Presentation on theme: "EVALUATION OF SYSTOLIC FUNCTION OF LEFT VENTRICLE BY ECHOCARDIOGRAPHY"— Presentation transcript:
1 EVALUATION OF SYSTOLIC FUNCTION OF LEFT VENTRICLE BY ECHOCARDIOGRAPHY DR SANDEEP.RSR CARDIO
2 Basic Principle Systole The period of the cardiac cycle from the closure of the mitral valve to the closure of the aortic valveProlate-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 systoleEF=STROKE VOLUME/EDV=EDV-ESV/EDVNORMALMILD LV DYSFUNCTIONMODERATE LV DYSFUNCTIONSEVERELV DYSFUNCTIONEF >55%45 – 54%30 – 44 %<30%
4 IDEAL METHOD FOR EF CALCULATION AccurateQuickReproducibleSimpleRelatively independent of LV geometry
5 M-Mode Quantification Use Parasternal Short-Axis or Long-Axis views to measure LVEDD and LVESDMeasurement is taken perpendicular to the ventricle at the level of tip of mitral leafletAssumes that no significant regional wall motion abnormalities are present
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 cyclein which the cardiac dimension is largest. In sinus rhythm, this follows atrial contraction. End systole is best defined as the frame preceding mitral valveopening 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 notalways 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 fromthe 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 CADLV internal dimensions (LVIDd and LVIDs &wall thicknesses be measured at mitral chordae level2D minor-axis dimensions smaller than M-mode measurementsRecommendations 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 ofLV diameters are the midesophageal (Figure 2) andransgastric (Figure 3) 2-chamber views. LV diameers are measured from the endocardium of theanterior wall to the endocardium of the inferior walln a line perpendicular to the long axis of theventricle at the junction of the basal and middlehirds of the long axis. The recommended TEE viewor measurement of LV wall thickness is the transgastric 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 viewRecommendations for chamber quantiﬁcation*Eur J Echocardiography (2006) 7,79 108
14 TEICHOLZ /CUBED FORMULA LV Volume calculation is based on assumption that the LV is a prolate ellipseBasic assumptionsLV dilates along the minor axisLV internal diameter is equal to one of the minor axis of the ellipse D1Both minor axisof ellipse D1,D2 are equalLV VOLUME= 4/3 xPi x D1/2 x D1/2 x 2D1/2= Pi/3 x D cube =1.047 x D cube = D cubeThis structure has two minor axis D1 & D2 anda major axis LV=4/3 Pi X D1/2 X D2/2 X L/2
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 shapeLVV=( 7.0/2.4+D) x Dcube
17 MODIFIED QUINONES METHOD Measure LVIDd &LVIDsCalculate radial EFIf significant RWMA average EF measurement from basal & mid LV levelsAdd factor for longitudinal shortening
18 SIMPSON’S METHODIn the presence of RWMA all the above methods will be less accurate, since inclusion of RWMA- causes volume overestimationThe 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
22 Simpson’s Rule – the biplane method of disks LV-ED LV-ESVolume left ventricle- manual tracings in systole and diastole- area divided into series of disks- volume of each disc(πr2x h )summed = ventricular volumePreferred method of choiceLV-ED LV-ESA4CA2Cmitral and papillary muscle cross sections and an apical four chamber viewUsually 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 = cylinderApex of ventricle = ellipsoidVolume 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/2V = 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 metersVOLUME=5 (Area )(length)/6
26 VISUAL EFEchocardiographic assessment of global left ventricular systolic function is usually performed subjectivelyExperienced 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 measurementsCorrelate fairly well with angiographic assessment of the EFLimitations:Irregular rhythmVery large or very small LVExtremes of heart rate
31 Evaluation of LV MassThis 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)
33 Evaluation of LV Mass Total volume= Total area x length Chamber volume = Chamber area x LengthMyocardial volume = Total volume – Chamber volumeLV mass = Myocardial volume x densityLV mass = Myocardial volume x 1.05
36 LV Mass Quantification 2D M-Mode method using parasternal short axis view or parasternal long axis viewAssumes that LV is ellipsoid (2:1 long/short axis ratio)Measurements made at end diastoleASE approved cube formula:LV mass (g) = 1.04 [(LVID + PWT + IVST)3 - (LVID)3]XLV mass index (g/m2) = LV mass / BSASmall errors in M-Mode cause large errors in mass values. Can have off axis/tangential cuts due to motion.
