0 jb basic lv and rv - nsw agency for clinical innovation · how cardiologists assess lv size &...
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Basic LV and RV assessment
Justin Bowra
Critical Care Ultrasound Course
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Summary
Keep it simple2D imaging only
The Goldilocks method
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A simple rule
Assess LV/RV size in diastole (tells you about preload)
Find where the LV/RV looks LARGEST
Assess LV/RV function in systole
Find where the LV/RV looks SMALLEST
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DIASTOLE SYSTOLE
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Qualitative or quantitative?
The Goldilocks Approach
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How cardiologists assess LV size & function
a. Sonographer guesstimate: bizarrely, the most accurate!
b. LV fractional shortening (PLAX) c. End-diastolic area method (PSAX) d. Simpson’s method (A4C and A2C)
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PLAX: LV size & fractional shortening
• B mode or M mode• Freeze image & measure LVIDd & LVIDs- ‘simple!’• Normal LVIDd = 3.9–5.3cm (F) / 4.2-5.9 (M)• Normal LVFS = [(LVIDd – LVIDs)/LVIDd] = 25-45%
Pitfalls:• Need to get PLAX just right• Need to measure at just the right spot• 1D measurement of a 2D image of 3D structure! (i.e.
assumes symmetry)
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RV
LVLA
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RV
LVLA
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A B
Pitfall
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PSAX: End-diastolic area method
IHYPOVQLAEMlA ORMA!L DILATED
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End-diastolic area method
Parasternal SAX (B mode) Mid-way down the papillary musclesn Trace endocardial border at end diastole The machine does the rest! Normal LV in diastole: 8-14cm2 (70kg male) Normal LVEF = 55-70%
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Pitfalls
Needs to be at the right level (mid papillary muscle) Needs to be perpendicular to heart's long axis Needs to be a good view! Need the right software Need time!
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A4C, A2C: Simpson’s method
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Simpson’s method
A4C and A2C views Trace endocardial border at end diastole ‘The machine does the rest!’ Divides 2D image of LV into segments Normal LV end diastolic volume: men 67-155 mL, women
56-104 mL
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Pitfalls
Can only be done from apical window Bloody difficult!
– Finding the right window– Finding the endocardium
Notoriously easy to under- / overestimate
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‘Echocardiography is a science’
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‘Echocardiography is a science’
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At best it’s semiquantitative… i.e. subjective.
Even the best echocardiographer has bad days.
And this tells you nothing about diastolic failure. (Need other tricks eg tissue Doppler)
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How we do it in BELS:A rough 'eyeball' approach
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The rough guess
Too big? Too small? Grossly normal? (NOT ‘Just right’) Experienced full-time cardiac sonographers are very
accurate at this But for us, only useful at extremes
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The trick is to recognise what’s normal.
(And that it’s just grossly normal)
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What’s normal?
LV internal diameter in diastole (LVIDd): ROUGHLY 4– 6cm (PLAX)
LV free walls and IV septum: 0.6 – 1.0 cm
RV internal diameter in diastole: up to 2/3 of LV diameter
RV free wall < 0.6 cm
LA up to 4cm diameter, RA up to 4.5
Aortic root: up to about 4cm (PLAX)
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What’s normal?
LV internal diameter in diastole (LVIDd): ROUGHLY 4– 6cm (PLAX)
RV internal diameter in diastole: up to 2/3 of LV diameter
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Normal function
Normal LV: moves substantially, but doesn’t ‘kiss’
Normal RV: moves substantially, but doesn’t squash the LV
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How’s this LV?
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How’s this LV?
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Caveat
All these numbers are averages.
They change with age and sex (M>F)
They change with BSA (e.g. small people have small hearts)
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LV
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The ‘grossly normal’ LV
SIZE: LVIDd = 4–6cm (PLAX)
FUNCTION: moves substantially, but doesn’t ‘kiss’
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TEST
Window?LV size?
LV contraction?
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Top tip
If in doubt, look from different windows.
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Top tip
Remember the ‘mimics’(eg LVH mimicking hypovolaemia)
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Top tip
Try different windows(eg subcostal SAX)
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RV
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The ‘grossly normal’ RV
SIZE:
Internal diameter in diastole = up to 2/3 of LV diameter
FUNCTION: Moves substantially, but doesn’t squash LV
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Top tip
RV contracts more in the long axis (watch the tricuspid valve)
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TEST
Window?RV contracting?
RV big?RV squashing LV?
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Top tip
Make sure probe is round the right way!
Look for aortic rootTV is closer to apex than MV
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LV
RV
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Top tip
Thick RV free wall =chronic cor pulmonale
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Putting it together
What the ventricles can tell you in basic echo
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Is this hypovolaemic shock?
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Is this hypovolaemic shock?
Small, collapsing IVC
Small LV
LV systolic kissing
NB beware LVH, HOCM, & cylinder artifact
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Is this cardiogenic shock?
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Is this cardiogenic shock?
Large IVC
Large LV (only if chronic)
LV may be contracting ‘normally’ (NB diastolic failure)
NB beware the chronically crappy heart with acute septic shock
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Is this septic shock?
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Is this septic shock?
This can be tricky!
IVCSmall (systemic vasodilation) …
Or large (because of hypocontractile heart)…Or ‘normal’
LV‘Kissing’ (systemic vasodilation)… Or hypokinetic (septic ‘stunning’)…
Or ‘normal’
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Is this obstructive shock?
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Is this obstructive shock?
Add lung, IVC
Tension PTX: check lungs, IVC
Tamponade: check IVC, RV
Massive PE:Occasionally RV/ pulm a thrombus
RV bigRV squashes LV
False positive = chronic cor pulmonaleFalse negative = lower grade cor pumonale
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You’re not in Kansas now
Cardiac US is harder than you think
And this is just 2D
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Summary
Chamber size in diastole, function in systole
Know normal dimensions
Practice +++ on normal patients & those with known pathology
Stick to Goldilocks
Avoid overcalling things (the big trap)… try different windows if in doubt
Know the limitations of BELS (eg ‘minor’ cor pulmonale)
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Thanks to
Sharon KayConn Russell