mitral annulus excursion in the 4 CV.

References

  1. Int J Cardiol. 2005 May 25;101(2):209-12. Visually estimated left ventricular ejection fraction by echocardiography is closely correlated with formal quantitative methods.
    Gudmundsson P1, Rydberg E, Winter R, Willenheimer R
  2. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC
    Piotr Ponikowski Adriaan A Voors Stefan D Anker Héctor Bueno John G F Cleland Andrew J S Coats Volkmar Falk José Ramón González-Juanatey Veli-Pekka Harjola Ewa A Jankowska
  3. https://www.123sonography.com/ebook/left-ventricular-function
  4. How to visually estimate left ventricular ejection fraction https://vimeo.com/85768153

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