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

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


Global Myocardial Function

  • Fractional shortening (FS)

    • Assumes symmetric contraction

  • Ejection fraction (EF)

EF=EDV-ESV/EDV



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



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 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



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



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 RADIONUCLIDE VENTRICULOGRAPHY


Evaluation of lv mass
Evaluation of LV Mass RADIONUCLIDE VENTRICULOGRAPHY

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)


LV Total Area RADIONUCLIDE VENTRICULOGRAPHY

LV Cavitary Area

Length


Evaluation of lv mass1
Evaluation of LV Mass RADIONUCLIDE VENTRICULOGRAPHY

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 LV Mass RADIONUCLIDE VENTRICULOGRAPHY


Lv mass
LV MASS RADIONUCLIDE VENTRICULOGRAPHY


Lv mass quantification
LV Mass Quantification RADIONUCLIDE VENTRICULOGRAPHY

  • 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 RADIONUCLIDE VENTRICULOGRAPHY


Lv mass tee
LV MASS-TEE RADIONUCLIDE VENTRICULOGRAPHY

  • 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 RADIONUCLIDE VENTRICULOGRAPHY

RELATIVE WALL thickness= 2XPW/LVIDd


Other m mode methods of lv function assesment

OTHER M-Mode METHODS OF LV FUNCTION ASSESMENT RADIONUCLIDE VENTRICULOGRAPHY


EPSS RADIONUCLIDE VENTRICULOGRAPHY

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 RADIONUCLIDE VENTRICULOGRAPHY

  • 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 RADIONUCLIDE VENTRICULOGRAPHY

  • 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 RADIONUCLIDE VENTRICULOGRAPHY

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 RADIONUCLIDE VENTRICULOGRAPHY


Doppler stroke volume calculation
Doppler Stroke Volume Calculation RADIONUCLIDE VENTRICULOGRAPHY

CARDIAC OUTPUT= STROKE VOLUME X HEART RATE


Doppler stroke volume calculation1
Doppler Stroke Volume Calculation RADIONUCLIDE VENTRICULOGRAPHY

  • 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.


ECHO VIEW PHASE RADIONUCLIDE VENTRICULOGRAPHY

ECHO VIEW PW SAMPLE VOLUME POSN.


Doppler evaluation of lv function
DOPPLER EVALUATION OF LV FUNCTION RADIONUCLIDE VENTRICULOGRAPHY


Problems RADIONUCLIDE VENTRICULOGRAPHYin 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 RADIONUCLIDE VENTRICULOGRAPHY

  • 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 RADIONUCLIDE VENTRICULOGRAPHY

  • 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 ( RADIONUCLIDE VENTRICULOGRAPHYdp/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- RADIONUCLIDE VENTRICULOGRAPHYLv function assesment

dt

1 m/s, 4 mmHg

dP

3 m/s, 36 mmHg


Evaluation of LV Systolic Function RADIONUCLIDE VENTRICULOGRAPHY

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.


CW RADIONUCLIDE VENTRICULOGRAPHYdoppler 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)


Limitations RADIONUCLIDE VENTRICULOGRAPHY:

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 LV Systolic Function RADIONUCLIDE VENTRICULOGRAPHY

  • 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 RADIONUCLIDE VENTRICULOGRAPHY

Ejection Time

Deceleration Time

Acceleration Time

Mean Acceleration

Peak Acceleration

Peak velocity


Systolic time intervals
SYSTOLIC TIME INTERVALS RADIONUCLIDE VENTRICULOGRAPHY

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 RADIONUCLIDE VENTRICULOGRAPHY


Regional lv function1
REGIONAL LV FUNCTION RADIONUCLIDE VENTRICULOGRAPHY


Regional lv function2
REGIONAL LV FUNCTION RADIONUCLIDE VENTRICULOGRAPHY


Regional lv function3
REGIONAL LV FUNCTION RADIONUCLIDE VENTRICULOGRAPHY


Nonischemic rwma
NONISCHEMIC RWMA RADIONUCLIDE VENTRICULOGRAPHY


Diff ischemic vs nonischemic
DIFF ISCHEMIC VS NONISCHEMIC RADIONUCLIDE VENTRICULOGRAPHY


