Case - Severe Biventricular Dysfunction

Case of a patient born with asphyxia and severe biventricular dysfunction. 

Parasternal Long Axis View

One may already appreciate from the parasternal long axis view that there is profound depression of the left ventricular function. The panel on the right also performs a posterior sweep where one may appreciate that there are signs of RV dilation. The aortic valve has a very short opening time, leading to the suspicion that there is limited flow through the valve during systole.

Parasternal Short Axis View

Sweep from the mitral annulus to the base. One may already appreciate the significant LV systolic dysfunction. The aortic valve is tri-leaflet. The PDA can be visualized and seems large. The pulmonary valve opens and closes, outlining that there is flow generated by the RV and ejection through the RVOT. 

Another sweep in PSAX outlining that the LV dysfunction is global, starting from the Apex to the Base of the heart. 

The shortening fraction is very limited, at 11.5% (1.65-1.46)/1.65*100. One may appreciate some of the vibrations (artefacts) from the high frequency oscillation.

View outlining LV dysfunction (systolic) that is circumferential at the papillary muscle level. There may be some flattening or dyskinesis of the septum in systole. 

View outlining LV dysfunction (systolic) that is circumferential also at the apical level.

The PDA is large and right to left (blue) outlining that the flow is going from the pulmonary artery to the aorta. This may be secondary to the significant impaired output from the LV compartment, with a systemic output dependent on the flow generated by the right ventricle. There may be also a component of increased PVR. All in all, the right to left flow may be essential to provide some perfusion into the aorta in the context of the profound LV dysfunction. The peak gradient in systole (right to left) is of 3 mmHg. This is not surprising considering that the PDA is quite large, leading to rapid equalization of pressure between the PA and the Aorta (i.e. two structures being connected by a non-restrictive conduit will rapidly equalize pressure).

Apical Views

Severe biventricular dysfunction. The atrio-ventricular valves are seen opening and closing, outlinig that there is some filling. We may perceive the vibration from the high frequency oscillator. The RV systolic and LV systolic function are both impacted. 

Ejection fraction is profoundly affected. EF by disc methods in the apical 4 chamber view is 10% = (2.22-1.99)/2.22*100.

Colour Doppler is covering the LV inflow. There is limited colour generated in the body of the LV at a velocity filter of 77 cm/s. This means that there is not a lot of blood flow having a velocity beyond 77 cm/s due to the profound wall motion abnormalities. One may perceive briefly that the PFO is left to right and seem of high velocity, outlining that there is likely higher LA than RA pressure, from the LV diastolic dysfunction (impaired filling due to residual volume in the cavity of the LV at the end of systole).  There is some mild mitral insufficiency. 

Upon the sweep, we may appreciate the 5 chamber view. Initially we visualize the RV - which has the free wall barely moving. The LVOT is then observed and looks unobstructed. 

Aortic insufficiency (mild) from likely ventricular suffering and LV dilatation. 

Mild aortic insufficiency with pressure half-time more than 500 msec. The peak of the AI is 2.4 m/s, telling us there is a diastolic pressure in the Aorta of about 23-28 mmHg (which was the case based on the umbilical arterial line reading). 

RVOT Velocity Time Integral indicating significantly imparied RV output.  The stroke distance is at 0.042 m.

Similarly, the LVOT stroke distance is profoundly diminished, indicating decrease LV output. 

Tricuspid Annular Plane Systolic Excursion (TAPSE) is at 0.18 cm, indicating severe RV dysfunction (systolic) for a newborn. 

Subcostal View

Subcostal view at the atrial level. This outline - at this point of the scan - that the shunt is now bidirectional. 

Subcostal long-axis sweep. This view indicates there is no significant pericardial or pleural effusions. The biventricular function (systolic) is affected. There is no significant intra-cardiac congenital heart defect. 

Subcostal short axis sweep. One may appreciate again the biventricular dysfunction. We can see that the RVOT is unobstructed and that the pulmonary valve opens and closes. 

Colour over the inter-atrial shunt. One may appreciate the flap of the PFO. We can see that there is bidirectional shunting. Nyquist (velocity filter) is at 57.2 cm/s.

Situs view. The Aorta is on the left (see the "P" marker). The IVC is on the right. The stomach is seen on the left. There is no clear ascites. at this level of the abdomen. 

An umbilical arterial line is seen in the descending aorta. The liver is seen, as well as the diaphragm. There is no clear pleural effusion, or ascites in this view. 

Subcostal view with the curvilinear probe. No pleural effusions may be appreciated. There is consolidated B-lines in regards of both lung fields. 

Profound LV systolic dysfunction. 

Vascular Line Position

In these views, you can see the umbilical venous line going towards the IVC-RA junction, with a zoom in the left-panel.

Head and Bladder POCUS

Significantly dimished velocities in the vessels of the brain, from the profoundly dimished LV output. 

No catastrophic bleed on this quick head POCUS> 

In this anuric patient, one may appreciate the bladder, not looking overfilled. This informs that there is likely a decrease urinary production, as the etiology for the low / absent urine output - likely from acute kidney injury and ongoing low perfusion to the kidneys. 

Created by Gabriel Altit - Neonatologist / Créé par Gabriel Altit (néonatalogiste) - © NeoCardioLab - 2020-2024 - Contact us / Contactez-nous