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PubMed1990

Thermodilution right ventricular ejection fraction. Catheter positioning effects.

Right ventricular (RV) ejection fractions have been difficult to estimate clinically. It has been demonstrated recently that RV ejection fractions can be calculated by thermodilution techniques using a rapid response thermistor and computer. This method critically depends on adequate mixing of the thermal bolus and sensing of the rapid response thermistor. This study examined the effects of the thermistor position within the pulmonary artery and injectate site within the right atrium on RV thermodilution ejection fraction measurements. Ten pigs were instrumented with a RV thermodilution catheter in the pulmonary artery, an injectate catheter in the right atrium, an atrial-pacing electrode, and a systemic arterial catheter. The RV ejection fractions were determined using thermodilution in two ways: (1) with incremental increases in pulmonic valve to thermistor distance, and (2) with incremental increases in injectate port to tricuspid valve. These measurements were obtained at a paced rate of 107 +/- 1 beats per minute (bpm) and then repeated with pacing-induced tachycardia (140 bpm). The highest RV ejection fraction with the lowest coefficient of variation was with the thermistor 2 cm from the pulmonic valve (50 +/- 2 percent), with a significant decline from this value at 10 cm (42 +/- 4 percent, p less than 0.05). This reduction in RV ejection fraction values with increased pulmonic valve to thermistor distance became more pronounced with tachycardia where a significant decline in RV ejection fraction occurred at 4 cm from the valve when compared with 0 cm (38 +/- 6 percent vs 47 +/- 3 percent, respectively, p less than 0.05). There was no significant change in RV ejection fraction at any injectate port to tricuspid valve distance at the lower heart rate. With tachycardia, however, a significant decline in RV ejection fraction occurred with the injectate port located 7 cm from the tricuspid valve (p less than 0.05). These results demonstrate that RV ejection fractions can be reliably obtained using thermodilution. Positioning of the thermodilution catheter is an important consideration for obtaining optimal RV ejection fraction measurements. Care should be taken to position the catheter with the thermistor a minimal distance from the pulmonic valve and the injectate port within the central body of the right atrium.

Animals↗
PubMed1997

Clinical decision making based on radionuclide determined ejection fraction in oncology patients.

UNLABELLED: Decreased left ventricular ejection fraction (LVEF) is a relative contraindication for the use of potentially cardiotoxic chemotherapy. A resting LVEF of 50% is usually used as the lower limit of normal values. The decision to change chemotherapy, however, is complex and is affected by many factors, including ejection fraction. METHODS: To determine how LVEF data were used by clinical oncologists in clinical decision making, we performed a retrospective analysis of patients referred for ejection fraction measurements from the hematology/oncology divisionS of Stanford University from March 1992 through March 1995. The records of 565 patients treated with potentially cardiotoxic chemotherapy were evaluated. RESULTS: LVEFs < 50% were found in 153 patients. The charts of patients with reduced ejection fractions were reviewed to determine if the radionuclide measurement resulted in either discontinuation of the cardiotoxic agent or substitution of a less cardiotoxic drug or mode of administration. These specific changes in therapy occurred in only 43 of the 153 (28%) patients with ejection fractions below 50%; 24 of the 43 (57%) had ejection fractions < or = 40%. Patients with lower ejection fraction values were more likely to have their therapy changed than those with LVEFs close to normal. Patients with ejection fractions < or = 30 generally had cardiotoxic agents discontinued. Of patients who had a resting LVEF < 50% and whose therapy was not changed, 81% had a normal increase in LVEF with exercise. CONCLUSION: In clinical practice at our institution, ejection fraction < 50% is not used as an absolute contraindication to cardiotoxic chemotherapy. When the LVEF is less than 40%, potentially cardiotoxic therapy is most often discontinued or omitted. Radionuclide evidence of cardiac reserve may account for decisions to continue cardiotoxic agents despite ejection fractions < 50% in the majority of patients. Further study will be needed to establish standard criteria. Reserve function, as measured by the change in ejection fraction from rest to stress may be an important parameter used by oncologists to help select patients for continued therapy in spite of a reduced ejection fraction. Our results argue that use of fixed criteria may be too restrictive.

