Evaluation of systolic function of left ventricle by echocardiography
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EVALUATION OF SYSTOLIC FUNCTION OF LEFT VENTRICLE BY ECHOCARDIOGRAPHY. DR SANDEEP.R SR CARDIO. Basic Principle. Systole The period of the cardiac cycle from the closure of the mitral valve to the closure of the aortic valve. EJECTION FRACTION.

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EVALUATION OF SYSTOLIC FUNCTION OF LEFT VENTRICLE BY ECHOCARDIOGRAPHY

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Evaluation of systolic function of left ventricle by echocardiography

EVALUATION OF SYSTOLIC FUNCTION OF LEFT VENTRICLEBY ECHOCARDIOGRAPHY

DR SANDEEP.R

SR CARDIO


Basic principle

Basic Principle

Systole

The period of the cardiac cycle from the closure of the mitral valve to the closure of the aortic valve


Ejection fraction

EJECTION FRACTION

  • Ejection fraction-percentage of LV diastolic volume that is ejected with systole

  • EF=STROKE VOLUME/EDV=EDV-ESV/EDV


Ideal method for ef calculation

IDEAL METHOD FOR EF CALCULATION

  • Accurate

  • Quick

  • Reproducible

  • Simple

  • Relatively independent of LV geometry


M mode quantification

M-Mode Quantification

  • Use Parasternal Short-Axis or Long-Axis views to measure LVEDD and LVESD

  • Measurement is taken perpendicular to the ventricle at the level of tip of mitral leaflet

  • Assumes that no significant regional wall motion abnormalities are present


Technical aspects

TECHNICAL ASPECTS

Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108


Lv measurement tte

LV MEASUREMENT - TTE

1.PLAX

2.PSAX AT PAPILARY MUSCLE


Lv measurement tte1

LV MEASUREMENT -TTE

  • 3) 2D METHOD

  • Useful for assessing patients with CAD

  • LV internal dimensions (LVIDd and LVIDs &

  • wall thicknesses be measured at mitral chordae level

  • 2D minor-axis dimensions smaller than M-mode measurements

Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108


Lv measurements tee

LV MEASUREMENTS - TEE

a) ME-LAX

b)TG-LAX

c) TG –SAX preferred view

Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108


Lv measurements

LV MEASUREMENTS

Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108


Lv measurements1

LV MEASUREMENTS

Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108


Evaluation of systolic function of left ventricle by echocardiography

Global Myocardial Function

  • Fractional shortening (FS)

    • Assumes symmetric contraction

  • Ejection fraction (EF)

EF=EDV-ESV/EDV


Ejection fraction1

EJECTION FRACTION


Teicholz cubed formula

TEICHOLZ /CUBED FORMULA

  • LV Volume calculation is based on assumption that the LV is a prolate ellipse

  • Basic assumptions

    • LV dilates along the minor axis

    • LV internal diameter is equal to one of the minor axis of the ellipse D1

    • Both minor axisof ellipse D1,D2 are equal

LV VOLUME= 4/3 xPi x D1/2 x D1/2 x 2D1/2

= Pi/3 x D cube =1.047 x D cube = D cube

This structure has two minor axis D1 & D2 and

a major axis L

V=4/3 Pi X D1/2 X D2/2 X L/2


Teicholz

TEICHOLZ


Modified techolz

MODIFIED TECHOLZ

  • As LV becomes more spherical as it dilates the relation between major and minor axis changes.

  • Therefore a regression formula was devised to correct for this change in shape

  • LVV=( 7.0/2.4+D) x Dcube


Modified quinones method

MODIFIED QUINONES METHOD

  • Measure LVIDd &LVIDs

  • Calculate radial EF

  • If significant RWMA average EF measurement from basal & mid LV levels

  • Add factor for longitudinal shortening


Simpson s method

SIMPSON’S METHOD

  • In the presence of RWMA all the above methods will be less accurate, since inclusion of RWMA- causes volume overestimation

  • The apical biplane methods are more robust in this setting, using summation of a series of disks from apex to base (often called Simpson’s Rule).

