On the screen:

1) Display the parasternal long axis view (PLAX)

2) Make sure you transect the LV so it appears at its largest

3) Freeze a full cine loop covering a whole heart cycle

4) Use the trackball to scroll to diastole (just before the aortic valve opens)

5) Activate the measurement button (machine dependent)

6) Measure as perpendicularly to the septum and posterior wall as possible

7) Measure only the free of the tip of the mitral leaflets

8) Repeat for systole when convenient

On the screen:

1) Display the correct apical 4 chamber view

2) Activate the cursor

3) Place the cursor line through the AV plane on the lateral wall

4) Activate M-mode recording

5) Freeze the image when correct M-mode recording is obtained

The videos below show PLAX views from 4 hearts with different degrees of impaired left systolic function

Watch the hearts and observe the mitral septal separation by simple eyeballing

A, B and D show abnormal MSS (> 1 cm), while C shows normal MSS

From an M-mode recording in position 2 – the apical 4 chamber (A4CH) view – the mitral annular plane systolic excursion (MAPSE) can be obtained

MAPSE is given by the movement of the atrio-ventricular plane during systole

After marking has been finished:

– The fractional shortening is most often calculated automatically

– The EF is normally calculated automatically by the ultrasound machine using the Teicholtz formula

– Repeat measurements to enhance accuracy – e.g. three successive sinus beats

On the M-mode image:

– Activate LV measurement (machine dependent)

– Mark endocardium in diastole from the R-wave in ECG (septum and posterior wall – red)

– Repeat for systole where the posterior wall is maximally contracted – yellow

On the screen:

1) Display the correct PLAX view

2) Activate the cursor

3) Place the cursor line as perpendicular as possible to the septum and posterior wall

4) Place the cursor line just distal to the tip of the anterior mitral leaflet

5) Activate M-mode recording

6) Freeze the image when correct M-mode recording is obtained

From M-mode recording through the anterior mitral leaflet the distance between the anterior mitral leaflet and the interventricular septum can be measured

The shortest distance between anterior mitral leaflet and inter-ventricular septum is called mitral septal separation (MSS)

In the past there has been a trend to measure LV dimensions on the 2D image

The reasons are:
– Appreciating the difficulties in obtaining the correct M-mode scan (remember 2D imaging was not available when clinical echocardiography was developed and normal values established)
– The 2D image quality has improved dramatically over the last two decades
– The frame rate has increased significantly over the last two decades
– Very accurate 2D measurement tools have been developed

Measurements can be done in both diastole and systole

The dimensions of the LV myocardium and LV cavity should be measured from the parasternal long axis view alternatively in the short axis view

The left ventricle diastolic dimension (LVDd) and the left ventricle systolic dimension (LVSd) are both obtained from the M-mode recording through the left ventricle (red arrow)

Fractional shortening (FS) is calculated using the formula in the box below

2 * FS is a rough measure of EF

Ultrasound systems use the Teichholz formula for a more precise calculation of EF

Since volume estimates are derived from a one dimensional measure, the accuracy of the estimate depends on the ventricular geometry and regional myocardial variability