The superiority of mitral E point-ventricular septum separation to other echocardiographic indicators of left ventricular performance

A Pilot Study Evaluating LV Diastolic Function with M-Mode Measurement of Mitral Valve Movement in the Parasternal Long Axis View

This pilot study aimed to develop a new, reliable, and easy-to-use method for the evaluation of diastolic function through the M-mode measurement of mitral valve (MV) movement in the parasternal long axis (PSLA), similar to E-point septal separation (EPSS) used for systolic function estimation. Thirty healthy volunteers from a tertiary emergency department (ED) underwent M-mode measurements of the MV anterior leaflet in the PSLA view. EPSS, A-point septal separation (APSS), A-point opening length (APOL), and E-point opening length (EPOL) were measured in the PSLA view, along with the E and A velocities and e' velocity in the apical four-chamber view. Correlation analyses were performed to assess the relationship between M-mode and Doppler measurements, and the measurement time was evaluated. No significant correlations were found between M-mode and Doppler measurements in the study. However, M-mode measurements exhibited high reproducibility and faster acquisition, and the EPOL value consistently exceeded the APOL value, resembling the E and A pattern. These findings suggest that visually assessing the M-mode pattern on the MV anterior leaflet in the PSLA view may be a practical approach to estimating diastolic function in the ED. Further investigations with a larger and more diverse patient population are needed to validate these findings.

Focused cardiac ultrasound with mitral annular plane systolic excursion (MAPSE) detection of left ventricular dysfunction

OBJECTIVES

Detecting reduced left ventricular ejection fraction (LVEF) by an emergency physician (EP) is an important skill. The subjective ultrasound assessment of LVEF by EPs correlates with comprehensive echocardiogram (CE) results. Mitral annular plane systolic excursion (MAPSE) is an ultrasound measure of vertical movement of the mitral annulus, which correlates to LVEF in the cardiology literature, but has not been studied when measured by an EP. Our objective is to determine whether EP measured MAPSE can accurately predict LVEF <50% on CE.

METHODS

This is a prospective observational single center study using a convenience sample to evaluate the use of a focused cardiac ultrasound (FOCUS) for patients with possible decompensated heart failure. The FOCUS included standard cardiac views to estimate LVEF, MAPSE, and E-point septal separation (EPSS). Abnormal MAPSE was defined as <8 mm and abnormal EPSS as >10 mm. The primary outcome assessed was the ability of an abnormal MAPSE to predict an LVEF <50% on CE. MAPSE also was compared to EP estimated LVEF and EPSS. Inter-rater reliability was determined by two investigators performing independent blinded review.

RESULTS

We enrolled 61 subjects, 24 (39%) had an LVEF <50% on a CE. MAPSE <8 mm had a 42% sensitivity (95% CI 22-63), 89% specificity (95% CI 75-97), and accuracy of 71% for detecting LVEF <50%. MAPSE demonstrated lower sensitivity than EPSS (79% sensitivity [95% CI 58-93], and 76% specificity [95% CI 59-88]) and higher specificity than estimated LVEF (100% sensitivity [95% CI 86-100], 59% specificity [95% CI 42-75]). PPV and NPV for MAPSE was 71% (95% CI 47-88) and 70% (95% CI 62-77) respectively. The ROC for MAPSE <8 mm is 0.79 (95% CI 0.68-0.9). MAPSE measurement interrater reliability was 96%.

CONCLUSIONS

In this exploratory study evaluating MAPSE measurements by EPs, we found the measurement was easy to perform with excellent agreement across users with minimal training. A MAPSE value <8 mm had moderate predictive value for LVEF <50% on CE and was more specific for reduced LVEF than qualitative assessment. MAPSE had high specificity for LVEF <50%. Further studies are needed to validate these results on a larger scale.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Estimation of Cardiac Systolic Function Based on Mitral Valve Movements: An Accurate Bedside Tool for Emergency Physicians in Dyspneic Patients

OBJECTIVES

The purpose of this study was to determine the success of mitral valve movements in the estimation of left ventricular ejection fraction (LVEF).