  • The ASE (American Society of Echocardiography) recommends use of biplane apical views with a modified Simpson’s rule approach


Simpson s method1

SIMPSON’S METHOD


Biplane simpsons

BIPLANE SIMPSONS


Simpson s method2

Simpson’s method


Simpson s rule the biplane method of disks

Simpson’s Rule – the biplane method of disks

LV-ED LV-ES

  • Volume left ventricle

    - manual tracings in systole and diastole

    - area divided into series of disks

    - volume of each disc(πr2x h )

    summed = ventricular volume

  • Preferred method of choice

LV-ED LV-ES

A4C

A2C


Simpsons rule rule of disc

SIMPSONS RULE\ RULE OF DISC


Evaluation of systolic function of left ventricle by echocardiography

AREA - LENGTH METHOD

Hemi-cylindrical Hemi-ellipsoid Model

Assumes:

Base of ventricle = cylinder

Apex of ventricle = ellipsoid

Volume is calculated using a long axis length L and cross-sectional area Am of an orthogonal short-axis view at the mid-papillary muscle.

V = (Am) L/2 + 2/3 (Am) L/2

V = 5/6 AL (Bullet Formula)

VOLUME=5 (Area )(length)/6


Visual ef

VISUAL EF

  • Echocardiographic assessment of global left ventricular systolic function is usually performed subjectively

  • Experienced echocardiographers - estimate EF by looking at the overall size and contractility as well as the inward movement and thickening of the various segments of the LV walls without actually taking measurements

  • Correlate fairly well with angiographic assessment of the EF

  • Limitations:

  • Irregular rhythm

  • Very large or very small LV

  • Extremes of heart rate


Lv quantification methods

LV QUANTIFICATION METHODS


Comparision of various echo methods with cine angio radionuclide ventriculography

COMPARISION OF VARIOUS ECHO METHODS WITH CINE ANGIO & RADIONUCLIDE VENTRICULOGRAPHY

ESV & EDV CORRELATION

Modified simpson’s rule showed maximum correlation with cine angio & RVG

EF CORRELATION


Lv mass assesment

LV MASS ASSESMENT


Evaluation of lv mass

Evaluation of LV Mass

This is done by tracing the epicardial to calculate the total ventricular volume and the endocardial border to calculate chamber volume.

LV mass = 1.05 (total volume – chamber volume)


Evaluation of systolic function of left ventricle by echocardiography

LV Total Area

LV Cavitary Area

Length


Evaluation of lv mass1

Evaluation of LV Mass

Total volume= Total area x length

Chamber volume = Chamber area x Length

Myocardial volume = Total volume – Chamber volume

LV mass = Myocardial volume x density

LV mass = Myocardial volume x 1.05


Evaluation of systolic function of left ventricle by echocardiography

Evaluation of LV Mass


Lv mass

LV MASS


Lv mass quantification

LV Mass Quantification

  • 2D M-Mode method using parasternal short axis view or parasternal long axis view

  • Assumes that LV is ellipsoid (2:1 long/short axis ratio)

  • Measurements made at end diastole

  • ASE approved cube formula:

  • LV mass (g) = 1.04 [(LVID + PWT + IVST)3 - (LVID)3]

    X 0.8 + 0.6

    LV mass index (g/m2) = LV mass / BSA

  • Small errors in M-Mode cause large errors in mass values. Can have off axis/tangential cuts due to motion.


Lv mass assesment1

LV MASS ASSESMENT


Lv mass tee

LV MASS-TEE

  • TEE evaluation of LV mass highly accurate,but has minor systematic differences in LV PWT

  • LV mass derived from TEE wall-thickness measurements is higher by an average of6 g/m2

  • .


