1. Systolic and diastolic function an up-to-date approach to echocardiographic assessment
Muhammad Mustafa MD
Medical Director of Echocardiography, Winter Haven Hospital
Medical Director of Nuclear Cardiology, Winter Haven Hospital

2. overview Classic techniques of assessing LV systolic function
New techniques (strain/strain rate/speckle tracking)
All new approach for assessment of diastolic function
2016 Diastology Guidelines Update

3. TEICHOLZ METHOD LVEF = (EDV – ESV)/EDV
End diastole defined as first frame after mitral valve closure, and end systole first frame after aortic valve closure or when LV size is smallest. Teicholz assumes LV is prolate ellipse with uniform geomatry. But as LV dilates it becomes more spherical so Modified Teicholz tries to correct for this with a regression formula. Still not accurate, not currently recommended as best practice by ASE. Further limitations are wall motion abnormalities, beam position needs to be perpendicular which isn’t always the case.
Lang, et al. “Recommendation for chamber quantification…”, J Am Soc Echocardiogr 28. (2015):1-39

4. MODIFIED SIMPSONS METHOD OF DISKS
LVEF = (EDV – ESV)/EDV
4 chamber and 2 chamber views as they are orthogonal views. This is currently recommended by ASE as accurate method
Lang, et al. “Recommendation for chamber quantification…”, J Am Soc Echocardiogr 28. (2015):1-39

5. 3D Volume assessment
Most accurate, very close to MRI which is gold standard, but variable results since very dependent on quality of image acquisition and experience of operator. Most current guidelines 2015 still recommend 2D assessment of LVEF except in labs that are very experienced in 3D which in that case would be superior.
Lang et al. “EAE/ASE Recommendations for Image Acquisition and Display Using Three-Dimensional Echocardiography” J Am Soc Echocardiogr 25. (2012):3-46

6. Myocardial strain describes elastic properties of cardiac muscle

7. Doppler tissue imaging (DTI). -measures velocity in one dimension
Doppler tissue imaging (DTI) -measures velocity in one dimension -Limited by beam alignment
On top left image, beam which is yellow is not well aligned with movement of myocardium which is red. Top right is closer approximation and better result, but still not exact. Reverberation artifact and aliasing artifact are known limitations.
Mor-Avi, et al. “Current and Evolving Echocardiographic Techniques for the Quantitative Evaluation of Cardiac Mechanics” J Am Soc Echocardiogr 24. (2011):

8. Speckle tracking echocardiography (STE)
Speckle Tracking was actually around since 1988, but technology was very primitive, now it has been perfected. Has nothing to do with echo beam, no issue with beam alignment, no angle dependency, no noise interference (reverberation, aliasing artifact, etc), Highly reproducible. Also strain rate imaging subtracts motion from neighboring segments, i.e. tethering.
Leitman M et al. JASE 2004; 17:

9. Segmental strain curves
A correlates to D and C correlates to E C and E showing more motion as you get further away from transmural infarct region. B shows Cardiac MR showing bright transmural infarct in inferior apical segment and subendocardial infarct in anterior wall. In A, the green and purple strain curves are derived from transmural-infarcted segments, the red and blue curves represent subendocardial-infarcted segments, and the yellow and cyan curves are from non-infarcted segments
Mor-Avi, et al. “Current and Evolving Echocardiographic Techniques for the Quantitative Evaluation of Cardiac Mechanics” J Am Soc Echocardiogr 24. (2011):

10. GLOBAL LONGITUDINAL PEAK SYSTOLIC STRAIN
Normal Strain varies by vendor and software post-processing differences, but accepted normal is around -18% and more negative than that. So -20% is definitely normal.

12. Longitudinal strain clinical relevance
Longitudinal strain clinical relevance - longitudinal fibers most predominant in sub-endocardium - most susceptible to impairment and most sensitive to myocardial disease
Approximately 85% of all fibers participate in longitudinal strain. Clinical relevance is huge as discussed by Dr. Agoche in Cardio-Oncology Lecture.
Geyer et al. “Assessment of myocardial mechanics using speckle tracking echocardiography…” J Am Soc Echocardiogr 23. (2010):

13. Paradigm Shift
HFPEF may in reality not be a diastolic dysfunction issue but a subclinical systolic dysfunction entity as LVEF preserved but global longitudinal strain reduced…

14. 2016 diastology guideline update
Builds on 2009 guidelines
Attempts to provide more accurate assessment
Attempts to simplify/streamline assessment

15. Nagueh et al. “Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography…” J Am Soc Echocardiogr 29. (2016):

16. Nagueh et al. “Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography…” J Am Soc Echocardiogr 29. (2016):

17. Case # 1 69 yo male hx of copd and Normal LVEF presents with dyspnea
Number Positive
Case # yo male hx of copd and Normal LVEF presents with dyspnea I
Normal Diastolic Function

18. Number Positive I
Normal Diastolic Function. Make a point how if 2 criteria of 4 are met, it is indeterminate, and must write that in report. If more than 2/4 true, then Diastolic Dysfunction present and go to next algorithm.

19. Nagueh et al. “Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography…” J Am Soc Echocardiogr 29. (2016):

21. Case # 2 57 yo female hX CAD, copd presents with dyspnea, LVEF 40-45%
Number Positive
Case # yo female hX CAD, copd presents with dyspnea, LVEF 40-45%

22. Number Negative
Number Positive I

23. Number Negative
Number Positive I I I

24. Number Positive
Case # yo male Hx htn, esrd, nicm presents with dyspnea, LVEF 25-30%

25. Case # 4 61 yo female hx cad presents with dyspnea, lVEF 35-40%
Number Positive
Case # yo female hx cad presents with dyspnea, lVEF 35-40%

26. Number Positive I
Sharon Tillman

27. Number Positive I I
Grade II Diastolic Dysfunction

28. DIASTOLIC GRADE CLINICAL RELEVANCE
Conclusion — In patients with normal baseline left ventricular ejection fraction, worsening of diastolic function is an independent predictor of mortality.
Followed approximately 1000 patients, mean age 68 yo, 58% male who started with normal diastolic function for about 3.5 years
AlJaroudi, et al. “Impact of Progression of Diastolic Dysfunction on Mortality in Patients with Normal Ejection Fraction” Circulation 125. (2012):

29. Thank you