METHODS

Adult patients whose principal symptom was dyspnea were included in this prospective observational study. The distance from the anterior mitral valve (AMV) to the interventricular septum (IVS) during early diastole was measured first in B-mode in the parasternal long axis (PLAX) named parasternal long axis-anterior leaflet septal separation. Second, the AMV-IVS distance was measured in M-mode in the PLAX named E-point septal separation. Third, AMV-IVS distance was measured in B-mode in the apical 4-chamber view named apical 4-chamber view-anterior leaflet septal separation. Finally, maximum distance between the 2 mitral leaflets in the apical 4-chamber view was measured and named mitral valve leaflet separation. Comprehensive echocardiography was performed by an experienced cardiologist. Correlation was calculated between mitral valve measurements and LVEF. Cutoff values were determined using receiver operating characteristic curves and the chi-square test.

RESULTS

A total of 118 patients were included in the study. Parasternal long axis-anterior leaflet septal separation, E-point septal separation, and apical 4-chamber view-anterior leaflet septal separation were highly correlated with LVEF (correlation coefficient, -0.848, -0.833, and-0.822 [P < .001]). Parasternal long axis-anterior leaflet septal separation values less than 2.30 mm, E-point septal separation values less than 2 mm, and mitral valve leaflet separation values greater than 25.15 mm exhibited a 100% negative predictive value in excluding reduced LVEF. Parasternal long axis-anterior leaflet septal separation values less than 4.95 mm, EPSS values less than 5.85 mm, apical 4-chamber view-anterior leaflet septal separation values less than 6.95 mm, and mitral valve leaflet separation values greater than 24.05 mm exhibited a 100% negative predictive value in excluding severe reduced LVEF.

CONCLUSIONS

Mitral valve measurement methods may be useful in predicting LVEF or values thereof as a complementary method of diagnosing challenging patients on echocardiographic images.

Effects of sedation with acepromazine on echocardiographic measurements in eight healthy thoroughbred horses

Eight normal thoroughbred horses were examined by echocardiography before and 10 minutes after they had been sedated by the intravenous administration of 0.03 mg/kg acepromazine. There were significant (P<0.025) increases in the diameters of the pulmonary artery and the aorta, measured at end-systole, and in the thickness of the interventricular septum, measured at end-systole and end-diastole. In addition, there was a significant (P<0.001) decrease in the diameter of the left atrium measured at end-diastole. The remaining cardiac dimensions, all the indices of cardiac function, and the occurrence and severity of valvular regurgitation were not affected by sedation.

Mitral valve prolapse and mitral regurgitation are common in patients with polycystic kidney disease type 1

Patients with autosomal dominant polycystic kidney disease (ADPKD) have an increased occurrence of cardiac valve abnormalities. However, the prevalence of cardiac abnormalities in patients with a uniform genotype of ADPKD has not been previously reported. We performed M-mode and color Doppler echocardiography on 109 patients from 16 families with polycystic kidney disease type 1 (PKD1). Findings were compared with those of 73 unaffected family members and 73 healthy controls. Mitral valve prolapse was found in 26% of patients with PKD1, 14% of unaffected relatives, and 10% of control subjects. The prevalence of hemodynamically significant mitral regurgitation (grade 2 or 3) was 13%, 4%, and 3%, respectively. Prevalences of grade 2 or 3 aortic regurgitation (8%, 4%, and 3%, respectively) and tricuspid regurgitation (4%, 6%, and 7%, respectively) were not significantly different among the three groups. Left ventricular hypertrophy (LVH) was found in 19% of subjects with PKD1, 6% of unaffected relatives, and 4% of control subjects. Systolic blood pressure and severity of renal insufficiency were related to mitral regurgitation and LVH in subjects with PKD1. The prevalence of cardiac valve abnormalities did not differ between unaffected relatives and control subjects. Mitral valve prolapse is a characteristic finding in patients with PKD1. Conversely, mitral regurgitation and LVH are likely to be secondary to elevated blood pressure in these patients.

