assessment of myocardial systolic function by tee ......31 assessment of myocardial systolic...

31

Assessment of Myocardial Systolic

Function by TEE

Achikam Oren-Grinberg, MD*Boston, Massachusetts

Kyung W. Park, MDw

San Jose, California

Echocardiography was introduced to the operating suite in the1970s, with epicardial echocardiography as its initial application.Transesophageal echocardiography (TEE) during surgery was firstdescribed in 1980 but did not become commonplace until the mid-1980s. Since then, TEE has evolved to become one of the most widelyused and versatile modalities for diagnosing and monitoring critically illpatients. As such, its use has expanded into the perioperative period andthe intensive care unit (ICU). Echocardiography provides both anatomicand functional information about the heart—systolic and diastolicfunction, cavity size, and valvular function.1 This chapter will addressthe assessment of myocardial systolic function by TEE.

’ Indications and Guidelines

Since its introduction into the operating room setting in the 1970sand 80s, the role of TEE has evolved and expanded, leading to the needfor standardization of indications and practice. A task force created in1993 conducted a literature review of 558 studies in search of evidencefor the effectiveness of TEE in the perioperative setting. Three yearslater, the American Society of Anesthesiologists (ASA) and the Society ofCardiovascular Anesthesiologists (SCA) published guidelines for theindications and clinical settings in which TEE is indicated.2 Threecategories of evidence-based clinical indications were identified. Forindications grouped into category I, TEE was judged to be frequently

INTERNATIONAL ANESTHESIOLOGY CLINICSVolume 46, Number 2, 31–49r 2008, Lippincott Williams & Wilkins

FROM THE *BETH ISREAEL DEACONESS MEDICAL CENTER AND THE wSANTA CLARA VALLEY MEDICAL CENTER

REPRINTS: ACHIKAM OREN-GRINBERG, MD, BETH ISREAEL DEACONESS MEDICAL CENTER, ONE DEACONESS RD.,CC-470, BOSTON, MA, E-MAIL: [email protected]

useful in improving clinical outcomes. In category II indications, TEEwas judged to be only potentially useful and in category III, onlyinfrequently useful in improving clinical outcome.2 Included amongCategory I indications is evaluation of the cardiac function forhemodynamic instability, either intraoperatively or in the ICUs.

As TEE utilization in the perioperative setting became morewidespread, the need for consistency in imaging acquisition becameincreasingly evident. In 1999, the joint task force of the AmericanSociety of Echocardiography (ASE) and SCA published guidelinesdefining a comprehensive cardiac examination using TEE.3 Morespecifically, these guidelines defined a set of cross-sectional views andnomenclature that constitute a comprehensive intraoperative TEEexamination. It is important to note that occasional deviation from theguidelines is needed to acquire optimum imaging. The expectation wasthat ‘‘the guidelines may enhance quality improvement by providingmeans to assess the technical quality and completeness of individualstudies’’ and that ‘‘more consistent acquisition and description ofintraoperative echocardiographic data will facilitate communicationbetween centers and provide a basis for multicenter investigations.’’3

’ Basic Terminology of Echocardiography Techniques

A sonographer must use different echocardiographic imagingtechniques and hemodynamic modalities to achieve a diagnosis ormanagement plan. The following is a list of the basic techniques usedduring an echocardiographic study.

Two-dimensional Echocardiography

Two-dimensional echocardiography (2DE) is the backbone ofechocardiography.4 Using 2D, a complete visualization of the beatingheart is achieved by displaying anatomic structures in real-timetomographic images. By aiming the ultrasound probe at the heart,exactly oriented anatomic ‘‘slices’’ are obtained. Information acquiredincludes cardiac chamber sizes, global and regional systolic function, andvalvular anatomy.

