LV Function Cardiac Output EPSS
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1 LV Function Cardiac Output EPSS Mike Mallin, MD
2 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?
3 Fluid Responsive Fluid Responsive: A volume load Mike should induce a significant increase in cardiac output. 500cc-1L Matt 10-15% CO
4 Measuring CO How to measure SV/CO: SV = Length area SV = LVOTVTI r 2 CO = LVOTVTI r 2 HR
5 Stroke Volume CO = LVOTVTI r 2 HR Column of blood
6 CO = LVOT VTI r 2 HR Stroke Volume
7 CO = LVOT VTI r 2 HR Stroke Volume
8 CO = LVOT VTI r 2 HR Stroke Volume
9 CO = LVOT VTI r 2 HR Stroke Volume
10 CO = LVOT VTI r 2 HR Stroke Volume
11 CO = LVOT VTI r 2 HR Stroke Volume
12 Stroke Volume CO = LVOTVTI r 2 HR How to measure SV/CO: SV = LVOTVTI r 2 SV = Volume of Column of blood: Length of column x area
13 Stroke Volume Area Circle = r 2
14 Stroke Volume Area Circle = r 2
15 LVOT Diameter Measuring the LVOT: PSLX
16 LVOT Diameter Measuring the LVOT: PSLX RVOT Ao LV LA
17 LVOT Diameter Measuring the LVOT: PSLX RVOT Ao LV LA
18 LVOT Diameter Measuring the LVOT
19 LVOT Diameter Measuring the LVOT
20 LVOT Diameter Measuring the LVOT
21 LVOT Diameter Measuring the LVOT LVOTdiameter
22 LVOT Diameter Measuring the LVOT
23 SV Measurement Still need the length of the column L D
24 SV Measurement Still need the length of the column L D
25 SV Measurement Still need the length of the column L D
26 LVOT VTI (length of column) Measuring the LVOTVTI: Apical Long Axis or Apical 5 chamber window
27 LVOT VTI (length of column) Measuring the LVOTVTI: Apical Long Axis or Apical 5 chamber window Place Pulsed Wave gate at LVOT Just apical from the AoValve
28 LVOT VTI (length of column) Measuring the LVOTVTI: Apical Long Axis or Apical 5 chamber window
29 LVOT VTI (length of column) Measuring the LVOTVTI: Apical Long Axis or Apical 5 chamber window
30 LVOT VTI (length of column) Measuring the LVOTVTI: Apical Long Axis or Apical 5 chamber window
31 LVOT VTI (length of column) Measuring the LVOTVTI: Apical Long Axis or Apical 5 chamber window
32 LVOT VTI (length of column) Measuring the LVOTVTI: Apical Long Axis or Apical 5 chamber window Place Pulsed Wave gate at LVOT Just apical from the AoValve
33 LVOT VTI (length of column) Measuring the LVOTVTI
34 Passive Leg Raise Testing Semirecumbent patient Measure CO/SV at baseline Raise legs by Repeat CO/SV measurement
35 Passive Leg Raise Testing Who cares what the CO is? I want to know if they are a responder! CO=SV HR CO PLR=SVPLR x HRPLR LVOTVTI r 2 x HR : LVOTVTI-PLR r 2 x HRPLR
36 Passive Leg Raise Testing Who cares what the CO is? I want to know if they are a responder! CO=SV HR CO PLR=SVPLR x HRPLR LVOTVTI r 2 x HR : LVOTVTI-PLR r 2 x HRPLR
37 Passive Leg Raise Testing Who cares what the CO is? I want to know if they are a responder! CO=SV HR CO PLR=SVPLR x HRPLR LVOTVTI r 2 x HR : LVOTVTI-PLR r 2 x HRPLR
38 Passive Leg Raise Testing Who cares what the CO is? I want to know if they are a responder! CO=SV HR CO PLR=SVPLR x HRPLR LVOTVTI r 2 x HR : LVOTVTI-PLR r 2 x HRPLR
39 Passive Leg Raise Testing Who cares what the CO is? I want to know if they are a responder! CO=SV HR CO PLR=SVPLR x HRPLR LVOTVTI r 2 x HR : LVOTVTI-PLR r 2 x HRPLR
40 Passive Leg Raise Testing Who cares what the CO is? I want to know if they are a responder! CO=SV HR CO PLR=SVPLR x HRPLR LVOTVTI r 2 x HR : LVOTVTI-PLR r 2 x HRPLR LVOTVTI : LVOTVTI-PLR
41 Passive Leg Raise Testing Who cares what the CO is? I want to know if they are a responder! CO=SV HR CO PLR=SVPLR x HRPLR LVOTVTI r 2 x HR : LVOTVTI-PLR r 2 x HRPLR LVOTVTI : LVOTVTI-PLR
42 Passive Leg Raise Testing Who cares what the CO is? I want to know if they are a responder! CO=SV HR CO PLR=SVPLR x HRPLR LVOTVTI r 2 x HR : LVOTVTI-PLR r 2 x HRPLR LVOTVTI : LVOTVTI-PLR
43 confusid?
44 Need less information? Just want to know: Is the pump working?
45 Leg raise?
46 LV Function Measuring EF: Eyeball Fractional Shortening Method of Discs Tricks -- EPSS
47 The Eyeball Method
48 Eyeballin Not always this obvious
49 Easy when...
50 Hard when...
51 Hard when...
52 Eyeball Hyperdynamic: EF >75% Normal: EF 55-65% Moderately Reduced: EF 30-55% Severely Reduced: EF <30%
53 Hyperdynamic Normal
54 Hyperdynamic Normal
55 Normal Moderately Decreased
56 Normal Moderately Decreased
57 Moderately Depressed Severely Depressed
58 Fractional Shortening Fractional Shortening : Normal 25-45% FS = (EDV-ESV) / EDV
59 Ways to measure LV EF Simpson s Method - Method of Discs
60 EPSS History: EPSS EPSS correlated with angio 125 patients: Strong negative correlation r = EPSS absent or <5mm in most normal hearts
61 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 Jul; 106: in 108 patients EPSS > 7mm 87% sen, 75% spec for EF<50%
62 EPSS: Novice v Expert 12 PGY3s&4s perform EPSS on patients with dyspnea Correlated EPSS with EM US director and cardiologist visual estimation
63 EPSS: Novice v Expert 12 PGY3s&4s perform EPSS on patients with dyspnea Correlated EPSS with EM US director and cardiologist visual estimation
64 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 EPSS measured on MRI and compared to MRI Ejection Fraction MRI LVEF = MRI EPSS with r=0.82
65 EPSS v MRI
66 PSLA RVOT Ao LV LA
67 PSLA RVOT Ao LV LA
68 PSLA
69 PSLA
70 PSLA
71
72
73
74
75
76
77
78
79
80
81 E
82 E
83 E A
84
85
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87
88 Pitfalls Aortic Insufficiency Mitral Stenosis Mitral Calcifications
89 Aortic Insufficiency Pitfalls
90 Mitral Stenosis Pitfalls
91 Mitral Calcification Pitfalls
92 Mitral Calcification Pitfalls
93 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.
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