EVALUATION OF SYSTOLIC FUNCTION ECHOCARDIOGRAPHY/ANGIOGRAPHY DEEPAK NANDAN

“SYSTOLE”- CONTRACTION “DIASTOLE”-TO SEND APART

Systolic function is affected by preload afterload,contractility and heart rate. Asynchronous systolic contraction also may affect systolic function

LV SYSTOLIC FUNCTION Quantitative echo STROKE VOLUME EJECTION FRACTION LV VOLUME LV MASS EJECTION INDICES STROKE VOLUME EJECTION FRACTION FRACTIONAL SHORTENING VELOCITY OF CIRCUMFERENCIAL FIBRE SHORTENING

Quantify LV function -MODES 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 Use Parasternal Short-Axis or Long-Axis views to measure LVEDD and LVESD May take several measurements at different levels and calculate average Assumes that no significant regional wall motion abnormalities are present

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

Global Myocardial Function Fractional shortening (FS) Assumes symmetric contraction Ejection fraction (EF)

M-MODE-LINEAR MEASUREMENTS

INDIRECT M-MODE MARKERS EPSS GRADUAL CLOSURE OF AORTIC VALVE MEAN Vcf-rate of shortening of LV

EPSS NORMAL ≤6mm EF<50% >7mm EF≤35% ≥13mm

Mitral Annular Excursion toward LV Apex 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%

Velocity of Circumferential shortening Vcf is the mean velocity of LV shortening through the minor axis Vcf = FS/ET ET is the time between LV isovolumetric contraction and isovolumetric relaxation Measure by obtaining M-mode of AV opening to AV closure, aortic flow by doppler, or by an external pulse recording of carotid artery NL values are > 1.0 c/s Slow Vcf may suggest diminished systolic function

2-D MEASUREMENTS

Ejection Fraction Quantitative - accuracy, reproducibility limited - assumes shape of LV cavity - best in symmetric ventricles Better is contrast ventriculography, or MRI.

SIMPSONS RULE\ RULE OF DISC

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 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.

LEFT VENTRICULAR MASS

TEICHOLZ /CUBED FORMULA

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 Quantification LV mass = 1.04[(IVS + LVID + PWT)3 – (LVID)3] – 13.6 g NL LV mass index for males: 93±22g/m2 NL LV mass index for females: 76±18g/m2

LV MASS BY 2-D

RWT = 2(PWT/LVID)

REGIONAL LEFT VENT FUNCTION

Regional Myocardial Function Assessment of motion of regions of the myocardium Useful for detection of myocardial ischemia Leads to decreased or paradoxical motion of the wall in affected areas Regions can be roughly mapped to coronary arteries

NONISCHEMIC RWMA

DIFF ISCHEMIC VS NONISCHEMIC

LBBB

DOPPLER EVALUVATION OF GLOBAL LVF

SCHEMATIC REP OF ASSESSMENT OF LV VOL

Stroke Volume and Cardiac Output Flow = Cross sectional area (CSA) x Average velocity Average velocity not usually measured directly VTI = velocity-time integral Area under the velocity curve for a single beat Represents ‘stroke distance’ SV = VTI * CSA

Stroke Volume Measurement Measurement of VTI Measurement of CSA

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

WALL STRESS

LEFT VENTRICULAR dp/dt

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)

INDEX OF MYOCARDIAL PERFORMANCE

Index of Myocardial Performance Uses systolic and diastolic time intervals to evaluate global ventricular performance Systolic dysfunction causes prolonged isovolumetric contraction time (ICT) and a shortened ejection time (ET). IMP = (ICT + IRT)/ET

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) PW or CW to capture semilunar outflow signal to measure ejection time (ET) IMP = (AVco – ET)/ET

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

ANGIOGRAPHIC ASSESSMENT OF LV FUNCTION

LV PRELOAD Amout of passive tension or strectch on the ventricular walls prior to systole This load determines end diastolic sarcomere length and force of contraction This inturn decides stroke volume and cardiac output

AFTERLOAD AND CONTRACTILITY Afterload is the wall stress during ejection Three major components are-peripheral resistance,arterial compliance,& peak intraventricular pressure. Contractility is the inherent property of the myocardium to contract independent of the changes in pre & afterload

EVALUATION OF SYSTOLIC PERFO CONTRACTILITY INDICES Isovolumic indices Maximum dp/dt Maximum (dp/dt)/p Vpm or peak([dp/dt]/28p) (dp/dt)/Pd at Pd=40 mm hg Ejection phase indices LVSW LVSWI EF MNSER(mean normalised syst eject rate) Mean Vcf

Isovolumic indices Dp/dt-max rate of rise of LV systolic pressure-oldest & widely used Nl-1610±290 mmHg/sec

EJECTION INDICES

LVSW Area within PV diagrams-most accurate Other methods LVSW=(LVSP−LVDP)SV(0.0136) LVSP&LVDP=MEAN SYST/DIAST PR SV=STROKE VOL IN ml 0.0136=for converting mm Hg-ml into g-m

LVSW=(AoSP−PCWP)SV(0.0136) LVSW –good measure in the absence of vol or pressure overload Nl-90±30g-m Values ≤25 indicate severe Lv syst failure & <20 prognosis is grave. But reflects syst performance only when ventricle is homogenous in consistency-DCMP In ext MI LVSW may be depressed even if contractility is normal

Lv syst function can be assessed using only volume data from P-V diagram EF=[(LVEDV−LVESV)/LVEDV] EF/ Ejection time obtained from Ao pressure tracing =Mean normalised syst ejection rate MNSER=(LVEDV−LVESV)/(LVEDVхET) NL-EF(angio)=.72±0.08 Nl MNSER(angio)=3.32±0.84EDV/sec

Vcf=velocity of the circumferential fiber shortening Rate of shortening of lv myo fiber in a circmferential plane at the midpoint of the long axis of the ventricle MeanVcf=end diast endocardial circum fiber length −end syst length Vcf=(Ded−Des)/Ded(ET) Nl-1.83±0.56ED circ/sec

Drawbacks-influenced by preload & afterload An Lvef≤.40 indicates depressed lv contractility, if there is no loading to account for the reduction. Interpretation of ejection phase indices are improved by consideration of the preload & afterload.

PRESSURE VOLUME LOOPS

ESPVR Fundamental principle of end-systolic Pv analysis is that, at end-systole there is a single line relating LV chamber vol to pressure,unique for the level of contractility & independent of loading conditions. Most reliable index of contractility Insensitive to changes in pre,afterload& heart rate Slope of the end syst pr vol curve is called elastance-sensitive parameter

Slope of this as an index of contractility Other indices LVdp/dt max and EDV Slope of this as an index of contractility

Stress-shortening relationship Inverse relation between the two ↑afterload→↑syst wallstress→↓myocardial shortening

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