How to assess the left ventricle using handheld ECHO

26th Nov 2020

Left ventricular (LV) dimensions and function can be assessed qualitatively with a handheld echocardiography (HHE) device. 

 

Assessing left ventricular dimensions with handheld echocardiography

Left ventricular size is reduced when the ventricular cavity appears small in an under-filled patient. On the other hand, LV dimensions may be increased when there is LV dysfunction or volume overload, such as severe mitral or aortic regurgitation. 

Multi-component video of left ventricle echocardiograms for a small and dilated LV cavity.

Figure 1. Signs of reduced left ventricle (LV) dimensions include a small LV cavity in an underfilled patient and a dilated LV cavity in a patient with severe mitral or aortic regurgitation. 

 

Assessing left ventricular function with handheld echocardiography

Left ventricular function is described qualitatively by assessing myocardial wall thickening, inward motion of the LV cavity in systole, and outward motion in diastole. 

Each myocardial segment should be assessed, and the presence of regional wall motion abnormalities described. In the parasternal long-axis (PLAX) view, regional wall motion abnormalities can be seen affecting the anteroseptal wall. 

Left ventricular echocardiogram with anteroseptal wall highlighted. Parasternal long-axis (PLAX) view.

Figure 2. Signs of left ventricular dysfunction in the parasternal long-axis (PLAX) view include regional wall motion abnormalities affecting the anteroseptal wall. 

To see a great example of left ventricular dysfunction (regional wall abnormalities in the anteroseptal wall), check out this short video clip from our COVID Mini: Handheld ECHO Course:

 

Ventricular function should be described as normal or impaired (mild, moderate, or severe). In cases where myocardial contraction is more pronounced than normal (as seen in pathological states such as sepsis or hypovolemia), the term ‘hyperdynamic’ is applied.

 

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Assessing left ventricle function in patients with COVID-19

Case reports of patients with COVID-19 have shown evidence of myocarditis. In an echocardiogram, there may be evidence of reduced myocardial wall thickness and a reduction in LV systolic function in patients with COVID-19. 

Myocarditis after a SARS-CoV-2 infection may cause global or regional ventricular impairments, which typically do not correspond to coronary territory. 

Echocardiogram showing global ventricular impairments with myocarditis from the parasternal long-axis (PLAX) view.

Figure 3. Parasternal long-axis (PLAX) view of global ventricular impairments in a patient with myocarditis after infection with SARS-CoV-2. 

Check out this short video clip from our COVID Mini: Handheld ECHO Course to see an example of myocarditis in a patient with COVID-19:

 

There are also documented cases of acute Takotsubo—or stress-induced—cardiomyopathy after a SARS-CoV-2 infection. 

Typically, there is transient LV dysfunction with a characteristic pattern of apical and midsegment hypokinesia which gives rise to the classical apical ballooning appearance. There are also widespread electrocardiogram (ECG) changes with raised troponin levels. 

Echocardiograms showing Takotsubo cardiomyopathy features. Apical views.

Figure 4. Signs of acute Takotsubo cardiomyopathy include transient LV dysfunction with a characteristic pattern of apical and midsegment hypokinesia, which gives rise to the apical ballooning appearance seen here.

To see an example of the apical and midsegment hypokinesia, characteristic of Takotsubo cardiomyopathy in a patient with COVID-19, check out this short video clip from our COVID Mini: Handheld ECHO Course:

 

Where doubt remains and infection control measures allow, cardiac magnetic resonance (CMR) imaging can provide incremental information that allows for the detection of relevant functional and tissue changes useful in differentiating Takotsubo cardiomyopathy from acute coronary syndromes. 

 

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Recommended reading

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