LV Systolic Function 2

This station covers LV systolic function evaluation. We will look at MAPSE, EPSS and Simpson’s Biplane Method. These are obtained in the PLAX view and apical 4 chamber view.

A. MAPSE

Image from: Clinical implication of mitral annular plane systolic excursion for patients with cardiovascular disease. Kai Hu et al. European Heart Journal 2013.
  • MAPSE – Mitral Annular Plane Systolic Excursion.
  • This is a measure of longitudinal shortening of the LV, which plays an important role for LV pump function.
  • MAPSE ia a clinically useful echocardiographic parameter for the assessment of LV longitudinal function and correlates with global systolic function of the LV.
  • MAPSE is measured using M-Mode. The lateral or septal annulus is usually used.
  •  The image shows (A)measurement of MAPSE, (B) ECG, (C) Mitral inflow(Diastole) (D) M-MODE Trace of systolic annular displacement, & (E) LVOT Outflow (LVOT VTI).

The average normal value of MAPSE ranges between 12 and 15 mm and a value of MAPSE <8 mm was associated with a depressed LV EF (<50%) with a specificity of 82% and a sensitivity of 98%. A mean value for MAPSE of ≥10 mm was linked with preserved EF (≥55%) with a sensitivity of 92% & specificity of of 87%.

B. EPSS

Image From: Can Junior Emergency Physicians Use E-Point Septal Separation to Accurately Estimate Left Ventricular Function in Acutely Dyspneic Patients? Secko et al. AEM 2011
  • EPSS refers to E-point septal separation. It is the distance from the tip of the anterior leaflet of the mitral valve to the interventricular septum in early diastole.
  • Step 1: Obtain a PLAX view
  • Step 2: Use M-MODE. Align the cursor over the tips of the anterior leaflet of the mitral valve.
  • Step 3: Freeze the tracing.
  • Step 4: Measure the distance from the E-Wave to the IVS.
  • See image.
  • An EPSS < 7mm indicates Normal LVEF.
  • An EPSS > 10mm indicates Severe LV Systolic Failure

C. Simpson's Biplane

Simpson's Biplane used to determine LV volumes and EF.
Grading of LV Ejection Fraction
  • Step1: Apical four chamber view and two chamber views are obtained in both systole and diastole.
  • Step 2: The endocardial borders are traced out. The computer algorithm divides the left ventricular cavity into discs, usually 20 in number. Sum of volumes of these discs will give the left ventricular volume.
  • Step 3: Difference between the diastolic and systolic volumes divided by the diastolic volume will give the LVEF.
  • This is the method recommended by American Society of Echocardiography for LVEF quantification. 

Ejection fraction = (EDV – ESV)/EDV x 100%

EDV: End diastolic volume; ESV: End systolic volume. The difference between the two gives the stroke volume. Ejection fraction is in fact the stroke volume divided by the end diastolic volume.

Clinical Scenarios

Clip 1

Scenario
Answer
A 2D PLAX clip and an M-Mode tracing are shown aboe. What is the visual estimate of ejection fraction? What is measured on the M-Mode trace? What does the measurement indicate? What are the limitations of this method?
The PLAX view shows an LV with severe LV systolic dysfunction. The M-Mode trace on the right shows movement of the anterior leaflet of the mitral valve against time. This is an EPSS measurement. The EPSS is measured as 14mm, indicating severe LV systolic failure.

Clip 2

Scenario
Answer
A 25 year old man is admitted with Diabetic Ketoacidosis. His BP is 83/59 mmHg. What does this M-Mode tracing show? What is his LV systolic function?
This is an M_Mode tracing showing EPSS. The E and A waves are seen, corresponding to movement of the anterior leaflet of the mitral valve in diastole. The tip of the MV anterior leaflet almost touches the interventricular septum. The distance is < 7mm, consistent with normal LV systolic function

Workshop Stations

LV Systolic Function 2

LV Systolic Function 3

eFAST

RV Function 1

RV Function 2