REVIEW ARTICLE

https://doi.org/10.5005/jp-journals-10089-0042
Journal of Acute Care
Volume 2 | Issue 3 | Year 2023

Evaluation of Systolic Function of Left Ventricle

Ajay Kumar Jha¹ https://orcid.org/0000-0002-8968-9216

Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, Puducherry, India

Corresponding Author: Ajay Kumar Jha, Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India, Phone: +91 9868477642, e-mail: drajaykjha@rediffmail.com

Received: 05 February 2023; Accepted: 22 March 2023; Published on: 19 February 2024

ABSTRACT

The left ventricle (LV) is a complex structure, and understanding functional complexity is crucial while evaluating the systolic function. Systolic function is the predominant determinant of stroke volume and cardiac output and has substantial clinical implications. Internal dimension, volumes, and fractional shortening are routinely used in clinical practice to assess LV systolic function. Ejection fraction (EF) estimation using two-dimensional (2D) echocardiography is ubiquitous. However, the reliability of EF in prognostication and decision among patients with normal to mildly reduced EF is questionable. Therefore, other 2D or three-dimensional (3D) echocardiographic variables and strain measurements are continuously evolving to supplement and complement EF. However, we need to generate sufficient normative data in normal patients and those with various cardiac pathologies to validate and strengthen the clinical utility of strain.

How to cite this article: Jha AK. Evaluation of Systolic Function of Left Ventricle. J Acute Care 2023;2(3):121–128.

Source of support: Nil

Conflict of interest: None

Keywords: Ejection fraction, Global longitudinal strain, Left ventricle, Systolic function, Three-dimensional echocardiography, Two-dimensional echocardiography.

INTRODUCTION

Anatomical and functional characterization of the LV is important in diagnosis, management, and prognostication in the perioperative, daycare, and critical care settings.¹ Several echocardiographic parameters need to be assessed to analyze the functionality of LV due to complex myofiber arrangement and contractility pattern.² In this review, left ventricular myocardial organization and echocardiographic parameters commonly used to assess left ventricular systolic function have been discussed. Additionally, the clinical and research importance of echocardiographic variables according to the guidelines has been emphasized.

Selection Criteria and Search Strategy

References for this review were identified through searches of PubMed with search items “Left ventricle anatomy,” “left ventricular systolic function,” “left ventricular contraction,” “Echocardiographic assessment of left ventricular function,” “echocardiography and left ventricular dimension,” “left ventricular chamber quantification,” “ejection fraction,” “left ventricular strain,” and “3 D echocardiography and left ventricular function.” Articles were also extracted from the reference lists of searched articles. Only papers published in English were reviewed. We also included European and American guidelines related to chamber quantification of LV and strain analysis. Preferences were given to systematic reviews, randomized trials, registries, and observation studies with a higher sample population.

Anatomy of LV

The left ventricle is a bullet-like prolate ellipsoid structure with a unique myofiber arrangement. Myocardial fibers are arranged in a helical manner and follow a gradual transition from right-handed epicardial fibers arrangement to left-handed subendocardial fibers arrangement. Subepicardial and subendocardial fibers are longitudinal fibers oriented in an oblique direction, while midmyocardial fibers are circumferential fibers oriented in a transverse direction.¹^,³^,⁴ The ratio of circumferential to longitudinal fibers is 10:1. This unique fiber arrangement produces opposite rotation at the base and the apex, resulting in torsion and wringling-like emptying.⁵ The midmyocardial fibers are responsible for the majority of inward shortening and ventricular ejection due to their predominance. The mechanical activity of the heart is preceded by electrical activity, and excitation–contraction coupling classically begins at the sinoatrial node. The coordinated and cyclic influx and efflux of calcium ions during depolarization and repolarization produce myofiber contraction and relaxation.⁶ Myocardial contraction produces ventricular systole and leads to left ventricular emptying into the aorta. Ventricular systole begins with mitral valve closure and isovolumetric contraction and is followed by ventricular ejection.