Antineoplastic Agents↗
PubMed1977

A simple and rapid non-invasive radioisotope method to determine ventricular ejection fractions and cardiopulmonary transit times.

Ejection fractions and cardiopulmonary transit times were measured in 20 hospital patients by means of intravenously injected 99mTc-radiocardiography. Time activity curves from the regions of the whole heart, superior vena cava, right atrium, right ventricle, right lung, left atrium and left ventricle were drawn and analyzed by using the modified gamma function fitting method. The comparison between the ejection fractions determined from the whole heart curves and those from the ventricular curves shows a correlation coefficient of 0.93 for the right ventricle and of 0.90 for the left, although there was a systematic difference between the determinations. The analysis of the single ventricular curves gave about 10% higher values than those obtained from the whole heart curves. The cardiopulmonary parameters measured from the whole heart curves for 16 normal subjects the following results gave: right ventricular ejection fraction=0.57+/-0.08 left ventricular ejection fraction=0.62+/-0.08 pulmonary mean transit time=6.1+/-1.1 heart-beats intracardiac mean transit time=10.5+/-1.8 heart-beats right/left ventricular volume=1.10+/-0.09 These values agree closely with the data accumulated using more elaborate methods. The method presented here is simple to perform, it is non-invasive, time-saving, inexpensive, easy to analyze and suitable for exercising subjects and for bed-side measurements. Data assembly and analysis are easily automated so that results are obtainable immediately after measurements.

Adult↗
PubMed2006

Atrial fibrillation raised its head 15 months ago for the first time, and medication has stabilized me. An echocardiogram at the time of diagnosis showed an ejection fraction of 35 percent with some mitral valve leakage and left chamber enlargement. A new echo indicates an ejection fraction of 50 percent with minimal valve leakage, and only mild chamber enlargement. What could account for this improvement?

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Atrial Fibrillation↗
PubMed1997

Can we rely on 99Tcm-sestamibi gated tomographic myocardial perfusion imaging to quantify left ventricular function? A comparative study with classical isotopic techniques for the measurement of ejection fraction.

The assessment of left ventricular ejection fraction is an important element in the evaluation of cardiac performance, and one of the most commonly performed tests in nuclear cardiology. The aim of this study was to evaluate the accuracy and reliability of ejection fraction values calculated from ECG-gated myocardial perfusion single photon emission tomography (GSPET) in comparison with standard scintigraphic methods. Eight-frame gated SPET was recorded 60-90 min after the injection of 99Tcm-sestamibi at rest. The ejection fraction was calculated using a semi-automatic edge-detection technique based upon a threshold-searching method and compared with values obtained from first-pass (FPRNA) or equilibrium radionuclide angiography (ERNA) in 60 and 40 patients respectively with a broad range of ejection fraction values. Very good reproducibility was noted, with an inter- and intra-observer variability of -0.2 +/- 3.5% (range -7.6 to 6.9%, r = 0.97) and -0.2 +/- 2.2% (range -5.9 to 3.5%, r = 0.99) respectively. Similarly, a high concordance was found between GSPET and FPRNA and between GSPET and ERNA over the range of ejection fraction values (13 to 77%), the mean (+/-S.D.) difference being 0.8 +/- 3.8% (r = 0.97, P = N.S.) and 0.03 +/- 5.3% (r = 0.94, P = N.S.) respectively. Applying the Bland-Altman plot, no systematic bias of one method related to the other was observed, even at extreme ejection fraction values. Gated myocardial perfusion SPET with a 99Tcm tracer thus offers a unique opportunity to quantify cardiac performance and perfusion simultaneously and non-invasively.

Adult↗
PubMed1978

Value of the QRS complex in assessing left ventricular ejection fraction.

