lv function - cecentral

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 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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LVOT Diameter• Measuring the LVOT: PSLX

Monday, May 6, 13

LVOT Diameter• Measuring the LVOT: PSLX

LV LA

RVOTAo

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• Measuring the LVOT

LVOT Diameter

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LVOTdiameter

LVOT Diameter

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LVOT Diameter

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SV Measurement

• Still need the length of the column

LD

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• Measuring the LVOTVTI:

• Apical Long Axis or

Apical 5 chamber window

LVOT VTI (length of column)

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• Place Pulsed Wave gate at LVOT

• Just apical from the AoValve


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Monday, May 6, 13




• Place Pulsed Wave gate at LVOT

• Just apical from the AoValve


Monday, May 6, 13

• Measuring the LVOTVTI


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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


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


LVOTVTI : LVOTVTI-PLR

Monday, May 6, 13

confusid?

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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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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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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 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

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EPSS v MRI

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PSLA

LV LA

RVOTAo

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PSLA

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E

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EA

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Pitfalls

• Aortic Insufficiency

• Mitral Stenosis

• Mitral Calcifications

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Pitfalls• Aortic Insufficiency

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Pitfalls• Mitral Stenosis

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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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