# Ejection fraction

ejection fraction (EF) is the fraction of blood in the left and right ventricles pumped out with each heartbeat. In mathematics allowed by medical imaging, EF is applied to both the right ventricle, which ejects blood via the pulmonary valve into the pulmonary circulation, and the left ventricle, which ejects blood via the aortic valve into the cerebral and systemic circulation. RVEF + LVEF = EF.

Imaging of the heart allows for mathematical expressions defining flow of blood into and out of the heart. EF is essentially a ratio; a mathematical expression of forward movement of blood out of the heart contrasted to the amount retained in a single cardiac cycle. One important mathematical expression involves easily reproduced volumetrics. As a volumetric mathematical term, ejection fraction is an extension of work by Adolph Fick entitled Cardiac Output. EF=CO. Fick's theory was gradually merged to fit the precision of wall motion mathematics first defined by Laplace. This led to the introduction of compliance and length-tension in the Frank–Starling law of the heart. Echocardiography, computed tomography (CT scan), magnetic resonance imaging (MRI) and radionuclide angiography (MUGA) scanning have allowed the study of ischemia, congenital heart disease, conduction disease, infectious disease, granulomatous disease and resulting heart failure.

## Overview

By definition, the volume of blood within a ventricle immediately before a contraction is known as the end-diastolic volume (EDV). Likewise, the volume of blood left in a ventricle at the end of contraction is end-systolic volume (ESV). The difference between EDV and ESV represents a ratio between the ventricles full and emptied. This ratio allows many variables such as stroke volume (SV). SV describes the volume of blood ejected from the right and left ventricles with each heartbeat. Ejection fraction is the fraction of the end-diastolic volume that is ejected with each beat; that is, it is stroke volume (SV) divided by end-diastolic volume (EDV):[1]

$E_f (\%) = \frac{SV}{EDV}\times100$

Where the stroke volume is given by:

$SV = EDV - ESV$

## Normal values

Measure Typical valueNormal range
end-diastolic volume (EDV)120 mL[2][non-primary source needed]65–240 mL[2][non-primary source needed]
end-systolic volume (ESV)50 mL[2][non-primary source needed]16–143 mL[2][non-primary source needed]
stroke volume (SV)70 mL55–100 mL
ejection fraction (Ef)58%55–70%[3]
heart rate (HR)75 bpm60–100 bpm[4]
cardiac output (CO)oo5.25 L/minute4.0–8.0 L/min[5]

In a healthy 70-kilogram (150 lb) man, the SV is approximately 70 mL and the left ventricular EDV is 120 mL, giving an ejection fraction of 70120, or 0.58 (58%).

Right ventricular volumes being roughly equal to those of the left ventricle, the ejection fraction of the right ventricle physiologically matches that of the left ventricle within mathematically narrow beat-to-beat limits.

Healthy individuals typically have ejection fractions between 50% and 65%.[6] However, normal values depend upon the modality being used to calculate the ejection fraction, and some sources consider an ejection fraction of 55% to 75% to be normal. Damage to the muscle of the heart (myocardium), such as that sustained during myocardial infarction or in atrial fibrillation or a plurality of etiologies of cardiomyopathy, compromises the heart's ability to perform as an efficient pump (ejecting blood) and, therefore, reduces ejection fraction. This reduction in the ejection fraction can manifest itself clinically as heart failure. A low ejection fraction has its cutoff below 40% with symptomatic manifestations constant at 25%.[7] In the USA, a chronically low ejection fraction less than 30% is qualifying support for eligibility of disability benefits from the Social Security Administration.[8]

Healthy older adults favorably adapt as the ventricles become less compliant and are routinely echocardiographically proven to have an EF from 55–85% with the help of good genetics and a healthy lifestyle. Compliance changevolume /changepressure is a property of the heart that allows contractility. Encyclopedic documentation of the commonly documented "hyperdynamic" ventricle remains sparse.

The ejection fraction is one of the most important predictors of prognosis; those with significantly reduced ejection fractions typically have poorer prognoses. However, recent studies have indicated that a preserved ejection fraction does not mean freedom from risk.[9][non-primary source needed][10][non-primary source needed]

The QT interval as recorded on a standard electrocardiogram (EKG) represents ventricular depolarazation and ventricular repolarazation and is rate-dependent.[11][non-primary source needed]

## Measurement

Ejection fraction is commonly measured by echocardiography, in which the volumes of the heart's chambers are measured during the cardiac cycle. Ejection fraction can then be obtained by dividing stroke volume by end-diastolic volume as described above.

Accurate volumetric measurement of performance of the right and left ventricles of the heart is inexpensively and routinely echocardiographically interpreted worldwide as a ratio of the dimension between the ventricles in systole and diastole. For example, a ventricle in greatest dimension could measure 6 cm while in least dimension 4 cm. Measured and easily reproduced beat to beat for ten or more cycles, this ratio may represent a physiologically normal EF of 50-60%. Mathematical expression of this time-dependent ratio can then be interpreted as the greater half as cardiac output and the lesser half as cardiac input.

Other methods of measuring ejection fraction include cardiac MRI, fast-scan cardiac computed axial tomography (CT) imaging, ventriculography, gated SPECT, and the MUGA scan. A MUGA scan involves the injection of a radioisotope into the blood and detecting its flow through the left ventricle. The historical gold standard for the measurement of ejection fraction is ventriculography.

## References

1. ^ Morton Kern 5th edition page 180
2. ^ a b c d Schlosser, Thomas; Pagonidis, Konstantin; Herborn, Christoph U.; Hunold, Peter; Waltering, Kai-Uwe; Lauenstein, Thomas C.; Barkhausen, Jörg (2005). "Assessment of Left Ventricular Parameters Using 16-MDCT and New Software for Endocardial and Epicardial Border Delineation". Am J Roentgenol 184 (3): 765–773. doi:10.2214/ajr.184.3.01840765. Values:
• End-diastolic volume (left ventricular) – average 118 and a range of 68 – 239mL and
• End-systolic volume (left ventricular) – average 50.1 and range, 16 – 143 mL:
• Also, ejection fraction was estimated in this study to be average 59.9% ± 14.4%; range, 18 – 76%, but secondary source (see above) is used in this article instead.
3. ^ O'Connor, Simon (2009). Examination Medicine (The Examination). Edinburgh: Churchill Livingstone. p. 41. ISBN 0-7295-3911-3.
4. ^ Normal ranges for heart rate are among the narrowest limits between bradycardia and tachycardia. See the Bradycardia and Tachycardia articles for more detailed limits.
5. ^
6. ^ Kumar, Vinay; Abbas, Abul K; Aster, Jon. (2009). Robbins and Cotran pathologic basis of disease (8th ed.). St. Louis, Mo: Elsevier Saunders. p. 574. ISBN 1-4160-3121-9.
7. ^
8. ^
9. ^ Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM (July 2006). "Trends in prevalence and outcome of heart failure with preserved ejection fraction". N. Engl. J. Med. 355 (3): 251–9. doi:10.1056/NEJMoa052256. PMID 16855265.
10. ^ Bhatia RS, Tu JV, Lee DS, et al. (July 2006). "Outcome of heart failure with preserved ejection fraction in a population-based study". N. Engl. J. Med. 355 (3): 260–9. doi:10.1056/NEJMoa051530. PMID 16855266.
11. ^ Bazett, H. C. (1920). "An analysis of the time-relations of electrocardiograms". Heart 7: 353–370.