The relation between electrocardiographic findings and the angiographic left ventricular ejection fraction and the augmented ejection fraction after a premature ventricular contraction was investigated in 73 patients with documented chronic coronary artery disease. The patients were separated into four groups according to the presence or absence of abnormal Q waves. Twenty-four patients had diaphragmatic myocardial infarction, 21 had anterior myocardial infarction, 15 had both and 13 had no myocardial infarction. There was no statistically significant differences in cardiac index, left ventricular end-diastolic pressure or number of coronary vessels showing critical narrowing in the four groups. The sum of R waves (in mv) in leads aVL, aVF and V1 to V6 (sigmaR) was correlated with the ejection fraction (EF) and the augmented ejection fraction (EFa). EF in percent = 6.6 sigmaR mv + 9.4 (no. =73, r = 0.61); and EFa in percent = 8.6 sigmaR mv + 11.0 (no. = 73, r = 0.77). Among patients with sigmaR of less than 4.0 mv, augmented ejection fraction was less than 0.45 in 73 percent; among patients with sigmaR of 4.0 mv or more the augmented ejection fraction was greater than 0.45 in 93 percent (P less than 0.001). Thus, the sigmaR, calculated from six precordial and two augmented leads in patients with chronic coronary artery disease, correlated with both ejection fraction and augmented ejection fraction. The electrocardiogram in patients with coronary artery disease may prove useful as a simple, readily available and noninvasive guide in the assessment of left ventricular function in patients with coronary artery disease.

Blood Pressure↗
PubMed2006

Trends in prevalence and outcome of heart failure with preserved ejection fraction.

BACKGROUND: The prevalence of heart failure with preserved ejection fraction may be changing as a result of changes in population demographics and in the prevalence and treatment of risk factors for heart failure. Changes in the prevalence of heart failure with preserved ejection fraction may contribute to changes in the natural history of heart failure. We performed a study to define secular trends in the prevalence of heart failure with preserved ejection fraction among patients at a single institution over a 15-year period. METHODS: We studied all consecutive patients hospitalized with decompensated heart failure at Mayo Clinic Hospitals in Olmsted County, Minnesota, from 1987 through 2001. We classified patients as having either preserved or reduced ejection fraction. The patients were also classified as community patients (Olmsted County residents) or referral patients. Secular trends in the type of heart failure, associated cardiovascular disease, and survival were defined. RESULTS: A total of 6076 patients with heart failure were discharged over the 15-year period; data on ejection fraction were available for 4596 of these patients (76 percent). Of these, 53 percent had a reduced ejection fraction and 47 percent had a preserved ejection fraction. The proportion of patients with the diagnosis of heart failure with preserved ejection fraction increased over time and was significantly higher among community patients than among referral patients (55 percent vs. 45 percent). The prevalence rates of hypertension, atrial fibrillation, and diabetes among patients with heart failure increased significantly over time. Survival was slightly better among patients with preserved ejection fraction (adjusted hazard ratio for death, 0.96; P=0.01). Survival improved over time for those with reduced ejection fraction but not for those with preserved ejection fraction. CONCLUSIONS: The prevalence of heart failure with preserved ejection fraction increased over a 15-year period, while the rate of death from this disorder remained unchanged. These trends underscore the importance of this growing public health problem.

Aged↗
PubMed1982

Inotropic contractile reserve: a useful predictor of increased 5 year survival and improved postoperative left ventricular function in patients with coronary artery disease and reduced ejection fraction.

The increase in left ventricular ejection fraction produced by postextrasystolic potentiation or epinephrine infusion has been used to demonstrate inotropic contractile reserve in patients with coronary artery disease and a depressed ejection fraction (less than 0.50). Prior studies have shown that a change in ejection fraction of 0.10 or more after postextrasystolic potentiation or epinephrine infusion is helpful in discriminating those patients with a better short-term (1 year) prognosis whether treated medically or surgically. This study related inotropic contractile reserve to 5 year prognosis in 54 patients receiving postextrasystolic potentiation or epinephrine infusion between 1971 and 1974. Current left ventricular function in surviving patients was assessed with radionuclide ventriculograms whenever possible. Five year survival was significantly better in patients with an initial change in ejection fraction greater than 0.10 in both the surgically treated group (16 of 20 versus 5 of 15, p less than 0.01) and the medically treated group (6 of 8 versus 1 of 11, p less than 0.01). Furthermore, among the surviving patients in the surgical group, current ejection fraction in the radionuclide ventriculogram was significantly greater in patients who demonstrated inotropic contractile reserve in their 1971 to 1974 contrast left ventriculogram. These findings support the concept that coronary revascularization enhances function of ischemic but viable myocardium.

