1. Left ventricle Michel Slama Amiens France

2. LV ventricle Ejection fraction Cardiac output Left ventricular filling pressure

3. Ejection fraction : systolic function, contractility?

4. Shortening Fraction of LV Area Ejection Fraction Systolic Function LEVEL 1

6. Mitral valve opening

9. NB Shiller, Heart, 1996;75:17-26 Estimated and measured EF LEVEL 1

10. Pouleur, Am J Cardiol, 1983;52:813-21 Influence of afterload on EF HT, AS Septic Shock

12. Cardiac output

14. How to perform echocardiographic examination in shocked patient? Cardiac output TTE: LEVEL 2

15. How to perform echocardiographic examination in shocked patient? Cardiac output TTE: LEVEL 2

16. Diastolic function

17. LV relaxation

18. Pathophysiology Pressure Normal Diastolic dysfunction Volume

19. LVEDP LVEDV 18 mmHg

20. Mitral flow : how to record ? Pulsed Doppler Correct Alignement Small window At the tip of mitral valve Visible opening sound Settings et filters 100 mm/s Average of 3 measurements

21. Early filling Late filling Vitesses LAP LVP Velocies P1 – P2 = 4 x V 2

22. LV Pressure Mitral flow

23. Type I of Appleton relaxation impairement Early diastole Late diastole Vitesses LAP LVP Velocities

24. Decreased preload SOHN, JACC 1997 BASETNT

25. Ea Aa DTI Mitral annulus Minimum settings Normal values Ea > 8 cm/s et Ea / Aa > 1 Ea = 15 ± 4 cm/s Aa = 10 ± 3 cm/s

26. Mitral annulus movement Ea AaEa Aa normal Ea = 18cm/s Ea > Aa Relaxation impairement (HT) Ea = 7,5cm/s et Ea < Aa

27. Left atrial size LAV = 0,5 x L1 x L2 x L3

28. Practical approach to assess diastolic function E’ lateral E’ Septal LA volume E’ lateral>10cm/s E’ Septal>8cm/s LA volume<34 ml/m² E’ lateral>10cm/s E’ Septal>8cm/s LA volume>34 ml/m² E’ lateral<10cm/s E’ Septal<8cm/s LA volume>34 ml/m² Normal left ventricular relaxation Athlet’s heart or constriction Left ventricular dysfunction

29. PAOP (Wedge pressure)

30. E (Mitral flow) depends on PAOP and on LV relaxation E’ (TDI mitral annulus) evaluate LV relaxation (preload independent) E/Ea ratio depends on PAOP LEVEL 2

31. E/E’ ratio predicts PAOP LEVEL 2

32. Combes A Int Care Med 2004 E/Ea ICU, mechanical ventilation LEVEL 2

33. Other tools to evaluate cardiac function Speckle tracking and strain evaluation 3D imaging assessement of EF MAPSE S wave on TDI at the mitral annulus

34. Septic shock

35. Myocardial infarction with cardiogenic shock

36. Pulmonary oedema

37. Congestive heart failure with pulmonary oedema

38. Unexplained shock

40. Conclusion