1. Echocardiographic Assessment of LV Systolic Function
Ryan Tsuda, MD

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

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

5. 2D Clips

6. LV Mass Quantification
M-mode
Area-length method
Truncated ellipsoid method
Subjective assessment

7. 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
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.

9. LV Mass Quantification
Penn convention formula (Another form of the cube equation)
LV mass = 1.04[(IVS + LVID + PWT)3 –
(LVID)3] – 13.6 g
NL LV mass index for males: / g/m2
NL LV mass index for females: / g/m2

11. RWT = 2(PWT/LVID)

13. LV Volume Measurement With M-Mode
Assuming nl ventricle morphology:
V = (LVID)3
If ventricle is dilated (spherical):
Teichholz equation
Vdiastole = [7/(2.4 + LVID)] x [LVID]3

14. 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

15. 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

16. M-Mode Quantification
Use Parasternal Short-Axis (Mayo) or Long-Axis (ASE) views to measure LVEDD and LVESD
May take several measurements at different levels and calculate average
Assumes no significant regional wall motion abnormalities present….

17. 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

19. Modified Simpson’s Method (Disc Summation Method)
Use apical 4 chamber and apical 2 chamber views to measure dimension and area
Trace borders manually or by acoustic quantification
Divides area into 20 cylinders of equal height

20. Acoustic Quantification
Automatic detection of blood-tissue border based on integrated backscatter analysis
This is the difference in amplitude of backscatter between the myocardial wall and blood
Blood-tissue border is recognized by echo machine, and marked with dots

21. Acoustic Quantification
Area of study is quantified continuously in real time throughout cardiac cycle
Therefore, the change in LV cavity area or volume with systolic contraction is calculated instantaneously, thereby providing LVEF.
AQ limited by its dependency on echocardiographic gain and image quality
Echo gain: Amplification of the returning RF signal which weakens with distance; i.e. an increased echodensity is seen as “tissue,” thereby decreasing accuracy……Lateral wall is especially subject to error…….

23. Derivation of 3.14(R)2 X D

24. Modified Simpson’s Method
EDV – ESV
LVEF = X
EDV

26. Single plane area-length method

27. 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

28. 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%

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

30. 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)

31. Index of Myocardial Performance (mayo clinics)
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). Systolic and Diastolic dysfunction causes a prolonged isovolumetric relaxation time (IRT)…
IMP = (ICT + IRT)/ET

32. Index of Myocardial Performance
Normal LV: /- 0.05
LV, DCM: /- 0.10
Normal RV: /- 0.04
Primary Pulm Htn: /- 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

33. 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

38. 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%

39. 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

43. 2D Clips

44. 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

46. Color Kinesis by 2D-Echo to Evaluate Wall Motion
Real time color-coded display of LV endocardial motion on sequential frames
Color is added to pixels that are identified as changing from blood to tissue in systole
Create a color map of endocardial border
This method limited by poor endocardial definition and translational motion of heart.

48. 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……..

49. 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……..

50. Eye Candy

51. References Oh, Jae K., The Echo Manual 2nd edition, 1999, p. 37-43.
Kerut, Edmund, Handbook of Echo- Doppler Interpretation, 1996, p
Atlas of Echocardiography Website
Braunwald, Eugene, Heart Disease 6th edition, p