Skip to main content

Left ventricular ejection fraction assessment by non-cardiologists from transverse views using a simplified wall motion score index

Abstract

For the non-cardiologist emergency physician and intensivist, performing an accurate estimation of left ventricular ejection fraction (LVEF) is essential for the management of critically ill patients, such as patients presenting with shock, severe respiratory distress or chest pain. Our objective was to develop a semi-quantitative method to improve visual LVEF evaluation. A group of 12 sets of transthoracic echocardiograms with LVEF in the range of 18–64% were interpreted by 17 experienced observers (PRO) and 103 untrained observers or novices (NOV), without previous training in echocardiography. They were asked to assess LVEF by two different methods: i) visual estimation (VIS) by analysing the three classical left ventricle (LV) short-axis views (basal, midventricular and apical short-axis LV section) and ii) semi-quantitative evaluation (base, mid and apex (BMA)) of the same three short-axis views. The results for each of these two methods for both groups (PRO and NOV) were compared with LVEF obtained by radionuclide angiography. The semi-quantitative method (BMA) improved estimation of LVEF by PRO for moderate LV dysfunction (LVEF 30–49%) and normal LVEF. The visual estimate was better for lower LVEF (<30%). In the NOV group, the semi-quantitative method was better than than the visual one in the normal group and in half of the subjects in the moderate LV dysfunction (LVEF 30–49%) group. The visual estimate was better for the lower LVEF (ejection fraction <30%) group. In conclusion, semi-quantitative evaluation of LVEF gives an overall better assessment than VIS for PRO and untrained observers.

References

  1. Sabia P, Abbott RD, Afrookteh A, Keller MW, Touchstone DA, Kaul S 1991 Importance of two-dimensional echocardiographic assessment of left ventricular systolic function in patients presenting to the emergency room with cardiac-related symptoms. Circulation 84 1615–1624. (doi:10.1161/01.CIR.84.4.1615)

    CAS  Article  Google Scholar 

  2. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ 2013 Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. Journal of the American Society of Echocardiography 26 567–581. (doi:10.1016/j.echo.2013.04.001)

    Article  Google Scholar 

  3. Choi BG, Mukherjee M, Dala P, Young HA, Tracy CM, Katz RJ, Lewis JF 2011 Interpretation of remotely downloaded pocket-size cardiac ultrasound images on a web-enabled smartphone: validation against workstation evaluation. Journal of the American Society of Echocardiography 24 1325–1330. (doi:10.1016/j.echo.2011.08.007)

    Article  Google Scholar 

  4. Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, Kaplan A, Oropello J, Vieillard-Baron A, Axler O, Lichtenstein D et al. 2009 American College of Chest Physicians/La Societe de Reanimation de Langue Francaise: statement on competence in critical care ultrasonography. Chest 135 1050–1060. (doi:10.1378/chest.08-2305)

    Article  Google Scholar 

  5. Solomon SD, Saldana F 2014 Point-of-care ultrasound in medical education–stop listening and look. New England Journal of Medicine 370 1083–1085. (doi:10.1056/NEJMp1311944)

    CAS  Article  Google Scholar 

  6. Cawthorn TR, Nickel C, O’Reilly M, Kafka H, Tam JW, Jackson LC, Sanfilippo AJ, Johri AM 2014 Development and evaluation of methodologies for teaching focused cardiac ultrasound skills to medical students. Journal of the American Society of Echocardiography 27 302–309. (doi:10.1016/j.echo.2013.12.006)

    Article  Google Scholar 

  7. Jones AE, Tayal VS, Sullivan DM, Kline JA 2004 Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Critical Care Medicine 32 1703–1708. (doi:10.1097/01.CCM.0000133017.34137.82)

    Article  Google Scholar 

  8. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K 2010 Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography 23 1225–1230. (doi:10.1016/j.echo.2010.10.005)

    Article  Google Scholar 

  9. Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW 2009 Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest 135 1416–1420. (doi:10.1378/chest.08-2440)

    Article  Google Scholar 

  10. Reant P, Dijos M, Arsac F, Mignot A, Cadenaule F, Aumiaux A, Jimenez C, Dufau M, Prevost A, Pillois X et al. 2011 Validation of a new bedside echoscopic heart examination resulting in an improvement in echo-lab workflow. Archives of Cardiovascular Diseases 104 171–177. (doi:10.1016/j.acvd.2011.01.003)

    Article  Google Scholar 

  11. Lebeau R, Di Lorenzo M, Amyot R, Veilleux M, Lemieux R, Sauve C 2003 A new tool for estimating left ventricular ejection fraction derived from wall motion score index. Canadian Journal of Cardiology 19 397–404.

