Left Ventricle
Global LV Systolic Dysfunction
Diffuse or global left ventricular systolic dysfunction may be seen in the following conditions:
- Ischaemic Cardiomyopathy
- Hypertrophic Cardiomyopathy
- Dilated Cardiomyopathy
- Valvular Heart Disease
- Septic Shock
- Infiltrative Cardiomyopathies – eg Amyloidosis
Qualitative Assessment
We can determine Global LV Systolic Function and Ejection Fraction with QUALITATIVE & QUANTITATIVE methods. Qualitatively, the ‘eyeballing’ method is used – by evaluating LV contractility (wall thickening), left ventricular end diastolic cavity size and left ventricular end systolic cavity size (endocardial border excursion).
The parasternal short axis view at the level of the papillary muscles (video below), where the LV is seen as a doughnut is the best view for qualitative estimation of LV ejection fraction. All 4 cardiac views should however be evaluated.
What do you think of the heart above ?
This is a normal left ventricle seen in the parasternal short axis view. Read further to learn about the characteristics that allow us to grade this as a normal left ventricle.
The following should be evaluated when making a qualitative evaluation LVEF:
- Wall thickening during systole
- The LV wall should thicken by > 40% during systole
- Wall thickness in diastole
- A thin & hyperechoiec wall indicates prior infarct and scar tissue
- Endocardial border excursion
- The endocardial border should move in unison towards the center of the LV cavity in systole.
- Abnormal endocardial excursion indicates presence of RWMAs.
Grading LVEF%
LV Ejection Fraction can be graded as follows:
- Normal – EF 50-70%
- Mild Systolic Dysfunction – EF 40-49%
- Moderate Systolic Dysfunction – Ef 30-39%
- Severe Systolic Dysfunction – EF < 30%
LVEF% = LV end diastolic area – LV end systolic area / LV end diastolic area x 100%
Consider the heart above. What do you think about the LVEF% ?
This is a parasternal long axis view. The left ventricular septal and posterior walls are seen. Both walls thicken well in systole. There is good endocardial border excursion into the LV cavity in systole. Visually, the ejection fraction (EF%) is normal.
Can you visually estimate the ejection fraction in the above clip ?
Parasternal Long Axis : Normal LV Contractility and Ejection Fraction. The walls appear to thicken by more than 40% during systole indicating normal function. There is significant difference in the size of the LV cavity in systole and diastole. There is good endocardial border excursion in all visible walls. This is Normal LV Systolic Function (EF>50%)
Are you worried about the above echocardiogram ?
Parasternal Long Axis: There is minimal thickening and movement of the LV walls during systole. LV systolic and diastolic cavity sizes are almost the same. There is minimal endocardial excursion seen. This is severe LV systolic dysfunction (EF<30%).
What should you do next ?
It is important to evaluate the LV in all 4 views. Proceed to obtain the short axis, apical and subcostal views before deciding on the EF%.
Tell me about the wall thickening here ?
Parasternal Short Axis: There is excellent wall thickening seen in systole. This view is useful for evaluation of RWMAs as the walls supplied by all 3 major coronary arteries are seen. All 4 LV walls thicken well, with > 40% change in wall thickness from diastole to systole.
How about the endocardial wall excursion ?
If you place your index finger at the centre of the LV, you can better judge this. All 4 walls move in synchrony. There is equal endocardial border excursion of all walls.
What is the EF% ?
Ejection fraction is good, > 50%
Compare this to the previous echocardiogram. Difference ?
Parasternal Short Axis: LV wall thickening and endocardial excursion is significantly reduced here.
Quantitative Left Ventricular Function Evaluation
Quantitative Assessment – Covered in the next course
- Fractional Shortening (FS%)
- Fractional Area Change (FAC%)
- Mitral Annular Plane Systolic Excursion (MAPSE)
- E-Point Septal Separation (EPSS)
- Doppler determination of stroke volume
These are covered in a separate course.
Regional Wall Motion Abnormalities
Assessment of Regional Wall Motion Abnormalities (RWMA) is generally not recommended with bedside scanning, although opinions differ. This is because RWMAs may sometimes be subtle and may not be easily detected. Experience of the individual practitioner should be considered in this regards. It should be noted that RWMAs are one of the earliest signs of myocardial ischaemia and there are numerous examples of patients being taken to the cardiac catheter lab based on RWMA findings alone.
Regional Wall Motion Abnormalities can be described according to the LV wall (17 segment model) or coronary artery territory affected and the wall motion abnormality seen as follows:
- Hyperkinetic
- Increased systolic inward excursion
- Normal
- Normal systolic wall thickening and inward excursion
- Hypokinetic
- Reduced systolic wall thickening and inward excursion
- Akinetic
- Absent systolic wall thickening and inward excursion
- Dyskinetic
- Systolic outward excursion and absent wall thickening
Which View is this ?
Apical 4 Chamber.
Can you grade the LV systolic function visually ?
Ideally, the short axis, long axis and subcostal views should be obtained.
This LV is not normal. There is moderate to severe LV systolic dysfunction.
Are there any wall motion abnormalities ?
Yes ! The lateral, septal and apical LV walls are seen. Only the lateral wall is contracting. The apical and septal walls hardly move.
There is apical and septal wall akinesia consistent with LAD territory ischaemia.
What is seen above ?
The posterior and septal LV walls are seen. The posterior wall is thin and brighter when compared to the septal wall, suggestive of scar tissue. Wall thickening is reduced. This patient may have had an RCA territory infarct in the past.
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Right Ventricular Function
Right Ventricular Failure can occur in the setting of ischaemia, infarction, sepsis and pulmonary embolism. When doing a FCU scan, the size, shape and contractility of the RV should be assessed. RV wall thickness can be measured in the subcostal 4 chamber view. This gives an indication of chronicity of conditions such as pulmonary hypertension. POCUS Cardiac assessment of the RV can be found in a separate course.
What do you see in the above clip ?
Apical 4 Chamber view showing biventricular failure. Both the LV (right of image) and RV (left of image) are dilated and contracting poorly. Note how the RV now forms the apex of the heart and is almost as large as the LV. Image from POCUS Atlas.
Valvular Function
Gross evaluation of valvular function can be made at the bedside. The aortic valve, mitral and tricuspid valves can be seen. Valves can be evaluated by 2D imaging looking at leaflet morphology and mobility (normal, thickened, calcified, vegetations, restricted mobility, prolapse or flail). Color doppler can be used to look for turbulence of blood flow across a stenotic valve or for regurgitant jets. FCU only allows for gross evaluation of valvular function. A comprehensive TTE should be obtained if valvular pathology is suspected.
Examples of cardiogenic shock secondary to valvular pathology include acute mitral regurgitation secondary to ruptured chords or papillary muscle. Type A Aortic Dissection may involve the aortic root and valvular apparatus. The aortic dissection flap may prolapse through the aortic valve leading to acute severe aortic regurgitation. Arrythmias can precipitate acute cardiogenic shock in the presence of valvular stenosis such as severe mitral or aortic valve stenosis.