1. EVALUATION OF SYSTOLIC FUNCTION
ECHOCARDIOGRAPHY/ANGIOGRAPHY
DEEPAK NANDAN

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

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

5. 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

6. 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

7. 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

9. 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, % aneurysm

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

11. M-MODE-LINEAR MEASUREMENTS

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

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

15. 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%

16. 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

17. 2-D MEASUREMENTS

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

19. SIMPSONS RULE\ RULE OF DISC

20. 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.

23. LEFT VENTRICULAR MASS

24. TEICHOLZ /CUBED FORMULA

25. 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.

26. 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

27. LV MASS BY 2-D

29. RWT = 2(PWT/LVID)

30. REGIONAL LEFT VENT FUNCTION

31. 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

32. NONISCHEMIC RWMA

33. DIFF ISCHEMIC VS NONISCHEMIC

34. LBBB

35. DOPPLER EVALUVATION OF GLOBAL LVF

36. SCHEMATIC REP OF ASSESSMENT OF LV VOL

37. 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

38. Stroke Volume Measurement
Measurement of VTI
Measurement of CSA

39. 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

40. WALL STRESS

41. LEFT VENTRICULAR dp/dt

42. 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)

43. INDEX OF MYOCARDIAL PERFORMANCE

44. 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

45. 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)
PW or CW to capture semilunar outflow signal to measure ejection time (ET)
IMP = (AVco – ET)/ET

46. 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

47. ANGIOGRAPHIC ASSESSMENT OF LV FUNCTION

50. 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

51. 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

52. 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

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

54. EJECTION INDICES

55. 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

56. 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

57. 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

58. 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

59. 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.

62. PRESSURE VOLUME LOOPS

63. 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

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

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

68. THANK YOU