M-mode Echocardiography

M-mode or motion-mode images are a continuous 1-dimensionalgraphic display that can be derived by selecting any of the individualsector lines from which a 2D image is constructed.4 It is useful forquantification of the heart wall and chamber sizes, which in turn can beused to estimate left ventricular (LV) mass and chamber volumes,respectively. In addition, as it has high temporal resolution, M-mode is

32 ’ Oren-Grinberg and Park

helpful in assessing the motion of rapidly moving cardiac structures suchas cardiac valves.

Doppler Echocardiography

Doppler echocardiography is used to supplement 2D and M-modeechocardiography. It can provide functional information regardingintracardiac hemodynamics, systolic and diastolic flows, blood velocitiesand volumes, severity of valvular lesions, location and severity ofintracardiac shunts, and assessment of diastolic function. The 4 typesof Doppler modalities used include continuous-wave, pulsed-wave, colorflow mapping, and tissue Doppler.4 Continuous-wave Doppler is used formeasuring high-pressure gradient/high-velocity flows such as seen withaortic stenosis. Pulsed-wave Doppler (PWD) is used for measuring lowerpressure gradient/lower velocity flows such as in mitral stenosis. Colorflow mapping is useful for screening valves for stenosis or regurgitation,qualifying the degree of valvular regurgitation, imaging systolic anddiastolic flow, and detection of intracardiac shunts. Doppler tissue imaging(DTI) has been introduced as a new method of quantifying segmentaland global LV function. It records systolic and diastolic velocities withinthe myocardium and at the corners of the mitral annulus and is usefulfor studying diastolic function and contractile asynchrony of the LV.

Contrast Echocardiography

Contrast echocardiography is used to enhance the diagnostic qualityof the echocardiogram.5 It may be used to improve assessment of globalfunction and regional wall motion abnormalities by 2DE. Althoughapproved only for LV opacification, recent clinical studies suggest apotential use in assessing myocardial perfusion.

’ Echocardiography Compared With TraditionalMonitoring

For almost 4 decades, the pulmonary artery catheter (PAC) was usedas a mainstay monitoring tool for complex ICU patients. It providesdirect information on pressure variables such as pulmonary arterypressure, pulmonary artery wedge pressure (PAWP), and central venouspressure (CVP). It can also provide flow related data such as cardiacoutput (CO) and, in oximetrically equipped devices, mixed venousoxygen saturation. From all these data, other hemodynamic variables,such as systemic vascular resistance, pulmonary vascular resistance, andstroke volume (SV) can be calculated.

Despite its extensive use (more than 1.5 million PACs insertedannually in North America), the clinical value of data obtained from

Assessment of Myocardial Systolic Function by TEE ’ 33

PACs remains unproven.6 Measurement of PAWP does not alwaysreflect end-diastolic volume. Although in patients with normal systolicfunction, CVP and PAWP parallel each other with a high degree ofcorrelation,7 in patients with impaired systolic function [ejectionfraction (EF)<40%], no correlation between CVP and PAWP exists.8

This can be due to the changes in myocardial compliance, such as can berelated to myocardial ischemia. Early studies of the use of PAC insurgical patients yielded inconsistent results. Although some studiesdemonstrated decreased mortality,9–11 others showed no effect.12,13

In contrast, other studies demonstrated increased morbidity andmortality.14,15 Two systematic reviews that included a mixedpopulation of surgical and medical patients and patients with myo-cardial infarction demonstrated no overall benefit and increasedmorbidity and mortality from the use of PAC.16,17 Finally, a recentrandomized, prospective study of nearly 2000 patients found no benefitto therapy directed by PAC in high-risk surgical patients requiringintensive care.6