Lv mass1

LV MASS

RELATIVE WALL thickness= 2XPW/LVIDd


Other m mode methods of lv function assesment

OTHER M-Mode METHODS OF LV FUNCTION ASSESMENT


Evaluation of systolic function of left ventricle by echocardiography

EPSS

LIMITATIONS-INACCURATE

AR

MS

3) IWMI

Lew W et al , American journal of cardiology 41:836-845,1978

Ahmadpour,H et al , American heart journal 106:21-28,1983:


B notch

B- notch

  • Delayed closure of mitral leaflets between the A and C (leaflet coaptation) points, determining a "notch" known as B-bump (small arrows)

  • Indicates increased left ventricular end-diastolic pressure ( > 20mmhg)

  • LIMITATIONS

  • 1) Low sensitivity

  • 2)false positive with first degree AV block & LBBB-due to prolonged AC interval

Ambrose J A et al Circulation60:510-519 1979


Mitral annular plane excursion

MITRAL ANNULAR PLANE EXCURSION

  • M-mode tracings in systole

  • The magnitude of systolic motion is proportional to the longitudinal shortening of the LV

  • Normal mitral annular systolic motion is > 8mm (average 12 +/- 2 on apical4 or apical 2 views)

  • If motion is < 8 mm, the EF is likely < 50%

  • If <8mm -98% sensitive & 82% specific for EF <50%


Gradual closure of aortic valve

GRADUAL CLOSURE OF AORTIC VALVE

Decreased LV forward flow causes gradual reduction in forward flow in late systole

This results in rounded appearance of aortic valve closure in late systole


Doppler evaluvation of global lvf

DOPPLER EVALUVATION OF GLOBAL LVF


Doppler stroke volume calculation

Doppler Stroke Volume Calculation

CARDIAC OUTPUT= STROKE VOLUME X HEART RATE


Doppler stroke volume calculation1

Doppler Stroke Volume Calculation

  • Assumption used for measuring SV using Doppler are:

  • Accurate cross-sectional flow area measurement.

  • Laminar Flow.

  • 3. Parallel intercept angle between Doppler beam and

  • direction of blood flow.

  • 4. Velocity and diameter measurements are made at the

  • same anatomic site.


Evaluation of systolic function of left ventricle by echocardiography

ECHO VIEW PHASE

ECHO VIEW PW SAMPLE VOLUME POSN.


Doppler evaluation of lv function

DOPPLER EVALUATION OF LV FUNCTION


Evaluation of systolic function of left ventricle by echocardiography

Problems in this technique

  • 1. Apical 3-chamber view can be tried if Apical 5-c is difficult to obtain

    of velocities.

  • 2. Underestimation of flow velocities- LVOT may not be aligned with the direction of the PWD

    • an apical 3-chamber view may sometimes offer better alignment.

  • 3.When the parasternal long axis view is not obtainable, a LVOT diameter of 2cms for males and 1.75cms for females can be assumed.

  • 4.Variations in VTI with respiration

    • Movement of entire cardiawith respiration –difficult to obtain uniform velocities with PWD at LVOT


Pitfalls in echo calculation of co

Pitfalls in Echo Calculation of CO

  • Accurate measurement of CSA

    • Weakest link in the calculation

    • VTI very good for assessing change in cardiac output with therapy, by following changes in VTI, since CSA is largely invariant in an individual

  • Measures forward flow only

    • Regurgitant fraction not considered

    • May over-estimate systemic cardiac output

  • Echocardiographic window in mechanically ventilated patients may be poor


Myocardial performance index

Myocardial Performance Index

  • Applied to either the left or right ventricle.

  • Ejection time (ET), isovolumic contraction time (IVCT) and the isovolumic relaxation time (IVRT).

  • MPI = ( IVCT + IVRT ) / ET

Systolic dysfunction is associated with a prolongation of IVCT and a shortening of the ET

Normal range is 0.39 ± 0.05, and values > 0.50 are considered abnormal


Rate of ventricular pressure rise dp dt

RATE OF VENTRICULAR PRESSURE RISE (dp/dt)

  • When Mitral regurgitation is present the CW Doppler velocity curve indicates the instantaneous pressure difference between the left ventricle and left atrium

  • The slope of the MR jet velocity can be quantitated as the rate of change in pressure over time (dP/dt) by measuring the time interval between the MR jet velocity at 1 and 3 m/s


Dp dt lv function assesment

DP/DT-Lv function assesment

dt

1 m/s, 4 mmHg

dP

3 m/s, 36 mmHg


Evaluation of systolic function of left ventricle by echocardiography

Evaluation of LV Systolic Function

At each velocity, the corresponding pressure gradient is 4v squared per Bernoulli.

dP/dt = [ 4 (3) (3) – 4 (1) (1)] = 32 mmHg

Time interval Time interval

Thus a longer time interval indicates a depressed dP/dt and thus a decreased LV systolic function.


