What Ejection Fraction Increase Is Clinically Meaningful

Middle Left Ventricle Ejection Fraction

Left ventricular ejection fraction (LVEF) has obvious shortcomings as a predictor of patients at run a risk for implantable cardioverter defibrillator placement and SCD.

From: ASE's Comprehensive Strain Imaging , 2022

Sexual activity-specific gamble assessment of sudden cardiac expiry

Anne Chiliad. Kroman , Kristen K. Patton , in Sex and Cardiac Electrophysiology, 2022

Ejection fraction

Left ventricular ejection fraction (LVEF) is the cornerstone of SCD risk stratification. Unfortunately, LVEF is neither a sensitive or specific tool to identify those at risk; as LVEF declines, the risk of mortality from both sudden and nonsudden death increases [17,18]. The competing causes of pump failure and other nonsudden deaths consequence in a declining proportion of arrhythmic deaths in patients with lower LVEF and worse clinical heart failure [19,20]. In the Oregon Sudden Unexpected Death Study, subjects with severely reduced LVEF (≤35%) accounted for thirty% of SCD, 22% of subjects had mild to moderately reduced LVEF (36%–54%), and 48% had normal LVEF prior to SCD [21]. Additionally, SCD subjects with normal LVEF were characterized equally younger, more likely to exist women (47% women, 27% men), with a higher prevalence of CAD, and a higher prevalence of seizure disorder [21]. LVEF is most useful as a tool to identify a high-risk population [ii,22], all the same no other chance marker has been shown to take ameliorate predictive power [23]. Limitations to the use of LVEF in the use of take chances stratification for SCD include measurement variability and inaccuracies, no straight causal relationship between decreased LVEF and arrhythmias, spontaneous variation in LVEF in certain individuals, and lack of sensitivity and specificity for SCD [iv,23,24].

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Aging and Activity Tolerance

Ethan A. Hood , ... Michelle Thou. Lusardi , in Orthotics and Prosthetics in Rehabilitation (Quaternary Edition), 2022

Left Ventricular Ejection Fraction

Left ventricular ejection fraction (LVEF) is the proportion of blood pumped out of the heart with each contraction of the left ventricle, which is expressed by the following equation:

$LVEF = (EDV - ESV) + EDV$

At balance, the LVEF does not appear to exist reduced in older adults. Under atmospheric condition of maximal exercise, however, the rising in LVEF is much less than that in younger adults. ^23,57,58 This reduced ascent in the LVEF with maximal practise conspicuously illustrates the bear on that functional cardiovascular age-related changes in preload and afterload take on performance.

A substantial reduction in EDV, an expansion of ESV, or a more than modest change in both components may account for the decreased LVEF of the exercising older adult:

$\begin{array}{l} ↓ EDV = ↓ LVEF \\ ↑ ESV = ↓ LVEF \end{array}$

When going from resting to maximal exercise atmospheric condition, the amount of blood pumped with each beat for immature healthy adults increases by 20% to 30% from a resting LVEF of 55% to an exercise LVEF of 80%. For a healthy older adult, in dissimilarity, LVEF typically increases less than 5% from rest to maximal exercise. ^57,59 The LVEF may actually decrease in adults who are threescore years of historic period and older. ^57,lx Equally LVEF and CO decrease with aging, so does the power to work over prolonged periods (functional cardiopulmonary reserve chapters) because the volume of blood delivered to agile tissue decreases (Fig. 2.3). Functional reserve chapters is further compromised by the long-term effects of inactivity and by cardiopulmonary pathology. ^{23,thirty,61,62} The contribution of habitual exercise to achieving effective maximum practice LVEF is not well understood, but the decline may non be equally substantial for highly fit older adults. ²³

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Detection of subclinical heart failure

Paaladinesh Thavendiranathan Medico, SM , Kazuaki Negishi Doctor, PhD , in ASE'due south Comprehensive Strain Imaging, 2022

