Left Ventricular Function

Presentation on echocardiographic assessment of LV function


More on assessment of LV function in the subsections of the Normal echocardiography section (Apical views, Parasternal Long Axis, Parasternal Short Axis).

More information in the section related to inotropic support

Classification of left ventricular systolic function

Tissot C, Singh Y, Sekarski N. Echocardiographic Evaluation of Ventricular Function-For the Neonatologist and Pediatric Intensivist. Front Pediatr. 2018 Apr 4;6:79. doi: 10.3389/fped.2018.00079. PMID: 29670871; PMCID: PMC5893826.

This article classifies left ventricular function based on LV-EF in pediatric:

Tissot et al. also provides normal and abnormal values based on shortening fraction (SF). SF (same as fractional shortening - FS) can be obtained from the M-Mode at the tip of the mitral valve in the parasternal long or short axis view. The LV end diastolic and end systolic diameters can also be obtained from the B-Mode obtained in the same view. The use of this measurement is discouraged by the recent guidelines of the American Society of Echocardiography.

Caveat about shortening fraction: relies on 2 point in the LV and many guidelines recommend against its use in comprehensive evaluation of the LV considering the tendency to have dyskenesis of the LV that may not be homogenous, as well as the septal flattening often found in the context of high PVR due to the transitional period of the newborn. The American Society of Echocardiography mentions: "Fractional Shortening (use is discouraged)" - complete article here.

As per the American College of Cardiology (ACC), mostly geared at adult functional classification but applied often in pediatric: 

As per the American College of Cardiology, in adults, there is the context of heart failure (HF) with reduced ejection fraction (HFrEF) and HF with preserved EF (HFpEF).

"Heart failure (HF) encompasses a broad range of left ventricular (LV) function. New treatment guidelines address the entire spectrum of HF. The classification of HF is as follows: 

Other methods to evaluate LV systolic function include: 

List of LV functional markers by Echocardiography

Left ventricular Diastolic Function


LV dysfunction in neonatal Permanent Junctional Reciprocating Tachycardia

Infant who had episodes of protracted arrhythmias secondary to PJRT with residual LV dysfunction in A5C, A2C and A4C.

LV dysfunction in a term newborn with HIE on therapeutic hypothermia

Parasternal long axis view indicating poor LV contractility. 

Parasternal long axis view indicating poor LV contractility and some mitral regurgitation. Infants with perinatal depression often have some degree of myocardial ischemia. Subendocardial ischemia may manifest as papillary muscle ischemia and mitral insufficiency.  

One can notice that the colour box, which filters for velocities above 77 cm/s, is not filled despite a colour gain at 40%, potentially indicating low blood flow velocities generated by this LV with dysfunction.  

Premature newborn with asphyxia, RDS and hypoxic respiratory failure

Parasternal short axis demonstrating some degree of LV performance anomaly (moderate to severe). The flow through the aortic valve is almost completely filtered at a Nyquist of 68 cm/second, indicating that the systolic dysfunction impairs flow velocity generation in the outflow tract (possibly with secondary decreased output). 

Significantly altered contractility of the LV

Parasternal short axis view. 

Other structural causes of cardiac dysfunction were rule out: coronaries were evaluated with 2D and Colour (not presented) and were normal. Aortic arch did not show any signs of obstruction. LVOT was unobstructeded. 

Sweep in parasternal short axis indicates that the apex seems to be more affected than the papillary area and base. 

Degree of biventricular dysfunction with a depressed TAPSE. 

Isosystemic pulmonary pressures by TR jet velocity (55 RV-RA gradient). The PFO was bidirectional. 

LV dysfunction in A2C

Unobstructed LV outflow tract. This patient also has some mild MR and TR, indicating some suffering of the underlying ventricle during the asphyxiated event (papillary muscle subendocardial ischemia)

Bidirectional PDA from isosystemic pulmonary pressure (PVR) and possibly decreased LV output from LV dysfunction. 

Altered TDI profile, with S' depressed for both ventricles. 

LV dysfunction in the context of Congenital Diaphragmatic Hernia

Mild to moderate mitral regurgitation in the apical 4 chamber view

Some degree of LV dysfunction in A4C

Moderate dysfunction in the A2C

Depressed Ejection fraction by Speckle Tracking echocardiography

Abnormal strain (deformation) using speckle tracking echocardiography for the LV. 

