left ventricle michel slama amiens france. lv ventricle ejection fraction cardiac output left...

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