Evaluation of systolic function of left ventricle by echocardiography

CW doppler to measure rate of rise of MR jet may correlate to LVEF

A slow rate of rise may indicate poor systolic function

Must have MR present, and good doppler study present (more difficult with eccentric jets)


Evaluation of systolic function of left ventricle by echocardiography

Limitations:

This method is only useful in patients with enough MR to obtain a well-defined velocity curve.

LA should be compliant. 

Click artifact(caused by valve closure) can obscure the descending limb of the CWD envelope, which makes measurements difficult.

Eccentric MR jets may not reflect true velocity and will result in underestimation of dp/dt unless careful colour Doppler examination of the jet is made to minimize CWD error. 

A normal dp/dtmaybe present in hypertension and aortic stenosis even with impaired LV function.


Evaluation of systolic function of left ventricle by echocardiography

Evaluation of LV Systolic Function

  • The other Doppler measurements that can be used to measure LV systole function are

    • Peak velocity

    • Mean acceleration

    • Acceleration Time

    • Deceleration Time

    • Ejection time

    • Mean deceleration


Evaluation of lv systolic function

Evaluation of LV Systolic Function

Ejection Time

Deceleration Time

Acceleration Time

Mean Acceleration

Peak Acceleration

Peak velocity


Systolic time intervals

SYSTOLIC TIME INTERVALS

LVPre ejection period(LVPEP)- measured from Q wave on ECG to onset of aortic valve opening

LV Ejection time(LVET)- aortic valve opening to aortic valve closure

LVPEP/LVET independent of Heart Rate

Lv dysfunction causes increase in LVPEP & shortening of LVET

1)Weissler,A.M et al Systolic time intervals in heart failure in man Circulation 37:149-159,196

2)Garrard et al ,circulation 42 :455-462,1970


Regional lv function

REGIONAL LV FUNCTION


Regional lv function1

REGIONAL LV FUNCTION


Regional lv function2

REGIONAL LV FUNCTION


Regional lv function3

REGIONAL LV FUNCTION


Nonischemic rwma

NONISCHEMIC RWMA


Diff ischemic vs nonischemic

DIFF ISCHEMIC VS NONISCHEMIC


Evaluation of systolic function of left ventricle by echocardiography

LBBB


3d echo

3D ECHO

  • Provides detailed anatomic relationship

  • Accurate quantitation

  • Faster acquisition and may reduce interobserver variability

  • 3d quantitation of LV function avoids geometric assumptions and is more accurate & reproducible


3d echo1

3D echo


Tissue doppler imaging

TISSUE DOPPLER IMAGING

  • The annular velocity in systole has shown a good correlation with the LVEF

  • Can detect impaired longitudinal systolic function (Sm < 4.4 m/s)

  • SEPTAL ANNULAR TDI


Newer methods of evaluation of lv function

NEWER METHODS OF EVALUATION OF LV FUNCTION


Strain rate imaging speckle tracking

STRAIN RATE IMAGING & SPECKLE TRACKING


Colour kinesis

COLOUR KINESIS


Central line method

CENTRAL LINE METHOD


Thank you

THANK YOU


Bibilography

BIBILOGRAPHY

  • LANGE ET AL;Recommendations for Chamber Quantification: A Report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, Developed in Conjunction with the European Association of Echocardiography, a Branch of the

    European Society of Cardiology;J Am Soc Echocardiogr 2005;18:1440-1463

  • AssessmentofLeft Ventricular Systolic Function by Echocardiography.CARDIOLOGY CLINICS

  • Reliability of reporting left ventricular systolic function by echocardiography: A systematic review

    of 3 methodsAmerican Heart Journal Volume 146, Number 3

  • Techniques for comprehensive two dimensional echocardiographic assessment of left ventricular systolic

    function

  • TEXTBOOK OF CLINICAL ECHOCARDIOGRAPHY FIFTH EDITION


Evaluation of systolic function of left ventricle by echocardiography

MCQ

  • 1.WHICH IS THE METHOD RECOMMENDED BY American Society of Echocardiography For EF ESTIMATION?