Management of the hemodynamically unstable patient has alwaysbeen a challenge. Hemodynamic optimization is a complex taskrequiring monitoring of arterial and venous pressures, urine output,acid-base balance, and oxygen content in the blood. However, theseparameters reflect the overall circulatory state and not the basicphysiologic determinants of CO: preload, afterload, and contractility.In many conditions, such as pericardial and pleural effusion, pulmonaryembolism and valvular pathologies, current invasive monitors provideonly minimal and indirect information to facilitate satisfactory manage-ment. In addition, the current monitoring modalities provide little to noinformation for the assessment of ventricular compliance and relaxation.At present, echocardiography is the only method that can provide real-time bedside imaging of the heart.18,19 It allows, among otherparameters, the assessment of LV systolic and diastolic function,measurement of CO and also reliable assessment of pulmonary arterypressure and PAWP.20 Data obtained from TEE examination frequentlydiffer from PAC assessments of LV preload and systolic functionand, when used, can lead to a change in therapy in 40% to 60% ofpatients.21,22

’ Echocardiographic Evaluation of Cardiac Function

Currently, there is no single modality that can comprehensivelyevaluate cardiac function. Echocardiography is the technique mostwidely used for the evaluation of LV systolic function. Comparedwith other techniques, echocardiography has the advantages that itcan be performed at the bedside, is rapid, very safe, and relativelyinexpensive.


Utilization of several echocardiographic assessment modalities isnecessary to monitor cardiac function. These assessments include LVsystolic and diastolic function, right ventricular systolic function, cardiacpreload, myocardial performance index, valvular function, pathology ofthe thoracic aorta, pericardial disease, and evaluation for sources ofemboli. This discussion is limited to assessment of perioperative LVsystolic function, which is often done to determine the etiology(ies) ofhemodynamic instability. Evaluation of LV systolic function, which isusually one of the first questions answered in echocardiographic study,is probably one of the most important applications of perioperativeechocardiography. TEE provides both quantitative and qualitativemeasures of systolic function; quantitative ventricular volumes and EFbased on endocardial border tracing, and also visual estimates of globaland regional function from 2DE images.23

’ Quantitative Assessment of LV Systolic Function

Fractional shortening—M Mode

M-mode echocardiography facilitates the measurement of internalventricular dimensions and wall thickness throughout the cardiac cycleby recognition of the endocardial borders.24 Using M-mode echocar-diography, the following parameters can be measured (Fig. 1):

(a) LV wall thickness(b) LV internal dimensions (LVID) at the end of diastole (EDD)(c) LV internal dimension at the end of systole (ESD)

Figure 1. Transgastric short-axis M-mode view of the LV showing end-diastolic diameter (EDD),end-systolic diameter (ESD), and LV wall thickness. From this, fractional shortening can becalculated using the formula % fractioning = (EDD – ESD)/EDD which in this figure equals 47%.


Fractional shortening can then be calculated using the formula:

Fractional shortening ð%Þ ¼ ðEDD� ESDÞ=EDD� 100%:

Fractional shortening can also be determined by 2D echocardio-graphy. EDD and ESD are determined from a 2D image, and fractionalshortening (and thus EF) is then calculated using the same formula asabove (Fig. 2).

Fractional shortening is one of the simplest methods for attemptingto quantify LV systolic function with the normal range being 25%

Figure 2. Transgastric short-axis view of LV. A, LV at end diastole measuring 4.63 cm. B, LV atend systole measuring 3.87 cm. From this, % shortening can calculated as (EDD – ESD)/EDD or(4.63 to 3.87)/4.63� 100% which equals 16% for this depressed LV.


to 45%. The major limitation of this technique is that it is only a1-dimensional measurement of EF; it provides information regardingchamber size and contractility along a single line only. This may notaccurately reflect global LV function. It is possible to underestimate theseverity of dysfunction if an area of normal function is interrogated or,conversely, to overestimate overall LV dysfunction if the beam transitsthrough an area of focal dysfunction.25 Because of these limitations,fractional shortening is rarely used as a technique for the assessment ofLV performance.

