Ventricular function and wall motion

Why examiners ask this

Biventricular function and wall motion lead the outline's list of echo diagnoses,¹ and the commonest echo loop in the station is a ventricle that is not squeezing normally, and the facilitator wants three answers in a minute: global or regional, left or right, and what I do about it. Echo shows ischemia before the ECG does, so a candidate who reads wall motion well is reading the earliest monitor of myocardial supply and demand. It tests application of knowledge and judgment.

The 60-second answer

Decision points and the "why"

• Thickening over motion — the ASE score is normal or hyperkinetic, hypokinetic (reduced thickening), akinetic (absent or negligible thickening) and dyskinetic (systolic thinning or stretching, outward bulging).³ Normal myocardium thickens by roughly 30% or more. Judging thickening protects me from calling a segment normal when the heart is simply translating.
• Map the segment to a coronary artery — in the mid-papillary short-axis, anterior and anteroseptal walls are LAD, anterolateral and inferolateral are circumflex, inferior and inferoseptal are right coronary. A new inferior akinesis after coming off bypass points to air in the right coronary, which sits most anterior. That localization tells the surgeon which graft or vessel to look at; supply varies between patients, so I say "territory" rather than a certain vessel.³
• New versus old — a thinned, bright, akinetic segment is old scar; a normal-thickness segment that has stopped thickening is acute ischemia. Only the acute one responds to raising perfusion pressure, slowing the rate or nitroglycerin.
• Small hyperdynamic LV — end-systolic cavity obliteration with "kissing" papillary muscles means low preload or low afterload. I give volume or a vasoconstrictor, not an inotrope, because inotropes worsen this picture and can provoke outflow obstruction.
• Dilated globally hypokinetic LV — reduced function with a high filling pressure; I support with an inotrope such as epinephrine or dobutamine, reduce afterload if the pressure allows, and stop giving fluid.
• RV dilation and dysfunction — RV basal diameter over 41 mm or larger than the LV in the four-chamber view, reduced free-wall excursion (TAPSE under 17 mm, fractional area change under 35%), and a septum that flattens into a "D".³ I treat the cause, avoid fluid, keep systemic pressure above pulmonary pressure with norepinephrine or vasopressin, and add a pulmonary vasodilator such as inhaled nitric oxide.
• Estimate EF in ranges — I say "roughly 30 to 35%", not "32%". Visual estimates are imprecise even in experienced hands, and false precision does not earn credit. Normal is about 52–72% in men and 54–74% in women; mildly reduced is 41–51% (men) or 41–53% (women), moderately 30–40%, severely under 30%.³

The complication they will inject

The first clip shows a normal mid-papillary short-axis. The second, after the facilitator announces the ST segments have changed, shows the anterior and anteroseptal walls no longer thickening while the rest contracts briskly. I say: "Transgastric mid-papillary view; new akinesis of the anterior and anteroseptal segments; this is acute LAD-territory ischemia."² Then the actions: tell the surgeon, 100% oxygen, restore diastolic pressure with phenylephrine or norepinephrine, slow a fast heart rate with esmolol if the pressure tolerates it, nitroglycerin if the pressure is adequate, 12-lead ECG and troponin, and a cardiology call. In a cardiac case I ask the surgeon to check the LAD graft. The harder variant adds a dilated, hypokinetic RV with the same LV picture, which means a proximal right coronary lesion or air; I add RV support rather than more fluid.

Pitfalls that cost points

• Grading wall motion from an off-axis or foreshortened view.
• Calling a segment abnormal on motion alone when it thickens normally.
• Giving an inotrope to a small, hyperdynamic, underfilled ventricle.
• Ignoring the RV because the question seemed to be about the LV.
• Quoting a single EF number instead of a range and a category.

Rapid-why

Q: Why does echo detect ischemia before the ECG? A: In the ischemic cascade, diastolic and then systolic wall motion fail before ST changes appear, so a new regional abnormality is the earlier sign.

Q: Why is the right coronary artery prone to air after bypass? A: Its ostium is the most anterior with the patient supine, so air rising in the aortic root enters it first.

Q: What does septal flattening in diastole alone mean? A: RV volume overload; flattening through systole as well means RV pressure overload.

Q: Why can a segment move but be ischemic? A: Adjacent normal myocardium tethers it and the whole heart translates, so only thickening proves contraction.

Numbers to know

Links

• The 11 TEE views, The 5 POCUS cardiac views, Perioperative myocardial ischemia and infarction, Pulmonary hypertension and right ventricular failure (coming), Vasopressors and inotropes: choosing and titrating
• Atlas: The 11 TEE views; The 5 POCUS cardiac views
• ASE/EACVI Recommendations for Cardiac Chamber Quantification (2015)