Written by Chris Thom
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In this study of pediatric echocardiograms, the end point septal separation (EPSS) was an accurate test for the detection of left ventricular systolic dysfunction.
Left ventricular systolic function is easy in kids too
This single center retrospective study evaluated pediatric echocardiograms performed by cardiology during the time period of 2019-2023. Children with known congenital heart disease were excluded from the analysis. Patients were categorized into three age groups, 0-3 years old, 4-12 years old, and 13-18 years old. The diagnostic accuracy of an EPSS threshold of 7 mm, commonly cited in the adult literature, was initially tested across age groups and compared to the measured LVEF on echocardiogram.
The analysis included 770 echocardiograms, 622 of which had normal LV systolic function and 148 with abnormal LV systolic function. EPSS measurements increased with worsening LV dysfunction; 8.4 mm for mildly depressed, 12.3 mm for moderately depressed, and 19.6 mm for severely depressed LVEF. The AUROC was 0.92 for EPSS and any LV systolic dysfunction. Across all age groups, the derived optimal EPSS threshold was 6.0 mm, which resulted in a sensitivity of 82% (95%CI 74-87%) and specificity of 91% (95%CI 89-94%).
How will this change my practice?
The current study suggests that EPSS works well in pediatrics as a surrogate for normal versus abnormal LVEF. I use this tool frequently in assessing LVEF in adult patients, though I admittedly don’t often measure the exact value. Rather, this supplements my visual estimation of the LVEF in the parasternal long axis. If contractility looks visually normal and the anterior leaflet of the mitral valve is hitting the septum in diastole, or getting very close, then one can reasonably call “normal LVEF”. If there appears to be a gap in that distance, then I will formally measure the EPSS to categorize “normal” versus “reduced LVEF”. This tool is evidence-based and applicable in pediatrics.
POCUS Pro-Tips and Clips
When assessing the EPSS, it helps to have a parasternal long view where you can clearly see the two leaflets of the mitral valve, as well as position the image so that the LV cavity is at its widest point. This will be the center of the LV from the long axis perspective, wherein the visual estimation of LVEF and assessment of EPSS will be most accurate. When you steer the M-mode line, try to position it as perpendicular as possible to the septum and ensure you are measuring the EPSS at the tip of the anterior mitral valve leaflet.
Source
Use of e-point septal separation to screen for left ventricular function in children. Am J Emerg Med. 2026 Jan;99:39-45. doi: 10.1016/j.ajem.2025.09.013. Epub 2025 Sep 6. PMID: 40972483.
