1. Assessment of left ventricular function
The InGenious HyperCare European Network Excellence in phenotyping:
Assessment of left ventricular function
Tatiana Kuznetsova
University of Leuven, Belgium

2. LVF Outline Systolic function Diastolic function
Echocardiographic protocol (JRP A3)

3. LVF
Systolic function
Conventional echocardiography enables the assessment of LV dimensions, volumes, sphericity index, and severity of mitral regurgitation;
HF due to systolic dysfunction is relatively easy to diagnose by echocardiography (dilated left ventricle with a reduced ejection fraction)

4. LVF Components of regional function Radial function Longitudinal
Circumferential
Without the longitudinal component, sarcomere shortening would lead to an EF < 30%.

5. LVF Tissue Doppler imaging
Tissue Doppler Imaging (TDI) makes it possible to specifically evaluate the longitudinal and radial components of regional LV systolic function.
Measurements of myocardial deformation with the Doppler technique have been validated using microcrystals and MRI (Urheim S, Circulation 2000; Edvardsen T, Circulation 2002).

6. Basal segments of inferior and infero-lateral walls
LVF
Off-line analysis
Strain rate
Strain
AVC
MVO
Time
integration
AVC
MVO
Basal segments of inferior and infero-lateral walls
Peak systolic SR
End-systolic S
SPEQLE: Software Package for Echocardiographic Quantification, Leuven; version 4.06

7. LVF
Inter-observer differences in percent versus average of two readings
Mean of 2 readings
Bland and Altman, 1986

8. LVF Longitudinal S and SR by RWT
Mean values are adjusted; * P 0.05 ***P0.001

9. LVF Regional LV geometry Wall stress related to: σ = P x R / 2WT
Pressure ↑ → σ ↑
Shape, cavity size ↑ → σ ↑
Wall thickness ↑ → σ ↓
σ = P x R / 2WT
Since R curvature is larger in longitudinal direction, the stress on longitudinal fibres is higher, they show decreased deformation first.

10. LVF
Systolic function
TDI, compared with conventional echocardiography, is a more sensitive method for the detection of LV systolic dysfunction, particularly in subjects with LV remodelling and normal EF.
Our observations underscore the importance of normal long axis function in maintaining a coordinated ventricular contraction.
The clinical utility of strain and strain rate in risk stratification or as therapeutic target remains to be established.

11. LVF Diastolic function
About 50% of patients with new onset of HF do have a normal EF (HF with preserved EF).
HF with preserved EF is associated with a high mortality rate, comparable to that of patients with reduced EF (Bhatia R.S., N Engl J Med 2006; Bursi F., JAMA 2006)
Assessment of diastolic function requires conventional and Tissue Doppler Imaging

12. LVF
Transmitral blood flow vs pulsed Tissue Doppler Imaging A E Ea Aa

13. LVF
Inter-observer differences in percent versus average of two readings
Mean of 2 readings
Bland and Altman, 1986

14. LVF Determinants of TDI velocities Stepwise analysis:
Ea: age, BMI, DBP, LVMI; LV length, EF;
Aa: age, HR, DBP, LV length, EF;
Ea/Aa: age, BMI, HR, DBP.
Intrafamilial correlation coefficients (P< for all) were:
Ea: ;
Aa: ;
Ea/Aa: 0.46.

15. Echo Echocardiographic performance protocol
A single observer performs all echocardiographic examinations by means of Vivid 7 ultrasound scanner (GE Vingmed, Horten, Norway)
Standardized echocardiography scanning sequence (about 40 min, page MOP JRP A3)
Correct orientation of the ultrasound beam and imaging planes to LV structure and blood flow is essential
All echocardiographic examinations in a digital format are stored on a local network for off-line reading by two independent observers (EchoPack, GE and SPEQLE, University of Leuven)

16. Echo Methods to limit echocardiographic measurement variability
Use echocardiography central reading laboratory:
a. Minimize number of readers,
b. Monitor reader variability,
c. Rapid communication with study sites on study quality.
Standardized “hands-on” training of sonographers onsite.
Monitoring of sonographers for technical quality; encode study quality in database.
American Society of Echocardiography Recommendations for Use of Echocardiography in Clinical Trials. J Am Soc Echocardiogr 2004;17:

17. Echo Methods to limit echocardiographic measurement variability
Reading off-line strategies:
Batch read when possible to minimize systematic temporal drifts;
Average multiple beats (minimum of 3);
Single reader preferable.
Establish acquisition and reader variability:
Test-retest of small sample of participants, ie, same participant repeated over small interval, same machine, same sonographer, same reader;
Blind duplicates for inter-reader and intra-reader variability assessment.

18. JRP A3
Echo-centers
Katholieke Universiteit Leuven, B JA Staessen, T Kuznetsova, T Richart
Jagiellonian University Cracow, PL K Kawecka-Jaszcz, K Stolarz, M Loster
Medical University of Gdansk, PL K Narkiewicz, W Sakiewicz, A Rojek
Universitá degli Studi di Padova, I E Casiglia, V Tikhonoff
Hospital Universitari Valencia, SP E Lurbe, J Alvarez
Institute of Internal Medicine, RU Y Nikitin, S Malyutina, A Ryabikov