Angina Pectoris↗
PubMedDate not supplied

[Coronary score in patients with low ejection fraction after myocardial infarct].

INTRODUCTION: The most frequent cause of heart failure is ischemic heart disease (1). This paper was aimed at comparing the coronary score of patients with low ejection fraction whose ejection fraction was not significantly changed after sustained myocardial infarction. MATERIAL AND METHODS: The study involved patients after sustained myocardial infarction treated at the Institute of Cardiovascular Diseases in Sremska Kamenica. Total coronary score and score of each individual coronary artery were emphasized. RESULTS: The investigation study comprised 56 patients aged 33-83 years of various occupations. Patients were divided into two groups: the first--A group consisted of 28 (50%) patients with ejection fraction 35% or lower; the second--B group also consisted of 28 (50%) patients with ejection fraction higher that 35%. Table 1. shows the dominant coronary artery in investigated groups of patients. Table 2. shows values of total and scores of each coronary artery. The right coronary artery was dominant in 75% of patients from the A group and in 82.1% of patients from the B group. A significantly higher individual score of coronary arteries, as well as the total score, was established in the group of patients with low ejection fraction, and especially the score of the anterior descendent artery which is almost twice higher in regard to the second group of examined patients. Table 3. describes the analyzed score in male and female patients. DISCUSSION: Patients with low ejection fraction after sustained myocardial infarction have more changes of coronary arteries than patients with better ejection fraction. The total score, score of the right coronary artery (ACD), circumflex artery (RCX) and especially anterior descendent artery (LAD) are significantly higher in patients with ejection fraction lower than 35%. There are no differences in the dominant coronary artery in investigated patients. In both investigated groups women had a smaller score of ACD and RCX and a higher score of LAD, but the difference is not significant. In regard to total score there were no differences in men and women. Numerous investigations also point to the fact that patients with lower ejection fraction and ischemic heart disease have more changes on coronary artery than patients with better ejection fraction. CONCLUSION: 1. Patients with low ejection fraction after sustained myocardial infarction have a higher total score and scores of ACD. LAD and RCX. 2. There are no differences in coronary score of men and women within the same investigated groups. 3. There are no differences in dominant coronary artery in investigated groups of patients.

Adult↗
PubMed2003

Risk stratification for sudden death: do we need anything more than ejection fraction?

Recent studies have emphasized the prognostic significance of left ventricular ejection fraction in patients with coronary and other types of heart disease. Ejection fraction relates as a continuous variable to mortality risk. In patients with a variety of underlying heart diseases, the lower the ejection fraction, the higher observed mortality. However, while ejection fraction is statistically associated with mortality, it is only one of multiple factors that impact on mortality. In order to assess the clinical utility of ejection fraction, it is necessary to assess the sensitivity as well as the specificity of commonly used cut points in identification of patients at mortality risk. In this manuscript, it is shown that ejection fraction lacks sensitivity, and its specificity is suspect in patients with chronic coronary artery disease. The dangers of focusing on ejection fraction are that many patients whose ejection fractions exceed commonly used cut offs experience sudden death. Finally, because ejection fraction is not specific in predicting mode of death, utilization of expensive technology such as the implantable defibrillator based solely on ejection fraction will not be very cost-effective.

Death, Sudden, Cardiac↗
PubMed2006

Outcome of heart failure with preserved ejection fraction in a population-based study.