  • 1) TECHOLZ

  • 2) QUINONES

  • 3) AREA LENGTH

  • 4) SIMPSON’S BIPLANE

  • ans4


Evaluation of systolic function of left ventricle by echocardiography

  • 2.Pt. presumed to have a EF < 35% if the EPSS

    is

    1)4

    2) 8

    3)15

    4)10

    Ans 3


Evaluation of systolic function of left ventricle by echocardiography

3.Preferred choice for Ef estimation in patients with RWMA

  • 1) TEICHOLZ

  • 2) QUINONES

  • 3) SIMPSONS

  • 4) AREA LENGTH

  • Ans 3


Evaluation of systolic function of left ventricle by echocardiography

4.MITRAL ANNULAR PLANE EXCURSION SUGGESTIVE OF LV DYSFUNCTION

  • 1) 5

  • 2)8

  • 3)10

  • 4)12

  • Ans 1


Evaluation of systolic function of left ventricle by echocardiography

5.WHAT IS WALL MOTION SCORE FOR DYSKINESIS

  • a) 1

  • b)2

  • c)3

  • d)4

  • Ans D


Evaluation of systolic function of left ventricle by echocardiography

6.What is the normal wall motion score index?

  • a)2

  • B)4

  • C)1

  • D)3

  • Ans c


Evaluation of systolic function of left ventricle by echocardiography

8.Which method is known as the D cube method

  • 1) QUINONES

  • 2) SIMPSONS

  • 3) AREA LENGTH METHOD

  • 4) TEICHOLZ

  • Ans 4


Evaluation of systolic function of left ventricle by echocardiography

9.DP/DT OF MR JET IS 1400 THE PT HAS

  • 1) MILD LV DYSFN.

  • 2) SEVERE LV DYSFUNCTION

  • 3) NORMAL LV FUNCTION

  • 4) MODERATE LV DYSFUNCTION

  • ans3


Evaluation of systolic function of left ventricle by echocardiography

10.IF RWT >0.42 AND LV MASS IS NORMAL, THE PATIENT HAS

  • 1) CONC LVH

  • 2) CONSCENTRIC REMODELLING

  • 3) ECCENTRIC LVH

  • 4)NORMAL

  • Ans 2


Evaluation of systolic function of left ventricle by echocardiography

11. All of the following can cause RWMA except

  • Anterior wall myocardial infarction

  • LBBB

  • Preexcitation (WPW syndrome)

  • Acute Pericarditis

    Ans 4


Evaluation of systolic function of left ventricle by echocardiography

12All of these indirectly denote LV dysfunction EXCEPT ?

  • A) EPSS > 15

  • B) MAPSE < 8

  • C) DP/dt< 800

  • D) Myocardial performance index < 0.5

  • Ans d


Evaluation of systolic function of left ventricle by echocardiography

13. Which is known as TEI index?

1)Cardiac index

2) Myocardial performance index

3) LV preejection time/ LV ejection time

4)DP/DT of MR jet

Ans 2


Evaluation of systolic function of left ventricle by echocardiography

14.Inferolateral segment is supplied by which arterial territory

  • A) RCA

  • B) LAD

  • C) RAMUS

  • D) LCX

  • Ans d


Evaluation of systolic function of left ventricle by echocardiography

15.Which is the true statement

  • A) LV dysfunction causes shortening of ejection time

  • B) LV dysfunction causes shortening of preejection period

  • C) LV dysfunction causes Lvpreejection period/LV ejection period < 0.35

  • D) LV dysfunction causes prolongation of ejection time and shortening of preejection period

  • Ans a


Evaluation of systolic function of left ventricle by echocardiography

16.If the MR velocity is 1m/s at 1sec and if it accelerates to 4m/s at 4 sec then what is the DP /dt?

