1. ISCHEMIC CASCADE

4. RWMA
ISCHEMIC
NON ISCHEMIC

5. Normal myocardial contraction involves
Myocardial thickening &
Endocardial excursion
So always assess these two during wall motion analysis
Interruption Of Myocardial Contractility causes abnormality in Regional wall motion

6. Degrees of wall motion abnormality and Wall motion score
STANDARD SCORE
OPTIONAL SCORE
HYPERDNAMIC
NORMAL 1
1.5
MILDLY HYPOKINETIC
HYPOKINETIC 2
2.5
SEVERLY HYPOKINETIC
AKINETIC 3
DYSKINETIC 4
ANEURYSMAL 5 6
AKINETIC WITH SCAR 7
DYSKINETIC WITH SCAR
Wall Motion Score= Total Score In All Segments /No Of Segments Evaluated

7. Regional Wall Motion Abnormality Analysis Methods
QUALITATIVE Eyeballl assessment SEMIQUANTITATIVE Wall motion score/score index
QUANTITATIVE
Fractional shortening
Radial shortening
Cavity/fractional cavity area
change
Doppler tissue based analysis
Wall velocity
Myocardial displacement
Myocardial gradient
Strain
Strain rate
Ventricular torsion

8. NON ISCHEMIC CAUSES FOR RWMA
Conduction abnormalities 
Epicardial pacing 
Translation 
Rotation
Respiratory variation
Image plane in obtuse angle

9. Why normally septum shows Wall Motion abnormality ?
IVS:
Membranous basal septum:
Lesser myocardium Than Muscular mid/apical
section. So basal region normally show mild hypokinesia
compared to apical septum
Part of the basal section of the septum is attached to the left ventricular outflow tract. This portion can exhibit paradoxical motion during systole. 

10. NON ISCHEMIC CAUSES OF RWMA

11. Normal spread of electrical activity in the heart
Depolarization of the ventricular muscle starts at the left side of the interventricular septum and moves first to the right across the midportion of the septum

12. LBBB Initial septal activation is reversed.
Right side of the ventricular septum is initially activated
Right septal activation before activation of the body of the left ventricle
Initial right to left movement of the ventricular septum (anterior to posterior)

13. Myocardial Activation Pattern
RBBB
LBBB
RV PACING
WPW
LEFT IVS
RT IVS
RV FREE WALL
RV (SMALL SEGMENT) LV RV
IVS
RIGHT IVS
RIGHT/LEFT VENTRICLE

14. Normal M-mode Echo

15. M-Mode in LBBB
M-mode echocardiogram recorded in a patient with a left bundle branch block shows an early systolic downward motion of the ventricular septum (arrows).

16. DIFFERNCIATION OF RWMA IN LBBB,RV PACED AND ISCHEMIC WMA
ISCHEMIC RWMA
LBBB
RV PACED
MAXIMAL LOCATION
DISTAL SEPTUM,
APEX ,
ANTERIOR WALL,
PROXIMAL /MID ANTERIOR SEPTUM
DISTAL SEPTUM OFTEN INFERIOR
THICKENING
ABSENT OR THINNING
PARTIALLY PRESERVED
PARTILLY PRESERVED
DURATION
USUALLY MONOPHASIC
MULTIPHASIC
ABNORMAL GEOMETRY
COMMON
UNCOMMON
TEMPORAL DYSYNCHRONY NO
YES

17. Various M- Mode abnormalities

18. Epicardial pacing
The activation sequence is similar to a LBBB pattern except the right ventricular free wall is stimulated prior to the interventricular septum.

19. Postoperative Motion
Opening the pericardium can cause paradoxical cardiac motion.  Exaggerated anterior motion of the whole myocardium occurs when the restraint of the pericardium is released. 
The effect is due to exaggerate the movement of the posterior and lateral walls of the heart while decreasing the motion of the septum of the heart. 
Complicating the exaggerated postoperative motion with a LBBB or a paced rhythm, will make wall motion interpretation difficult.  The only reliable method to determine wall motion is to look solely at wall thickening

20. Pericardial Constriction   :
The effect mainly occurs at the interventricular septum appearing as a septal bounce, and is influenced by the presence of respiratory variation. 

21. Restriction
While tethering can make a hypokinetic or akinetic segment appear to move normally or less hypokinetic,  If the mitral valve annulus is heavily calcified, it may restrict the movement of basal segments of the left ventricular wall. Neighboring walls, particularly the inferior and posterior walls of the left ventricle appear to be hypokinetic if the movement of the mitral valve is restricted by mitral annular calcification. 

22. Off-Axis Scans :  Off-axis scans can cause
normal segments to appear akinetic or
dyskinetic. 

23. Thank u