Echocardiographic Assessment

Several echocardiographic modalities can perform global and regional LV systolic function.⁷^,⁸ The commonly employed methods are:

Subjective assessment or eyeballing
M-mode-based measurement
2D volumetric and Doppler-based assessment
3D volumetric assessment
Wall motion analysis
Strain measurement

Subjective assessment or eyeballing is commonly practiced in routine care, and it provides approximate estimates of LV systolic function (Video 1). It may help in excluding the presence of moderate to severe left ventricular systolic dysfunction. Furthermore, visual assessment helps in anatomical characterization without quantification. Wall thickening, chamber volume and dimension, aneurysm, noncompaction and thrombus can reliably be assessed during eyeballing. The presence of a thrombus indicates akinetic, dyskinetic, or aneurysmal ventricle. A small ventricle indicates acquired or congenital hypertrophy due to hypertension, aortic stenosis, various forms of hypertrophic cardiomyopathies, and metabolic and storage disorders affecting the ventricular walls. Similarly, a large-sized LV internal dimension indicates systolic dysfunction and regurgitant left-sided valvular regurgitant lesions.⁹ However, mild systolic dysfunction may be challenging to distinguish from normal systolic function.

M-mode-based Assessment

M-mode-based measurement is the easiest way to analyze the thickness, mass, internal dimension, and fractional shortening of the LV.⁷^,¹⁰ It is available in all echocardiographic machines and requires minimal training to acquire and analyze. Nonetheless, good quality images with clear, crisp demarcation of the wall from the internal cavity are needed to calculate the dimension correctly. The linear internal dimension of LV should be obtained in the parasternal long-axis view and M-mode cursor should align the mitral valve leaflet tip (Fig. 1A). The calipers should be positioned between the myocardial wall and LV cavity and the interface between the pericardium and the wall. Assessing relative wall thickness (2 × posterior wall thickness/LV diastolic diameter) and LV mass help distinguish concentric hypertrophy, eccentric hypertrophy, and concentric remodeling from normal geometry. Additionally, mitral annular plane systolic excursion (MAPSE) is similar to tricuspid annular plane systolic excursion (TAPSE). It can be acquired quickly by aligning the M-mode cursor perpendicular to the lateral mitral annulus.¹¹ Similarly, mitral valve E-point septal separation is obtained by aligning the M-mode cursor in such a way as to scan the anterior mitral leaflet tip in diastole.¹² However, assessment MAPSE and E-point septal separation is not recommended by the current guidelines, and both are of historical interest only (Figs1B and C). M-mode measurement has high temporal resolutions and is reproducible. One-dimensional, beam alignment, and a single-point assessment are the major limitations of M-mode-based measurement, and it does not indicate global function.⁷

Figs 1A to D: (A) M-mode application in 2D parasternal long-axis view to estimate internal dimension, fractional shortening, and EF; (B) M-mode application in 2D apical view to calculate MAPSE; (C) M-mode application in 2D parasternal long-axis view to estimate E wave-ventricular separation; (D) Estimation of EF in four-chamber and two-chamber view (transthoracic echocardiography) by modified Simpson method

Fractional shortening can be obtained from M-mode or 2D-based measurement of the internal dimension of LV.⁷ It may not always be reliable in patients with coronary artery disease, conduction abnormalities, hypertrophic cardiomyopathies, and aneurysmal dilatations. Therefore, fractional shortening is a segmental indicator of ventricular contractility, and it does not represent the global LV function.

Two-dimensional Volumetric and Doppler-based Assessment

Similar to M-mode-based measurement, the 2D echocardiographic technique is useful in the measurement of wall and internal dimensions. Linear dimension can be obtained either by M-mode or 2D mode by placing the calipers perpendicular to the ventricular long axis in parasternal long-axis and short-axis views. However, it has a lower frame rate than M-mode, and measurement can be obtained in a single dimension only.