    PubMed  Google Scholar 

  12. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS et al. 2005 Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. Journal of the American Society of Echocardiography 18 1440–1463. (doi:10.1016/j.echo.2005.10.005)

    Article  Google Scholar 

  13. Lebeau R, Serri K, Morice MC, Hovasse T, Unterseeh T, Piechaud JF, Garot J 2012 Assessment of left ventricular ejection fraction using the wall motion score index in cardiac magnetic resonance imaging. Archives of Cardiovascular Diseases 105 91–98. (doi:10.1016/j.acvd.2012.01.002)

    Article  Google Scholar 

  14. Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA 2002 Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Academic Emergency Medicine 9 186–193. (doi:10.1111/j.1553-2712.2002.tb00242.x)

    Article  Google Scholar 

  15. Randazzo MR, Snoey ER, Levitt MA, Binder K 2003 Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Academic Emergency Medicine 10 973–977. (doi:10.1111/j.1553-2712.2003.tb00654.x)

    Article  Google Scholar 

  16. Johri AM, Picard MH, Newell J, Marshall JE, King ME, Hung J 2011 Can a teaching intervention reduce interobserver variability in LVEF assessment: a quality control exercise in the echocardiography lab. JACC. Cardiovascular Imaging 4 821–829. (doi:10.1016/j.jcmg.2011.06.004)

    Article  Google Scholar 

  17. Dahlslett T, Karlsen S, Grenne B, Eek C, Sjoli B, Skulstad H, Smiseth OA, Edvardsen T, Brunvand H 2014 Early assessment of strain echocardiography can accurately exclude significant coronary artery stenosis in suspected non-ST-segment elevation acute coronary syndrome. Journal of the American Society of Echocardiography 27 512–519. (doi:10.1016/j.echo.2014.01.019)

    Article  Google Scholar 

  18. Dall’Armellina E, Morgan TM, Mandapaka S, Ntim W, Carr JJ, Hamilton CA, Hoyle J, Clark H, Clark P, Link KM et al. 2008 Prediction of cardiac events in patients with reduced left ventricular ejection fraction with dobutamine cardiovascular magnetic resonance assessment of wall motion score index. Journal of the American College of Cardiology 52 279–286. (doi:10.1016/j.jacc.2008.04.025)

    Article  Google Scholar 

  19. Duncan RF, Dundon BK, Nelson AJ, Pemberton J, Williams K, Worthley MI, Zaman A, Thomas H, Worthley SG 2011 A study of the 16-segment regional wall motion scoring index and biplane Simpson’s rule for the calculation of left ventricular ejection fraction: a comparison with cardiac magnetic resonance imaging. Echocardiography 28 597–604. (doi:10.1111/j.1540-8175.2011.01394.x)

    Article  Google Scholar 

  20. Klein P, Holman ER, Versteegh MI, Boersma E, Verwey HF, Bax JJ, Dion RA, Klautz RJ 2009 Wall motion score index predicts mortality and functional result after surgical ventricular restoration for advanced ischemic heart failure. European Journal of Cardio-Thoracic Surgery 35 847–852. (discussion 852–853) (doi:10.1016/j.ejcts.2008.12.046)

    Article  Google Scholar 

  21. Yao SS, Qureshi E, Sherrid MV, Chaudhry FA 2003 Practical applications in stress echocardiography: risk stratification and prognosis in patients with known or suspected ischemic heart disease. Journal of the American College of Cardiology 42 1084–1090. (doi:10.1016/S0735-1097(03)00923-9)