LBBB RADIONUCLIDE VENTRICULOGRAPHY


3d echo
3D ECHO RADIONUCLIDE VENTRICULOGRAPHY

  • 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 RADIONUCLIDE VENTRICULOGRAPHY


Tissue doppler imaging
TISSUE DOPPLER IMAGING RADIONUCLIDE VENTRICULOGRAPHY

  • 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 RADIONUCLIDE VENTRICULOGRAPHY


Strain rate imaging speckle tracking
STRAIN RATE IMAGING & SPECKLE TRACKING RADIONUCLIDE VENTRICULOGRAPHY


Colour kinesis
COLOUR KINESIS RADIONUCLIDE VENTRICULOGRAPHY


Central line method
CENTRAL LINE METHOD RADIONUCLIDE VENTRICULOGRAPHY


Thank you

THANK YOU RADIONUCLIDE VENTRICULOGRAPHY


Bibilography
BIBILOGRAPHY RADIONUCLIDE VENTRICULOGRAPHY

  • 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


MCQ RADIONUCLIDE VENTRICULOGRAPHY

  • 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



3.Preferred choice for RADIONUCLIDE VENTRICULOGRAPHYEf estimation in patients with RWMA

  • 1) TEICHOLZ

  • 2) QUINONES

  • 3) SIMPSONS

  • 4) AREA LENGTH

  • Ans 3


4.MITRAL ANNULAR PLANE EXCURSION SUGGESTIVE OF LV DYSFUNCTION

  • 1) 5

  • 2)8

  • 3)10

  • 4)12

  • Ans 1


5.WHAT IS WALL MOTION SCORE FOR DYSKINESIS DYSFUNCTION

  • a) 1

  • b)2

  • c)3

  • d)4

  • Ans D


6.What is the normal wall motion score index? DYSFUNCTION

  • a)2

  • B)4

  • C)1

  • D)3

  • Ans c


8.Which method is known as the D cube method DYSFUNCTION

  • 1) QUINONES

  • 2) SIMPSONS

  • 3) AREA LENGTH METHOD

  • 4) TEICHOLZ

  • Ans 4


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

  • 1) MILD LV DYSFN.

  • 2) SEVERE LV DYSFUNCTION

  • 3) NORMAL LV FUNCTION

  • 4) MODERATE LV DYSFUNCTION

  • ans3


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

  • 1) CONC LVH

  • 2) CONSCENTRIC REMODELLING

  • 3) ECCENTRIC LVH

  • 4)NORMAL

  • Ans 2


11. All of the following can cause RWMA except DYSFUNCTION

  • Anterior wall myocardial infarction

  • LBBB

  • Preexcitation (WPW syndrome)

  • Acute Pericarditis

    Ans 4


12All of these indirectly denote LV dysfunction EXCEPT ? DYSFUNCTION

  • A) EPSS > 15

  • B) MAPSE < 8

  • C) DP/dt< 800

  • D) Myocardial performance index < 0.5

  • Ans d


13. Which is known as TEI index? DYSFUNCTION

1)Cardiac index

2) Myocardial performance index

3) LV preejection time/ LV ejection time

4)DP/DT of MR jet

Ans 2


14.Inferolateral segment is supplied by which arterial territory

  • A) RCA

  • B) LAD

  • C) RAMUS

  • D) LCX

  • Ans d


15.Which is the true statement territory

  • 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


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



  • 18. In which formula for LV function increased then the patient hasassesment is the assumption of prolate ellipse considered

  • 1) QUINONE’S

  • 2) TEICHOLZ

  • 3) AREA LENGTH

  • 4) SIMPSON’S

  • Ans


  • 19 . identify the false statement increased then the patient has

  • 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


  • 20.In which method of LV function increased then the patient hasassesment is the apical contraction considered for EF calculation?

  • 1) TEICHOLZ

  • 2) MODIFIED QUINONES

  • 3) SIMPSONS

  • 4) AREA LENGTH

  • Ans 2




  • 23.Transthoracic echo is superior to said to have transesophageal echo in

  • A) Assesing prosthetic valve function

  • B) Assess LA clot

  • C) Diagnosisof infective endocarditis

  • D) Assesment of LV systolic function

  • Ans:D





27.Akinesis of a segment is defined said to have

  • 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



  • 29.Hypokinesia is defined as said to have

  • 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



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