Volume measurement is performed by tracing the blood–tissue interface at the endocardial border in four-chamber and two-chamber views in both transthoracic and transesophageal echocardiography. Volume estimation by 2D methods is more reliable than M-mode-based measurements as it corrects for shape distortions and has better geometric assumptions. However, apical foreshortening, poor tracing of the endocardial border, endocardial dropouts, and blind spots may affect LV volume quantification.¹³

Ejection Fraction

Ejection fraction is stroke volume indexed to end-diastolic volume (left ventricular end-diastolic volume – left ventricular end-systolic volume/left ventricular end-diastolic volume) and is expressed as a percentage. EF is ubiquitously performed and quoted by clinicians in everyday practices for diagnosis, risk stratification, prognostication, and guiding therapy. EF can be estimated by M-mode, 2D, and 3D echocardiography.¹⁴ M-mode echocardiography uses LV internal dimension to calculate LV volume using Teichholz and Quinones methods. However, it is now no longer recommended for clinical use. 2D echocardiography is the most frequently used imaging modality to assess LVEF. However, it has been shown to have substantial intraobserver and interobserver variability and suboptimal accuracy and repeatability. Guidelines suggest modified Simpson methods (disk summation method) to measure EF during 2D echocardiography.⁷ LV volume is segmented as several cylinders, and areas of all cylinders are summated to approximate the LV volume (Fig. 1D). There are certain geometrical assumptions, and that may lead to overestimation or underestimation of EF. The endocardial border (blood–tissue interface) is traced in end-diastole and end-systole in four-chamber and two-chamber views to obtain the average value of EF (Video 2). The contour is closed at mitral valve level by a straight line joining the mitral annulus. A good blood–tissue interface and maximum LV area acquisition are crucial to obtain a good approximation of EF. In a person with poor endocardial delineation, contrast agents can be used for better definition of the blood–tissue interface. Furthermore, contrast agents should be used whenever two contiguous segments are not visualized during tracing. Contrast-based echocardiographic acquisition of images and calculation of LV volumes is similar to those obtained from magnetic resonance imaging (MRI). However, excessive contrast agents may produce acoustic shadowing and poor endocardial border definition.⁷ The normative values of dimensions and EF have been provided in Table 1.

**Table 1:** Normal values of interval dimension, volumes, and EF of LV in male and female (adapted from Lang et al.)⁷
Parameters		Male		Female
Parameters		Mean ± SD	2-SD range	Mean ± SD	2-SD range
LV internal dimension	Diastolic dimension (mm)	50.2 ± 4.1	42.0–58.4	45 ± 3.6	37.8–52.2
LV internal dimension	Systolic dimension (mm)	32.4 ± 3.7	25–39.8	28.2 ± 3.3	21.6–34.8
LV volumes (biplane)	LVEDV (mL)	106 ± 32	62–150	76 ± 15	46–106
LV volumes (biplane)	LVESV (mL)	41 ± 10	21–61	28 ± 7	14–42
LV volumes indexed to body surface area	LVEDV (mL/m²)	54 ± 10	34–74	45 ± 8	29–61
LV volumes indexed to body surface area	LVESV (mL/m²)	21 ± 5	11–31	16 ± 4	8–24
LVEF (%)		62 ± 5	52–72	64 ± 5	54–74

Three-dimensional echocardiographic examination is now increasingly implemented in clinical practice. 3D echocardiography provides a more accurate LVEF quantitation as it avoids geometric assumptions and left ventricular foreshortening and has incremental value to predict adverse outcomes compared to conventional 2D echocardiography.¹⁵ 3D image acquisition mainly focuses on including the entire ventricle within the pyramidal data set while maximizing temporal resolution.

Contrast 2D echo and non-contrast 3D echo show good reproducibility and good agreement of MRI measurement of LVEF. The accuracy of 3D echocardiography improves as the number of assessed planes increases.¹⁶^,¹⁷ Despite potentially high accuracy and precision, 3D data sets are affected by the acoustic window, cardiac rhythm, breath hold, and poor temporal and spatial resolution.

Full-volume multi-beat acquisition provides the recommended data set for LV volume measurement. However, wide-angle single-beat acquisition may avoid stitching artifacts and the need for prolonged breath-holding. Several vendors have provided the option for automated 3D EF analysis. Echocardiographer role in view selection, marker positioning, and endocardial tracing is limited and the software automatically facilitates view selection and endocardial border tracing (Video 3).¹⁸ Nevertheless, semiautomatic methods are commonly practiced in routine practice, where the marker is placed at the annulus and apex, and the automatic tracing can be edited innumerable times in both end-systole and end-diastole till user satisfaction.

