Echo 1 - Case October 2025

Parasternal long-axis view: There is subjective dyskinesis of the interventricular septum and posterior wall of the left ventricle, consistent with abnormal wall motion. The papillary muscles of the mitral valve appear subjectively more echogenic, possibly reflecting inflammation, ischemia or edema. The left atrium is dilated. Both the aortic and mitral valves demonstrate opening, but with markedly shortened opening duration. The anterior mitral leaflet exhibits limited excursion, and reduced anterior movement toward the interventricular septum during diastole (suggestive of an increased E–point septal separation). Overall findings are consistent with systolic left ventricular dysfunction.

M-mode assessment: The left ventricular shortening fraction is calculated as ( 1.57 – 1.45 ) / 1.57 × 100 (1.57–1.45)/1.57×100, yielding 7.6%, consistent with severely reduced systolic function. There is paradoxical motion of the interventricular septum, characterized by anterior expansion during peak posterior wall contraction. The E–point septal separation (EPSS)—measured at the peak anterior excursion of the mitral valve leaflet—is increased (not measured here), further supporting left ventricular systolic dysfunction.

Mitral valve insufficiency: There is mitral regurgitation present. Color Doppler imaging demonstrates minimal flow signal within the left ventricular outflow tract (LVOT) at a Nyquist limit of 70 cm/s, indicating no detectable systolic flow at or above this velocity through the aortic valve. This finding suggests reduced systolic ejection velocity and low LVOT output, consistent with depressed left ventricular systolic performance.

Parasternal long-axis view including the right ventricular outflow tract (RVOT): In comparison, color Doppler demonstrates clear antegrade flow through the RVOT at a Nyquist limit of 70 cm/s, indicating preserved right ventricular ejection. There is trace pulmonary insufficiency noted on color Doppler.

LCA coronary seen by colour doppler and 2D in normal configuration.

RCA colour seen in normal configuration. 

PSAX. Here we can appreciate the excursion of the mitral valve to be limited during diastole. There is mitral insufficiency by colour. The LV function at the base is significantly reduced. 

Parasternal short axis at mid-papillary level showing significant LV systolic dysfunction. The mitral valve papillary muscles are brighter / more echogenic than the rest of the myocardium. 

Dysfunction is global including the Apex.

Sweep towards the base of the heart outlining circumferential LV dysfunction. 

Apical 4 chamber view confirming that the LV systolic funcion is significantly reduced. 

Pulmonary venous flow seen by Colour Doppler in the right lower pulmonary vein. There is mild-moderate mitral insufficiency with the jet reaching almost the roof of the left atrium and some left atrial dilation, likely due to increased LV end diastolic filling pressure.

A5C confirming that there is no clear obstruction in the LVOT below or at the aortic valvular level. 

Flow by colour seen originating below the valve and crossing through the aortic valve. No evidence of obstruction at the LVOT. 

Flow through the RVOT observed from the apical view. 

Trivial tricuspid insufficiency. 

Branch Pulmonary Arteries of good caliber and flow. 

Unobstructed pulmonary venous blood flow. 

IVC to RA. There is some degree of variation with breathing. The size is appropriate indicating sufficient filling - although the patient is at this point on mechanical ventilation with positive pressure in the intra-thoracic space which can influence IVC size.

Short-axis view of the subcostal region outlining the bicaval view. There is again the jet from the left to right inter-atrial shunt seen entering the right atrium. 

Short-axis view of the subcostal region outlining the left to right inter-atrial shunt seen entering the right atrium. 

RVOT in the subcostal view with unobstructed flow. 

Significant LV dysfunction at the mid-papillary level. 

Gradient accross the PFO is 3.1 mmHg of peak gradient and 1.9 mmHg of mean gradient. The PFO is completely left to right.