lv function - cecentral
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LV FunctionCardiac Output
EPSS
Mike Mallin, MD
Monday, May 6, 13
Why is LV function important?
• Systolic Dysfunction is bad.......
• Is it worse?
• Is it the cause of my patients dyspnea?
• Does my patient need a inotrope?
• Why is this person hypotensive?
Monday, May 6, 13
Fluid Responsive
• Fluid Responsive: A volume load should induce a significant increase in cardiac output.
• 500cc-1L
• ↑10-15% CO
Mike
Matt
Monday, May 6, 13
Measuring CO
• How to measure SV/CO: SV = Length × area
• SV = LVOTVTI × ∏r2
• CO = LVOTVTI × ∏r2 × HR
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Stroke Volume
• Column of blood
CO = LVOTVTI × ∏r2 × HR
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Stroke VolumeCO = LVOTVTI × ∏r2 × HR
Monday, May 6, 13
Stroke VolumeCO = LVOTVTI × ∏r2 × HR
Monday, May 6, 13
Stroke VolumeCO = LVOTVTI × ∏r2 × HR
Monday, May 6, 13
Stroke VolumeCO = LVOTVTI × ∏r2 × HR
Monday, May 6, 13
Stroke VolumeCO = LVOTVTI × ∏r2 × HR
Monday, May 6, 13
Stroke VolumeCO = LVOTVTI × ∏r2 × HR
Monday, May 6, 13
Stroke Volume
• How to measure SV/CO:
• SV = LVOTVTI × ∏r2
• SV = Volume of Column of blood:
• Length of column x area
CO = LVOTVTI × ∏r2 × HR
Monday, May 6, 13
Stroke Volume
Area Circle = ∏r2
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Stroke Volume
Area Circle = ∏r2
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LVOT Diameter• Measuring the LVOT: PSLX
Monday, May 6, 13
LVOT Diameter• Measuring the LVOT: PSLX
LV LA
RVOTAo
Monday, May 6, 13
LVOT Diameter• Measuring the LVOT: PSLX
LV LA
RVOTAo
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• Measuring the LVOT
LVOT Diameter
Monday, May 6, 13
• Measuring the LVOT
LVOT Diameter
Monday, May 6, 13
• Measuring the LVOT
LVOT Diameter
Monday, May 6, 13
• Measuring the LVOT
LVOTdiameter
LVOT Diameter
Monday, May 6, 13
• Measuring the LVOT
LVOT Diameter
Monday, May 6, 13
SV Measurement
• Still need the length of the column
LD
Monday, May 6, 13
SV Measurement
• Still need the length of the column
LD
Monday, May 6, 13
SV Measurement
• Still need the length of the column
LD
Monday, May 6, 13
• Measuring the LVOTVTI:
• Apical Long Axis or
Apical 5 chamber window
LVOT VTI (length of column)
Monday, May 6, 13
• Measuring the LVOTVTI:
• Apical Long Axis or
Apical 5 chamber window
• Place Pulsed Wave gate at LVOT
• Just apical from the AoValve
LVOT VTI (length of column)
Monday, May 6, 13
• Measuring the LVOTVTI:
• Apical Long Axis or
Apical 5 chamber window
LVOT VTI (length of column)
Monday, May 6, 13
• Measuring the LVOTVTI:
• Apical Long Axis or
Apical 5 chamber window
LVOT VTI (length of column)
Monday, May 6, 13
• Measuring the LVOTVTI:
• Apical Long Axis or
Apical 5 chamber window
LVOT VTI (length of column)
Monday, May 6, 13
• Measuring the LVOTVTI:
• Apical Long Axis or
Apical 5 chamber window
LVOT VTI (length of column)
Monday, May 6, 13
• Measuring the LVOTVTI:
• Apical Long Axis or
Apical 5 chamber window
• Place Pulsed Wave gate at LVOT
• Just apical from the AoValve
LVOT VTI (length of column)
Monday, May 6, 13
• Measuring the LVOTVTI
LVOT VTI (length of column)
Monday, May 6, 13
Passive Leg Raise Testing
• Semirecumbent patient
• Measure CO/SV at baseline
• Raise legs by 30˚ - 45˚
• Repeat CO/SV measurement
Monday, May 6, 13
• Who cares what the CO is?
• I want to know if they are a responder!
• CO=SV×HR COPLR=SVPLR x HRPLR
• LVOTVTI×∏r2 x HR : LVOTVTI-PLR×∏r2 x HRPLR
Passive Leg Raise Testing
Monday, May 6, 13
• Who cares what the CO is?
• I want to know if they are a responder!
• CO=SV×HR COPLR=SVPLR x HRPLR
• LVOTVTI×∏r2 x HR : LVOTVTI-PLR×∏r2 x HRPLR
Passive Leg Raise Testing
Monday, May 6, 13
• Who cares what the CO is?
• I want to know if they are a responder!