Volumetric Method Using Geometric Models

Quantitative assessment of LV systolic function relies on volumeassessment using 2DE tomographic images. To determine the volume atend-diastole (LVEDV) and end systole (LVESV), measurements areperformed by tracing the endocardial border in one or moretomographic planes at end diastole and end systole. Several geometricassumptions and formulas have been developed (eg, truncated ellipse,‘‘bullet’’ formula, cylinder, and cone) to determine the LVEDV andLVESV based on these 2DE images. Once LVEDV and LVESV havebeen determined, the stoke volume, and thus CO can be calculated:

SV ¼ LVEDV� LVESV

CO ¼ SV�HR:

In addition, EF can be calculated from these volumes using theformula:

EF ¼ SV=LVEDV� 100%:

The advantage of the geometric assumption techniques is that theyrequire only limited visualization for calculation of ventricular volumes.However, these formulas work only in a symmetrically contractingventricle and the presence of regional wall motion abnormalitiesdecreases their accuracy. In addition, foreshortening of the LV cavityis a common source of underestimation of LV end-diastolic and end-systolic volumes,1,26 thus decreasing the accuracy of systolic functionassessment with these formulas. Lastly, as the models depend onaccurate endocardial border definition, their use requires adequatevisualization. Incomplete endocardial definition is described in 10% to20% of routine echocardiographic studies27 and can reach 25% in ICUpatients.28 This challenge is even greater in patients requiringmechanical ventilation in which imaging can be particularly challenging.These limitations have led to an extensive decrease in the utilization ofthe geometric models and formulas for the assessment of LV systolic


function, especially because modern echocardiographic machinescontain powerful computational packages enabling accurate assessmentof LV systolic function with other echocardiographic modalities.

Disc Method (Simpson’s Rule)

Another method for volumetric assessment of LV systolic function isthe disc method, which may be more accurate than other volumetricmethods, particularly in the presence of distorted LV geometry. In this

Figure 3. Calculation of CO using the disc method (Simpson’s rule). Midesophageal 4-chamberview in diastole (A) and systole (B) is shown. Using the Simpson’s rule, LVEDV (81 mL) andLVESV (56 mL) were calculated by the echocardiographic computer. From these volumes, the CO wascalculated to be 1.7 L/min (81 – 56 mL)� 69 bpm.


method, the ventricle is divided into a series of discs of equal height andeach disc volume is calculated as follows:

Disc volume ¼ disc height� disc area:

The ventricular volume can be calculated from the sum of the discsvolumes (Fig. 3). This technique requires true apical images, which inclinical practice may not be achieved. Foreshortening of the ventricularapex will result in inaccurate assessment of the LV EF and CO.

’ Qualitative Assessment of Systolic Function

2D Evaluation of Ventricular Systolic Function

Using 2D, two of the most important questions regardinghemodynamic stability can be rapidly answered: are the ventriclescontracting well and are they adequately filled? An experiencedobserver can qualitatively evaluate systolic function. This should beassessed from multiple tomographic planes and attention must be givento obtaining adequate endocardial definition. Normal ventricularcontraction consists of simultaneous myocardial thickening andendocardial incursion toward the center of the ventricle. There is someregional heterogeneity of this motion with the proximal lateral andinferolateral or posterior walls contracting somewhat later than theseptum and inferior wall.25 For qualitative assessment of overall systolicfunction, the echocardiographer integrates the degree of wall thicken-ing and endocardial motion in all tomographic views and reaches aconclusion about overall LV systolic function and EF. Although differentinstitutions use different standards, severe LV systolic dysfunction isusually defined as an EF <30%, moderate dysfunction 30% to 45%,mild depression 45% to 55%, and normal >55%. This method of EFestimation is of great clinical utility and can be performed with goodcorrelation to quantitative measurements. There are a few potentialpitfalls to 2D assessment of EF that must be considered:

� As mentioned, accurate assessment requires satisfactory endocar-dial border definition. Qualitative EF estimation becomes inaccu-rate when the endocardium is inadequately defined.� Accurate estimation of EF depends on the experience of the

echocardiographer.� In asynchronous contraction (paced-rhythm, conduction defects,

etc), assessment of EF is more difficult.

