Can Junior EPs Use E-Point Septal Separation to Accurately Estimate Left Ventricular Function?

Background

Point-of-care echocardiography can provide a rapid and accurate assessment of left ventricular function, which is valuable in differentiating causes of hypotension and dyspnea at bedside. Visual estimation of LV function by experienced practitioners has been shown to correlate well with quantitative estimates. However, the number of examinations required before a practitioner is qualified to visually estimate LV function accurately is unknown. Although there are various comparable parameters for assessing LV function, mitral valve E-point septal separation (EPSS) is an easy-to-obtain measurement inversely correlated with LV function. EPSS is an M-mode measurement of the minimum distance between the anterior mitral valve leaflet and the interventricular septum during diastole. Despite its applicability, the reproducibility and accuracy of EPSS as a bedside tool for evaluating LV function in less experienced emergency physicians has yet to be established.

Can Junior Emergency Physicians Use E-Point Septal Separation to Accurately Estimate Left Ventricular Function in Acutely Dyspneic Patients? 

Clinical Question

This study aims to determine if novice emergency physicians (PGY 3 and PGY 4) are able to obtain EPSS measurements and determine if these measurements correlate to echocardiographic visual estimations of LV function by experienced emergency physicians.

Methods & Study Design

Design:
Prospective observational study of correlation between EPSS to visual estimation and LV function in patients who present to ED with chief complaint of acute dyspnea.

Population:
Convenience sampling of 70 subjects enrolled in the ED from July 2008 and July 2009. Criteria for enrollment included age > 18 years, chief complaint of dyspnea, ED length > 2 hours, no history of trauma, and normal mental status. Patients with known history of mitral valve repair or replacement, aortic insufficiency, or mitral stenosis were excluded.

Intervention:
12 senior residents (PGY 3 and PGY 4) in EM residency program with variable levels of ultrasound experiences (70 to 150 total ED ultrasound examinations; average of fewer than 25 cardiac examinations) performed transthoracic echocardiogram of patients with chief complaint of acute dyspnea. Ultrasound examination included subcostal, parasternal long axis (PLAX), parasternal short axis, and apical four chamber views. Six-second video clips in parasternal short and long axes were obtained. M-mode measurements of EPSS were recorded in PLAX orientation after all video clips were obtained and calculated during diastole. All examinations were performed without the presence of experienced emergency physicians (EPs).

Outcomes:
One of two experienced EPs reviewed stored video and visually estimated LVEF. Two board-certified cardiologists subsequently reviewed one-half of the video clips and estimated LVEF, blinded to both junior EPs’ EPSS measurements and visual estimations by experienced EPs.

Results

58 out of 70 enrolled subjects had complete echocardiographic studies recorded.

Concordance rates between EPSS measurements by EPs and cardiologist for LVEF were acceptable with kappa for visual LVEF estimation of 0.75 (95% CI = 0.48 to 1.00).

Spearman correlation analysis revealed significant correlation (p = -0.844, p< 0.001) between novice physicians’ measurements of EPSS and visual estimation of LVEF by experienced EPs.

Strengths and Limitations

This study compared EPSS measurement by junior EPs with visual assessment by experienced EPs showing a strong correlation. Experienced EPs were not blinded to results, which may have induced bias, but the authors find this less likely given what they interpret as good agreement on visual estimations between experienced EPs and blinded cardiologists. It is debatable whether the agreement between EPs and cardiologists with kappa of 0.75 represents good agreement. This study utilized a convenience sampling design due to logistical constraints, which may impact the generalizability of its results. Many subjects were excluded for incomplete ultrasound views, but authors note that junior EPs were actually able to assess EPSS for all subjects, further supporting the use of this measurement even when other views are difficult to obtain.

Authors Conclusions

PGY 3 and PGY 4 EM residents were able to obtain measurements of EPSS that correlated closely with visual assessments of LVEF by experienced emergency physicians with extensive point-of-care ultrasound and echocardiography experience. EPSS can serve as a quantitative alternative to visual estimation of LVEF in dyspneic ED patients.

