Echocardiographic Assessment of LV Systolic Function MR. MOHAMMED AL GHAMDI

Causes of LV Systolic Dysfunction CAD HTN Cardiomyopathy (iDCM, HCM, Etoh, Peripartum, Viral, Infiltrative, Toxins, Thyroid Dz., Tachyarrythmias) Valvular Disease

Dimensions and Area Parasternal short-axis at level of papillary muscles Parasternal long-axis Apical 4-chamber Apical 2-chamber

LV Systolic Function Variables LVEDD – LVESD FS = -------------------- X 100 LVEDD Percent change in LV dimension with systolic contraction FS approximates EF if there are no significant wall motion abnormalities SV = EDV - ESV CO = SV x HR EDV - ESV EF = ----------------- X 100 EDV

How do we quantify LV function? M-Mode Modified Simpson’s Method Single plane area-length method Velocity of Circumferential Shortening Mitral Annular Excursion E-point to septal separation Rate of rise of MR jet Index of myocardial performance Subjective assessment

M-Mode Quantification Uncorrected (LVEDD)2 - (LVESD)2 LVEF = ------------------------------ X 100 (LVEDD)2 If apical contractility is normal (Quinones group): Corrected LVEF = Unc LVEF + ((100 – Unc LVEF) X 15%) 5% hypokinetic, 0% akinetic, -5% dyskinetic, -10% aneurysm

Modified Simpson’s Method EDV – ESV LVEF = --------------- X 100 EDV

Normal E point to septal separation is < 6 mm With reduced lvef, EPSS may be increased.

Index of Myocardial Performance Normal LV: 0.39 +/- 0.05 LV, DCM: 0.59 +/- 0.10 Normal RV: 0.28 +/- 0.04 Primary Pulm HTN: 0.93 +/- 0.34 Use PW of AV inflow signal, or CW to get AV regurgitant signal…..Also need to measure interval between AV closure and opening (AVco). Then, need to use PW or CW to capture semilunar outflow signal to measure ejection time (ET). After all of this, IMP can be calculated. IMP = (AVco – ET)/ET

Assessment of Regional Function Based on grading wall motion divided into the 16 (17) segment model as proposed by the American Society of Echocardiography Each segment can be viewed in multiple tomographic planes

Assessment of Regional Function 1 = normal 2 = hypokinesis 3 = akinesis 4 = dyskinesis 5 = aneurysmal WMSI = Sum of scores / Number of visualized segments WMSI > 1.7 may suggest perfusion defect > 20%

Assessment of Regional Function Qualitative estimation errors due to: Underestimation of EF due to endocardial echo dropout and seeing mostly epicardial motion Underestimation of EF with enlarged LV cavity; a large LV can eject more blood with less endocardial motion Overestimation of EF with a small LV cavity Significant segmental wall motion abnormalities

Doppler Tissue Imaging for Wall Motion Analysis Myocardium is color-coded according to velocity On P-Short Axis view, normal LV anterior wall motion during systole is blue (away from transducer), and the posterior wall motion is red (toward transducer); akinesis will have no color

Summary LV Mass Quantification: M-mode, Area-length method, Truncated ellipsoid method, and Subjective assessment. LV Volume Quantification: M-mode, Subjective assessment LV Function Quantification: Modified Simpson’s and Subjective Assessment by region………….Also by M-mode, Single plane area length method, Velocity of Circumferential Shortening, Mitral Annular Excursion, EPSS, Rate of Rise of MR jet, Index of myocardial performance, etc……..

Summary Modalities limited by quality of echo windows, accurate measurements are based on the ability to identify and capture ideal axis (recognize misleading off axis/tangential slices), and of course, echocardiographer experience……..

CORONARY ARTERY SUPPLY Regional wall analysis correlates well with coronary artery supply LAD – anterior, septum RCA – inferior, basal septum Circumflex – lateral, posterior

LV SYSTOLIC FUNCTION-EYEBALL ASSESSMENT Experienced operator Quick and easy Subjective