Limitations of left ventricular ejection fraction for detection of subclinical cardiomyopathy

Left ventricular ejection fraction (LVEF) plays a principal role in the diagnosis and management of cardiovascular disease. ¹ However, in many scenarios, a reduction in LVEF occurs at a belatedly stage of disease, is often irreversible, and is associated with poor prognosis. ² Furthermore, LVEF equally a measure of myocardial office has several limitations. First the two-dimensional (2D) measurement of LVEF relies on a shape assumption and can result in inaccurate quantification of LVEF, specially in the context of regional myocardial dysfunction. Although this shape assumption can be overcome past the utilise of iii-dimensional (3D) echocardiography, this method is non feasible in upward to ∼20% of the patients. LVEF is also an ejection phase index influenced by ventricular loading. The latter is peculiarly a problem for sequential follow-up of myocardial office in patients in whom loading conditions may change constantly (e.m., those receiving cancer therapies). LVEF measurements are likewise influenced by LV geometry and can be limited in the assessment of myocardial function in patients with LV hypertrophy. Finally LVEF measurements are subject to temporal and interobserver variability, which tin can be as high equally ten% for 2d LVEF and vi% for 3D LVEF. ³ ^, ^four Equally a consequence of these challenges, LVEF has limitations as a marker of myocardial role for the recognition of subclinical heart failure (HF).

To overcome some of the limitations of LVEF measured by echocardiography, myocardial strain has emerged every bit a robust measure of subclinical HF. ² Strain measurements, especially peak systolic global longitudinal strain (GLS), allows detection of prognostically of import myocardial dysfunction fifty-fifty when LVEF is normal. ² This is driven past several factors, including the fact that strain measures myocardial deformation as opposed to endocardial translation; global measurements are obtained as an average of multiple views; and strain measurement, particularly GLS, has skillful intraobserver, interobserver, and test-retest variability. Although strain measurements are certainly subject to image quality, they may exist less affected past deposition in 2d epitome quality when compared with second LVEF and likely 3D LVEF. ^v Therefore, especially in diseases that diffusely affect the myocardium, myocardial strain may be a more robust measure of subclinical HF than LVEF.

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Ventricular Tachycardia in Nonischemic Dilated Cardiomyopathy

Ziad F. Issa Doc , ... Douglas P. Zipes MD , in Clinical Arrhythmology and Electrophysiology (Third Edition), 2022

Left Ventricular Ejection Fraction

LVEF remains the most studied and the nigh useful predictor of SCD despite limitations (see below) and is the primary method currently used in clinical decisions for the prevention of SCD in patients with HF. Depressed LVEF is also a powerful predictor of cardiac bloodshed. On the basis of the results of large studies, in clinical practice an LVEF ≤35% has go the primary benchmark used for prophylactic implantable cardioverter-defibrillator (ICD) placement. ⁷

However, the use of LVEF as the predominant risk stratifier has serious limitations because it lacks both sensitivity and specificity for prediction of SCD. There is no evidence of whatsoever direct mechanistic link betwixt depression LVEF and mechanisms responsible for ventricular tachyarrhythmias, and no report has demonstrated that reduced LVEF is specifically related to SCD. Although low LVEF predicts total bloodshed (SCD and hear failure expiry), its value in predicting benefit from ICD implantation is limited. In these patients, ICD may reduce the risk of SCD but total mortality may not be modified. Fifty-fifty a very depression LVEF (less than 20%) may not take a high positive predictive value for SCD. Many DCM patients who die from SCD have only a moderately depressed LVEF. Furthermore, the arrhythmic mechanisms underlying DCM and the gamble of SCD can be different in unlike etiologies and clinical situations. Clinical factors such as functional class, symptomatic HF, nonsustained VT, age, LV conduction abnormalities, inducible sustained VT, and AF influence the risk of arrhythmic expiry and total bloodshed, and hence potentially influence the prognostic value of a depressed LVEF. Therefore patients with an LVEF greater than 30% and other risk factors may have a higher mortality and a college risk of SCD than those with an LVEF less than thirty% but no other take a chance factors. ^viii

