Left ventricle
Michel SlamaAmiensFrance
LV ventricle
• Ejection fraction• Cardiac output
• Left ventricular filling pressure
Ejection fraction : systolic function, contractility?
Shortening FractionShortening
Fraction of LV Area
Ejection Fraction
Systolic
Function
LEVEL 1
Mitral valve opening
NB Shiller, Heart, 1996;75:17-26
Estimated and measured EF
LEVEL 1
Pouleur, Am J Cardiol, 1983;52:813-21
Influence of afterload on EF
HT, AS
Septic
Shock
Cardiac output
How to perform echocardiographic examination in shocked patient?
• Cardiac output TTE:
LEVEL 2
How to perform echocardiographic examination in shocked patient?
• Cardiac output TTE: LEVEL 2
Diastolic function
LV relaxation
Pathophysiology
Pressure
Normal
Normal
Diastolic dysfunction
Volume
LVEDP
LVEDV
18 mmHg
Mitral flow : how to record ?
• Pulsed Doppler• Correct Alignement• Small window• At the tip of mitral valve• Visible opening sound• Settings et filters • 100 mm/s• Average of 3 measurements
Early filling Late filling
Vitesses
LAP
LVP
Velocies
P1 – P2 = 4 x V2
LV Pressure
Mitral flow
Type I of Appletonrelaxation impairement
Early diastole
Latediastole
Vitesses
LAP
LAPLVP
Velocities
Decreased preload
SOHN, JACC 1997
BASE TNT
Ea
Aa
• DTI• Mitral annulus• Minimum settings
Normal values
Ea > 8 cm/s et Ea / Aa > 1
• Ea = 15 ± 4 cm/s Aa = 10 ± 3 cm/s
Mitral annulus movement
EaAa Ea
Aa
normalEa = 18cm/s Ea > Aa
Relaxation impairement (HT)Ea = 7,5cm/s et Ea < Aa
Left atrial size
LAV = 0,5 x L1 x L2 x L3
Practical approach to assess diastolic function
E’ lateralE’ Septal
LA volume
E’ lateral>10cm/sE’ Septal>8cm/s
LA volume<34 ml/m²
E’ lateral>10cm/sE’ Septal>8cm/s
LA volume>34 ml/m²
E’ lateral<10cm/sE’ Septal<8cm/s
LA volume>34 ml/m²
Normal left ventricular relaxation
Athlet’s heart or constriction
Left ventricular dysfunction
PAOP (Wedge pressure)
E (Mitral flow) depends on PAOP and on LV
relaxation
E’ (TDI mitral annulus) evaluate LV relaxation
(preload independent)
E/Ea ratio depends on
PAOP
LEVEL 2
E/E’ ratio predicts PAOP
LEVEL 2
Combes A Int Care Med 2004
E/Ea
ICU, mechanical ventilation
LEVEL 2
Other tools to evaluate cardiac function
• Speckle tracking and strain evaluation• 3D imaging assessement of EF• MAPSE• S wave on TDI at the mitral annulus
Septic shock
Myocardial infarction with cardiogenic shock
Pulmonary oedema
Congestive heart failure with pulmonary oedema
Unexplained shock
Conclusion