Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5189_Библиотеки_им_академика_М_И_Перельмана.pdf
10 Artifacts andPitfalls inTransesophageal Echocardiography
Questions
1. What artifact is identied by the arrow in the
following image?
127
A. Side-Lobe Artifact
B. Stich Artifact
C. Mirror Artifact
D. Reverberation Artifact
E. Ring down Artifact
Answer: D. This is an example of reverberation artifact. The left atrial–aortic wall
interface is a strong reector allowing for
echoes to be re-reected before reaching the
ultrasound probe. The reverberation artifact
can mimic an intimal ap. With a reverberation
artifact, there should be decreasing intensity
with increasing distance from the probe. The
artifact also should lack independent
movement.
128
2. What structure is identied by the arrow in the
following image?
M. Behrens and T. T. Tauh
A. Eustachian Valve
B. Chiari Network
C. Cor Triatriatum Dexter
D. Pulmonary Artery Catheter
E. Crista Terminalis
F. Moderator Band
Answer: B.This is a TEE image with an
example of a Chiari network labeled with the
white arrow. The operator has pushed the
probe in from the mid-esophageal four chamber and is showing the inferior vena cava
(IVC) and right atrial (RA) junction. This anatomic location helps narrow the differential of
the structure being a Chiari network versus an
eustachian valve. The very thin, lamentous,
and mobile nature of the structure make it a
Chiari network.
10 Artifacts andPitfalls inTransesophageal Echocardiography
129
3. What structure is identied by the arrow in the
following image?
A. Eustachian Valve
B. Chiari Network
C. Cor Triatriatum Dexter
D. Pulmonary Artery Catheter
E. Crista Terminalis
F. Moderator Band
Answer: F.This an example of a moderator
band. As a review, this is a prominent myocardial trabeculation seen in the mid to apical
right ventricle and can be found in much of
the population. Most of the time this test question will present an image in the midesophageal four chamber view similar to the above
and Image 14. It possible that a deep transgastric ve-chamber view in TEE or apical four-
chamber view from TTE could be used to
show this structure. Remember the moderator
band is a normal anatomical variant.
References
1. Le HT, Hangiandreou N, Timmerman R, Rice
MJ, Smith WB, Deitte L, Janelle GM. Imaging
artifacts in echocardiography. Anesth Analg.
2016;122(3):633–46.
2. Hykes DL, Hedrick WR, Starchman DE.Ultrasound
physics and instrumentation. Mosby; 1992.
3. Quien M, Saric M. Ultrasound imaging artifacts:
how to recognize them and how to avoid them.
Echocardiography. 2018;35(9):1388–401.
4. Bertrand PB, Levine RA, Isselbacher EM, Vandervoort
PM.Fact or artifact in two-dimensional echocardiography: avoiding misdiagnosis and missed diagnosis. J
Am Soc Echocardiogr. 2016;29(5):381–91.
5. Allen MN, editor. Echocardiography. Lippincott
Williams & Wilkins; 1999.
6. Scanlan KA.Sonographic artifacts and their origins.
AJR Am J Roentgenol. 1991;156(6):1267–72.
7. Oxorn D, Otto CM.Intraoperative and interventional
echocardiography: atlas of transesophageal imaging
E-book. Elsevier Health Sciences; 2016.
8. Klopman MA, Chen EP, Sniecinski RM.Positioning
an intraaortic balloon pump using intraoperative
transesophageal echocardiogram guidance. Anesth
Analg. 2011;113(1):40–3.
9. Otto CM. Textbook of clinical echocardiography.
Elsevier Health Sciences; 2018.
10. Lang RM, Badano LP, Tsang W, Adams DH, Agricola
E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP,
Kamp O. EAE/ASE recommendations for image
acquisition and display using three-dimensional
echocardiography. Eur Heart J Cardiovasc Imaging.
2012;13(1):1–46.
11. Pamnani A, Skubas NJ. Imaging artifacts during
transesophageal echocardiography. Anesth Analg.
2014;118(3):516–20.