Another limitation is that methods of LVEF determination lack precision. Different imaging modalities tin can produce significantly different LVEF values, and the accuracy of techniques varies amongst laboratories and institutions, and there is evidence that prognosis, and hence risk, depends on the method by which the LVEF is measured. Clinically, when a patient has multiple LVEF measurements over time, information technology raises the question of which of the many measurements should exist used—the nigh recent, the boilerplate, or the lowest. ^5,nine In cases in which frequent atrial or ventricular ectopic complexes or AF is nowadays, sampling of representative contractions for the interpretation of LVEF is especially problematic.

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Regional and Global Ventricular Part and Volumes from SPECT Perfusion Imaging

Guido Germano , ... Daniel S. Berman , in Clinical Nuclear Cardiology (4th Edition), 2010

EJECTION FRACTION

LVEF is typically measured using a volume-based rather than a count-based approach. In other words, the location of the LV endocardium is estimated in the 2D or 3D infinite, and the LV cavity volume is calculated every bit the territory leap by the endocardium and its valve airplane. The process is repeated for every interval in the cardiac cycle, later which the EDV and ESV are identified as the largest and smallest LV crenel volume, respectively, and the LVEF derived every bit:

$% LVEF = (EDV - ESV) / EDV * 100$

As Tabular array 13-3 shows, the agreement between gated SPECT and reference standard measurements of quantitative LVEF is in the very good to excellent range and relatively independent of the isotope, protocol, standard, and algorithm used. Reproducibility (defined as the understanding between independent measurements of LVEF resulting from multiple applications of the same quantitative algorithm to the same gated SPECT report) is also excellent, beingness directly related to the degree of automation of the algorithm. ²² ^,57, ⁶⁶ ^,67

Repeatability (defined as the agreement between independent measurements of LVEF resulting from separate applications of the same quantitative algorithm to different, but presumably equivalent, gated SPECT studies) is also extremely adept, both for sequential studies ^74–76 and for acquisition involving different isotopes, ^50, ^52, ^58, ^76–79 injected dose and acquisition time, ^lxxx–82 acquisition orbit, ⁸³ cameras, ⁸⁴ ^,85 number of gating intervals, ⁵³ and patient position. ⁸⁶ ^,87 Moreover, the apply of attenuation correction or resolution recovery in conjunction with gated SPECT imaging does not appear to greatly affect quantitative measurements of LVEF. ⁸⁸ ^,89

Cross-algorithm reproducibility (divers as the agreement betwixt LVEF values measured by different quantitative algorithms applied to the same gated SPECT study) has been reported to exist in the very adept to excellent range. All the same, it is also well established that systematic differences among algorithms exercise exist and effectively prevent the direct comparison (or pooling) of differently analyzed data. ⁵⁵ ^,59, ^xc–95 Normal limits for LVEF are similarly algorithm dependent ⁵⁵ ^,73, ^96–100 and also gender specific, ^98, ^100–108 as shown in Table xiii-4 for the QGS software.

There are some limitations common to most algorithms continued with the quantification of LVEF from gated perfusion SPECT. For example, information technology is well known that the relatively depression resolution of nuclear cardiology images may make it difficult to visualize pocket-size objects, such as the LV cavity of patients with small ventricles, particularly at end-systole (Fig. thirteen-xiv). This phenomenon, likewise referred to as fractional book effect, ²⁶ will pb to the underestimation of LV cavity volumes (particularly the ESV), with consequent overestimation of the LVEF. ^109–111 The trouble can be alleviated through magnification of the LV either in conquering (by employing a larger conquering zoom) and/or in reconstruction (by employing zoomed centered or zoomed off-axis reconstruction), ^111–114 or by applying numerical modeling and compensation of blurring. ¹¹⁵ ^,116 However, a simpler solution is to discard the overestimated value and study the LVEF as existence "in the normal range."