M-mode echocardiographic diagnosis of dilated cardiomyopathy in giant breed dogs

M-mode echocardiograms were recorded from 62 giant breed dogs without historical, clinical, electrocardiographic and roentgenologic signs of heart disease, from six dogs with asymptomatic dilated cardiomyopathy (DCM, NYHA class I), and 13 dogs with symptomatic DCM (NYHA class III-IV). There was a general trend that several echocardiographic parameters were significantly in control Great Danes as compared to Newfoundlands and Irish Wolfhounds. There were substantial differences in left ventricular size both in systole and diastole and in systolic indices of the left ventricle between the control group, the asymptomatic dogs and symptomatic dogs with DCM (P = 0.0001). There was also a significant decreased in the interventricular septum thickness (P = 0.0001) and left ventricular free wall thickness in systole (P = 0.002) and diastole (P = 0.005) between the three groups. Furthermore, the left atrial/aortic ratio was significantly different between the three groups (P = 0.0001). It was concluded that this study established echocardiographic reference values in giant breed dogs which may be useful in the study of heart diseases in giant breed dogs.

Noninvasive evaluation of left ventricular performance by the shortest distance between mitral leaflets coaptation and interventricular septum at end-systole

We attempted to evaluate left ventricular performance from the shortest distance between the mitral leaflets coaptation and the interventricular septum at end-systole (MVC-IVS distance). The subjects were 37 patients with coronary artery disease (CAD) with prior myocardial infarction (MI), 8 with CAD without prior MI, 22 with atypical chest pain, and 4 with aortic regurgitation. The MVC-IVS distance was measured on a two-dimensional echocardiogram obtained from the parasternal or apical long-axis view and frozen at end-systole. Left ventricular end-systolic volume and end-diastolic volume were obtained by left ventriculography, and the left ventricular ejection fraction was calculated. A significant positive correlation was observed between the MVC-IVS distance and the end-systolic volume (r = 0.83, p less than 0.001); a close correlation was observed between the MVC-IVS distance end-systolic volume and ejection fraction by monoexponential fitting (r = -0.91, p less than 0.001). Thus, a significant negative correlation was observed between the MVC-IVS distance and the left ventricular ejection fraction (LVEF) (r = -0.83, p less than 0.001). An MVC-IVS distance of greater than or equal to 30 mm suggests diagnosis of left ventricular dysfunction (LVEF less than 50%) with high sensitivity (94.4%) and specificity (90.6%), while a value less than 30 mm suggests that the left ventricular performance is likely to be normal. Thus one can easily evaluate the left ventricular performance noninvasively using this new index.

Classification of left ventricular thrombi by their history of systemic embolization using pattern recognition of two-dimensional echocardiograms

Although one can diagnose left ventricular (LV) thrombi by two-dimensional echocardiography (2DE), the factors associated with peripheral embolization, given a 2DE with LV thrombi, have not been well delineated. Therefore we looked at 2DE and clinical variables that included texture features in the 2DE of 38 patients whose 2DE had LV thrombi and questioned these patients to see if clinical embolization had occurred in the 8.9 +/- 6.1 month (+/- SD) average follow-up period. Eight patients, four with acute myocardial infarction (AMI) and four with dilated LV and decreased LV systolic wall motion, had clinically apparent leg or brain emboli, whereas the remaining patients did not. Emboli occurred within a week of obtaining the 2DE in question. The variables considered were the age of the patient, the type of heart disease present, warfarin administration, exercise tolerance, standard M-mode measurements, LV dyssynergy by 2DE, clot size and mobility, and gray scale statistics which include run length, Sobel edge points followed by 50% gradient thresholding, gray level second-order statistics, offset 1 and gray level difference statistics, offset 1. The values of the variables were then entered into an expert system (Expert Ease) in order to achieve classification of patients into emboli versus no emboli groups, while using a minimal number of variables. The only variables that were needed included run length, long runs emphasis, gray level difference statistics (entropy, contrast, mean, and angular second moment), gray level second-order statistics (contrast), and warfarin status. When probability statistics were applied to this schema, its accuracy was predicted to be at least 96%.(ABSTRACT TRUNCATED AT 250 WORDS)

