Volume 8 Issue 3 - Australasian Society for Ultrasound in Medicine

ASUM Ultrasound Bulletin 2005 August; 8 (3): 31–32DIAGNOSTIC ULTRASOUNDA pictorial essay of left ventricular failureJustin O’Leary BExSc, DMURoyal Prince Alfred Hospital, Camperdown, Sydney, New South Wales, AustraliaCorrespondence to Justin_Oleary@hotmail.comFigure 1 Figure 2Clinical historyA 74-year-old male presented for an outpatient cardiacassessment prior to surgical treatment of a left renal tumour.Reported symptoms included occasional episodes of centralchest tightness during rest as well as on exertion. There wasno past history of other cardiac disease. On examination,the pulse was 100 and regular with occasional extrasystoles,the systolic blood pressure was 120/95, the JVP was raisedat 8 cm with the cardiac impulse laterally displaced. Onauscultation there was an apical pan-systolic murmur anda third heart sound. The ECG showed sinus rhythm withleft axis deviation and diffuse T-wave abnormalities. Thechest x-ray showed cardiomegaly. An echocardiogram wasrequested to assess left ventricular systolic function.Materials and methodsThe echocardiogram was performed on a GE medical systemVivid 7. A multi-frequency (1.5 – 4.0 MHz) phasedarray transducer was used in real time for 2D (harmonicand non-harmonic), M-mode, colour flow, continuous andpulsed wave Doppler examination. A frequency of 1.7 MHzfrequency with harmonic imaging was selected for adequatepenetration and resolution. Depth settings, overall gain,TGC, colour and spectral Doppler settings and focal zoneswere set to allow optimal imaging of structures of interest.The mechanical index (MI) was 1.0 and the thermal index(TI) was 0.7–1.5. The total imaging time was 30 minutes.TechniqueParasternal long axis views of the left ventricle showedmild to moderately impaired systolic contraction with mildantero-septal wall hypokinesis and severe posterior hypokinesis.The mitral valve appeared mildly echodense withnormal leaflet excursion. The aortic valve appeared mildlyechodense with normal excursion and cusp separation.M-mode through the aortic valve demonstrated a normalsized aortic root and, superiorly, a normal ascending aortawith mild dilatation of the left atrium. M-mode across themitral valve showed an increase in the mitral valve E pointto septal separation (EPSS) indicating left ventricular dilatation.M-mode through the left ventricle showed a mildlyincreased left ventricular end-diastolic dimension andreduced systolic thickening of both the antero-septal andposterior walls. The calculated ejection fraction (afterTeicholtz and Simpson) was 37%. There was mild concentricleft ventricular hypertrophy.Colour Doppler revealed a very mild central jet of aorticregurgitation and mild mitral regurgitation.The right ventricular inflow view showed a normal tricuspidvalve with normal valve excursion. The right atriumappeared mildly dilated. Colour Doppler revealed a milddegree of tricuspid regurgitation. The continuous waveDoppler across the jet shows a pressure difference betweenthe right ventricle and right atrium of 39 mmHg with spectralbroadening indicating mild severity.The right ventricular outflow tract view with colourDoppler and continuous wave Doppler across the pulmonaryvalve showed normal outflow velocities.The parasternal short axis view showed the commissureof the non-coronary aortic cusp was mildly thickened. Theleft ventricle visualised at the level of the papillary musclesshowed a mild to moderate global impairment in systolicfunction.Apical views of the mitral valve and tricuspid valvesshowed normal excursion. The left ventricular lateral andseptal walls showed reduced contraction with impaired contractionof the lateral wall of the right ventricle, mild bi-atrialASUM Ultrasound Bulletin 2005 August; 8 (3)31