• CO=SV×HR COPLR=SVPLR x HRPLR
• LVOTVTI×∏r2 x HR : LVOTVTI-PLR×∏r2 x HRPLR
Passive Leg Raise Testing
Monday, May 6, 13
• Who cares what the CO is?
• I want to know if they are a responder!
• CO=SV×HR COPLR=SVPLR x HRPLR
• LVOTVTI×∏r2 x HR : LVOTVTI-PLR×∏r2 x HRPLR
Passive Leg Raise Testing
Monday, May 6, 13
• Who cares what the CO is?
• I want to know if they are a responder!
• CO=SV×HR COPLR=SVPLR x HRPLR
• LVOTVTI×∏r2 x HR : LVOTVTI-PLR×∏r2 x HRPLR
Passive Leg Raise Testing
Monday, May 6, 13
• Who cares what the CO is?
• I want to know if they are a responder!
• CO=SV×HR COPLR=SVPLR x HRPLR
• LVOTVTI×∏r2 x HR : LVOTVTI-PLR×∏r2 x HRPLR
Passive Leg Raise Testing
LVOTVTI : LVOTVTI-PLR
Monday, May 6, 13
• Who cares what the CO is?
• I want to know if they are a responder!
• CO=SV×HR COPLR=SVPLR x HRPLR
• LVOTVTI×∏r2 x HR : LVOTVTI-PLR×∏r2 x HRPLR
Passive Leg Raise Testing
LVOTVTI : LVOTVTI-PLR
Monday, May 6, 13
• Who cares what the CO is?
• I want to know if they are a responder!
• CO=SV×HR COPLR=SVPLR x HRPLR
• LVOTVTI×∏r2 x HR : LVOTVTI-PLR×∏r2 x HRPLR
Passive Leg Raise Testing
LVOTVTI : LVOTVTI-PLR
Monday, May 6, 13
confusid?
Monday, May 6, 13
Need less information?
• Just want to know:
• Is the pump working?
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• Leg raise?
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LV Function
• Measuring EF:
• Eyeball
• Fractional Shortening
• Method of Discs
• Tricks -- EPSS
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The Eyeball Method
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Eyeballin’
• Not always this obvious
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Easy when....
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Hard when....
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Hard when....
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Eyeball
• Hyperdynamic: EF >75%
• Normal: EF 55-65%
• Moderately Reduced: EF 30-55%
• Severely Reduced: EF <30%
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Hyperdynamic Normal
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Hyperdynamic Normal
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Normal Moderately Decreased
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Normal Moderately Decreased
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Severely DepressedModerately Depressed
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Fractional Shortening• Fractional Shortening : Normal 25-45%
• FS = (EDV-ESV) / EDV
Monday, May 6, 13
Ways to measure LV EF• Simpson’s Method - Method of Discs
Monday, May 6, 13
EPSS• History: EPSS- 1977 EPSS correlated with
angio
• 125 patients: Strong negative correlation
• r = -0.87
• EPSS absent or <5mm in most normal hearts
Monday, May 6, 13
EPSS
• E-Point Septal Separation:• Ahmadpour H et al. Mitral E point septal separation: a reliable index of left ventricular
performance in coronary artery disease. Am Heart J. 1983 Jul; 106:21-8
• 1983 in 108 patients
• EPSS > 7mm 87% sen, 75% spec for EF<50%
Monday, May 6, 13
EPSS: Novice v Expert
• 12 PGY3s&4s perform EPSS on patients with dyspnea
• Correlated EPSS with EM US director and cardiologist visual estimation
Monday, May 6, 13
EPSS: Novice v Expert
• 12 PGY3s&4s perform EPSS on patients with dyspnea
• Correlated EPSS with EM US director and cardiologist visual estimation
Monday, May 6, 13
EPSS v MRI
• Quantitative Estimation of Left Ventricular Ejection Fraction from Mitral Valve E-Point Septal Separation and Comparison to Magnetic Resonance Imaging. Silverstein J et al. Am J Cardiol. 2006
• EPSS measured on MRI and compared to MRI Ejection Fraction
• MRI LVEF = MRI EPSS with r=0.82
Monday, May 6, 13
EPSS v MRI
Monday, May 6, 13
PSLA
LV LA
RVOTAo
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PSLA
LV LA
RVOTAo
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PSLA
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PSLA
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PSLA
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E
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E
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EA
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Pitfalls
• Aortic Insufficiency
• Mitral Stenosis
• Mitral Calcifications
Monday, May 6, 13
Pitfalls• Aortic Insufficiency
Monday, May 6, 13
Pitfalls• Mitral Stenosis
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Pitfalls• Mitral Calcification
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Pitfalls• Mitral Calcification
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Summary
• CO may be useful when evaluating fluid responsiveness.
• May only need the VTI.
• Eyeball and EPSS are excellent ways of assessing cardiac function and EF.
Monday, May 6, 13
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