Widened E point septal separation in a normal pediatric population

To determine the age and gender distribution of the E point septal separation (EPSS), M-mode echocardiograms were obtained from 121 normal subjects aged four months to 82 years. A small but consistent age factor was found. In subjects less than age 20, EPSS was 3.0 +/- 2.6 mm, whereas in those greater than 20 years, EPSS was 1.4 +/- 1.8 (p less than .001). In females EPSS did not vary appreciably at different ages. By contrast, in males EPSS increased with age, peaking between ages 15 and 19 and then decreasing. Between ages 10 and 19, EPSS was significantly wide in males than in females. Thus, EPSS is wide in male adolescents than in adults. The cause for this phenomenon is unclear, but judging from its age and gender distribution, it may be related to the effect of androgens on the myocardium.

Value of two-dimensional echocardiographic detection of incomplete mitral leaflet closure

The echocardiographic pattern of incomplete mitral leaflet closure (IMLC) is reported to be present in about 90% of patients with acute myocardial infarction and new onset of mitral regurgitation. To determine the significance of this echocardiographic sign, we retrieved all echocardiograms containing this abnormality from a file of 1200 consecutive echocardiograms. Seventy-three echocardiograms manifested IMLC. We also studied a control group consisting of 52 patients without IMLC, but who were matched with the IMLC group with respect to a range of left ventricular (LV) diameters at end diastole and fractional shortening. The following was found in the control group: fewer wall motion abnormalities per patient, less frequent mitral "B bumps," and a smaller LV end-diastolic dimension (LVEDD) (p less than 0.05 for each comparison). By logistic regression, the variable most important to the probability of having IMLC was the presence of mitral valve "B bumps." We conclude that: (1) elevated left ventricular filling pressure is associated with IMLC and (2) IMLC is not specific for the subset of patients with papillary muscle dysfunction due to acute myocardial infarction. Rather, IMLC is commonly seen in association with dilated, usually ischemic cardiomyopathy.

Mitral valve E point to ventricular septal separation in infants and children

This investigation establishes heretofore unavailable norms that permit clinical application of mitral valve E point to ventricular septal separation (EPSS) as an ejection phase index in infants and children. The study consisted of 105 normal subjects (1 day through 15 years of age, mean 7.4 years) and 67 patients of comparable age. Fifty-seven patients had increased left ventricular (LV) volume with normal function (ventricular septal defect or patent ductus arteriosus) and 10 patients had increased LV volume with depressed function (dilated cardiomyopathy). In normal subjects, EPSS was 2.5 +/- 1.7 mm and "normalized" EPSS, that is, the ratio of EPSS to end-diastolic dimension (EPSS/EDD), was 0.08 +/- 0.06 (mean +/- standard deviation); there was no correlation between either of these indexes and age, body surface area, height or weight. In patients with ventricular septal defect or patent ductus arteriosus, or both, the EPSS and EPSS/EDD were similar to those of normal subjects (3.2 +/- 2.3 mm and 0.09 +/- 0.06 mm, respectively). In patients with dilated cardiomyopathy, these indexes were significantly increased (p greater than 0.05) (EPSS 16.5 +/- 5.1 mm; EPSS/EDD 0.39 +/- 0.09). The data provide normal values for EPSS and EPSS/EDD in infants and children and show that these indexes are independent of age, body surface area, height or weight. Mitral valve EPSS and EPSS/EDD can now be used in pediatric echocardiography as a simple, practical and accurate means of separating normal from abnormal LV function.

