left ventricle michel slama amiens france. lv ventricle ejection fraction cardiac output left...
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Left ventricle
Michel SlamaAmiensFrance
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LV ventricle
• Ejection fraction• Cardiac output
• Left ventricular filling pressure
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Ejection fraction : systolic function, contractility?
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Shortening FractionShortening
Fraction of LV Area
Ejection Fraction
Systolic
Function
LEVEL 1
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Mitral valve opening
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NB Shiller, Heart, 1996;75:17-26
Estimated and measured EF
LEVEL 1
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Pouleur, Am J Cardiol, 1983;52:813-21
Influence of afterload on EF
HT, AS
Septic
Shock
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Cardiac output
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How to perform echocardiographic examination in shocked patient?
• Cardiac output TTE:
LEVEL 2
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How to perform echocardiographic examination in shocked patient?
• Cardiac output TTE: LEVEL 2
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Diastolic function
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LV relaxation
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Pathophysiology
Pressure
Normal
Normal
Diastolic dysfunction
Volume
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LVEDP
LVEDV
18 mmHg
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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
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Early filling Late filling
Vitesses
LAP
LVP
Velocies
P1 – P2 = 4 x V2
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LV Pressure
Mitral flow
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Type I of Appletonrelaxation impairement
Early diastole
Latediastole
Vitesses
LAP
LAPLVP
Velocities
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Decreased preload
SOHN, JACC 1997
BASE TNT
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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
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Mitral annulus movement
EaAa Ea
Aa
normalEa = 18cm/s Ea > Aa
Relaxation impairement (HT)Ea = 7,5cm/s et Ea < Aa
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Left atrial size
LAV = 0,5 x L1 x L2 x L3
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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
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PAOP (Wedge pressure)
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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
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E/E’ ratio predicts PAOP
LEVEL 2
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Combes A Int Care Med 2004
E/Ea
ICU, mechanical ventilation
LEVEL 2
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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
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Septic shock
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Myocardial infarction with cardiogenic shock
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Pulmonary oedema
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Congestive heart failure with pulmonary oedema
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Unexplained shock
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Conclusion