Despite the optimism, 3D echo has not been able to replace 2D echo-based assessment of EF in clinical practices and trials.¹⁹

Doppler Assessment of Stroke Volume

Measuring stroke volume and cardiac output also assesses LV systolic function. In addition to direct hemodynamic variables, several indirect hemodynamic variables can be obtained with the stroke volume and cardiac output.²⁰^,²¹ Pulse wave Doppler should be placed 1 cm deep into the left ventricular outflow tract (LVOT) to obtain the velocity time integral (VTI). The diameter of LVOT is obtained at the same place where the pulse wave cursor was placed to measure VTI. The diameter is halved to get the radius, and the cross-sectional area of LVOT is multiplied with VTI to obtain stroke volume (Fig. 2A). Cardiac output can be obtained by multiplying stroke volume with heart rate. There are technical challenges associated with stroke volume measurement. Firstly, the placement of calipers to measure LVOT may not be accurate and erroneous calculation of LVOT diameter will get squared. The calculated stroke volume may not be reliable. Furthermore, perpendicular alignment of the pulsed wave (PW) beam with the blood flow stream may not be always possible to generate a perfect VTI envelope. The heart moves during systole, diastole, and respiratory excursion, and measured LVOT and PW sample volume may not remain fixed.

Figs 2A to D: (A) Calculation of stroke volume in apical five-chamber view using 2D Doppler echocardiography; (B) Longitudinal strain (2D speckle tracking echocardiography) in transthoracic echocardiography apical view; (C) Bull’s eye plot (distribution of regional strain of LV); (D) Estimation of SDI (3D volumetric analysis)

Derived Hemodynamic Parameters

SVR = MAP – CVP/CO

DO₂ = 1:34 × Hb × CO × SaO₂/100

VO₂ = CaO₂ − CvO₂ × CO

Stroke work = 0.0136 × SV × (MAP − LVEDP)

Cardiac power output = CO × MAP/451

Myocardial contraction fraction = SV/LVEDV

DO₂, systemic oxygen delivery; VO₂, systemic oxygen consumption; MAP, mean arterial pressure; CVP, central venous pressure; CO, cardiac output; CaO₂, arterial oxygen content; CvO₂, venous oxygen content; SV, stroke volume; LVEDP, left ventricular end-diastolic pressure; SaO₂, systemic arterial oxygen saturation; SVR, systemic vascular resistance; LVEDV, left ventricular end-diastolic volume.

Rate of Ventricular Pressure Rise

Left ventricle contractility can be assessed by measuring instantaneous pressure rise as a result of the gradient between LV and left atrium. It is a good indicator of LV contractility during the isovolumic contraction phase of systole. It is least affected by a change in preload and afterload. However, it is not recommended by guidelines and is not routinely used in clinical practices. A good mitral regurgitant envelope is required to obtain the time between velocity rise from 1 m/s to 3 m/s. The resultant pressure gradient (32 mm Hg) is divided by time to obtain dp/dt.¹³^,²² Normal LV dp/dt is <1200 mm Hg/s.

Strain Analysis

Traditionally, EF has been the cornerstone for risk stratification, management decision-making, and prognostication. However, the reliability of EF is now constantly questioned as a prognostic indicator of LV systolic function.²³^,²⁵ LV myocardial fiber arrangement and contractility pattern are complex and a single-dimensional echocardiographic marker may not be suitable for prognostication and guided therapy. The early development of tissue Doppler strain and strain rate use Doppler to assess myocardial motion at one point relative to other in the myocardium. Strain is myocardial deformation, and is described as a percentage change in myocardial length. Strain is a dimensionless index measured in various directions such as longitudinal, circumferential, radial, and torsion. Shortening is denoted as a negative fractional length change, and lengthening is denoted as a positive fractional length change. However, tissue Doppler-based strain suffers from several limitations, including angle dependency and larger interobserver and intraobserver variability. Speckle tracking strain measurement is based on Lagrangian strain. Therefore, the length at a particular point during the cardiac cycle (end-systole) is subtracted from the length at the original point (end-diastole) and is divided by the original length (end-diastole).²⁶^,²⁷

