1. Assessment of LV Systolic Function
Dr Nithin P G

2. Overview Normal LV contraction
Global & regional indices of LV systolic Function
Angiographic assessments
Echocardiography
MRI
Computed Tomography
Nuclear Imaging
Take home message

3. Introduction
Mechanical pump
LV systolic function = Contractility

4. Normal contraction of LV
J Am Coll Cardiol Img 2008;1:366 –76

5. Assessment of LV function

6. Clinically relevant indicators of global LV function
EJECTION FRACTION.
Ratio of SV to EDV. [EDV-ESV/EDV]
Simplicity of its derivation
Ability to determine easily
Reproducibility using different imaging techniques
Extensive documentation of its clinical usefulness.

7. Ejection fraction Drawbacks
Depends on preload and afterload, as well as HR and synchronicity of contraction.
Global parameter, major regional differences in contractility are presented as an average
Given EF may have different prognostic importance according to clinical situation eg severe MR
Preload increases [AR,MR, Anemia]
EF increases
Afterload increases [AS]
EF decreases

8. Hemodynamic measurements
Cardiac index (liter/min/m2) = HR × SV/BSA
Stroke Volume index (ml/m2) = SV/BSA
Stroke Work index (ml×mmHg/m2) = SVI × mean SBP
LVSW reasonably good measure of LV contraction ,exceptions
Volume or Pressure overload
RWMA

9. ESPVR ESPVR or maximum elastance- method for LV contractility
Nearly independent of preload and afterload
Multielectrode catheters –impedance, Vol., micromanometer Pressure recordings [aortic dicrotic notch pressure as ESPr & Minimum LV chamber volume ]
Pacing/ IVC balloon occlusion/ Drugs  PV loops at different loads  line drawn across ES points
Slope of line = measure of LV contractility

10. ESPVR
ESPVR accurately reflect myocardial contractility independent of ventricular loading [ in various canine and human studies]
Drawbacks
Difficult to perform
Invasive
Spontaneous variability over the time it takes to make measurements
Curves dependent on gender, age, position of IVS [RV filling pressure, LBBB]

11. MAXIMAL RATE OF PRESSURE RISE
Maximum rate of rise of LV Sys. Pr. [IVC]
Analogous to the maximal rate of tension development of isolated cardiac muscle [well-established index of myocardial contractility]
Relatively load independent [ changes to afterload & preload < 10% in normal physiological limits]
Drawbacks
Comparison b/w individuals difficult
c/c AS dP/dt less when contractility normal
RWMA & marked dyssynchrony

12. Regional Indices of Left Ventricular Function
WMS [wall motion score]
Center line chordal shortening
Radian change, regional area change
Strain rate imaging
Torsion imaging

13. Centerline method

14. Angiographic assessment

15. Volume calculations V= 4/3 p [L/2] [M/2] [N/2] = p /6 LMN
ARAO= p [LRAO/2] [ M/2]= p [LRAO][M]/4
ALAO= p [LLAO/2] [N/2]= p [LLAO][N]/4
V= p /6 Lmax [4ARAO] [4ALAO]
[p LRAO][p LLAO]
Usu, Lmax= LRAO
=> V= 8 ARAO ALAO
3 p LLAO

16. Regional indices Angiographic wall motion score Normal score is 5
2= moderate hypokinesis
3=severe hypokinesis
4=akinesis
5=aneurysm/dyskinesis
Normal score is 5

17. Echocardiography

18. Assesment by Echocardiography
Ejection Fraction
M- mode
EF= LVEDD2-LVESD2 x100
LVEDD2
EFc= [(1-%EF) x % DL] + %EF
DL=apex contractility
15% normal
5% hypokinetic
0% akinetic
-5% dyskinetic
-10% aneurysmal
Only along a single interrogation line, regional variation in function
Does not reflect true minor axis especcially in elderly with angulation

19. Ejection fraction 2. D3 method Vol = 4/3 p (D1/2) (D2/2) ( L/2)
= 4/3 p (D1/2) (D1/2) ( 2D1/2)
= p/3 (D3)
= D3
= D3
More spherical shape,
Vol. = (7/2.4+D) x D3 L D1 D2

20. Ejection fraction 3. Modified Simpson’s biplane method [2D-Echo] 20
Vol= p/4 S ai bi L i=
[Difference b/w ai & bi should be less than 20%]
Most reliable method in case of regional difference in function
EF calculated comparable to those measured hemodynamically

21. Ejection Fraction 4. Single plane Area- length Method
When only one view is available
Ventricle is considered symmetrical
Vol= 0.85 A2 L

22. Other parameters Fractional Shortening FS= LVEDD-LVESD x100 LVEDD
Velocity of Circumferential Fiber shortening [Vcf]
Mean Vcf= FS/ LVET
Mean velocity of ventricular shortening of the minor axis of LV
Ejection phase index of systolic function

23. Other parameters Myocardial Performance index [TEI index] ICT + IRT ET
Measure of both sys & diastolic function
Normal <0.4
Strong inverse relationship with EF
Independent of ventricular geometry
Hellenic J Cardiol 2009; 50: 60-6

24. Other parameters M- mode parameters EPSS Descent of base
>6mm abnormal
Descent of base
Linear correlation b/w magnitude of annular excursion & LV function
Rounded appearance of aortic valve closure in late systole
Rates of systolic thickening of PW