  • 10

  • 15

  • 20

  • 25

    Ans 3


Evaluation of systolic function of left ventricle by echocardiography

  • 17.If the relative wall thickness is 0.39 and LV mass increased then the patient has

  • 1) conc. LVH

  • 2) NORMAL

  • 3) ECCENTRIC LVH

  • 4) CONSCENTRIC REMODELLING

  • Ans 3


Evaluation of systolic function of left ventricle by echocardiography

  • 18. In which formula for LV function assesment is the assumption of prolate ellipse considered

  • 1) QUINONE’S

  • 2) TEICHOLZ

  • 3) AREA LENGTH

  • 4) SIMPSON’S

  • Ans


Evaluation of systolic function of left ventricle by echocardiography

  • 19 . identify the false statement

  • 1) presence of B notch denotes LV dysfunction

  • 2) EPSS is not accurate if patient has AR

  • 3) EPSS > 15 denotes severe LV dysfunction

  • 4) MPI < 0.5 denotes LV dysfunction

  • Ans 4


Evaluation of systolic function of left ventricle by echocardiography

  • 20.In which method of LV function assesment is the apical contraction considered for EF calculation?

  • 1) TEICHOLZ

  • 2) MODIFIED QUINONES

  • 3) SIMPSONS

  • 4) AREA LENGTH

  • Ans 2


Evaluation of systolic function of left ventricle by echocardiography

  • 21.A patient is found to have a calculated EF of 42% .He is said to have

  • Normal LV fn.

  • Mild LV dysfunction

  • Moderate LV dysfunction

  • Severe LV dysfunction

    Ans 3


Evaluation of systolic function of left ventricle by echocardiography

  • 22.EPSS on echo is increased in

  • A) Dilated cardiomyopathy

  • B) Hypertrophic cardiomyopathy

  • C) Aortic stenosis

  • D) Pulmonary stenosis

  • Ans a


Evaluation of systolic function of left ventricle by echocardiography

  • 23.Transthoracic echo is superior to transesophageal echo in

  • A) Assesing prosthetic valve function

  • B) Assess LA clot

  • C) Diagnosisof infective endocarditis

  • D) Assesment of LV systolic function

  • Ans:D


Evaluation of systolic function of left ventricle by echocardiography

  • 24.Assumption of LV used in calculation of simpsons formula

  • 1) Prolate ellipse

  • 2) Cone

  • 3) Circle

  • 4) Disc

  • Ans 4)


Evaluation of systolic function of left ventricle by echocardiography

  • 25.LVEDD is measured at

  • 1) onset of P wave

  • 2) R wave

  • 3) peak of T wave

  • 4) U wave

  • Ans 2)


Evaluation of systolic function of left ventricle by echocardiography

  • 26.LVESD measurement is done during

  • 1) Q wave

  • 2) R wave

  • 3)T wave

  • 4) U wave

  • Ans 3


Evaluation of systolic function of left ventricle by echocardiography

27.Akinesis of a segment is defined

  • 1) increase of systolic wall thickness < 10%

  • 2) Increase in systolic wall thickness >50 %

  • 3)increase in systolic wall thickness <40%

  • 4) outward movement of wall during systole with associated systolic wall thinning

  • Ans 1


Evaluation of systolic function of left ventricle by echocardiography

  • 28.Wallmotion score for akinesis is

  • A)1

  • B) 2

  • C) 3

  • D)4

  • E)5

  • Ans C


Evaluation of systolic function of left ventricle by echocardiography

  • 29.Hypokinesia is defined as

  • 1) increase of systolic wall thickness < 10%

  • 2) Increase in systolic wall thickness >50 %

  • 3)increase in systolic wall thickness <40%

  • 4) outward movement of wall during systole with associated systolic wall thinning

  • Ans 3


Evaluation of systolic function of left ventricle by echocardiography

  • Normal stroke volume is

  • 1) 30-50

  • 2) 50 – 70

  • 3) 70 – 90

  • 4)>100

  • Ans 3


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