1. EVALUATION OF SYSTOLIC FUNCTION OF LEFT VENTRICLE BY ECHOCARDIOGRAPHY
DR SANDEEP.R
SR CARDIO

2. Basic Principle Systole
The period of the cardiac cycle from the closure of the mitral valve to the closure of the aortic valve
Prolate-ellipse. The so-called cube formula is based on a model of the LV as a prolate ellipse of revolution where V 4/3 L/2 D1/2 D2/2, where D1 and D2 are orthogonal minor axes; L is the long axis, which equals 2 D; and D1 D2. Hence, the volume approximates D3 , which has been taken as the single linear dimension representing the shortaxis of the LV at the tips of the mitral valve.

3. EJECTION FRACTION NORMAL MILD LV DYSFUNCTION MODERATE LV DYSFUNCTION
Ejection fraction-percentage of LV diastolic volume that is ejected with systole
EF=STROKE VOLUME/EDV=EDV-ESV/EDV
NORMAL
MILD LV DYSFUNCTION
MODERATE LV DYSFUNCTION
SEVERE
LV DYSFUNCTION
EF >55%
45 – 54%
30 – 44 %
<30%

4. IDEAL METHOD FOR EF CALCULATION
Accurate
Quick
Reproducible
Simple
Relatively independent of LV geometry

5. 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

6. TECHNICAL ASPECTS
Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108

7. LV MEASUREMENT - TTE 1.PLAX 2.PSAX AT PAPILARY MUSCLE
Accurate linear measurement - parasternal long-axis acoustic window – 1st preference Measured at the level of the LV minor axis at the mitral valve leaflet tips. End diastole can be defined at the onset of the QRS, but is preferably defined as the frame after mitral valve closure or the frame in the cardiac cycle
in which the cardiac dimension is largest. In sinus rhythm, this follows atrial contraction. End systole is best defined as the frame preceding mitral valve
opening or the time in the cardiac cycle in which the cardiac dimension is smallest in a normal heart. In the 2-chamber view, mitral valve motion is not
always clearly discernible and the frames with the largest and smallest volumes should be identified as end diastole and end systole, respectivelyDone with M mode/2d imagingAlternate view – parasternal short axisAlternatively, chamber di-
mension and wall thicknesses can be acquired from
the parasternal short-axis view using direct 2D mea-
surements or targeted M-mode echocardiography provided that the M-mode cursor can be positioned perpendicular to the septum and LV posterior wall.

8. 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

9. LV MEASUREMENTS - TEE a) ME-LAX b)TG-LAX c) TG –SAX preferred view
The recommended TEE views for measurement of
LV diameters are the midesophageal (Figure 2) and
ransgastric (Figure 3) 2-chamber views. LV diame
ers are measured from the endocardium of the
anterior wall to the endocardium of the inferior wall
n a line perpendicular to the long axis of the
ventricle at the junction of the basal and middle
hirds of the long axis. The recommended TEE view
or measurement of LV wall thickness is the trans
gastric midshort-axis view (Figure 4). With TEE, the long-axis dimension of the LV is often foreshortened in the midesophageal 4-chamber and long-axis views;Therefore, the midesophageal 2-chamber view is preferred for this measurement.
c) TG –SAX preferred view
Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108

10. LV MEASUREMENTS
Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108

11. LV MEASUREMENTS
Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108

12. Global Myocardial Function
Fractional shortening (FS)
Assumes symmetric contraction
Ejection fraction (EF)
EF=EDV-ESV/EDV

13. EJECTION FRACTION

14. 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

15. TEICHOLZ

16. MODIFIED TECHOLZ LVV=( 7.0/2.4+D) x Dcube
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

17. 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

18. 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

19. SIMPSON’S METHOD

20. BIPLANE SIMPSONS

21. Simpson’s method

22. 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
mitral and papillary muscle cross sections and an apical four chamber view
Usually about 20 disks, biometric software can do this for us.

23. SIMPSONS RULE\ RULE OF DISC
The principle underlying this method is that the total LV volume is calculated from the summation of a stack of elliptical disks. The height of each disk is calculated as a fraction (usually 1/20) of the LV long axis based on the longer of the two lengths from the 2- and 4-chamber views. The cross-sectional area of the disk is based on the two diameters obtained from the 2- and 4-chamber views.When two adequate orthogonal views are not available, a single plane can be used and the area of the disk is then assumed to be circular. The limitations of using a single plane are greatest when extensive wall-motion abnormalities are present.

24. 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)
The mid-LV cross-sectional area is computed by planimetry in the parasternal short-axis view and the length of the ventricle taken from the midpoint of the annulus to the apex in the apical 4-chamber view. These measurements are repeated at end diastole and end systole, and the volume is computed according to the formula: volume [5 (area) (length)]/6. The most widely used parameter for indexing volumes is the body surface area (BSA) in square meters
VOLUME=5 (Area )(length)/6

25. AREA LENGTH METHOD

26. 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

27. LV QUANTIFICATION METHODS

29. 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

30. LV MASS ASSESMENT

31. 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)

32. LV Total Area
LV Cavitary Area
Length

33. 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

34. Evaluation of LV Mass

35. LV MASS

36. 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
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.

37. LV MASS ASSESMENT

38. 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 .

