Anesthesiology APPLIED Exam › OSCE: echocardiography and POCUS

Ventricular function and wall motion

OSCE: echocardiography and POCUS·~5 min read· Physician-reviewed✓ Sourced · 3

Stem

Monitors and echo station. A 69-year-old man, 88 kg, with ischemic cardiomyopathy is hypotensive at 82/54 after induction for an open colectomy; the CVP is 16 mmHg. The loop is a transgastric mid-papillary short-axis view on TEE. The LV cavity is large, every segment thickens only slightly and uniformly, and the cavity barely changes size from diastole to systole. The RV is normal in size and the septum is round.

Question

How would you describe the ventricular function, and what will you do about it?

Ideal answer

HeadlineA dilated, globally hypokinetic left ventricle, ejection fraction under 30%, with a high filling pressure unmasked by induction. I support it with an inotrope and stop the fluid.

View: transgastric mid-papillary short-axis, which, like the parasternal short-axis on TTE, shows all three coronary territories.¹
Size and global function: dilated, severely reduced by eye, given as a range rather than one number.
Regional motion segment by segment, by thickening, not movement, because a tethered or translating segment moves without contracting;² every segment thickens a little and equally: global hypokinesis, not a territory.
RV: normal size, round septum, so the right heart is not the problem.
Epinephrine or dobutamine; afterload reduction once pressure allows; no fluid, because this ventricle is already full.

Watch for: better thickening and a smaller end-systolic cavity, or a new regional abnormality pointing to ischemia.

Breaking down the answer

Biventricular function and wall motion lead the outline's echo diagnoses;³ the facilitator wants global or regional, left or right, and what I do, in a minute. Each pattern has a different treatment, which is where judgment is graded.

The ASE thickening score — normal or hyperkinetic, hypokinetic (reduced), akinetic (absent or negligible) and dyskinetic (systolic thinning or stretching, outward bulging).² Normal myocardium thickens roughly 30% or more.
Segment to coronary territory — mid-papillary: anterior and anteroseptal LAD, anterolateral and inferolateral circumflex, inferior and inferoseptal right coronary. New inferior akinesis after bypass points to air in the right coronary, the most anterior. Supply varies, so I say "territory".²
New versus old — thinned, bright and akinetic is old scar; normal thickness that stopped thickening is acute ischemia, the only one that responds to perfusion pressure, a slower rate or nitroglycerin.
Small hyperdynamic LV — end-systolic obliteration with "kissing" papillary muscles means low preload or low afterload: volume or a vasoconstrictor. An inotrope worsens it and can provoke outflow obstruction.
RV dilation and dysfunction — basal diameter over 41 mm or larger than the LV in the four-chamber view, reduced free-wall excursion (TAPSE under 17 mm), fractional area change under 35%, a "D" septum.²
Treating RV failure — the cause first, no fluid, norepinephrine or vasopressin to keep systemic above pulmonary pressure, and a pulmonary vasodilator such as inhaled nitric oxide.
EF in ranges — visual estimates are imprecise; false precision earns nothing. Normal about 52–72% men, 54–74% women; mildly reduced 41–51% (men) or 41–53% (women), moderately 30–40%, severely under 30%.²

Follow-up question

Second scenario at the station, in a different patient: the first loop is a normal mid-papillary short-axis. Then the monitor shows:

The second loop shows the anterior and anteroseptal walls no longer thickening while the rest contracts briskly. What do you see, and what do you do?

Follow-up answer

What the monitor showed: pressure drifting from 122/68 to 96/50, with sinus rhythm steady at 80 and no ST change yet; the echo shows the ischemia first.

Headline"New akinesis of the anterior and anteroseptal segments: acute LAD-territory ischemia,"¹ the earliest warning I will get, and I tell the surgeon.

100% oxygen, diastolic pressure restored with phenylephrine or norepinephrine, esmolol for a fast rate if the pressure tolerates it, nitroglycerin if the pressure is adequate. A 12-lead ECG, troponin and cardiology; in a cardiac case, the surgeon checks the LAD graft. I reassess thickening on the next loop. The harder variant adds a dilated, hypokinetic RV: a proximal right coronary lesion or air, so RV support rather than more fluid.

Pitfalls that cost points

Grading wall motion from an off-axis or foreshortened view.
Calling a segment abnormal on motion alone when it thickens normally.
Giving an inotrope to a small, hyperdynamic, underfilled ventricle.
Ignoring the RV because the question seemed to be about the LV.

Rapid-fire

Q: Why does echo detect ischemia before the ECG? A: In the ischemic cascade, diastolic and then systolic wall motion fail before ST changes appear, so a new regional abnormality is the earlier sign.

Q: Why is the right coronary artery prone to air after bypass? A: Its ostium is the most anterior with the patient supine, so air rising in the aortic root enters it first.

Q: What does septal flattening in diastole alone mean? A: RV volume overload; flattening through systole as well means RV pressure overload.

Q: Why can a segment move but be ischemic? A: Adjacent normal myocardium tethers it and the whole heart translates, so only thickening proves contraction.

Numbers to know

Item	Value
Normal LVEF	52–72% men, 54–74% women²
Severely reduced LVEF	<30%²
Normal systolic thickening	~30% or more
Hypokinesis / akinesis	Reduced / absent or negligible thickening²
Old scar	Thinned, bright, akinetic
RV basal diameter, dilated	>41 mm²
TAPSE / FAC, abnormal	<17 mm / <35%²

Sources

1.Basic Perioperative Transesophageal Echocardiography Examination: A Consensus Statement · ASE/SCA, 2013 · asecho.org
2.Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the ASE and EACVI · ASE/EACVI, 2015 · asecho.orgLVEF ranges (Table 4), wall motion scoring, RV size and TAPSE/FAC cutoffs.
3.APPLIED Exam Objective Structured Clinical Examination (OSCE) Content Outline · ABA · theaba.org

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.