    Article  Google Scholar 

  22. Moller JE, Hillis GS, Oh JK, Reeder GS, Gersh BJ, Pellikka PA 2006 Wall motion score index and ejection fraction for risk stratification after acute myocardial infarction. American Heart Journal 151 419–425. (doi:10.1016/j.ahj.2005.03.042)

    Article  Google Scholar 

  23. Berning J, Rokkedal Nielsen J, Launbjerg J, Fogh J, Mickley H, Andersen PE 1992 Rapid estimation of left ventricular ejection fraction in acute myocardial infarction by echocardiographic wall motion analysis. Cardiology 80 257–266. (doi:10.1159/000175011)

    CAS  Article  Google Scholar 

  24. Galasko GI, Basu S, Lahiri A, Senior R 2001 A prospective comparison of echocardiographic wall motion score index and radionuclide ejection fraction in predicting outcome following acute myocardial infarction. Heart 86 271–276. (doi:10.1136/heart.86.3.271)

    CAS  Article  Google Scholar 

  25. Rifkin RD, Koito H 1990 Comparison with radionuclide angiography of two new geometric and four nongeometric models for echocardiographic estimation of left ventricular ejection fraction using segmental wall motion scoring. American Journal of Cardiology 65 1485–1490. (doi:10.1016/0002-9149(90)91360-I)

    CAS  Article  Google Scholar 

  26. Thune JJ, Kober L, Pfeffer MA, Skali H, Anavekar NS, Bourgoun M, Ghali JK, Arnold JM, Velazquez EJ, Solomon SD 2006 Comparison of regional versus global assessment of left ventricular function in patients with left ventricular dysfunction, heart failure, or both after myocardial infarction: the valsartan in acute myocardial infarction echocardiographic study. Journal of the American Society of Echocardiography 19 1462–1465. (doi:10.1016/j.echo.2006.05.028)

    Article  Google Scholar 

  27. McGowan JH, Cleland JG 2003 Reliability of reporting left ventricular systolic function by echocardiography: a systematic review of 3 methods. American Heart Journal 146 388–397. (doi:10.1016/S0002-8703(03)00248-5)

    Article  Google Scholar 

  28. Lebeau R, Potter BJ, Sas G, Moustafa S, Di Lorenzo M, Soulieres V, Beaulieu Y, Sauvé C, Amyot R, Serri K 2012 Performance of a simplified wall motion score index method for noncardiologists to assess left ventricular ejection fraction. ISRN Emergency Medicine 2012 1–5. (doi:10.5402/2012/309470)

    Article  Google Scholar 

  29. Beller GA, Bonow RO, Fuster V, F. American College of Cardiology A. American Heart C. American College of Physicians Task Force on Clinical, and Training ACCF 2008 Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training (COCATS 3) (revision of the 2002 COCATS Training Statement). Journal of the American College of Cardiology 51 335–338. (doi:10.1016/j.jacc.2007.11.008)

    Article  Google Scholar 

  30. Castel AL, Szymanski C, Delelis F, Levy F, Menet A, Mailliet A, Marotte N, Graux P, Tribouilloy C, Marechaux S 2014 Prospective comparison of speckle tracking longitudinal bidimensional strain between two vendors. Archives of Cardiovascular Diseases 107 96–104. (doi:10.1016/j.acvd.2014.01.007)

    Article  Google Scholar 

  31. Costa SP, Beaver TA, Rollor JL, Vanichakarn P, Magnus PC, Palac RT 2014 Quantification of the variability associated with repeat measurements of left ventricular two-dimensional global longitudinal strain in a real-world setting. Journal of the American Society of Echocardiography 27 50–54. (doi:10.1016/j.echo.2013.08.021)

    Article  Google Scholar 

Download references

Funding

This work was supported by the Echocardiography Laboratory of the Hôpital du Sacré-Coeur de Montréal.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Real Lebeau MD.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the articles Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the articles Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lebeau, R., Sas, G., El Rayes, M. et al. Left ventricular ejection fraction assessment by non-cardiologists from transverse views using a simplified wall motion score index. Echo Res Pract 2, 1–8 (2015). https://doi.org/10.1530/ERP-14-0003

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-14-0003

Key Words

  • left ventricular function
  • echocardiography
  • left ventricular ejection fraction
  • wall motion score index