25. Regional function indices
WMS
Normal =1
Hypo=2
Akinetic=3
Dyskinetic=4
WMSI
S WMS/N

26. Deformation analysis Newer methods of TDI & speckle tracking
Analysis of strain, strain rate or torsion
Strain- L-L0/L0
Strain rate- velocity of change over time

27. Deformation analysis Drawbacks
Strain not uniform from base to apex & in circumferential plane [anterior & lateral wall higher]
Angle dependency
Preload dependent
Heterogenicity within the same myocardium
Patient to patient variability
Inter & Intra observer variability
APEX

28. 2-D Echo evaluation of LV Function
Most common method used is Simpson’s rule
Most accurate when LV geometry is normal
Correlation coefficients ~ 0.75 compared to RNA, cine angiography & autopsy studies Circulation 1979, 60: ; Circulation 1980, 61:
Limited by reproducibility b/w individual studies
Improved by tissue harmonic imaging & contrast use.

29. 3D Echocardiography
Direct evaluation of cardiac chamber volumes without the need for geometric modelling and without the detrimental effects of foreshortened views
Direct 3D assessment of regional LV wall motion
Quantification of systolic asynchrony to guide CRT
3D color Doppler imaging with volumetric quantification of regurgitant lesions , shunts , and cardiac output
J Am Coll Cardiol 2006; 48:2053– 69

30. 3D Echocardiography
Am J Cardiol 2005;95:809–813

31. Magnetic resonance imaging

32. MRI Gold standard for assessing LV & RV function Parameters Comments
Global Function
LVEF
LV ESV, LV EDV
‘Gold standard’
Simpson’s rule & A-L method
Steady state free precession [SSPE]
Even in patients with abnormal geometry
Low inter & intra observer variability
Cardiol Clin 25 (2007) 15–33
Regional Function
RWMA
Tissue tagging
Displacement encoding [DENSE}
Wall thickening
Center line method
LV Strain
DENSE

33. MRI

35. Assessment by MRI
Gradient echo images of sequential multiple slices of the left ventricle in short-axis planes (from base to apex) are displayed for determining left ventricle volume by Simpson’s rule
Cardiol Clin 25 (2007) 15–33

36. Assessment by MRI Radiology 2004;233:210–6
Tagging of Ventricle for detection of RWMA
Radiology 2004;233:210–6
2-D displacement Map & Colour coded myocardial strain map
Radiology 2004:230:862–71

37. Computed tomography

38. Computed Tomography
EBCT & MDCT has excellent visualization of cardiac structures.
Delineation of epicardial & endocardial borders allow accurate & reproducible measure of wall thickness, ESV, EDV.
ECG gating & image post processing allows cine mode imaging

39. ECG gated CT

40. Computed Tomography Parameters Comments Global Function LVEF
LV ESV, LV EDV
Comparable to RNA Am J Cardiology 1999; 83 (7):
Regional Function
Wall Motion Abnormalities and Wall thickening
Stress rest EBCT comparable to Tc SPECT for detecting CAD [EF- 81, 76; EF+RWMA- 88, 100] Am J Cardiology 1998; 81 (6):
Ventricular Remodeling
Comparable to SPECT & Echocardiography J Comput Assist Tomogr 2006; 30 (4):

41. Computed Tomography MRI [Gold Standard] > MDCT>2D-Echo & SPECT
Radiology 2005; 234:381–390

42. Computed Tomography Disadvantages
Radiation risk
Contrast toxicity
Temporal resolution comparably limited
Used when echo window very poor & MRI contraindicated

43. Nuclear imaging

44. Radionuclide Angiography
Equilibrium method
ECG gated, data averaged from multiple cardiac cycles, MUGA
99mTc labeled RBC
First- pass method
Dynamic acquisition, rapid temporal sampling to look at initial transit
Principal application is measurement of LVEF
ICD, ACEI use, Surgical ventricular restoration, Cardiotoxic chemotherapeutics ( Adrimycin therapeutics), Heart Failure Trials

45. SPECT Parameters Comments Global Function LVEF LV ESV, LV EDV
Regional Function
Wall Motion, Wall Thickening
LV contraction Histogram
Dysynchrony- heterogenous phase angle distribution
Lung to Heart Ratio
Increased lung uptake = incrased PCWP also in MS,MR
Transient Ischemic Dilation Ratio
Apparent cavity dilation 20 to diffuse subendocardial ischemia
LV eccentricity & Shape Index

46. SPECT
LV contraction Histogram

47. SPECT
Prognostic Value of Lung Sestamibi Uptake in Myocardial Perfusion Imaging of Patients With Known or Suspected Coronary Artery Disease
Overall (n = 718)
Normal (n = 367) SSS<3
Mild (n = 136) SSS 4-8
Moderate (n = 78) SSS 9-13
Severe (n =137) SSS>13
Stress LHR
0.32±0.06
0.30±0.05
0.31±0.05
0.34±0.08
0.36±0.07
Rest LHR
0.31±0.06
0.32±0.07
0.35±0.06
Diff. LHR
0.006±0.05
0.003±0.046
0.000±0.048
0.017±0.065
0.012±0.053
p value:
sLHR vs. rLHR
0.001
0.15
>0.2
0.02
0.008
J Am Coll Cardiol, 2005; 45:

48. SPECT

49. Take Home message 2D Echo- most common
MRI- precision, complex geometry
Nuclear imaging, CT- used when other indications present
J Am Coll Cardiol Img 2008;1:652–62

50. Thank you