BACKGROUND: The importance of heart failure with preserved ejection fraction is increasingly recognized. We conducted a study to evaluate the epidemiologic features and outcomes of patients with heart failure with preserved ejection fraction and to compare the findings with those from patients who had heart failure with reduced ejection fraction. METHODS: From April 1, 1999, through March 31, 2001, we studied 2802 patients admitted to 103 hospitals in the province of Ontario, Canada, with a discharge diagnosis of heart failure whose ejection fraction had also been assessed. The patients were categorized in three groups: those with an ejection fraction of less than 40 percent (heart failure with reduced ejection fraction), those with an ejection fraction of 40 to 50 percent (heart failure with borderline ejection fraction), and those with an ejection fraction of more than 50 percent (heart failure with preserved ejection fraction). Two groups were studied in detail: those with an ejection fraction of less than 40 percent and those with an ejection fraction of more than 50 percent. The main outcome measures were death within one year and readmission to the hospital for heart failure. RESULTS: Thirty-one percent of the patients had an ejection fraction of more than 50 percent. Patients with heart failure with preserved ejection fraction were more likely to be older and female and to have a history of hypertension and atrial fibrillation. The presenting history and clinical examination findings were similar for the two groups. The unadjusted mortality rates for patients with an ejection fraction of more than 50 percent were not significantly different from those for patients with an ejection fraction of less than 40 percent at 30 days (5 percent vs. 7 percent, P=0.08) and at 1 year (22 percent vs. 26 percent, P=0.07); the adjusted one-year mortality rates were also not significantly different in the two groups (hazard ratio, 1.13; 95 percent confidence interval, 0.94 to 1.36; P=0.18). The rates of readmission for heart failure and of in-hospital complications did not differ between the two groups. CONCLUSIONS: Among patients presenting with new-onset heart failure, a substantial proportion had an ejection fraction of more than 50 percent. The survival of patients with heart failure with preserved ejection fraction was similar to that of patients with reduced ejection fraction.

Aged↗
PubMed2006

Serial changes in systolic and diastolic echocardiographic indices as predictors of outcome in patients with decreased left ventricular ejection fraction.

BACKGROUND: Echocardiographic estimation of left ventricular ejection fraction aids in predicting adverse outcomes in coronary artery disease. However, in patients with impaired left ventricular function, further risk stratification is difficult. METHODS: A 2 year retrospective review was performed to identify patients with ejection fraction < or=30%. Echocardiographic measures of systolic and diastolic function were independently performed offline. Outcome information, which included MI, stroke, or death, was obtained. The patient cohort identified those with follow-up having 1) a single echocardiogram and a subset 2) with an initial echocardiogram and a second echocardiogram at greater than one year follow-up. RESULTS: This study included 110 patients, ages 20-94. Mean follow-up time was 29+/-9 months. Ejection fraction did not predict cardiovascular events. LV mass predicted of mortality (p=0.03). Diastolic indexes of mitral inflow E wave was a significant predictor of outcome (p=0.05). Impaired diastolic filling grade 2, 3, or 4 showed a 76% event rate. Decreases in ejection fraction at follow-up were seen in those who had an event, with an average decrease in ejection fraction of 17% versus those who lived with no event of 1%. Changes in mitral inflow E wave and changes in E/A ratio were both significant predictors of outcome. CONCLUSIONS: These data indicate that echocardiographic measures of both systolic and diastolic function aid in risk stratifying patients with decreased ejection fraction. The changed detected in serial echocardiographic information may be important in treatment and secondary prevention of future events.

Adult↗
PubMed2002

Comparison of fatty meal and intravenous cholecystokinin infusion for gallbladder ejection fraction.

UNLABELLED: Gallbladder ejection fraction (GBEF) measured with a fatty meal (half-and-half milk) was compared with that measured with 2 equal sequential intravenous infusions of cholecystokinin (CCK-8) in a paired study of healthy subjects. METHODS: GBEF was measured by (99m)Tc-hepatic iminodiacetic acid cholescintigraphy in 13 healthy subjects. Each subject received 2 sequential doses of CCK-8 (3 ng/kg/min for 10 min) on day 1, followed by, on day 2, a 240-mL (8 oz) fatty meal (half-and-half milk) per 70 kg of body weight. RESULTS: The mean +/- SD GBEF of 53.6% +/- 20.2% with fatty meal was significantly lower than the mean of 75.8% +/- 16.3% (P < 0.01) with the first dose of CCK-8 and 71.3% +/- 17.4% (P < 0.05) with the second dose. Fatty meal GBEF varied widely, from 23.5% to 91.8%. Percentile rankings of the fatty meal GBEF were determined as the preferred methodology for reporting results. Latent and ejection periods were significantly longer with fatty meal than with either dose of CCK-8. CONCLUSION: GBEF measured with fatty meal can serve as an alternative method to intravenous injection of CCK-8 when the hormone is no longer available for clinical use. The measurement of GBEF with fatty meal requires careful attention to the details of the meal and the measurement time sequence.