Our Conclusions

Rapid assessment of LVEF with bedside echocardiography can provide useful clinical information in the acutely dyspneic patient. The level of expertise required to accurately visually assess a LVEF is unknown. This study supports EPSS as a useful quantitative addition to visual estimation of LVEF in patients with acute dyspnea for novice emergency physicians with less echocardiography experience. The level of correlation between EPSS and visual estimation was not perfect, suggesting use of EPSS as an addition to rather than replacement for standard visual estimation.

The Bottom Line 

EPSS can serve as a quantitative addition to qualitative visual estimation of LVEF with bedside echocardiography, especially for less experienced EM practitioners.

Authors

This post was written by Eugene Han, MS4 at UCSD School of Medicine, with editing by Ben Liotta, MD and Amir Aminlari, MD. 

References

1. Secko MA, Lazar JM, Salciccioli LA, Stone MB. Can junior emergency physicians use E-point septal separation to accurately estimate left ventricular function in acutely dyspneic patients? Acad Emerg Med. 2011 Nov;18(11):1223-6. doi: 10.1111/j.1553-2712.2011.01196.x. Epub 2011 Nov 1. PMID: 22044429.
2. McKaigney CJ, Krantz MJ, La Rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014 Jun;32(6):493-7. doi: 10.1016/j.ajem.2014.01.045. Epub 2014 Feb 3. PMID: 24630604.
3. Shahgaldi K, Gudmundsson P, Manouras A, Brodin LA, Winter R. Visually estimated ejection fraction by two dimensional and triplane echocardiography is closely correlated with quantitative ejection fraction by real-time three dimensional echocardiography. Cardiovasc Ultrasound. 2009 Aug 25;7:41. doi: 10.1186/1476-7120-7-41. PMID: 19706183; PMCID: PMC2747837.
4. McGowan JH, Cleland JG. Reliability of reporting left ventricular systolic function by echocardiography: a systematic review of 3 methods. Am Heart J. 2003 Sep;146(3):388-97. doi: 10.1016/S0002-8703(03)00248-5. PMID: 12947354.
5. Jacob M, Shokoohi H, Moideen F, Pousson A, Boniface K. An Echocardiography Training Program for Improving the Left Ventricular Function Interpretation in Emergency Department; a Brief Report. Emerg (Tehran). 2017;5(1):e70. Epub 2017 Jun 15. PMID: 29201952; PMCID: PMC5703747.

How accurate is EPSS in estimating ejection fraction?

epss echo

Background

Bedside echocardiography has an established role in the time-sensitive assessment for pericardial effusion, relative chamber size, and global cardiac function of emergency department (ED) patients. Most ED physicians use visual estimation to gauge left ventricular ejection fraction (LVEF), a method that may be subject to inter-observer variability and inaccuracy (1). E-point septal separation (EPSS), the minimum separation between the anterior mitral valve leaflet and the interventricular septum, may offer a more objective measure of LVEF.

epss echo

EPSS was first studied in the 1970s as a quantitative, easily measured, and reproducible index of left ventricular function (2). In healthy individuals, the mitral valve leaflet reaches its maximum excursion near or at the septum during early diastole. EPSS increases as left ventricular ejection fraction (LVEF) decreases, and an EPSS of greater than 7mm predicts poor LVEF (3,4).

The gold standard for evaluating LVEF is a quantitative, calculated value obtained from comprehensive transthoracic echocardiography, which is impractical in the emergency department, thus EPSS offers a simple to learn and easy to obtain alternative, requiring only one view in the parasternal long axis. EPSS measurement is a technique feasible for the ED physician to perform at the bedside that can provide a convenient and reliable estimate of LVEF. 

 

E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction

Clinical Question

Does EPSS measurements obtained by ED physicians correlate with calculated LVEF from comprehensive transthoracic echocardiography (TTE)?

Can certain EPSS cutoff values be used to predict systolic dysfunction? 

What is the relationship between bedside visual estimates of global cardiac function (GCF) and the calculated LVEF measurements?

Methods & Study Design

• Design 

This was a prospective observational trial.

• Population 

A convenience sample of 80 hospitalized patients undergoing comprehensive TTE for any indication. Subjects were recruited between February and April 2012 from an academic level I trauma center. Exclusion criteria were known pregnancy or age less than 18 years.

• Intervention 

Three emergency ultrasound fellows performed bedside 4-view basic echocardiographic examinations consisting of subxiphoid, parasternal long, and parasternal short and apical views and made estimates of GCF. The fellows then obtained separate parasternal long-axis views and performed M-mode measurements of the EPSS. Comprehensive TTE was separately performed by cardiac sonographers and LVEF was calculated via the Teichholz method.