LV Systolic Function
JonathanN.Wilkinson andFerozMohammed
11
Learning Objectives
1. Understand multiple methods of quantifying
left ventricular systolic function.
2. Recognize the limitations of these methods.
3. Correlate regional wall motion abnormalities
with the coronary distribution.
Assessment of left ventricular systolic function
is a core application of critical care echocardiography. In critically ill patients, most assessments of left ventricular function can be done
qualitatively to facilitate a decision at the bedside. One can recognize profound dysfunction
without quantication. However, familiarity
with quantication may develop one’s qualitative heuristics for the “eyeballing” function.
This chapter will review some common methods of quantifying LV systolic function used in
critical care. Throughout this chapter, we will
employ reference standards in accordance with
the American Society of Echocardiography and
the European Association of Cardiovascular
Imaging [1].
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 80038- 2_11.
J. N. Wilkinson (*) · F. Mohammed
Intensive Care and Anaesthesia, Northampton, UK
Structural Anatomy
The left ventricle has three parts: The inlet,
containing the mitral valve; the apex, containing a trabeculated network, and the outlet,
containing the aortic valve. The orientation of
the cardiac muscles provides the basis for the
heart to function as a pump. The ellipsoid
shape of the left ventricle is a result of the
laminar layering of spiraling bundles of cardiac muscles. The muscle bundles are longitudinal in the subepicardial myocardium,
circumferential in the middle segment and
become longitudinal again in the subendocardial myocardium.
This muscular conguration results in a more
complex contraction prole than is rst apparent on 2D ultrasound (pure up-down movement). At the apex and base, there is vertical
contraction, whereas in the middle, there is circumferential contraction. Movement therefore
occurs in a fashion more akin to the ringing of a
wet cloth with the LV ejecting blood in a corkscrew-type motion. It begins at the base and
ends at the apex.
The architecturally complex structure of the
LV allows maximal shortening of myocytes,
which results in increased wall thickness and the
generation of force during systole. Moreover, the
release of the twisted LV may provide a suction
mechanism facilitating the lling of the LV during diastole.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_11
131
132
J. N. Wilkinson and F. Mohammed
Chamber Dimensions andSize
Left ventricular size is commonly assessed using
the internal linear dimension from the parasternal
long-axis view. The internal diameter is measured at the level of the mitral valve leaet tips.
Measurement should be performed using twodimensional (2D) images rather than M-mode
images, as the internal diameter may be nonorthogonal to the ultrasound, although M-mode can
provide high temporal resolution. The measurement should be perpendicular to the long axis of
the ventricle. Care should be taken to avoid confusing the chordae or papillary muscle with the
inferolateral wall. The endpoints of the linear
segment should be positioned at the endocardial
border. Measurement should occur at enddiastole (LVIDd, Fig. 11.1) and end-systole
(LVIDs, Fig.11.2). Table11.1 demonstrates the
normal values of LV internal dimensions. These
linear measurements are assumed to be representative of the entire ventricle. In the case where the
mid-ventricle or apex is enlarged, the LVIDd may
not be accurate.
LV end-diastolic area (LVEDA), obtained
from the parasternal short-axis view at the midventricle, is less commonly quantied in standard
echocardiography, as volumetric assessments are
preferred (Fig.11.3). However, various studies in
critical care have used LVEDA from the transesophageal short-axis view at the mid-chamber,
tracing the endocardial border and taking care to
exclude the papillary muscles [2, 3]. One study
exploring intraoperative hypovolemia found that
LVEDA was 9.5–22cm2 in normal patients, with
an indexed LVEDA <5.5 cm2/m2 suggestive of
hypovolemia [2].
LV volumetric measurements can be obtained
from 2D echo and 3D echo. Volume should not
be calculated from linear dimensions given their
inaccuracies with approximating the shape of the
LV cavity. Rather, volume is calculated using
Simpson’s biplane method of disks, which traces
the compacted endocardial border from the apical four-chamber and apical two-chamber views.
