Determination of left ventricular ejection fraction by visual estimation during real-time two-dimensional echocardiography

doi:10.1016/0002-8703(82)90233-2

American Heart Journal

Volume 104, Issue 3, September 1982, Pages 603-606

https://doi.org/10.1016/0002-8703(82)90233-2 Get rights and content

Abstract

It has been shown that the measured reduction in the cross-sectional area of the left ventricle (LV), as viewed in the short axis, closely approximates its ejection fraction (EF). We assessed the reliability of using two-dimensional echocardiography (2DE) to visually estimate the EF during real-time viewing, without the need of digitizers, planimetry, or calculations. Twenty-five adult hospitalized patients with either suspected or known cardiac disease were evaluated prospectively. Each patient also had gated nuclear angiography during the same admission, and 14 had cardiac catheterization with left ventriculography. The EF was determined by 2DE using a visual estimate of the percent area reduction of the LV cavity in the short-axis view at the level of the papillary muscles. All 2 DE studies were read by two or more blinded reviewers, with a value for the EF to the nearest 2.5% determined by consensus. These values correlated closely to the values determined in all 25 patients with gated nuclear angiography (r = 0.927) and the 14 patients who had left ventriculography (r = 0.935). We believe that this method of visually estimating the LVEF will enable echocardiographers to easily use 2 DE for a reliable and instantaneous assessment of ventricular function, without the need of sophisticated analytical equipment.

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Cited by (134)

