Global Systolic Function (Fractional Area Change)

The measurement is made at the mid-papillary level by calculating the cross-sectional area of the LV during systole and
diastole. Note that the papillary muscles are excluded from the area calculation.

FAC = (LVAd - LVAs) / LVAd

The normal range for the variable is 35 - 65%

FACac = FAC x log 10(SVRI) x 100%

where systemic vascular resistance index (SVRI) is calculated without multiplication by 80.

The FAC at the mid-papillary level is also sometimes referred to as the 'Area Ejection Fraction'. See, for example, Clements
et al.

Global Systolic Function (Fractional Shortening)

Numerous indices of global systolic function have been described. In the context of TOE, one of the simplest to measure is
LV Fractional Shortening % (FS).

FS is calculated as:

FS = ((LVIDd - LVIDs)/(LVIDd)) * 100.

Where LVID = Left Ventricular Internal Dimension (diameter) during systole and diastole respectively. The normal value for
the measurement is 25-45%.

The typical diameter of the LV cavity at the mid-papillary level in systole is 3.1cms and diastole 4.7cms.

Either M-Mode or 2D echo may be used for the measurement.

In this case I've placed an M-Mode cursor across the ventricle at the mid-papillary level.

The end-diastolic diameter is 4.55 cms and end-systolic diameter 2.4 cms. This corresponds to a fractional shortening of
47%.
Global Systolic Function (LV dP/dT & preload)

In the presence of mitral regurgitation, left ventricular dP/dTmax can be measured and used as an index of global systolic
function. Left ventricular dP/dTmax is generally accepted to be relatively unaffected by changes in afterload, but is
exquisitely sensitive to changes in pre-load.

However, notwithstanding the sensitivity of dP/dTmax to changes in filling, it seems that the time taken to achieve dP/dTmax
is independent of preload and can be used as a measure of the contractile state  (Adler et al). In practise, the time to
achieve dP/dTmax is difficult to measure accurately using echocardiographic techniques.

In contrast, right ventricular dP/dTmax is probably sensitive to changes in both preload and afterload (Correia-Pinto et

Global Systolic Function (LVPEP/LVET Ratio) (1)

Last Modified: 5/2/2003

This ratio is measured using the 'M' mode cursor applied through the right and non-coronary leaflets of the aortic valve in
the 120 degree view. (Refer to the entry on MACS for a typical recording).

The left ventricular pre-ejection period (LVPEP) is measured from the Q wave on the ECG to the onset of aortic valve opening
while the left ventricular ejection time(LVET) is measured from aortic valve opening to aortic valve closure. Both these
intervals vary inversely with the heart rate.

The LVPEP/LVET is the ratio of pre-ejection period to the ejection period of the left ventricle. The ratio is unaffected by
heart rate and, therefore provides a simple method for the assessment of global systolic function.

When there is left ventricular systolic dysfunction, the left ventricular systolic time intervals vary from normal such that
the LVPEP is prolonged and the LVET is shortened, resulting in an overall increase in the LVPEP/LVET ratio. The ratio has
been found to correlate with the ejection fraction EF.

A ratio of < 0.35 correlates with an EF of > 55%, one between 0.35 and 0.65 with an EF of 30-55% and a ratio of > 0.65 with
an EF of < 30%.

The technique has been used quite extensively in children, but much less frequently in adults.
Global Systolic Function (LVPEP/LVET Ratio) (2)

The LVPEP/LVET is the ratio of pre-ejection period to the ejection period of the left ventricle. It is obtained using the
'M' mode cursor applied through the right and non-coronary leaflets of the aortic valve in the long-axis view.

The left ventricular pre-ejection period (LVPEP) (1-2) is measured from the Q wave on the ECG to the onset of aortic valve
opening while the left ventricular ejection time (LVET) is measured from aortic valve opening to aortic valve closure (2-3).
Both these intervals vary inversely with the heart rate.

The ratio is unaffected by heart rate and, therefore provides a simple method for the assessment of global systolic
function.

When there is left ventricular systolic dysfunction, the left ventricular systolic time intervals vary from normal such that
the LVPEP is prolonged and the LVET is shortened, resulting in an overall increase in the LVPEP/LVET ratio. The ratio has
been found to correlate with the ejection fraction EF.

