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 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.

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%

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

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 Recommendations for chamber quantification*Eur J Echocardiography (2006) 7,79 108

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.

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 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

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

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

EJECTION FRACTION

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

TEICHOLZ

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

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 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 METHOD

BIPLANE SIMPSONS

Simpson’s method

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.

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.

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

AREA LENGTH METHOD

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

LV QUANTIFICATION METHODS

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

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)

LV Total Area LV Cavitary Area Length

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

Evaluation of LV Mass

LV MASS

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 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 ASSESMENT

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 .

LV MASS RELATIVE WALL thickness= 2XPW/LVIDd

OTHER M-Mode METHODS OF LV FUNCTION ASSESMENT

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 41:836-845,1978 Ahmadpour,H et al , American heart journal 106:21-28,1983:

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 Circulation60:510-519 1979

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%

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

DOPPLER EVALUVATION OF GLOBAL LVF

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

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.

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.

DOPPLER EVALUATION OF LV FUNCTION

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

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

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

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

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

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)] = 32 mmHg Time interval Time interval Thus a longer time interval indicates a depressed dP/dt and thus a decreased LV systolic function.

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)

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.

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

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

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 37:149-159,196 2)Garrard et al ,circulation 42 :455-462,1970

REGIONAL LV FUNCTION

REGIONAL LV FUNCTION

REGIONAL LV FUNCTION

REGIONAL LV FUNCTION

NONISCHEMIC RWMA

DIFF ISCHEMIC VS NONISCHEMIC

LBBB

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

3D echo

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)

NEWER METHODS OF EVALUATION OF LV FUNCTION

STRAIN RATE IMAGING & SPECKLE TRACKING

COLOUR KINESIS

CENTRAL LINE METHOD

THANK YOU

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;18:1440-1463 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 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

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

3.Preferred choice for Ef 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 b)2 c)3 d)4 Ans D

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

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

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

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

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

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

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

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 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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