Nonvolumetric assessment of ventricular function by two-dimensional echocardiography in patients with coronary artery disease

Left ventricular ejection fraction (EF) was prospectively predicted by nonvolumetric parameters obtained by M-mode and two-dimensional (2DE) echocardiography in 55 patients with angiographically proven coronary artery disease. In particular, the mitral E-point to septum separation (EPSS) could predict the angiographic ejection fraction (EF) according to the formula %EF = 74 - 2 (EPSS) with a correlation of 0.81 and a standard error of the estimate (SEE) of 12%. An EPSS of greater than 10 mm predicted ventricular dysfunction with a sensitivity of 0.81 and a specificity of 0.93. A Wall Motion Score (WMS), obtained by summing segmental wall motion assessed as normal = 4, hypokinetic = 3, akinetic = 2, dyskinetic = 1, for each of seven segments and dividing by seven (the number of segments evaluated), also correlated with the angiographic EF (r = .76). An abnormal WMS was found to be less than 3.3 and together with an EPSS greater than 10 mm, these parameters had a sensitivity of 0.90, a specificity of 0.92, and predictive value of 0.90 for ventricular dysfunction, as evidenced by an EF of less than 0.51. We conclude that the EPSS has a great a predictive value for the EF as the more vigorous quantitative volumetric echocardiographic estimates. Together with the WMS, these parameters are of considerable clinical value in detecting ventricular dysfunction.

Assessment of ventricular function by combined noninvasive measures: factors accounting for methodologic disparities

We studied the predictive accuracy and disparities among cineventriculographic ejection fraction, pre-ejection period over left ventricular ejection time (PEP/LVET) obtained from the systolic time intervals and the percent shortening of the internal echocardiographic diameter (% delta D) in assessing left ventricular performance in 453 consecutive patients without valvular heart disease. In 308 patients all three tests were normal, and in 78 patients all three tests were abnormal. Overall agreement (predictive accuracy) among ejection fraction (normal greater than or equal to 57), % delta D (normal greater than or equal to 28%) and PEP/LVET (normal less than or equal to 0.42) was 85%. In 67 patients disparities among the tests as measures of global left ventricular performance were found. The major mechanisms accounting for such disparities were: (a) large segmental contraction abnormalities which selectively distort the % delta D and ejection fraction and (b) diminished isovolumic pressure (less than 45 mmHg) which distorts PEP/LVET. When patients with segmental contraction abnormalities and low isovolumic pressure were excluded the agreement between PEP/LVET and ejection fraction was 97%, ejection fraction and % delta D 98% and PEP/LVET and % delta D 97%. The combined uses of systolic time intervals and echocardiogram minimizes error due to segmental contraction abnormalities and isovolumic pressure. If both PEP/LVET and % delta D are concordant the agreement with ejection fraction is 94% for normal and 99% for abnormal left ventricular function.

Effect of left ventricular size on mitral E point to ventricular septal separation in assessment of cardiac performance

Increased mitral valve E point to ventricular septal separation (EPSS) is widely used as an echocardiographic index of depressed left ventricular (LV) ejection fraction (EF), yet LV size has not been examined as an independent variable potentially affecting EPSS. Accordingly, we studied end-diastolic dimensions (EDD). Twenty normal controls had EPSS 3.2 +/- 2.2 mm (mean +/- SD), EDD 47 +/- 5 mm, EPSS/EDD ("normalized" EPSS) 0.07 +/- 0.04, and fractional shortening (FS%) 38 +/- 6%. Nine patients with pure chronic mitral regurgitation had dilated LV (EDD = 65 +/- 7 mm) with normal LV function (FS% 41 +/- 5%; angiographic EF 62 +/- 9%); eight patients had dilated cardiomyopathy (EDD 69 +/- 8 mm) with decreased LV function (FS% 16 +/- 7%; angiographic EF 32 +/- 8%); and eight patients with amyloid cardiomyopathy had nondilated LV (EDD 42 +/- 5 mm) with decreased LV function (FS% 19 +/- 6; angiographic EF 35 +/- 7%). Mitral E point to ventricular septal separation and EPSS/EDD accurately separated individuals with normal and abnormal LV function irrespective of LV size (chi 2 = 36.7; p less than 0.00001). Increased internal dimensions per se did not affect EPSS unless depressed LV function coexisted. EPSS is therefore a valid predictor of depressed ejection phase indices independent of LV size.