Another limitation related to the partial volume effect is that nuclear cardiology techniques are incapable of measuring myocardial thickness with high accurateness. Most quantitative gated SPECT algorithms are either calibrated for the range of thicknesses most typically encountered in clinical do ²⁸ or assume a fixed myocardial thickness in the normal range ³³ ; consequently, gated SPECT LVEFs measured in patients with left ventricular hypertrophy are likely to be underestimated. ¹¹⁷

Gated SPECT imaging traditionally has been performed with 8-frame gating, which undersamples the time-volume curve compared to 16-frame gating, and thus leads to balmy underestimation of the LVEF. However, Effigy 13-15 shows that the degree of underestimation is small (three to iv LVEF pct points) and remarkably uniform over a wide range of ejection fractions, as also confirmed by other published reports. ^28, ^53, ^54, ^56, ^118–120

Finally, most quantitative gated SPECT algorithms tend to presume a regular or "polish" LV shape in areas with severely reduced or absent-minded perfusion, ²⁸ and this would be expected to upshot in the "cutting off" of aneurysms, with consequent overestimation of the measured LVEF. Although a big number of published reports deny the presence of major discrepancies between true and quantitatively measured LVEF in patients with large perfusion defects and/or depression LVEF, ^42, ^43, ^45, ^46, ^48, ^50, ^56, ^121–125 the possibility of aneurysms should always be considered in the presence of perfusion defects. ⁶⁹ ^,126

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A Comprehensive Prognostic Assessment of ST-Elevation Myocardial Infarction by Cardiac MRI

Sebastian Johannes Reinstadler , Ingo Eitel , in Coronary Microvascular Obstruction in Acute Myocardial Infarction, 2022

Left Ventricular Ejection Fraction

Left ventricular (LV) ejection fraction is currently the most important parameter for monitoring myocardial function, with major prognostic impact. Determination of resting LV ejection fraction is therefore crucial for post-STEMI risk stratification and is recommended by current guidelines [11]. Cardiac MRI studies in STEMI survivors convincingly demonstrated a strong and contained prognostic relevance of LV ejection fraction for the prediction of adverse outcome during brusque- and long-term follow-up [7,8,12–sixteen]. The increase in adverse events is near pronounced in patients with a severely depressed LV ejection fraction (<forty%) [16]. Moreover, it was shown that LV ejection fraction adds incremental prognostic data to established clinical hazard factors and chance scores such every bit the Thrombolysis In Myocardial Infarction (TIMI) chance score [eight,16].

The assessment of LV dysfunction after reperfused STEMI should not be performed too early (preferably presently earlier belch) due to the phenomenon of myocardial stunning. Although echocardiography is more suitable for clinical practice and currently preferred to cardiac MRI in the guidelines [11], in that location is clear evidence showing that cardiac MRI provides college accuracy and reproducibility in the measurement of LV ejection fraction [17,18]. Cine MRI is the technique of choice for the assessment of cardiac volumes and LV ejection fraction [18]. Breath-hold, electrocardiographic-gated, segmented steady-land free precession (SSFP) sequences are typically used for this purpose. Quantitative analysis of LV volumes and part is performed in a stack of short axis images (usually 9-12 slices covering the whole left ventricle) past delineating epicardial and endocardial boarders in stop-systolic every bit well equally stop-diastolic images [xix] (Effigy 11–i). Nevertheless, long axis techniques are also highly accurate for volumetric quantification of LV parameters [twenty].