Despite its limitations, 2D is the most widely used technique for theassessment of perioperative LV systolic function owing to its ease ofapplication in the clinical setting. In the operating room, aftercompleting the TEE examination, most physicians monitor LV systolic


function continuously with 2D using the transgastric midpapillary short-axis view. This allows for quick assessment of regional wall motionabnormalities in all coronary arterial circulatory beds and alsoevaluation of global ventricular function and volume status.29

Regional LV Function

Most commonly, abnormal regional wall motion is the result ofcoronary artery disease and resultant ischemia/infarction. Abnormal wallmotion is a continuum of a condition consisting of hypokinesis, akinesis,and then dyskinesis. With dyskinesis, the affected wall segment movesaway from the center of the ventricle during systole. To standardizeechocardiographic evaluations of wall motion, a 17-segment model ofthe LV has been defined.25 These 17 segments are evaluated separatelyfor the presence and degree of regional wall motion abnormality. Whenthe etiology of the wall motion abnormality is coronary artery disease,the location of the coronary lesion can be usually predicted from thelocation of the regional wall motion abnormality.

’ Nonischemic Wall Motion Abnormalities

Nonischemic conditions, such as left bundle branch block (LBBB),ventricular preexcitation (ie, Wolf-Parkinson-White syndrome), prema-ture ventricular contractions, and ventricular pacing can lead to regionalwall motion abnormalities. In the perioperative period, LBBB is the mostcommon etiology of regional wall motion abnormality. With LBBB, thesequence of contraction of the LV is altered, and the initial septalactivation sequence is reversed with the right side of the ventricularseptum activated before the body of the LV. This results in acharacteristic ‘‘septal bounce,’’ which can also be easily defined with M-mode echocardiography.25 It can sometimes be challenging to differ-entiate between ischemia-related regional wall motion abnormalitiesfrom those abnormalities caused by altered conduction pathways. It isimportant to appreciate that both conditions can be present at the sametime, which makes the diagnosis of ischemia even more challenging.When trying to differentiate between them, it is important to assess thedegree of myocardial thickening. With rhythm-related wall motionabnormalities, myocardial thickening is usually preserved while, withischemia, myocardial thickening is decreased or absent. This differentia-tion can be made using both 2D and M-mode echocardiography.

’ Contrast Echocardiography

Recent innovations have been made to overcome some of thetechnical obstacles related to endocardial border detection and image


quality. Intravenous echocardiographic contrast agents that opacify theleft side of the heart can markedly improve visualization of the LV cavityand enhance endocardial definition. These agents can aid assessmentof regional and global LV function.30–33 These agents have the abilityto ‘‘salvage’’ nondiagnostic transthoracic echocardiographies in ICUpatients. One study demonstrated a salvage rate of 51%34 and another77% of nondiagnostic transthoracic echocardiographies. Optison, asonicated perflouropropane-filled albumin microsphere contrast, andalso Definity and other contrast agents has been used safely to improveendocardial border visualization.31,35 In addition to improving endo-cardial border visualization and assessment of LV function, assessmentof myocardial perfusion defects with intravenous contrast has beenreported with a variety of imaging techniques and modalities.36–38

’ Doppler Evaluation of Ventricular Systolic Function

Doppler spectral profiles have been used by clinicians to evaluate LVfunction for many years. Evaluation of LV systolic function usingDoppler echocardiography is based on the calculation of SV and CO.

