LVEF for Non Cardiologist and Sonographers

We are offering a free teaching software for non cardiologists who want to learn or improve their evaluation of left ventricular ejection fraction (LFEF) in transthoracic echocardiography (TTE). It is based on a 3 level program.

Level number 1   

The goal of this level is to classify LVEF in 3 categories.

1-LVEF over 50% = normal LV function

2- LVEF between 30% and 50% = moderate LV dysfunction

3- LVEF less than 30% = severe LV dysfunction

In the level 1 to approximate LVEF for non cardiologist a percent quotation is obtained for each level in the short axis and the mean value represent the LVEF. This can be done for the 3 apical view (423C).

Example 1: For diffuse anomaly of LV wall motion

- If the basal short axis is diffusely normokinetic the result of the evaluation is LVEF equal to 60% (N);

- If the mid short axis is diffusely hypokinetic the result of the evaluation is LVEF equal to 40% (H);

- If the apical short axis is completely akinetic the result of the evaluation is LVEF equal to 20% (A).

The total of the 3 evaluation is 60+40+20/3=40%.

Dyskinesia (D) and aneurysm (AN) equal 0%.


Example 2: For regional anomalies of LV wall motion

  • If the 4C is half normal  60% and half Hypokinetic 40% the result of the evaluation is 60+40/2=50% (global Mild hypokinesia (MH))
  • If the 2C is half hypokinetic 40% and half akinetic 20% the result of the evaluation is 40+20/2=30% (global severe Hypokinesia (SH))
  • If the 3C is half normokinetic 60% and half akinetic 20% the result of the evaluation is 60+20/2=40%
  • The total of the 3 evaluation is 50+30+40=40%

The total LVEF obtained by BMA is generally equivalent to the total LVEF by 423C.

The approximate value of N=60%, H=40% and A=20% is derived from 2 studies we did (ref 3-5).


Level number 2 

There are two major advantages to this 12 segment division. First it correlates with coronary vessel circulation and second it is easier to evaluate the LV kinetic of BMA and 423C by splitting in 4 segment (visual focalisation of analysis is easier). The % quotation of the 12 short axis segment BMA and 12 apical segment 423C is derived from our article  with CMR (ref 4).

N=64%, MH =54% ,H=38% , SH =28% and A=15%

Example: For the basal short axis, if we quote the four segment N, N, H, and  A.

The summation is 64%+64%+38%+12% = 178/4 = 45%.

We complete the same processus for the mid portion and apical portion of left ventricle to complete BMA study.

We repeat the same analysis for the apical views (423C).

NB.: If you do not have the support of a computer use the simple classification N=60%, MH=50%, H=40%, SH=30%, A=20% and D, AN=0%.


Level number 3 

It's for experienced physicians or sonographers using the ASE score and the classical 16 segments polar map.

Normokinetic segment (N = score 1): normal thickening of the LV wall (M-MODE diastolic thickness 10mm pass to 15mm thickness in systole).

Hypokinetic segment (H = score 2): decrease thickening of LV wall (M-Mode diastolic thickness 10mm pass to 12mm thickness in systole).

Akinetic segment  (A = score 3): absence of thickening of the LV wall (M-Mode diastolic thickness 10mm is unchanged to 10mm in systole).

Dyskinetic segment (D= score 4): systolic bulging of a segment of the LV wall.

From the index score we derived LVEF from our study in CMR (Ref 4).


NB.:  You have the choice to use or not AN, MH and SH.

Aneurism (AN = score 5): systolic and diastolic deformation of LV wall was not used in the previous recommendations of the ASE (2015) but it was suggested to described them in the last recommendation (2019).

If you want to use MH and SH, these score has been evaluated in a previous study (Ref 1).

Mild hypokinetic segment (MH = score 1.5): between N and H.

Severe hypokinetic segment  (SH= score 2.5): between H and A.

In patient with hyperkinetic Left ventricle the Wall Motion Score (WMS) method can underestimate the LVEF compared to other volumetric methods (Biplane Simpson, Nuclear medicine, CMR…) but LV hyperkinesia is generally a transient phenomena secondary to adrenergic stimulation (acute myocardial infarction, acute valve disease, infection…) for that reason we do not use hyperkinetic score.

We classified non specific anteroseptal abnormal kinetic as hypokinetic (H) (Ex.: post-CABG, RV volume or pressure overload, LBBB, pericardial disease…)

In the 16 segments polar map we always use the apical views (4C, 2C, 3C) to confirm the 3 short axis score because dyskinesia and aneurism are often more evident in the apical views.

If the short axis (BMA) evaluation of bull’s eye 16 segment LV kinetic is technically difficult or incomplete use the apical views (4C, 2C, 3C) to check or fill up the difficult segment (and vice versa).

For printing the result, we use the print screen method.

PLEASE don’t totally give up your brain analytical skill to evaluate cardiac kinetic to automatic device.


REFERENCES

1-           Lebeau R , Di Lorenzo M , Amyot R et al.  A new tool for estimating left ventricular ejection fraction derived from wall motion score index. Can J Cardiol 2003; 19: 397-404.

2-           Lebeau R, Di Lorenzo M , Sauvé C et al.  Two- dimensional echocardiography estimation of right ventricular ejection fraction by wall motion score index Can J Cardiol 2004; 20 ;169-176.

3-           Lebeau R, Potter B, Sas G, Performance of a simplified wall motion score index method for non cardiologist to asses left ventricular ejection fraction. ISRN Emergency medicine 2012 ID 309470.

4-           Lebeau R, Serri K, Morice MC et al. Assessement of left ventricular ejection fraction using the wall motion score index in cardiac magnetic resonance imaging. Arch of cardiov disease 2012; 91-98.

5-           Lebeau R, Sas G, EL Rayes M et al. Left ventricular ejection fraction assessement by non cardiologist from transverse view using a simplified  wall motion score index. Echo Research and Practice 2015;2;1-8.

6-           Lebeau R, Serri K, Di Lorenzo M et al. Assessement of left ventricular ejection using a new 16 segment wall motion score in echocardiography Echo Research and Practice 2018 ; 63-6.