A ratio of < 0.35 correlates with an EF of > 55%, one between 0.35 and 0.65 with an EF of 30-55% and a ratio of > 0.65 with
an EF of < 30%. In this example (of a single cardiac cycle), the LVPEP has been measured at 93 msecs and the LVET at 367
msecs - which corresponds to a ratio of 0.25.

Recently, Swaminathan et al have examined the use of M-Mode interrogation of the aortic valve for the measurement of the
left ventricular ejection time. These authors found close agreement between M-mode and Doppler echocardiography for the
measurement of LVET by the transoesophageal approach.
Global Systolic Function (LV dP/dTmax)

In the presence of mitral regurgitation, left ventricular dP/dTmax can be measured and used as an index of global systolic
function.

The measurement is made using the mitral regurgitant continuous wave Doppler signal. An excellent account of this technique
has been given by Bonita Anderson in her book on Echocardiography. According to this author:

"The velocity of the mitral regurgitant signal reflects the instantaneous pressure gradient between the left ventricle and
left atrium during systole. Assuming that the left atrial pressure does not increase significantly during the isovolumic
contraction phase, the rate of rise of the Doppler velocity reflects the rate of rise of left ventricular pressure or dP/dT.

Measurement of dP/dT is performed by measuring the time interval between two arbitrary points on the mitral regurgitant
velocity spectrum (usually between 1 and 3 m/s). Using the modified Bernoulli equation, the velocity can be converted to
pressure; hence, the pressure difference between these two arbitrary points can be determined. For example, the pressure
difference between 1 and 3 m/s is 32 mm Hg. Under these circumstances, dP/dT, which measures the change in pressure over
time, can be defined as the time it takes for the left ventricle to generate 32 min Hg of pressure during the isovolumic
phase."

For the case of a velocity change from 1 to 3 m/sec:

dP/dT = 32/Dt.

Representative values of dP/dT in the awake patient are:

Normal:                > 1200 mm Hg/sec

Moderate dysfunction:  800 - 1200 mm Hg/sec
Severe dysfunction:    < 800 mm Hg/sec

Catheter-measured LV dP/dT has been shown to be an index of contractility which is largely unaffected by changes in
afterload. This finding has recently been confirmed using echo measurement of LV dP/dT by Broka et al.

An alternative way of presenting these data is to express the assessment in terms of the length of time required to
accelerate the regurgitant jet from 1 m/sec to 3 m/sec in which case:

Normal:                < 26 msec
Moderate dysfunction:  26 -  40 msec
Severe dysfunction:    > 40 msec

The values for LV dP/dT under anaesthesia are less clearly defined. In my clinical experience, the quoted ranges for the
awake patient are significantly different from those found in patients undergoing cardiac surgery and, in such cases, it
might be reasonable to categorise ventricular function according to the following schema:

Normal:                > 900 mm Hg/sec

Moderate dysfunction:  450 - 900 mm Hg/sec
Severe dysfunction:    < 450 mm Hg/sec

Which corresponds to a time required to accelerate the regurgitant jet from 1 m/sec to 3 m/sec of:

Normal:                < 35 msec
Moderate dysfunction:  35 - 70 msec
Severe dysfunction:    > 70 msec

De Hert et al have measured LV dP/dT in a group of patients with an ejection fraction of > 40% who were undergoing coronary
artery grafting. In those patients anaesthetised with sevoflurane, these authors found a mean value of LV dP/dT of 967 mm
Hg/sec before bypass which fell to 892 mm Hg/sec after bypass.
Global Systolic Function (Wall Motion)

The rate of excursion of the ventricular wall during systole has been used as an index of global systolic function. In the
context of perioperative transoesophageal echocardiography the technique is attractive because the measurement is easily
made using an 'M' mode cursor directed orthogonally over the anterior wall of the left ventricle in the transgastric short
axis view. The technique was first examined by Pernod et al, but does not appear to have been greatly studied since.
Obviously, the cursor should not be positioned in an area where there is a regional wall motion abnormality.

In my experience, in patients undergoing anaesthesia, good systolic function is associated with an average wall motion
velocity of more than 4 cm/sec, mild impairment with a value in the range of 3 - 4 cm/sec, moderate impairment with a value
in the range of 2 - 3 cm/sec and severe impairment with a value of less than 2 cm/sec.