Systemic Atrioventricular Valve Surgery in Patients With Congenitally Corrected Transposition of the Great Vessels
2023, Journal of the American College of Cardiology
Limited data exist regarding the long-term outcomes of systemic atrioventricular valve (SAVV) intervention (morphologic tricuspid valve) in congenitally corrected transposition (ccTGA).
The goal of this study was to evaluate the mid- and long-term outcomes of SAVV surgery in ccTGA.
We performed a retrospective review of 108 ccTGA patients undergoing SAVV surgery from 1979 to 2022. The primary outcome was a composite endpoint of mortality, cardiac transplantation, or ventricular assist device implantation. The secondary outcome was long-term systemic right ventricular ejection fraction (SVEF). Cox proportional hazard and linear regression models were used to analyze survival and late SVEF data.
The median age at surgery was 39.5 years (Q1-Q3: 28.8-51.0 years), and the median preoperative SVEF was 39% (Q1-Q3: 33.2%-45.0%). Intrinsic valve abnormality was the most common mechanism of SAVV regurgitation (76.9%). There was 1 early postoperative mortality (0.9%). Postoperative complete heart block occurred in 20 patients (18.5%). The actuarial 5-, 10-, and 20-year freedom from death or transplantation was 92.4%, 79.1%, and 62.9%. The 10- and 20-year freedom from valve reoperation was 100% and 93% for mechanical prosthesis compared with 56.6% and 15.7% for bioprosthesis (P < 0.0001). Predictors of postoperative mortality were age at operation (P = 0.01) and preoperative SVEF (P = 0.04). Preoperative SVEF (P < 0.001), complex ccTGA (P = 0.02), severe SAVV regurgitation (P = 0.04), and preoperative creatinine (P = 0.003) were predictors of late postoperative SVEF.
SAVV surgery remains a valuable option for the treatment of patients with ccTGA, with low early mortality and satisfactory long-term outcomes, particularly in those with SVEF ≥40%. Timely referral and accurate patient selection are the keys to better long-term outcomes.
The Impact on 30-Day Mortality From a Brief Focused Ultrasound-Guided Management Protocol Immediately Before Emergency Noncardiac Surgery in Critically Ill Patients: A Multicenter Randomized Controlled Trial
2022, Journal of Cardiothoracic and Vascular Anesthesia
To determine whether brief ultrasound-guided treatment of hemodynamic shock and respiratory failure immediately before emergency noncardiac surgery reduced 30-day mortality.
Parallel, nonblinded, randomized trial with 1:1 allocation to control and intervention groups.
Twenty-eight major hospitals within China.
Six-hundred sixty patients ≥14 years of age, scheduled for emergency noncardiac surgery with evidence of shock (heart rate >120 beat/min, systolic blood pressure< 90 mmHg or requiring inotrope infusion), or respiratory failure (Pulse Oxygen Saturation <92%, respiratory rate >20 beat/min, or requiring mechanical ventilation).
A brief (<15 minutes) focused ultrasound of ventricular filling and function, lung, and peritoneal spaces, with predefined treatment recommendation based on the ultrasound was performed before surgery or standard care.
The primary outcome was 30-day mortality. Secondary outcomes included changes in medical or surgical diagnosis and management due to ultrasound, intensive care unit, and hospital stay and cost, and Short Form-8 quality-of-life scores. Although there were frequent changes in diagnosis (82%) and management (49%) after the ultrasound, mortality at 30 days was not different between groups (50 [15.7%] v 53 [16.3%]; odds ratio 1.05, 0.69-1.6, p = 0.826). There were no differences in the secondary outcomes of the days spent in the hospital (mean 13.8 days, 95% confidence interval [CI] 12.1-15.6 v 14.4 d, 11.8-17.1, p = 0.718) or intensive care unit (mean 9.3 days, 95% CI 7.7-11.0 v 8.7 d, 7.2-10.2, p = 0.562), hospital cost (USD$14.5K, 12.2-16.7 v 13.7, 11.5-15.9, p = 0.611) or Short Form-8 scores at one year (mean 80.9, 95% CI 78.4-83.3 v 79.7, 76.9-82.5, p = 0.54) between participants allocated to the ultrasound and control groups.
In critically ill patients with hemodynamic shock or respiratory failure, a focused ultrasound-guided management did not reduce 30-day mortality but led to frequent changes in diagnosis and patient management.
Left Ventricular Ejection Fraction Assessment by Emergency Physician-Performed Bedside Echocardiography: A Prospective Comparative Evaluation of Multiple Modalities
2021, Journal of Emergency Medicine
Citation Excerpt :
These modalities are frequently taught to emergency medicine trainees who are less experienced with POC-TTE as a method of estimating LVEF (12,13). However, existing evidence evaluating the ability of EPSS and FS to accurately estimate LVEF is limited and requires further investigation (3,4,10,11,14–20). EPSS specifically is an attractive modality, as it is commonly taught and performed in the ED and has been shown to be easy to teach and implement with novice learners (12,13).
Although there is some support for visual estimation (VE) as an accurate method to estimate left ventricular ejection fraction (LVEF), it is also scrutinized for its subjectivity. Therefore, more objective assessments, such as fractional shortening (FS) or e-point septal separation (EPSS), may be useful in estimating LVEF among patients in the emergency department (ED).
Our aim was to compare the real-world accuracy of VE, FS, and EPSS using a sample of point-of-care cardiac ultrasound transthoracic echocardiography (POC-TTE) images acquired by emergency physicians (EPs) with the gold standard of Simpson's method of discs, as measured by comprehensive cardiology-performed echocardiography.
We conducted a single-site prospective observational study comparing VE, FS, and EPSS to assess LVEF. Adult patients in the ED receiving both POC-TTE and comprehensive cardiology TTE were included. EPs acquired POC-TTE images and videos that were then interpreted by 2 blinded EPs who were fellowship-trained in emergency ultrasound. EPs estimated LVEF using VE, FS, and EPSS. The primary outcome was accuracy.
Between April and May 2018, 125 patients were enrolled and 113 were included in the final analysis. EP1 and EP2 had a κ of 0.94 (95% confidence interval [CI] 0.87–1.00) and 0.97 (95% CI 0.91–1.00), respectively, for VE compared with gold standard, a κ of 0.40 (95% CI 0.23–0.57) and 0.38 (95% CI 0.18–0.57), respectively, for EPSS compared with gold standard, and a κ of 0.70 (95% CI 0.54–0.85) and 0.66 (95% CI 0.50–0.81), respectively, for FS compared with gold standard. Sensitivity of severe dysfunction was moderate to high in VE (EP1 85% and EP2 93%), poor to moderate in FS (EP1 73% and EP2 50%), and poor in EPSS (EP1 11% and EP2 18%).
