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Review
. 2024 Feb 7:11:1340708.
doi: 10.3389/fcvm.2024.1340708. eCollection 2024.

Left ventricular ejection fraction: clinical, pathophysiological, and technical limitations

Federico Vancheri  1 , Giovanni Longo  2 , Michael Y Henein  3
Affiliations
Review

Left ventricular ejection fraction: clinical, pathophysiological, and technical limitations

Federico Vancheri et al. Front Cardiovasc Med. .

Abstract

Risk stratification of cardiovascular death and treatment strategies in patients with heart failure (HF), the optimal timing for valve replacement, and the selection of patients for implantable cardioverter defibrillators are based on an echocardiographic calculation of left ventricular ejection fraction (LVEF) in most guidelines. As a marker of systolic function, LVEF has important limitations being affected by loading conditions and cavity geometry, as well as image quality, thus impacting inter- and intra-observer measurement variability. LVEF is a product of shortening of the three components of myocardial fibres: longitudinal, circumferential, and oblique. It is therefore a marker of global ejection performance based on cavity volume changes, rather than directly reflecting myocardial contractile function, hence may be normal even when myofibril's systolic function is impaired. Sub-endocardial longitudinal fibers are the most sensitive layers to ischemia, so when dysfunctional, the circumferential fibers may compensate for it and maintain the overall LVEF. Likewise, in patients with HF, LVEF is used to stratify subgroups, an approach that has prognostic implications but without a direct relationship. HF is a dynamic disease that may worsen or improve over time according to the underlying pathology. Such dynamicity impacts LVEF and its use to guide treatment. The same applies to changes in LVEF following interventional procedures. In this review, we analyze the clinical, pathophysiological, and technical limitations of LVEF across a wide range of cardiovascular pathologies.

Keywords: aortic regurgitation; aortic stenosis; echocardiography; implantable cardioverter defibrillator; left ventricular ejection fraction; mitral regurgitation.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Figures

Figure 1
Figure 1
Preserved LVEF (68%) (A) and impaired longitudinal systolic function (GLS −16%) (B) in a 68-year-old man, 4 months after non-ST elevation myocardial infarction (NSTEMI).
Figure 2
Figure 2
An asymptomatic 54-year-old woman with severe mitral regurgitation arising from anterior leaflet prolapse (A) preserved LVEF (67%) (B) and slightly reduced longitudinal systolic function GLS (−17.9) (C).
See this image and copyright information in PMC

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