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Nonischemic Mitral Regurgitation and Left Ventricular Dysfunction

David South. Bach MD, FASE , in Dynamic Echocardiography, 2022

Assessment of Left Ventricular Systolic Function in Chronic Mitral Regurgitation

Left ventricular ejection fraction (LVEF) is unremarkably a adept indicator of LV systolic role. Nonetheless, the presence of meaning MR tin mask LV systolic dysfunction when assessed using the ejection fraction. In the setting of pregnant MR, the left atrium presents a low-resistance sleeping accommodation into which the left ventricle ejects. Equally such, MR is a stiff afterload-reducing factor. Despite abnormal systolic office, the dumb left ventricle tin eject additional book into the low-resistance left atrium, resulting in an increase in LVEF disproportionate to underlying systolic office.

Early feel with MV replacement in patients with severe MR revealed a subtract in postoperative ejection fraction and a poor postoperative issue amidst patients with decreased preoperative LVEF. In part, this was due to papillary muscle transection and its impact on overall LV systolic performance. However, the observed postoperative subtract in LVEF as well was due in function to the abrupt loss of the depression-resistance left atrium.

In general, LVEF ≥60% probably correlates with preserved LV systolic function even in the setting of significant MR. ⁱ Withal, additional clues can suggest impaired ventricular systolic function even in the setting of a normal ejection fraction. The charge per unit of the ascent in LV pressure level (dP/dt) can be estimated using continuous wave spectral Doppler assessment of the MR jet ( Fig. 18.1 ). ² In improver, noninvasively derived pressure level-book loops can exist used to help appraise myocardial contractility. ³ ^, ⁴

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Adventure Stratification afterward Acute ST-Segment Pinnacle and Non-ST-Segment Elevation Myocardial Infarction

John J. Mahmarian , in Clinical Nuclear Cardiology (Fourth Edition), 2010

Left Ventricular Ejection Fraction

The LVEF remains the single all-time long-term predictor of mortality in survivors of AMI. ^6, ^10–12 Mortality rates are depression in patients with an LVEF greater than 40% merely rapidly increase with more astringent LV dysfunction. In the Multicenter Post Infarction Research Group (MPRG) ^ten written report, 799 survivors of AMI had gated radionuclide angiography following admission. The 1-twelvemonth mortality rate for all patients was nine%, but 60% of all deaths occurred in the 33% with an LVEF less than forty%. A very high mortality rate of 47% was observed in the 3% of patients with an LVEF less than xx% (Fig. 35-9).

The important prognostic information obtained from LVEF has been confirmed in patients receiving reperfusion therapy during STEMI. ^6, ^11, ^35–37 The resultant LVEF and subsequent bloodshed rate are clearly dependent on the degree to which early on coronary artery patency is achieved. In the GUSTO-I trial, LVEF and 30-day survival were both significantly higher in patients who achieved TIMI form iii flow (61% ± fourteen% [95.6%]) versus TIMI grade 0/1 (55% ± 14% [91.1%]) or TIMI grade 2 (56% ± 14% [92.6%]) flows, respectively. ³⁸ In the Survival and Ventricular Enlargement (Salve) study, gated radionuclide angiography was performed inside the first 2 weeks of AMI, and patients with an LVEF less than 40% were randomized to receive either placebo or captopril therapy. ³⁹ One-third of all patients had thrombolytic therapy during AMI. The mean LVEF in patients randomized to placebo was 31%, and the associated 1-twelvemonth bloodshed approximately 12%—similar to the 15% bloodshed reported by the MPRG in patients with an LVEF less than 40%. ¹⁰ Likewise, in the Western Washington Streptokinase Trials, LVEF measured viii.seven ± 6 weeks after enrollment was the all-time univariate and multivariate predictor of survival. ⁶ In the 20% of patients with an LVEF less than 35%, the 1-year bloodshed was xv%, which increased to 22% by three years—almost identical to the 22% placebo bloodshed reported in SAVE (Fig. 35-10).

