The Rejected Heart

A 28 year old female presented to the LLUMC ED with chest pain. She had a history of viral myocarditis at age 18 which culminated in dilated cardiomyopathy requiring a heart transplant – at age 19. Since then, she has been dealing with rejection and chest pain. She stated that she had recently been diagnosed with systolic heart failure but is no longer a candidate for another cardiac transplant as she has experienced rejection with her current cardiac transplant.
We were asked to evaluate her heart for pericardial effusions as well determine a rough quantitation of her ejection fraction (EF).
A simple way to estimate cardiac output is with the movement of the anterior leaflet of the mitral valve in a parasternal long axis view in a basic echocardiogram as seen in Figure 1.

If the anterior leaflet of the mitral valve touches the septum at maximal excursion during diastole with a strong LV squeeze observed during systole, you can estimate that the LV EF is at least >50%.
This is one of the most commonly used ways to have a rough estimation of EF in the emergency department.

Another simple way of determining EF in the parasternal long axis of a basic echocardiogram is via determining the e-point septal separation (EPSS). It is similar to the previously mentioned way except there is an extra step of calculation!
In the parasternal long axis view, turn on M mode. Place the cursor over the most actively moving portion of the mitral valve leaflet. Ensure that the M-mode cursor is over the leaflet in the most perpendicular position possible. When running the M-mode function in this position, the tracing in figure 2 will appear.

The E wave arises due to early diastolic filling. Most filling (70-75%) of the ventricle occurs during this phase. The A wave arises due to atrial contraction, forcing approximately 20-5% of stroke volume in the ventricle, in a normal heart. The ratio of E:A can be used to determine diastolic function as seen below:
1. Normal diastolic function (E > A)
2. Impaired relaxation (E:A reversal i.e. E is 2)

The E point septal separation (EPSS) can be calculated measuring the mitral valve E wave point to the septal point as shown in figure 2.
1. Normal EPSS = 50%
2. EPSS >8 mm = EF 18 mm = EF <30%

In calculating the EPSS of our heart transplant patient, we found that it was 19 mm, signifying an EF of <30%. This was consistent with her diagnosis of systolic heart failure.
The movement of the anterior mitral valve leaflet or a simple EPSS calculation are both very simple ways to evaluate EF in the emergency department with a simple echocardiogram.

– Carol Conceicao, MS4

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