LV Function

Transcription

LV Function

Evaluation of Left Ventricular Function
Julian Bick, MD
Assistant Professor of Clinical Anesthesiology
Division of Cardiothoracic Anesthesiology
Vanderbilt University
Tennessee, United States of America
Disclosures: Honoraria from Imacor Inc.
Some of the images used in this presentation were generated with HeartworksTM Echo Simulator (Inventive Medical, Ltd)
Some of the TEE clips and graphics used in this presentation are from www.e-echocardiography.com under the User
License.
Thursday, January 31, 13
After attending this session, the participant will be
able to:
1. Describe left ventricular anatomy
2. Describe TEE views of the left ventricle
3. Recognize global LV dysfunction and RWMAs
Left Ventricular Anatomy
• Review LV Anatomy
– Cardiac Axes
– 17-Segment LV Nomenclature
– Mid Esophageal
• 4-Chamber, 2-Chamber, and Long Axis Views
– Transgastric
• Basal , Mid, and Apical Short Axis Views
–Foreshortening
Short versus Long Axis
Left Ventricular Nomenclature
Anterior
Lateral
Septal
al
Bas
Mid
l
ica
Ap
Apical Cap
Inferior
Circulation 2002;105;539-542
ME 4C View 0-10o
This allows visualization of the interventricular septum
and the lateral wall of the left ventricle.
Anterior
ME 4C View
3 = Basal Inferoseptal
9 = Mid Inferoseptal
14 = Apical Septal
17 = Apex
16 = Apical Lateral
12 = Mid Anterolateral
6 = Basal Anterolateral
Lateral
Septal
Inferior
6
3
12
9
14
16
17
ME 2C View 90o
This allows visualization of the inferior and anterior
walls of the left ventricle.
Anterior
ME 2C View
1 = Basal Anterior
9 = Mid Anterior
13 = Apical Anterior
17 = Apex
15 = Apical Inferior
10 = Mid Inferior
4 = Basal Inferior
Lateral
Septal
Inferior
4
1
10
7
15
13
17
ME LAX View 145o
This view allows visualization of the inferolateral
(posterior) and anteroseptal walls of the left ventricle.
Anterior
ME LAX View
2 = Basal Anteroseptal
8 = Mid Anteriorseptal
5 = Basal Inferolateral
11 = Mid Inferolateral
Lateral
Septal
Inferior
5
11
2
8
3
2
Anterior
1 = Basal Anterior
2 = Basal Anteroseptal
3 = Basal Inferoseptal
4 = Basal Inferior
4
5
6
1
Anterior
Lateral
Septal
1
2
6
Inferior
TG Basal SAX
3
4
5
9
10
11
8
7
Anterior
7 = Mid Anterior
8 = Mid Anteroseptal
9 = Mid Inferoseptal
10 = Mid Inferior
12
Anterior
Lateral
Septal
7
16
Inferior
12
8
9
TG Mid SAX
11
10
15
14
16
13
Anterior
13 = Apical Anterior
14 = Apical Septal
15 = Apical Inferior
16 = Apical Lateral
Anterior
Lateral
Septal
13
Inferior
TG Apical SAX
14
16
15
Anterior
Left Ventricle Coronary
Blood Supply
Left Anterior Descending
Circumflex
Lateral
Septal
Inferior
Right
Anterior
Blood Supply
Circumflex
Lateral
Septal
Inferior
Right
Anterior
Blood Supply
Circumflex
Lateral
Septal
Inferior
Right
Anterior
Blood Supply
Circumflex
Lateral
Septal
Inferior
Right
Foreshortening of the Long Axis of the Heart
in the ME 4 C View
•Foreshortening is an error that occurs when the ultrasound scan sector is not parallel to a cardiac axis
usually the long axis but can occur along the short axis as well
• The apex of the left ventricle should be stationary in the mid esophageal views
• If the “apex” appears to move to toward the base of the heart foreshortening is occurring
• Correction of foreshortening involves subtle advancement/withdraw and or ante/retroflexion of the
probe
Left Ventricular Function
• Global LV Function
–Fractional Area of Change
–Ejection Fraction
• Regional LV Function
– LV Segmental Wall Thickening Score
Two Dimensional: Fractional Area Change
TG, mid-papillary SAX view
FAC% = (LVEDA – LVESA) / LVEDA x 100
3/4 of SV generated at this plane
(r = 0.96 preload & ventriculography)
End Diastole
End Systole
FAC-Ejection Fraction Correlation
Normal Heart
(No Regional Wall Motion Abnormalities)
Elevated ejection fraction may be cause by severe