During speckle tracking, bright speckles are generated by the interactions of ultrasound waves and myocardial tissue. The greyscale images consisting of speckles are tracked frame by frame during the cardiac cycle by the specialized software using Fourier analysis and the sum of absolute differences. Compared to tissue Doppler-based strain, speckle tracking-based strain track speckles in angle independent manner in 2D. Therefore, speckle tracking strain can differentiate abnormal contracting segments from normal contracting segments. Speckle tracking imaging has been validated against sonomicrometry and tagged MRI and has been shown to provide accurate, angle-independent measurements of regional myocardial function. However, variability between software vendors and machines and reproducibility are a cause of concern and consensus for practical application in wide-ranging cardiac pathologies.⁷^,²⁷^,²⁸

Three-dimensional speckle tracking is in the experimental phase and still evolving. It provides multi-dimensional deformation and rotation mechanics.²⁹ However, 3D full-volume imaging has poor temporal and spatial resolution than 2D speckle tracking and tissue Doppler-based strain imaging.

Step to perform speckle strain echocardiography³⁰:

Selection of appropriate 2D echocardiography view

↓

Marking of landmarks (annulus and apex) in four-chamber, two-chamber, and three-chamber and endocardial border in basal, mid, and apical short-axis view

↓

Editing the region of interest (endocardial and epicardial border)

↓

Submission to software for automatic analysis

Global longitudinal strain (GLS) measures myocardial deformation of subendocardial longitudinal fibers (Table 2) (Fig. 2B) (Video 4). In patients with normal or mildly reduced EF, GLS adds incremental information regarding heterogeneity and complexity of ventricular contraction and is helpful in evaluating wide varieties of myocardial pathologies.²⁸ GLS is a better marker of cardiac death and mortality in heart failure with preserved EF. A normal EF cannot rule out impaired systolic dysfunction. Ventricular remodeling, wall thickness changes, changes in GLS, and global circumferential strain (GCS) may maintain EF despite progressive myocardial dysfunction. GLS detects abnormalities in longitudinal fibers and a fall in EF in these patients is prevented by an increase in GCS, wall thickness, and a decrease in LV diameter. Similarly, if both GLS and GCS fall, EF is still preserved due to increased wall thickness and decreased LV diameter (Video 5).³¹^,³² Therefore, a fall in EF happens only after substantial myocardial damage. Regional strains such as bull’s eye plot help evaluate various cardiomyopathies and storage disorders that include hypertrophic cardiomyopathies, Friedreich ataxia, Fabry disease, and amyloidosis (Fig. 2C).³¹^,³⁴ In patients receiving cancer chemotherapy, GLS provides crucial information during chemotherapy drug titration and follow-up and helps estimate the extent of myocardial damage.³⁵^,³⁶ The GLS could provide management decision-making in valvular heart disease with normal EF and asymptomatic valvular heart disease.³⁷^,³⁸ GLS helps in the early detection of myocardial damage before the reduction in EF. Despite these potential benefits, the evidence base for using GLS in routine clinical practice is limited. A GLS in the range of –20 is considered normal.

**Table 2:** Normal values of GLS
Vendor	Software	Mean
Varying	Data derived meta-analysis	–19.7%
GE	EchoPAC BT 12	–21.2 to 21.5%
Philips	QLAB 7.1	–18.9%
Toshiba	UltraExtend	–19.9%
Siemens	VVI	–17.3 to 19.8%
Esaote	Mylab 50	–19.5%

Circumferential strain, radial strain, torsion, and twist are also used to assess LV systolic function. However, their utility is still limited to research purposes only.³⁹ A large base of normative data regarding GCS, radial strain, torsion in normal patients, and a wide range of cardiac pathologies need to be generated to provide recommendations.

Assessment of Segmental Function

The individual segment analysis is crucial in coronary artery diseases or ventricular remodeling and whenever coronary artery flow or integrity is compromised.⁷ Therefore, LV segmentation should follow coronary flow distribution. Six segments each at the basal and midventricular level and five segments at the apical level contribute to 17 segments. Cardiac magnetic resonance, single photon emission computed tomography, and positron emission tomography analyze coronary flow distribution according to 17 segment model.⁴⁰ However, regional strain and wall motion analysis should be based on 16 segments model and the apical cap should be excluded. The assessment of regional function can be performed by visual inspection, speckle tracking, tissue Doppler-based strain, and 3D segmental analysis.