3D echo may offer improved accuracy as it does
not rely on any geometric assumptions of the LV
cavity. Imaging the apical views with 2D echo
should attempt to maximize the LV area and
avoid foreshortening of the LV. The imaging
depth should be shortened to maximize the LV
area on the screen. Outpatient echocardiography
is typically performed with the patient in the left
lateral decubitus position, which improves both
image quality and reduces foreshortening.
Critical care echocardiography is often performed with a suboptimal position, which may
foreshorten the left ventricle. Additionally,
Fig. 11.1 Parasternal
Long Axis view,
showing a mid LV cavity
view at the end-diastolic
phase of contraction
(Mitral valve closed and
aortic valve about to
open)
11 LV Systolic Function
Fig. 11.2 Parasternal
Long Axis view,
showing a mid LV cavity
view at the end-systolic
phase of contraction
(Aortic valve open)
133
Table 11.1
LV internal diameter, diastolic (cm) 4.2–5.8 3.8–5.2
LV internal diameter, systolic (cm) 2.5–4.0 2.2–3.5
LV wall thickness (cm) 0.6–0.9 0.6–1.0
LV end-diastolic volume (mL) 62–150 46–106
LV end-systolic volume (mL) 21–61 14–42
LV ejection fraction (%) 52–72 54–74
Fig. 11.3 Measurement
of end-diastolic area on
a short axis view of the
heart. The Mid Papillary
view is seen here
Reference ranges for common echocardiographic parameters of LV size and function
Male Female
134
J. N. Wilkinson and F. Mohammed
increased intrathoracic pressure from mechanical
ventilation or obstructive lung disease may medially displace the heart apex, which may result in
foreshortened imaging. Contrast echocardiography (see Chap. 12) may improve assessment
when image quality is poor.
After optimizing an image for acquisition, the
measurement is performed by starting at the
mitral annulus and tracing the compacted endo-
Fig. 11.4 Apical 4
chamber image at end
diastole. Demonstrates
Simpson’s biplane
measurement of LV
cavity volume
cardial border to the other side of the mitral annulus. The papillary muscle should be excluded.
Viewing the cine loop or the frames immediately
before or after may help with discriminating the
endocardial border. The tracing should occur at
end-diastole (LVEDV) (Figs.11.4 and 11.5) and
end-systole (LVESV) (Figs. 11.6 and 11.7).
Although the electrocardiogram can aid in this
process, the timing is based on ventricular size
Fig. 11.5 Apical 4
chamber image at end
diastole. Demonstrates
Simpson’s biplane
measurement of LV
cavity volume
11 LV Systolic Function
Fig. 11.6 Apical 4
chamber image at end
systole. Demonstrates
Simpson’s biplane
measurement of LV
cavity volume
Fig. 11.7 Apical 4
chamber image at end
systole. Demonstrates
Simpson’s biplane
measurement of LV
cavity volume
135
rather than electrocardiographic signal. In most
software applications, the tracing can be adjusted
to conform with the endocardial walls after initial
placement.
This technique should be repeated for the
Apical two-chamber view. Simpson’s method
calculates ellipses from both the apical fourchamber and apical two-chamber. One cannot
simply average the two volume calculations.
Additionally, if one image is substantially foreshortened, the software may identify an error, as
the disks will not align. The biplane method of
disks should not be used for calculating stroke
volume. Minor errors in foreshortening and measurement can result in inaccurate stroke volume
calculation.
136
J. N. Wilkinson and F. Mohammed
Left Ventricular Hypertrophy
Left ventricular hypertrophy (LVH) is a condition in which there is an increase in left ventricular mass. This is either due to an increase in wall
thickness, or secondary to left ventricular cavity
enlargement, or both. Most commonly, left ventricular wall thickening occurs in response to
pressure overload, whereas chamber dilatation
often occurs in response to volume overload.
The etiology can often be ascertained on an
echocardiogram, this being the test of choice in
establishing the diagnosis of LVH.The patient’s
height and weight are considered along with left
ventricular end-diastolic diameter, posterior wall
thickness, and interventricular septum thickness,
to determine the LV mass index.