39. LV MASS
RELATIVE WALL thickness= 2XPW/LVIDd

40. OTHER M-Mode METHODS OF LV FUNCTION ASSESMENT

41. EPSS ≤6mm 87% 75% 84% LIMITATIONS-INACCURATE AR MS 3) IWMI NORMAL
SENSITIVITY
SPECIFICITY
EF<50%
>7mm
87%
75%
EF≤35%
≥13mm
84%
1)With lv dysfunction-ant. Displacement of ivs as lv dilates
2)reduced opening of MV bcos of decreased transmitral flow into LV
LIMITATIONS-INACCURATE AR MS
3) IWMI
Lew W et al , American journal of cardiology 41: ,1978
Ahmadpour,H et al , American heart journal 106:21-28,1983:

42. Ambrose J A et al Circulation60:510-519 1979
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:

43. 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%

44. 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

45. DOPPLER EVALUVATION OF GLOBAL LVF

46. Doppler Stroke Volume Calculation
CARDIAC OUTPUT= STROKE VOLUME X HEART RATE

47. 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.

48. SITE
CSA MEASUREMENT
VTI MEASUREMENT
Ascending aorta
PLAX ( at or above ST jn.)
Early systole
Suprasternal
view
Ascending aorta at 3.5 cm toward ascending aorta
Aortic annulus
PLAX
Apical 4 /5-C
LVOT (just below aortic valve)
Mitral inflow
Apical 4 -C
Mid diastole
Apical 4-C
Mitral annulus
Tricuspid inflow
Tricuspid annulus
Pulmonary annulus
PLAX (Rvot)
PSAX( RVOT)
PLAX(RVOT)
PSAX(RVOT)
RVOT (Prox. To Pulm. Valve)
Pulmonary artery
Distal to Pulm. Valve
( same level as diameter measurement)
ECHO VIEW PHASE
ECHO VIEW PW SAMPLE VOLUME POSN.

49. DOPPLER EVALUATION OF LV FUNCTION

50. 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 cardia with respiration –difficult to obtain uniform velocities with PWD at LVOT

51. 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

52. 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

53. 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

54. DP/DT-Lv function assesment
1 m/s, 4 mmHg dP
3 m/s, 36 mmHg

55. 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)] = mmHg
Time interval Time interval
Thus a longer time interval indicates a depressed dP/dt and thus a decreased LV systolic function.

56. 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)

57. 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/dt maybe present in hypertension and aortic stenosis even with impaired LV function.

58. 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

59. Evaluation of LV Systolic Function
Ejection Time
Deceleration Time
Acceleration Time
Mean Acceleration
Peak Acceleration
Peak velocity

60. SYSTOLIC TIME INTERVALS
LVPEP/LVET
SENSITIVITY
SPECIFICITY
NORMAL (EF>55%)
<0.35
24%
100%
EF<55%
>0.35
72%
EF<30%
>0.65
89%
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: ,196
2)Garrard et al ,circulation 42 : ,1970

61. REGIONAL LV FUNCTION

62. REGIONAL LV FUNCTION

63. REGIONAL LV FUNCTION

64. REGIONAL LV FUNCTION

67. NONISCHEMIC RWMA

68. DIFF ISCHEMIC VS NONISCHEMIC

69. LBBB

70. 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

71. 3D echo

72. TISSUE DOPPLER IMAGING
SEPTAL ANNULAR TDI
The annular velocity in systole has shown a good correlation with the LVEF
Can detect impaired longitudinal systolic function (Sm < 4.4 m/s)

76. NEWER METHODS OF EVALUATION OF LV FUNCTION

77. STRAIN RATE IMAGING & SPECKLE TRACKING

78. COLOUR KINESIS

79. CENTRAL LINE METHOD

80. THANK YOU

81. 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:
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

82. 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

83. 2.Pt. presumed to have a EF < 35% if the EPSSis
1)4
2) 8
3)15
4)10
Ans 3

84. 3.Preferred choice for Ef estimation in patients with RWMA
1) TEICHOLZ
2) QUINONES
3) SIMPSONS
4) AREA LENGTH
Ans 3

85. 4.MITRAL ANNULAR PLANE EXCURSION SUGGESTIVE OF LV DYSFUNCTION
1) 5
2)8
3)10
4)12
Ans 1

86. 5.WHAT IS WALL MOTION SCORE FOR DYSKINESIS
b)2
c)3
d)4
Ans D

87. 6.What is the normal wall motion score index?
B)4
C)1
D)3
Ans c

88. 8.Which method is known as the D cube method
1) QUINONES
2) SIMPSONS
3) AREA LENGTH METHOD
4) TEICHOLZ
Ans 4

89. 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

90. 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

91. 11. All of the following can cause RWMA except
Anterior wall myocardial infarction
LBBB
Preexcitation (WPW syndrome)
Acute Pericarditis
Ans 4

92. 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

93. 13. Which is known as TEI index
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

94. 14.Inferolateral segment is supplied by which arterial territory
A) RCA
B) LAD
C) RAMUS
D) LCX
Ans d

95. 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

96. 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

97. 17. If the relative wall thickness is 0
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

98. 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

99. 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

100. 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

101. 21. A patient is found to have a calculated EF of 42%
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

102. 22.EPSS on echo is increased in
A) Dilated cardiomyopathy
B) Hypertrophic cardiomyopathy
C) Aortic stenosis
D) Pulmonary stenosis
Ans a

103. 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

104. 24.Assumption of LV used in calculation of simpsons formula
1) Prolate ellipse
2) Cone
3) Circle
4) Disc
Ans 4)

105. 25.LVEDD is measured at
1) onset of P wave
2) R wave
3) peak of T wave
4) U wave
Ans 2)

106. 26.LVESD measurement is done during
1) Q wave
2) R wave
3)T wave
4) U wave
Ans 3

107. 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

108. 28.Wallmotion score for akinesis is
B) 2
C) 3
D)4
E)5
Ans C

109. 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

110. Normal stroke volume is
1) 30-50
2) 50 – 70
3) 70 – 90
4)>100
Ans 3