Visual assessment requires 2D echocardiographic images in four-chamber, two-chamber, and three-chamber views to analyze endocardial excursion and wall thickening in all segments. A semiquantitative score can be assigned to each LV segment to calculate the LV wall motion score index. Each LV segment assigned scores based on the following principles: (1) normal or hyperkinetic, (2) hypokinetic, (3) akinetic, and (4) dyskinetic. The recent guideline has omitted aneurysms from the scoring criteria.⁷

Regional wall motion abnormality can be induced by exercise or stress or during ventricular demand–supply mismatch in patients with impaired coronary reserve. Side-by-side comparison of echocardiographic views before and after stress can help in the visual detection of change in endocardial excursion and wall thickening.⁴⁰^,⁴¹

However, wall motion abnormality can also be detected in patients without coronary artery disease. Left bundle branch block, ventricular pacing, myocarditis, and takotsubo cardiomyopathy may lead to altered electrical activation sequence and manifest as wall motion abnormality. In these patients, primary myocardial dysfunction is absent. However, stroke volume and cardiac output may be reduced due to uncoordinated LV contraction.⁷

Tissue Doppler-based strain can map entire segments separately and the individual strain and strain rate can be depicted. However, Doppler-based strain is angle-dependent, and cannot distinguish tethering and translational movement from akinesia and hypokinesia.⁴² Septal–lateral delay and septal–posterior wall delay indicate regional heterogeneity in LV basal segment contraction pattern. A delay <65 ms is considered abnormal and indicates uncoordinated LV contraction. Despite preserved EF, a higher septal–lateral delay may lead to a reduction in stroke volume and cardiac output.⁴³

Two-dimensional speckle tracking provides LV segment data in a bull’s eye plot in both long-axis and short-axis view.⁴⁴ All LV segments should be adequately visualized in four-chamber, three-chamber, and two-chamber long-axis views to obtain the distribution of individual LV segment strain and strain. Similarly, basal, midventricular, and apical short-axis views can be analyzed to obtain all segment’s strain as a bull’s eye plot.

Three-dimensional wall motion analysis provides a model for visual inspection of all segments and also provides individual segment’s volume and displacement to indicate regional function.⁴⁵^,⁴⁶ Systolic dyssynchrony index (SDI) is the standard deviation of the time from cardiac cycle onset to minimum systolic volume in 17 LV segments and provides critical information related to regional LV function and functional homogeneity (Video 6).⁴⁷^,⁴⁸ SDI is in the experimental phase, and normative data in normal and disease states are still evolving. Therefore, no definite recommendation regarding clinical utility of SDI can be made at this time point. A delay between individual LV segments can also be measured using 3D wall motion analysis (Video 7). However, the utility of delay in minimum systolic volume in two LV segments in clinical practice is yet to be ascertained (Fig. 2D) (Supplementary Figs S1–S3).

Fig. S1: Estimation of LV dp/dt in midesophageal four-chamber view

Fig. S2: Tissue Doppler-based strain measurement

Fig. S3: Measurement of septal–lateral delay of LV in apical four-chamber view

CONCLUSION

Left ventricle systolic function assessment has important clinical implications in our routine practices. Perioperative decision-making, guiding therapy in critical care, risk stratification, and prognostication are influenced by LV systolic function. EF remains the cornerstone to assess LV systolic function. However, the reliability of EF in several cardiac pathologies, asymptomatic LV dysfunction, and heart failure with preserved EF is limited. Therefore, newer modalities are emerging to supplement and complement EF and other aspects of LV systolic function.

SUPPLEMENTARY MATERIAL

The supplementary videos 1 to 7 are available online on the website of https://www.jacutecare.com/journalDetails/JAC

Video 1: Visual assessment of LV contractility in apical four-chamber view.

Video 2: Automatic EF calculation in apical four-chamber view.

Video 3: 3D measurement of LV function.

Video 4: Longitudinal strain in apical view.

Video 5: Circumferential strain in midventricle short-axis view.

Video 6: 3D wall motion abnormality (intersegmental delay).

Video 7: Systolic dyssynchrony index (3D volumetric measurement).

ORCID

Ajay Kumar Jha https://orcid.org/0000-0002-8968-9216

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