LVH is dened as an increased left ventricular
mass index (LVMI) of: >95 g/m in women and
>115g/m in men, which is calculated from wall
thickness and size. There are multiple methods to
calculate mass, including the use of threedimensional echocardiography [1, 4]. In practice,
however, LVH is more commonly assessed using
LV wall thickness due to its simplicity.
The left ventricle wall thickness is typically
measured in the parasternal long-axis view, along
the same plane as the inner diameter: at the level of
the mitral valve leaet tips. Measurement of the
anteroseptal wall should be located at the myocardial border. Measurement of the inferolateral wall
should be located at the myocardial border and
should exclude the pericardium. As with LV chamber size, 2D echocardiography is preferred over
M-mode, as the walls may be nonorthogonal or
oblique. Measurement should occur at end-diastole (Fig.11.1). Normal values are in Table11.1.
In some elderly individuals, the upper interventricular septum might be prominent, a nding
called discrete upper septal thickening (DUST,
Video 11.1). This nding is associated with hypertension and is not independently associated with
cardiovascular disease, mortality risk, or adverse
prognosis [5
LV hypertrophy. The athlete’s heart typically
exemplies eccentric hypertrophy, with a maintained or large chamber diameter, while pathologic
hypertrophy is often concentric, demonstrating
]. Athletes may also demonstrate mild
reduced chamber diameter. Another simple way to
differentiate these phenotypes is to assess diastolic
function: the athlete’s heart will typically have
normal diastolic function with a low E/e’.
Hypertrophic heart disease, which occurs with
hypertension, valvulopathy, and cardiovascular
disease is often erroneously conated with hypertrophic cardiomyopathy (see Chap. 16).
Hypertrophy from hypertension or aortic stenosis
will typically be uniform in distribution, while
hypertrophic cardiomyopathy typically has a nonuniform presentation of severe hypertrophy in
some regions and sparing in others.
LV Function: Linear Measurements
One of the earlier methods of assessing LV function in the critical care literature was the E-point
Septal Separation (EPSS). This method was
adopted as it was simple and reproducible with
minimal training [6]. The concept of underpinning this measurement is that the amplitude of
mitral valve opening is dependent on the pressure
gradient between the left atrium and left ventricle: with decreased ejection fraction, the pressure
gradient between the left atrium and ventricle is
diminished during diastole, resulting in the
smaller opening of the valve. The measurement
of EPSS can be done from M-mode or 2D echocardiography from the parasternal long-axis view
(Figs. 11.8 and 11.9). M-mode can provide
greater temporal resolution. An EPSS >7mm is
associated with LV ejection fraction <30% [6].
This method of assessment can be inaccurate in
mitral stenosis. Although EPSS is reproducible
among novices, it is not commonly reported.
EPSS Method
• Obtain a parasternal long-axis view.
• Place the M-mode tracer over the distal tip of
the anterior leaet of the mitral valve.
• Measure during the early diastolic phase of
the cardiac cycle.
• Place a caliper between the E point of the
anterior mitral valve leaet and the septum.
11 LV Systolic Function
Fig. 11.8 Measurement
of E-point Septal
Separation (EPSS), in
the parasternal longf
axis view. Calipers are
placed across the mitral
valve leaets, tip-to-tip
Fig. 11.9 Measurement
of E-point Septal
Separation (EPSS), in
the parasternal longf
axis view. Calipers are
placed across the mitral
valve leaets, tip-to-tip
137
– EPSS <6mm=normal LVEF
– EPSS >7mm=reduced LVEF
– EPSS ≥13mm=severely decreased func-
tion, with an estimated LVEF of ≤35% 0.3
Caution
• Mitral stenosis results in decreased excursion
of their mitral valve with normal LV function.
• Severe Aortic Regurgitation may impair forward anterior leaet movement.
• Atrial brillation results in beat-to-beat variation. Averaging several EPSS readings is recommended to improve accuracy under this
circumstance.
Another linear measurement of function is
fractional shortening, which is the difference of
LVIDd and LVIDs, divided by the LVIDd. The
fractional shortening can correlate with LV systolic function but can be inaccurate when there
are regional wall motion abnormalities or conduction abnormalities [7].