The images below show PSAX views of 4 hearts with hypovolaemia

Observe the small volume of the left ventricle in systole – almost emptying the ventricle
The walls of the LV touch each other
This pattern is often called “kissing ventricle”

The myocardial function is good, and the EF is high
EF alone is of no clinical value
Identification of the real problem/s (here hypovolaemia) is the solution

Keep this image in your mind, and when you recognise it in your patient think of hypovolaemia and treat the condition with volume or norepenephrine or both – not inotropes (beta-1 stimulation)

The EF equation entails:

– That reduced diastolic chamber dimension (reduced EDV) will alter EF – progressive blood loss will often reduce EDV and thus increase the EF

– When EF increases – under these circumstances – the stroke volume will decrease concomitantly

– Thus the EF can go up to almost 100% without providing any clinically useful information about myocardial deformation or adequacy of circulation

– Recognition of the hypovolaemic state is the key to understanding and solving the problem in these patients

M-mode is an abbreviation of

It is important to notice that different pathologies may confound the interpretation of left ventricular systolic function

For example:

– Pericardial effusion (A)
– Adjacent chamber dilatation (B)
– Left ventricular dilatation (C)
– Hypovolaemia (D)

Diastolic cardiac function describes the filling of the ventricles

Impaired diastolic function – also known as diastolic dysfunction – is characterised by reduced filling of the ventricles despite increased filling pressure

As diastolic impairment induces stiffness of the left ventricle, reduced systolic function often accompanies diastolic dysfunction especially as reduced longitudinal deformation

2D ultrasound characteristics of left ventricular diastolic dysfunction are:
– Left ventricular myocardial hypertrophy and concomitant reduced LV cavity size
– Enlarged left atrium (the enlargement is proportional to the severity of the diastolic dysfunction)

Ejection fraction (EF) is considered the gold standard for assessment of left ventricular systolic function in daily clinical practice

EF can be reported either qualitatively or semi-quantitatively

Simple qualitative judgment:
– Eyeballing – probably the most commonly used method for assessment of EF
– EF is normal or reduced (mildly, moderately or severely)

Quantitative and semi-quantitative assessment of dynamic changes during the cardiac cycle:
– Fractional shortening (FS), mitral septal separation (MSS), mitral annular plane systolic excursion (MAPSE)

The images below are explained in the following topics

Several methods exist for the measurement of EF, with eyeballing as the most frequently used method

A high EF is not a bullet proof marker of adequate circulation, because certain clinical circumstances can impact the circulation dramatically without reducing the calculated value of the EF

EF is solely a measure of the LV function, and not a measure of adequate circulation

EF does not take into account the importance of pathological conditions that impair circulation

Several life-threatening pathological conditions – where the myocardial deformation is normal – may invalidate the EF as a measure of the adequacy of circulation

You have now learned:

– The anatomy of the FATE position 4 – the pleural view on the patient’s right and left side

– How to obtain the correct image with respect to transducer orientation and the relationship to the presentation on the screen

Review this lesson if you are not confident about how to obtain the view and identify the structures

When you feel confident move on to the next lesson concerning cardiac function

Before you start scanning, ask yourself:

1. Which position – 1, 2, 3 or 4?
2. How should I hold the probe?
3. Where should the orientation marker (OM) be pointing to?
4. What should appear on the screen?

Holding the probe in your right hand:

1. Apply gel without touching the footprint of the probe with the gel dispenser
2. Place the transducer on the chest wall where you expect to get the desired image
3. Circle with your hand until you recognise any anatomical structures on the screen
4. Then optimise the image in only one plane at a time by rotating / tilting / sliding

Anatomy

Evaluation of cardiac function is one of the key elements of FATE

It should be emphasised that all four cardiac chambers contribute to the overall cardiac function

The focused approach to cardiac function concentrates on the ventricles

The performance of the ventricles can be differentiated into systolic and diastolic function

The FATE card shows important reference values that you can make use of

You can download the FATE card from: usabcd.org/FATE-card