Like results are reported by Simoons and coworkers in 422 patients randomized to intracoronary streptokinase versus placebo, where the LVEF was measured 10 to xl days after AMI. ¹¹ In patients with LVEF greater than 40%, the 3-year bloodshed rate remained low (iv.3%). Conversely, in patients with an LVEF less than 40%, the i- and 3-yr bloodshed rates increased with worsening LVEF, but irrespective of initial therapy (Fig. 35-11). Mortality was strongly influenced past LVEF and the extent of angiographic coronary avenue disease (CAD) (Fig. 35-12), the latter presumably an indicator of the extent of jeopardized myocardium. In the series by Dakik and colleagues, the LVEF was the only significant predictor of infarct-free survival. The relative risk of expiry or nonfatal MI doubled for every 10% decrease in LVEF (RR = 2.06, 95% CI, one.17–3.64; P = 0.01) (Fig. 35-13). ³⁵

The TIMI-2 ³⁶ and Grupo Italiano por lo Studio della Streptochinase Nell'Infarcto Miocardico (GISSI)-two ³⁷ trials bespeak that survival at any given LVEF is better in patients who receive thrombolytic therapy compared to historical controls in the prethrombolytic era (see Fig. 35-9). ¹⁰ This may be due to differing patient characteristics, refinements in risk stratification, therapeutic improvements, or the use of thrombolytics, which may forbid long-term remodeling by maintaining arterial patency. In addition, patients who achieve early coronary reperfusion during AMI oft showroom regional myocardial stunning that can persist for weeks. ^27, ^thirty Patients with minimal LV dysfunction (i.e., LVEF > 40%) are expected to have a low subsequent mortality charge per unit. The TIMI-Ii ³⁶ and GISSI-two ³⁷ information confirm a similar and comparably low mortality rate in patients with normal LV function (LVEF > 50%; 1.2%), as reported earlier by the MPRG (come across Fig. 35-9). ¹⁰ However, if the LVEF is reduced due to extensive myocardial stunning that subsequently resolves, cardiac risk could be spuriously overestimated. This may partially explain the lower 1-year mortality rate in patients with LV dysfunction in the TIMI-Ii and GISSI-2 studies compared to the MPRG. Measuring LVEF 1 to ii months after infarction rather than within the first two weeks would reduce the confounding influence of stunning and offer a more reliable estimate of risk. Despite these caveats, the final LVEF remains an important predictor of long-term survival irrespective of initial therapy during STEMI.

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Remission and Recovery in Heart Failure

J.S. Guseh , J.Due east. Ho , in Encyclopedia of Cardiovascular Inquiry and Medicine, 2022

Abstract

The miracle of spontaneous left ventricular ejection fraction (LVEF) recovery is becoming increasingly apparent and is an area of new agreement and written report. This commodity highlights the emerging appreciation of LVEF recovery and how the process of opposite cardiac remodeling leads to a group of patients who experience improvements in LVEF and clinical outcomes, yet probable harbor continued residue risk. We specifically accost (i) differences in LVEF recovery versus myocardial recovery and remission, (ii) predictors of LVEF recovery, (3) clinical form after LVEF recovery, and (4) current knowledge gaps in the management of this evolving phenotype and futurity directions.

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The Function of Echocardiography in the Detection of Chemotherapy-Induced Cardiotoxicities

P.T. Gleason , ... S. Lerakis , in Cardio-Oncology, 2022

Calculating ejection fraction

LVEF is the nigh common echocardiographic parameter used to evaluate LV systolic role. The ASE/EACI recommend the modified biplane Simpson'south method for quantification of LV volumes and adding of EF. While fractional shortening was previously used to gauge EF, the technique does not adequately appraise the global LV, posing inherent errors in volume assessment, peculiarly in patients with regional wall motion abnormalities. An EF 53–73% is considered to be within normal limits. The addition of a 16 segment resting wall movement score index has been identified equally a sensitive marking of anthracycline-induced cardiotoxicity [10]. Unfortunately, a major limitation of current research on cardiotoxicity from oncologic agents is the employ of inconsistent methods of quantifying EF. Visual estimation of EF should always exist compared to prior studies in an effort to minimize intrareader variability and to readily place changes suggestive of myocardial impairment.

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