• Outcomes  

    • Subjective estimates of GCF categorized as normal systolic function (LVEF > 55%), moderate systolic dysfunction (30% > LVEF > 55%), or severe systolic dysfunction (LVEF < 30%)
    • EPSS measurements
    • Calculated LVEFs also categorized as normal/moderate/severe as above

Results

Calculated LVEF ranged from 13%-86%. EPSS ranged from 0.50-29.70 mm.

Men had higher EPSS scores and higher calculated estimates of LVEF. No other demographic or clinical variables were identified as potential covariates. 

The linear regression model revealed that EPSS is a statistically significant predictor (P < .001) of calculated LVEF.

An EPSS measurement of greater than 7 mm was 100% sensitive and 51.6% specific for severely reduced LVEF. An EPSS measurement of greater than 8 mm was 83.3% sensitive and 50.0% specific for any systolic dysfunction.

Estimated GCF and calculated LVEF were in agreement in 49 (69.0%) of subjects with a weighted Cohen κ of 0.58, with strongest agreement for subjects with severe systolic dysfunction.

epss echo

Strength & Limitations

Strengths:

This study is the first to demonstrate that EPSS can provide a quantitative prediction of LVEF. One strength of this study is the generalizability of the findings given that all indications for TTE were included. Another strength is that the ED ultrasound fellows and cardiac sonographers performed their studies independently, unlike a prior study that utilized the same scans performed by residents to obtain both EPSS and LVEF. 

Limitations:

There were possible misestimations of EPSS in certain pathologic states, such as overestimation of EPSS in mitral stenosis. Additionally, this paper describes the Teichholz method, which is subject to inaccuracies, especially in states of dyskinesis. Of note, the Teichholz method has since been supplanted by the modified Simpson’s rule and is no longer used clinically. On average, time from EPSS measurement to comprehensive echocardiogram was 6 hours with the possibility that systolic function changed during that window of time. Finally, the study size was fairly small with 71 subjects included in the final analysis.

Authors Conclusion

ED physicians can assess left ventricular systolic function using the EPSS, and EPSS is strongly correlated with calculated LVEF. An EPSS greater than 7 mm may be used to predict patients with severely reduced LVEF. ED physician visual estimation was less effective and less consistent than EPSS measurement for predicting systolic function.

Our Conclusion

We agree that EPSS is a feasible and useful tool for assessing systolic function at the bedside. This study establishes that a 7 mm EPSS cutoff is highly sensitive for detecting severe systolic dysfunction. The clinical utility of an EPSS cutoff of 8 mm for any systolic dysfunction is less clear. Employing EPSS measurement with the 7 mm cutoff in mind, in conjunction with visual estimation by an experienced ED sonographer, is likely to provide a more complete picture of a patient’s systolic function at the bedside prior to obtaining a formal echocardiogram.

The Bottom Line 

EPSS measured on bedside ultrasound the ED is an easily obtainable, quantitative predictor of systolic dysfunction. A cutoff of 7mm is sensitive in identifying systolic dysfunction.

Authors

This post was written by Jennie Xu, MS4 at UCSD School of Medicine, Charles Murchison, MD and Amir Aminlari, MD. 

References

McKaigney CJ, Krantz MJ, La Rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction. The American Journal of Emergency Medicine. 2014 Jun 1;32(6):493-7.

 

    1. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography. 2010 Dec 1;23(12):1225-30.
    2.  Massie BM, Schiller NB, Ratshin RA, Parmley WW. Mitral-septal separation: new echocardiographic index of left ventricular function. The American journal of cardiology. 1977 Jun 1;39(7):1008-16.
    3. Lew W, Henning H, Schelbert H, Karliner JS. Assessment of mitral valve E point-septal separation as an index of left ventricular performance in patients with acute and previous myocardial infarction. The American journal of cardiology. 1978 May 1;41(5):836-45.
    4. Massie BM, Schiller NB, Ratshin RA, Parmley WW. Mitral-septal separation: new echocardiographic index of left ventricular function. The American journal of cardiology. 1977 Jun 1;39(7):1008-16.