Echocardiographic Assessment of LV Systolic Function - PowerPoint PPT Presentation

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Echocardiographic Assessment of LV Systolic Function

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3 = akinesis. 4 = dyskinesis. 5 = aneurysmal. WMSI = Sum of scores / Number of visualized segments ... is red (toward transducer); akinesis will have no color ... – PowerPoint PPT presentation

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Title: Echocardiographic Assessment of LV Systolic Function


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

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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 (21 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.

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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 93 /- 22 g/m2
  • NL LV mass index for females 76 /- 18
    g/m2

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RWT 2(PWT/LVID)
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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 LVID3

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 Simpsons 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

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Modified Simpsons 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 accuracyLateral wall is
    especially subject to error.

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Derivation of 3.14(R)2 X D
24
Modified Simpsons Method
  • EDV ESV
  • LVEF --------------- X 100
  • EDV

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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 gt 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 lt 8 mm, the EF is likely lt 50

29
Normal E point to septal separation is lt 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 0.39 /- 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).
  • 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

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Assessment of Regional Function
  • 1 normal
  • 2 hypokinesis
  • 3 akinesis
  • 4 dyskinesis
  • 5 aneurysmal
  • WMSI Sum of scores / Number of visualized
    segments
  • WMSI gt 1.7 may suggest perfusion defect gt 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

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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

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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.

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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 Simpsons
    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. 54-63.
  • Atlas of Echocardiography Website
  • Braunwald, Eugene, Heart Disease 6th edition, p.
    165-169.
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