Case of biventricular dysfunction in the context of HIE

Echocardiography on day 1 - "normal" BP (mean BP 45)

Parasternal long axis outlining that the LV function (systolic) is depressed. The Aortic valve is opening and closing. There is no obvious LV hypertrophy or LVOT obstruction.

PLAX with posterior sweep outlining the tricuspid valve and RV inflow. One may appreciate that the myocardium of the RV does not seem to shorten during systole (or even thickening seems impaired). 

Sweep from base to Apex. The parasternal short axis demonstrates that there is LV systolic dysfunction. The pulmonary valve opens and closes. 

One may appreciate the RCA in B-mode. We also can appreciate that there is no obvious RVOT obstruction. The pulmonary valve opens and closes. 

Visualization of the LCA in appropriate configuration. This is not explained by ALCAPA

Biventricular dysfunction. The RV is hypertrophied and the apex is trabeculated. 

Sweep from posterior to anterior. Normal configuration of great vessels. Inflow valves are opening and closing. 

RV focus view outlining moderate RV dysfunction. 

RV FAC is decreased at 19%

LV focuse view. Colour shows that there is some mild mitral insufficiency, possibly from subendocardial ischemia to the papillary muscles (proxy that this LV has suffered an event of perinatal asphyxia).  

TAPSE is depressed at 3 mm

dp-dt of the MR < 1200 mmHg/s (at 844) outlining LV dysfunction (systolic). 

Flow is laminar via the LVOT. There is no LVOT obstruction. One may also appreciate the eccentric mitral insufficiency jet. 

LVOT - VTI (stroke distance) is depressed. This outlines the resulting depressed LV output. 

TDI of the RV free wall. 

Depressed RVOT-VTI (decreased stroke distance and output)

LV lateral wall and septal wall with depressed systolic peak velocities by tissue doppler imaging. 

Depressed EF by Simpson's in A4C (33%)

Shortening fraction is depressed at 18%. No signs of significant hypertrophy. 

There may be some early indicator of LV diastolic dysfunction with a low E/A ratio

No obvious coarctation with appropriate aortic caliber and laminar flow. A restrictive PDA may be observed (bidirectional in nature, although not fully appreciated from these clips). 

Decreased VTI in the descending Aorta from the depressed LV output. 

Echocardiography after Epinephrine IV

Improved biventricular function in A4C (EF: 57%, FAC 37%)

At a Nyquist of 77, nice laminar flow through the LVOT into the Ascending Aorta.

Mild TR - indicating some residual RV strain

PDA small and almost closed - bidirectional

One may observe in the subcostal view the UVL at the IVC-RA junction, some degree of free fluid below the diaphragm. 

Some pericardial fluid is observed in this PSAX view. 

Some mild mitral insufficiency from the residual subendocardial ischemia to the papillary muscles of the mitral valve. 

Adequate subjective RV and LV function by A4C view. 

Sweep in the PSAX: flattening of the septum in systole (iso-systemic PA pressure), some degree of RV dilation

RV looks similar in size to the LV. there is adequate RV function. 

Normalized TAPSE. 

Normalized RV TDI. 

Although angulated, one may appreciate the low-normal systolic velocity of the LV free wall (5th beat being the clearest)

E>A velocity. 

Improved LVO

Improved RVO

Improved VTI in the descending abdominal aorta. 

Improvement in the Shortening fraction, although there is paradoxical movement of the inter-ventricular septum from the isosystemic pulmonary pressure. 

Echocardiography on day 2 - after addition of Milrinone IV

Improved LV and RV function on the A4C

Good flow via pulmonary veins. No significant mitral insufficiency. 

Good left ventricular function with some flattening of the septal curve

E/A = 1

TAPSE has normalized

Systolic velocity of RV has normalized

Improved LV free wall systolic velocity

Improved LV septal systolic velocity

Some paradoxical movement of septum on the M-Mode (PSAX). Overall good movement of the LV posterior wall. E-seperation point normal. 

Normal RVO

normal LVO

Lung ultrasound - showcasing some degree of free fluid around the heart. 

Neonatal Heart Failure and Cardiomyopathy by Dr Alami

Presented at the McGill Neonatal Conference 2022

Insuffisance cardiaque néonatale et cardiomyopathie_eng.pdf

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