41 EPSS ≤6mm 87% 75% 84% LIMITATIONS-INACCURATE AR MS 3) IWMI NORMAL SENSITIVITYSPECIFICITYEF<50%>7mm87%75%EF≤35%≥13mm84%1)With lv dysfunction-ant. Displacement of ivs as lv dilates2)reduced opening of MV bcos of decreased transmitral flow into LVLIMITATIONS-INACCURATEARMS3) IWMILew W et al , American journal of cardiology 41: ,1978Ahmadpour,H et al , American heart journal 106:21-28,1983:
42 Ambrose J A et al Circulation60:510-519 1979 B- notchDelayed 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)LIMITATIONS1) Low sensitivity2)false positive with first degree AV block & LBBB-due to prolonged AC intervalAmbrose J A et al Circulation60:
43 MITRAL ANNULAR PLANE EXCURSION M-mode tracings in systoleThe magnitude of systolic motion is proportional to the longitudinal shortening of the LVNormal 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 systoleThis results in rounded appearance of aortic valve closure in late systole
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 anddirection of blood flow.4. Velocity and diameter measurements are made at thesame anatomic site.
48 SITECSA MEASUREMENTVTI MEASUREMENTAscending aortaPLAX ( at or above ST jn.)Early systoleSuprasternalviewAscending aorta at 3.5 cm toward ascending aortaAortic annulusPLAXApical 4 /5-CLVOT (just below aortic valve)Mitral inflowApical 4 -CMid diastoleApical 4-CMitral annulusTricuspid inflowTricuspid annulusPulmonary annulusPLAX (Rvot)PSAX( RVOT)PLAX(RVOT)PSAX(RVOT)RVOT (Prox. To Pulm. Valve)Pulmonary arteryDistal to Pulm. Valve( same level as diameter measurement)ECHO VIEW PHASEECHO VIEW PW SAMPLE VOLUME POSN.
50 Problems in this technique 1. Apical 3-chamber view can be tried if Apical 5-c is difficult to obtainof velocities.2. Underestimation of flow velocities- LVOT may not be aligned with the direction of the PWDan 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 respirationMovement of entire cardia with respiration –difficult to obtain uniform velocities with PWD at LVOT
51 Pitfalls in Echo Calculation of CO Accurate measurement of CSAWeakest link in the calculationVTI very good for assessing change in cardiac output with therapy, by following changes in VTI, since CSA is largely invariant in an individualMeasures forward flow onlyRegurgitant fraction not consideredMay over-estimate systemic cardiac outputEchocardiographic 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 ) / ETSystolic dysfunction is associated with a prolongation of IVCT and a shortening of the ETNormal 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 atriumThe 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
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)] = mmHgTime interval Time intervalThus 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 functionMust 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 arePeak velocityMean accelerationAcceleration TimeDeceleration TimeEjection timeMean deceleration
59 Evaluation of LV Systolic Function Ejection TimeDeceleration TimeAcceleration TimeMean AccelerationPeak AccelerationPeak velocity
60 SYSTOLIC TIME INTERVALS LVPEP/LVETSENSITIVITYSPECIFICITYNORMAL (EF>55%)<0.3524%100%EF<55%>0.3572%EF<30%>0.6589%LVPre ejection period(LVPEP)- measured from Q wave on ECG to onset of aortic valve openingLV Ejection time(LVET)- aortic valve opening to aortic valve closureLVPEP/LVET independent of Heart RateLv dysfunction causes increase in LVPEP & shortening of LVET1)Weissler,A.M et al Systolic time intervals in heart failure in man Circulation 37: ,1962)Garrard et al ,circulation 42 : ,1970
70 3D ECHO Provides detailed anatomic relationship Accurate quantitation Faster acquisition and may reduce interobserver variability3d quantitation of LV function avoids geometric assumptions and is more accurate & reproducible