SV, the volume of blood ejected during each cardiac cycle, is a keyindicator of cardiac performance. SV can be calculated by using PWD tomeasure the instantaneous blood velocity recorded during systole froman area in the heart where a cross-sectional area (CSA) can be easilydetermined. The LV outflow track (LVOT) is most commonly usedbecause its cross-section is essentially a circle. By measuring thediameter of the LVOT and assuming a circular geometry, the CSA iscalculated as p(D/2)2. Any cardiac chamber that has a measurable CSAcan be used, however (ie, mitral valve inflow, pulmonic valve outflow,and tricuspid valve inflow). By tracing the outline of the PWD profile,the echocardiographic computer can calculate the integral of velocityby time or the velocity time integral (VTI). The VTI is the distance(commonly referred as the stroke distance) that the average red cell hastraveled during the systolic ejection phase. SV (cm3) is then calculated bymultiplying the VTI (stroke distance in cm) by the CSA in cm2 of theconduit (ie, LVOT, aorta, mitral valve annulus, and pulmonary artery)through which the blood has traveled39–45; SV = CSA�VTI. CO is theneasily derived by multiplying the SV, as calculated above, by the heartrate (Fig. 4): CO (cm3/min) = SV�HR.

This approach to SV and CO calculations has shown very goodcorrelation with thermodilution derived CO measurements.46 There areseveral potential sources of error that must be considered:

(a) CSA determination is often the source of the greatest error. Whenusing the LVOT diameter for CSA determination, any error inmeasurement will be squared (CSA = pr2). This translates to about


a 20% error in calculation of CO for each 2-mm error whenmeasuring a 2.0-cm diameter outflow tract.25 Studies have shownthat although the Doppler velocity curves can be recorded consis-tently with little interobserver measurement variability (2% to 5%),the variability in 2D LVOT diameter measurements for CSA issignificantly greater (8% to 12%).24

(b) While the pattern of flow is assumed to be laminar (flat profile), inreality the flow profile is parabolic. This does have some impact on

Figure 4. Calculation of CO using spectral Doppler approach. A, Midesophageal long-axis viewof LVOT. LVOT measurement is 2.0 cm. The CSA is calculated as p(D/2)2 to be 3.14 cm2.B, Transgastric long-axis view using a PWD directed through the LVOT. VTI is calculated by thecomputer through tracing the outer envelope of the spectral signal and is determined to be 14.6 cm.SV is the product of CSA and VTI: 3.14� 14.6 = 46 mL. CO = SV�HR: 46� 61 = 2.8 L/min.


velocity-based calculations.25 However, in routine clinical practice,this factor is of little significance and can essentially be ignored.

(c) The Doppler signal is assumed to have been recorded at a parallel ornear parallel intercept angle, called y, to flow. The Doppler equationhas a cos y term in its denominator. With an intercept angle of 0degree, the cos y term equals 1. Deviations up to 20 degrees inintercept angle are acceptable since only a 6% error in measurementis introduced.

(d) Velocity and diameter measurements should be made at the sameanatomic site. When the 2 are measured at different places, theaccuracy of SV and CO calculations is affected.

’ Determination of LV dP/dt—Isovolumetric Indices

The changing rate of LV pressure (dP/dt) is an important parameterin the assessment of myocardial systolic function. This is a less load-dependent index of LV systolic function. Traditionally, dP/dt wasderived from the LV pressure curve acquired at cardiac catheterization,using a micromanometer catheter recording. It has been shown thatechocardiography can be used accurately and reliably to assess dP/dtusing the mitral regurgitation jet.47,48 Using continuous-wave Doppler, aspectral display of the mitral regurgitation jet is displayed. From thespectral display, information about the rate of pressure developmentwithin the LV can be derived using measurements undertaken in theearly phase of systole (the upstroke of the velocity curve is used forcalculations) (Fig. 5).

