Determinants of left ventricular ejection fraction and a novel method to improve its assessment of myocardial contractility

Manuel Ignacio Monge García, Zhongping Jian, Jos J Settels, Charles Hunley, Maurizio Cecconi, Feras Hatib, Michael R Pinsky, Manuel Ignacio Monge García, Zhongping Jian, Jos J Settels, Charles Hunley, Maurizio Cecconi, Feras Hatib, Michael R Pinsky

Abstract

Background: The aim of this study was to quantify the impact of different cardiovascular factors on left ventricular ejection fraction (LVEF) and test a novel LVEF calculation considering these factors.

Results: 10 pigs were studied. The experimental protocol consisted of sequentially changing afterload, preload and contractility. LV pressure-volume (PV) loops and peripheral arterial pressure were obtained before and after each intervention. LVEF was calculated as stroke volume (SV)/end-diastolic volume (EDV). We studied global cardiac function variables: LV end-systolic elastance (Ees), effective arterial elastance (Ea), end-diastolic volume and heart rate. Diastolic function was evaluated by means of the ventricular relaxation time (τ) and ventricular stiffness constant (β) obtained from the end-diastolic PV relationship. Ventriculo-arterial coupling (VAC), an index of cardiovascular performance, was calculated as Ea/Ees. LV mechanical efficiency (LVeff) was calculated as the ratio of stroke work to LV pressure-volume area. A linear mixed model was used to determine the impact of cardiac factors (Ees, Ea, EDV and heart rate), VAC and LVeff on LVEF during all experimental conditions. LVEF was mainly related to Ees and Ea. There was a strong relationship between LVEF and both VAC and LVeff (r2 = 0.69 and r2 = 0.94, respectively). The relationship between LVEF and Ees was good (r2 = 0.43). Adjusting LVEF to afterload ([Formula: see text]) performed better for estimating Ees (r2 = 0.75) and improved the tracking of LV contractility changes, even when a peripheral Ea was used as surrogate (Ea = radial MAP/SV; r2 = 0.73).

Conclusions: LVEF was mainly affected by contractility and afterload changes and was strongly related to VAC and LVeff. An adjustment to LVEF that considers the impact of afterload provided a better assessment of LV contractility.

Keywords: Afterload; Arterial elastance; Contractility; Diastolic function; Ejection fraction; Preload; Systolic function; Ventricular efficiency; Ventriculo-arterial coupling.

Conflict of interest statement

MIMG is a consultant to Edwards Lifesciences and received honoraria and/or travel expenses from Deltex Medical. M.R. Pinsky is a consultant to Edwards LifeSciences, LiDCO Ltd., and Cheetah. MC has received honoraria and/or travel expenses from Edwards Lifesciences, LiDCO, Cheetah, Bmeye, Masimo and Deltex Medical. CH is a consultant to Edwards Lifesciences. ZJ, JJS and FH are Edwards Lifesciences employees.

Figures

Fig. 1
Fig. 1
Relationship between ventriculo-arterial coupling, left ventricular mechanical efficiency and left ventricular ejection fraction. Left: linear regression analysis between ventriculo-arterial coupling (VAC), calculated as the ratio between effective arterial elastance (Ea) and left ventricular end-systolic elastance (Ees), and left ventricular ejection fraction (LVEF). Right: linear regression analysis between left ventricular mechanical efficiency, calculated as the ratio between stroke work (SW) and the left ventricular pressure–volume area (PVA), and left ventricular ejection fraction. Colors inside circles represent different experimental interventions: red, afterload; green: preload; blue: contractility
Fig. 2
Fig. 2
Relationship between left ventricular end-systolic elastance (Ees) and standard left ventricular ejection fraction (LVEF) calculation, Ea-adjusted LVEF and peripheral Ea-adjusted LVEF. Linear regression analysis for left ventricular end-systolic elastance (Ees) and standard LVEF, LVEF corrected to effective arterial elastance (Ea = left ventricular end-systolic pressure/left ventricular stroke volume) and peripheral Ea-adjusted LVEF (Eaperiph = radial mean arterial pressure/stroke volume). Colors inside circles represent different interventions: red, afterload; green: preload; blue: contractility
Fig. 3
Fig. 3
Concordance analysis for percentage changes in different approaches for estimating left ventricular contractility and end-systolic elastance (Ees) during different experimental stages. Four-quadrant plots showing the relationship between percentage changes in left ventricular (LV) end-systolic elastance (Ees) and different approaches studied: standard LVEF calculation, LVEF adjusted to effective arterial elastance (Ea = left ventricular end-systolic pressure/stroke volume) and peripheral Ea-adjusted LVEF (Eaperiph = radial mean arterial pressure/stroke volume). Excellent trending capability was assumed when ≥ 90% of the data lie in the right-upper and the left-lower quadrants. Open circles with bars represent the mean percentage change on each stage. Dashed green lines represent the line of equality

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