81 BIBILOGRAPHYLANGE 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 theEuropean Society of Cardiology;J Am Soc Echocardiogr 2005;18:AssessmentofLeft Ventricular Systolic Function by Echocardiography.CARDIOLOGY CLINICSReliability of reporting left ventricular systolic function by echocardiography: A systematic reviewof 3 methodsAmerican Heart Journal Volume 146, Number 3Techniques for comprehensive two dimensional echocardiographic assessment of left ventricular systolicfunctionTEXTBOOK OF CLINICAL ECHOCARDIOGRAPHY FIFTH EDITION
82 MCQ1.WHICH IS THE METHOD RECOMMENDED BY American Society of Echocardiography For EF ESTIMATION?1) TECHOLZ2) QUINONES3) AREA LENGTH4) SIMPSON’S BIPLANEans4
83 2.Pt. presumed to have a EF < 35% if the EPSS is1)42) 83)154)10Ans 3
84 3.Preferred choice for Ef estimation in patients with RWMA 1) TEICHOLZ2) QUINONES3) SIMPSONS4) AREA LENGTHAns 3
86 5.WHAT IS WALL MOTION SCORE FOR DYSKINESIS b)2c)3d)4Ans D
87 6.What is the normal wall motion score index? B)4C)1D)3Ans c
88 8.Which method is known as the D cube method 1) QUINONES2) SIMPSONS3) AREA LENGTH METHOD4) TEICHOLZAns 4
89 9.DP/DT OF MR JET IS 1400 THE PT HAS 1) MILD LV DYSFN.2) SEVERE LV DYSFUNCTION3) NORMAL LV FUNCTION4) MODERATE LV DYSFUNCTIONans3
90 10.IF RWT >0.42 AND LV MASS IS NORMAL, THE PATIENT HAS 1) CONC LVH2) CONSCENTRIC REMODELLING3) ECCENTRIC LVH4)NORMALAns 2
91 11. All of the following can cause RWMA except Anterior wall myocardial infarctionLBBBPreexcitation (WPW syndrome)Acute PericarditisAns 4
92 12All of these indirectly denote LV dysfunction EXCEPT ? A) EPSS > 15B) MAPSE < 8C) DP/dt< 800D) Myocardial performance index < 0.5Ans 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) RCAB) LADC) RAMUSD) LCXAns d
95 15.Which is the true statement A) LV dysfunction causes shortening of ejection timeB) LV dysfunction causes shortening of preejection periodC) LV dysfunction causes Lvpreejection period/LV ejection period < 0.35D) LV dysfunction causes prolongation of ejection time and shortening of preejection periodAns 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?10152025Ans 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 has1) conc. LVH2) NORMAL3) ECCENTRIC LVH4) CONSCENTRIC REMODELLINGAns 3
98 18. In which formula for LV function assesment is the assumption of prolate ellipse considered 1) QUINONE’S2) TEICHOLZ3) AREA LENGTH4) SIMPSON’SAns
99 19 . identify the false statement 1) presence of B notch denotes LV dysfunction2) EPSS is not accurate if patient has AR3) EPSS > 15 denotes severe LV dysfunction4) MPI < 0.5 denotes LV dysfunctionAns 4
100 20.In which method of LV function assesment is the apical contraction considered for EF calculation? 1) TEICHOLZ2) MODIFIED QUINONES3) SIMPSONS4) AREA LENGTHAns 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 haveNormal LV fn.Mild LV dysfunctionModerate LV dysfunctionSevere LV dysfunctionAns 3
102 22.EPSS on echo is increased in A) Dilated cardiomyopathyB) Hypertrophic cardiomyopathyC) Aortic stenosisD) Pulmonary stenosisAns a
103 23.Transthoracic echo is superior to transesophageal echo in A) Assesing prosthetic valve functionB) Assess LA clotC) Diagnosisof infective endocarditisD) Assesment of LV systolic functionAns:D
104 24.Assumption of LV used in calculation of simpsons formula 1) Prolate ellipse2) Cone3) Circle4) DiscAns 4)
105 25.LVEDD is measured at1) onset of P wave2) R wave3) peak of T wave4) U waveAns 2)
106 26.LVESD measurement is done during 1) Q wave2) R wave3)T wave4) U waveAns 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 thinningAns 1
108 28.Wallmotion score for akinesis is B) 2C) 3D)4E)5Ans 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 thinningAns 3
110 Normal stroke volume is 1) 30-502) 50 – 703) 70 – 904)>100Ans 3