Determination of dP/dt using mitral regurgitation spectraljet is done by calculation of the time required for the MR jetvelocity to go from 1to 3 cm/s. The time between these 2 pointsrepresents the time that it takes for a 32 mm Hg pressure change tooccur in the LV cavity. This is based on the modified Bernoulli equation(P = 4v2), which relates pressure to velocity. Thus, in going from1 to 3 m/s:

P ¼ ð4� V2BÞ � ð4� V2

AÞ ¼ ð4� 9Þ � ð4� 1Þ ¼ 32mmHg;

where VB is the velocity of 3 m/s and VA is 1 m/s.dP/dt is then calculated using the formula:

dP=dt ¼ 32mmHg� time ðsecondsÞ:

A depressed ventricle will take a longer time to develop thispressure gradient and have a lower dP/dt. Normal values for thisparameter are 1610 ± 290 mm Hg/s.49 Measurement of dP/dt is limitedby the need for enough mitral regurgitation to generate a well-defined


velocity curve. In addition, changes in the intercept angle betweenthe ultrasound beam and the regurgitant jet will result in an erroneousmeasurement. Even with the limitations, dP/dt of r700 mm Hg/shas been shown to predict late postoperative LV systolic dysfunctionafter aortic valve surgery, with a sensitivity of 94% and a specificityof 75%.50

’ Doppler Tissue Velocity

DTI is a relatively new echocardiographic technique that enables themeasurements of atrioventricular annular and regional myocardialvelocities. This modality may be more sensitive than conventionalechocardiography in detecting abnormalities of LV systolic and diastolicfunction.50–52 Mitral annular velocity determined by DTI is a relativelypreload-independent variable and may be superior to conventionalmitral Doppler indices.53 DTI is performed by placing a PWD samplevolume within a corner of the mitral valve annulus. The velocity of thisannular tissue is then displayed for quantification (Fig. 6). The systolicmotion of the annulus is toward the LV apex and is defined as Sa. Incontrast, the diastolic motion is biphasic and away from the apex. TheEa and Aa waves in diastole correspond to the E-waves and A-waves

Figure 5. Midesophageal 4-chamber view. A mitral regurgitation spectral jet is recorded with acontinuous-wave Doppler across the mitral valve inflow. dt was determined by the computer to be0.07 s. From this, dP/dt was calculated to be 457 mm Hg/s (32 mm Hg/0.07 s), which is severelydepressed.


(early and late diastolic filling, respectively) of the LV inflow velocityprofile. It has been shown that the late diastolic mitral annular velocity(Aa) is a sensitive index of pulmonary congestion in patients with LVsystolic dysfunction.54 In addition, the ratio between the transmitral flowvelocity (E) and the annular (Ea) velocity is a good noninvasive correlateof pulmonary capillary wedge pressure.55–58 An E/Ea ratio >10 has beenshown to correlate with high LV filling pressures. In one study, itdetected a PAWP >15 mm Hg with a sensitivity of 97% and a specificityof 78%.57 Moreover, the E/Ea ratio has been shown to be a potentialpredictor of diastolic filling pressures,55,57,59,60 cardiac mortality,61 andhospitalization owing to symptoms of heart failure.62

’ Conclusions

TEE is a versatile, inexpensive tool that may be used to assessmyocardial systolic function both intraoperatively and postoperatively inthe ICUs. The information derived from TEE may help guide treatmentof patients with hemodynamic instability and be superior or comple-mentary to the information obtained with a PAC. TEE-derivedassessment of systolic function includes calculation of fractional short-ening, volumetric calculation of EF, qualitative assessment of global andregional wall motion with or without echo contrast, Doppler-derivedmeasurement of CO and mitral regurgitation dP/dt, and tissue Dopplerparameters. Although none of these measurements may be the idealsystolic function assessment by itself, taken together they provide theclinician with useful information to guide his/her therapeutic plan.Validation studies are on-going in numerous centers.

Figure 6. DTI of the lateral mitral annulus. Lateral E0 (Ea) wave measured 13.8 cm/s (1.38 m/s)with a ratio of E/Ea of 5, indicating normal LV filling pressures.


’ Acknowledgment

The authors thank Dr Feroze Mahmood for providing the figures.

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