Adult↗
PubMed1980

Validity of different gated equilibrium blood pool methods for determination of left ventricular ejection fraction.

Left ventricular ejection fractions (EF) were determined in 37 patients by biplane cineventriculography (Angio) and by four modifications of the gated equilibrium blood pool (GBP) method: 1. Region of interest (ROI) in enddiastole (ED), correction by external background, 2. ROI in ED, correction by internal background between ED and endsystole (ES), 3. ROI in ED (maximum) and ES (mimimum); no background correction, 4. ROI in ES, correction by background between ED and ES. EFGBP were determined after injection of 20 mCi 99mTc human albumin (Anger-camera, all-purpose collimator, 16 ECG-segments, 64 x 64 matrix with 1.5 zoom). EF by biplane angiography (EFangio) was calculated by the formula of Dodge. The following correlation between angiographically and scintigraphically determined EF's were found: EFGBP1 = 0.504 EFangio + 8.08, EFGBP2 = 0.847 EFangio + 10.0, EFGBP3 = 0.911 EFangio + 3.75, EFGBP4 = 0.648 EFangio - 3.51 Intraobserver variability of GBP method 2 and 3 was +/- 5%. EFS determined by GBP methods 2 and 3 are as accurate as the EFs determined by cineventriculography.

Adult↗
PubMed1991

In vitro validation of a right ventricular thermodilution ejection fraction system.

Right ventricular ejection fraction (RVEF) is used clinically as an index of right ventricular (RV) pump function. Clinical measurements of RVEF are complicated by the need for complex imaging equipment to compute RV volumes. Recently, the use of thermodilution (TD) methods have been suggested as a simplified means to measure RVEF (RVEFTD) in patients using rapid response thermistors. Validation, however, by comparison of RVEFTD and other methods in vivo, is difficult. Accordingly, thermodilution derived EF measurements (EFTD) were compared to known values using an in vitro system, with known ejection fractions (EF) set from 17-78% and stroke rates varying independently from 50-100 strokes/min. EFTD was computed by fitting the downslope of the TD curve to a monoexponential function and computing the time constant of thermal decay. A significant correlation existed between EFTD and actual EF over the entire study (r = 0.96, p less than 0.001). Bias analysis showed that the points were within a 95% confidence interval of +/- 12%. Multivariate analysis showed that stroke rate did not significantly affect TD measurements (r = 0.03, p greater than 0.7). This study demonstrates that TD accurately predicts EF using an in vitro system and appears to be independent of stroke rate. Thus, TD methods may provide an accurate, simple and reliable means to serially measure RVEF in the clinical setting.

Algorithms↗
PubMed1995

[Arrhythmogenic right ventricle: dysplasia or cardiomyopathy? Value of left ventricle ejection fraction].

The left ventricular ejection fraction (LVEF) of 76 patients suffering from arrhythmogenic dysplasia or cardiomyopathy of the right ventricle (ventricular tachycardia associated with structural abnormalities of the right ventricle) demonstrated two subgroups situated above and below 45%. Values of LVEF less than 45% were similar to those of a control population of 6 cases of idiopathic dilated cardiomyopathy with ventricular tachycardia of left ventricular origin (p = 0.2). These patients also have the same unfavourable long-term prognosis. Histological data obtained from four cases belonging to the group of patients with dysplasia or cardiomyopathy of the right ventricle with a low ejection fraction demonstrated the presence of signs of myocarditis involving both ventricles. This suggests that these patients may suffer from an infectious phenomenon superimposed on a specific histological substrate, which may lead to deterioration of their myocardial function. These results are in line with those of the literature. The term arrhythmogenic cardiomyopathy of the right ventricle should therefore be reserved to the subgroup of patients with an LVEF less than 45%. Finally, arrhythmogenic cardiomyopathy of the right ventricle appears to be a complication of dysplasia following the development of a myocarditic phenomenon. This may explain the wide range of clinical forms observed in patients with ventricular tachycardia of right ventricular origin associated with structural abnormalities of the right ventricle.

Adolescent↗