AI, MR, VSD, or very low SVR.
EJECTION FRACTION
STROKE VOLUME / END DIASTOLIC VOLUME X 100%
Simpson’s Method
Method of Disks
GOOD NEWS: THE TEE MACHINE
CAN DO THIS FOR YOU
End Diastole
End Systole
Only 1 plane is shown here with a ME 4-Chamber view however performing the calculation
again in the ME 2-Chamber view increases the accuracy of this method.
LV EF with 3D TEE
LV Regional Assessment
What you are doing
At each segment of the left ventricle you are estimating whether the myocardium is
thickening by at least 30%, less than 30%, it is not thickening, or it is thinning during systole.
LV WALL MOTION SCORING SCALE
Normal
Hypokinetic
Akinetic
Dyskinetic
3
2
1
0
Mid Inferoseptal
Mid Inferior
Mid Inferolateral
Mid Anteroseptal
Mid Anterior
MId Anterolateral
Correct Wall Motion Analysis
Normal
Hypokinetic
Akinetic
Dyskinetic
3
2
1
0
Mid Inferoseptal
Mid Inferior
Mid Inferolateral
Mid Anteroseptal
Mid Anterior
MId Anterolateral
Mid Inferoseptal
Mid Inferior
Mid Inferolateral
3
3
2
Mid Anteroseptal
Mid Anterior
MId Anterolateral
3
3
2
Normal
Hypokinetic
Akinetic
Dyskinetic
3
2
1
0
Mid Inferoseptal
Mid Inferior
Mid Inferolateral
Mid Anteroseptal
Mid Anterior
MId Anterolateral
The lateral wall is hypokinetic
also notice the LV is hypertophied
Mid Inferoseptal
Mid Inferior
Mid Inferolateral
3
3
2
Mid Anteroseptal
Mid Anterior
MId Anterolateral
3
3
2
Case 1. A 65 year old male is in the OR for aortic valve
replacement for aortic stenosis. Biventricular function was normal
during the preprocedure TEE. An aortic root needle was used to de
air. CPB has been terminated and TEE reveals a normal prosthetic
valve function. The following image was obtained.
Findings? Cause? Treatment?
CPB was resumed for 10 minutes with a
MAP of 85 then CPB was terminated and the
following image was obtained. Note
ventricular dysnergy from V-Pacing.
Case 2. A 55 year old male is in the
OR for cardiac surgery.
Preprocedure TEE reveals the
following image.
Case 2 5-Chamber View
DIAGNOSIS ?
LV Models compared by
ventriculography
Simpson’s best
correlation
no geometric
assumption
“Method of discs”
20 discs, equal
thickness
Normal
Aneurysmal
Pichard M et al. J Am Soc Echocardiogr; 2008
Case 2.
S/P LV Aneurysm Resection and CABG
Case 3. A 60 year old female with no CAD and normal pre
procedure biventricular function has undergone a mitral
annuloplasty. CPB has been terminated and the following
TEE image was obtained?
Findings?
Cause?
Treatment?
Case 3. Iatrogenic circumflex artery injury
during mitral surgery.
A discussion with the surgeon prompted
the resumption of CPB and the mitral
annuloplasty ring was removed and
downsized. Care was taken to place the
annuloplasty sutures more superficial
relative to the location of the circumflex
artery. CPB was terminated and the LV
wall motion and function were normal.
An advantage of examining LV global and regional function in the trangastric
short axis views compared to the mid esophageal views includes.
1. Superior resolution of the LV apical cap
2. Visualization of the LV walls without dropout from a mitral prothesis or
mitral annular calcification
3. Visualization of all three coronary segments in one TEE imaging plane
Answer choices
A. 1 only
B. 1 and 2
C. 2 and 3
D. 1,2, and 3
E. None of the above
This image is
consistent with?
A. Normal LV wall motion
B. Occlusion of the right coronary artery
C. Occlusion of the left anterior descending artery
D. Occlusion of the anterior and circumflex coronary arterys
This image is
consistent with?
A. Normal anterior wall motion
B. Normal LV wall motion
C. Normal inferior wall motion
D. Global LV hypokinesis
Always be mindful of
foreshortening!
Global and regional LV dysfunction are much more common than

LV Function

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