Using a real-world sample of POC-TTE images, the quantitative measurements of EPSS and FS demonstrated poor accuracy in estimating LVEF, even among experienced sonographers. These methods should not be used to determine cardiac function in the ED. VE by experienced physicians demonstrated reliable accuracy for estimating LVEF compared with the gold standard of cardiology-performed TTE.
Right ventricular dysfunction in congenitally corrected transposition of the great arteries and risk of ventricular tachyarrhythmia and sudden death
2018, International Journal of Cardiology
Citation Excerpt :
Echocardiography is most frequently used at our institution and a combination of M-mode and 2-dimensional measurements was used to estimate the systemic right ventricular EF. The methodology behind visual estimation of EF for the sub-pulmonic left ventricle has also been previously described [13,24,29]. Given the limited number of patients with MRI estimation of their RV EF, we opted to rely on the echocardiographic estimate of the RV EF as has been used in prior data from our group in this patient population in evaluating long-term outcomes [13].
It is unknown whether systemic right ventricular (SRV) dysfunction confers increased risk for sudden death in congenitally corrected transposition of the great arteries (ccTGA). We sought to define risk of ventricular arrhythmias and sudden death attributable to systemic right ventricular dysfunction in ccTGA.
The study cohort is comprised of adult patients with a diagnosis of ccTGA. Clinical information and clinical outcomes including ICD therapy, incidence of VT/VF, and cause of death were reviewed.
129 patients with ccTGA were followed for 7.2 ± 3.4 years. Mean SRV ejection fraction (SRVEF) was 39% (n = 56 with an EF <35%). Significant documented arrhythmia (sustained VT requiring defibrillation or cardiac arrest due to VT/VF) occurred in 13/56 patients (23%) with SRV EF <35% compared with 2/73 (3%) with SRV EF >35% (p < 0.001). There was no significant difference in age at death, death from documented arrhythmia, or death from all cause between patients with SRV EF <35% and >35%. However, risk of sudden death was higher in patients with SRV EF <35% (16% vs 1%, p = 0.002). The combined clinical endpoint of ICD therapy, clinically significant VT/VF, and sudden death was significantly higher in patients with SRV EF <35% than in patients with SRV EF >35%, independent of the presence of LV EF <35% (p < 0.001).
Dysfunction of the systemic RV in ccTGA increases the risk of sudden death and clinically significant ventricular tachyarrhythmias. Further study is needed to determine if ventricular tachyarrhythmias comprise the primary cause of sudden death in these patients and if ICDs offer any significant mortality benefit.
Do differences in early hemodynamic performance of current generation biologic aortic valves predict outcomes 1 year following surgery?
2015, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
In addition to preoperative and intraoperative echocardiography assessment, patients underwent further comprehensive 2-dimensional and Doppler echocardiographic evaluation using state-of-the-art technology before hospital dismissal, and—among patients with midterm follow-up data—at 1 year following AVR. As previously detailed,9 left ventricular (LV) ejection fraction was evaluated by 2-dimensional echocardiography in the LV short-axis view, and using a modified technique detailed by Quinones and colleagues,10 or by visual estimate.11 In alignment with best practice, continuous-wave and pulsed Doppler measurements were recorded12 taking an average of 3 beats.
Small early postoperative hemodynamic differences were noted in a randomized comparison of 3 current-generation bioprosthetic aortic valves. Whether these differences persist and influence clinical outcomes 1 year following implantation is unknown.
Three hundred adults with severe aortic stenosis undergoing valve replacement were randomized to receive the Epic (St Jude, St Paul, Minn) (n = 99), Magna (Edwards LifeSciences Inc, Irvine, Calif) (n = 100), or Mitroflow (Sorin Biomedica Spa, Saluggio, Italy) (n = 101) bioprostheses. Hemodynamic valve performance was examined by echocardiography at 1 year, and clinical outcomes were assessed in 241 patients (79 Epic, 77 Magna, and 85 Mitroflow; P = .437).
Mean age was 75 ± 8 years and 164 were men (68%). Between dismissal and 1 year there were 9 deaths (3.7%) (Epic: 3.7%, Magna: 5.0%, and Mitroflow: 2.3%; P = .654), 6 episodes of heart failure (2.5%) (Epic: 1.3%, Magna: 1.3%, and Mitroflow: 5.8%; P = .265), 27 instances of atrial fibrillation/flutter (11.2%) (Epic: 8.1%, Magna: 11.0%, and Mitroflow: 7.9%; P = .577) and no strokes/transient ischemic attacks. One-year echocardiography demonstrated small hemodynamic differences between Epic, Magna, and Mitroflow bioprostheses in mean gradient (15.2 ± 5.5, 12.3 ± 4.3, and 16.2 ± 5.7 mm Hg, respectively; P < .001) and indexed aortic valve area (0.93 ± 0.28, 1.04 ± 0.28, and 0.96 ± −0.26 cm²/m², respectively; P = .015). Several early trends persisted when stratifying data by echocardiographic annulus diameter, universal annulus size, and implant size, particularly with annular size ≥23 mm. Overall left ventricular mass index regression between dismissal and 1 year was −16.5 ± 28.1 g/m², and was similar among groups (P = .262). There were no aortic valve reoperations.
Despite midterm persistence of small hemodynamic differences amongst current-generation porcine and pericardial aortic valves, our prospective randomized comparison reveals that clinical outcomes and mass regression are equivalent between devices at 1 year. These encouraging trends must continue to be assessed during longitudinal follow-up.
Point-of-care ultrasound diagnoses acute decompensated heart failure in the ED regardless of examination findings
2014, American Journal of Emergency Medicine

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^☆: Supported in part by National Heart, Lung and Blood Institute Grant HL 07387.

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Determination of left ventricular ejection fraction by visual estimation during real-time two-dimensional echocardiography☆

Abstract

Radiol Clin North Am

Measurement of left ventricular ejection fraction by mechanical cross-sectional echocardiography

Circulation

Assessment of left ventricular ejection fraction and volumes by real-time, two-dimensional echocardiography

Circulation