Assesement off Left

f Ventricular
Systolic Function
rem Diner MD
Ankara University
Facultyy of Medicine
Cardiology Department

EUROECHO CONGRESS - COPENHAGEN -

TEACHING COURSE 2010
Assesment of left ventricular systolic function
Diagnosis,
Treatment,
Prognosis

EUROECHO CONGRESS - COPENHAGEN -

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 Systolic Function
Ejection capacity

Related to
Contractility
Loading conditions

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Longitudinal fibers
Subendocardial and subepicardial
10-12% longitudinal shortening

Circumferancial fibers
Midlayer
25% radial thickening

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 Heart
Longitudinal
L it di l
Radial
Ci
Circumferantial
f ti l
Twisting
(
(apex counterclockwise,
t l k i
base clockwise)
Al changes
Also h position
iti
in chest cavity

EUROECHO CONGRESS - COPENHAGEN -

TEACHING COURSE 2010
Left Ventricular Longitudinal
g Function

Important in left ventricular systolic function

(without longitudinal contraction EF<30%)

Effected first in any kind of cardiac disease

(H
(Hypertension,
t i iischemia,
h i etc)
t )

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Almost all the measurements made for the
assessment of left ventricular systolic
function are affected by the

loading conditions
conditions, and

th entire
the ti movementt off the
th heart
h t

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 Fractional shortening
= [(LVEDD LVESD)/(LVEDD)] x100,

N: 25-40 %

EF
Teichholz's formula
(NOT RECOMENDED)
Can b
C be usedd iin patient
ti t without
ith t any segmental
t l wallll
motion abnormality
Widely validated in valvular heart disease
Inter and intraobserver variability is low

J Am Coll Cardiol. 1999 Nov 1;34(5):1625-32

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 Anatomic M Mode

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TEACHING COURSE 2010
 Doppler Echocardiography
Stroke V = LV outflow tract area x TVI
Cardiac
C di output
t t = St
Stroke
k volume
l x HR

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Ejection
j Fraction

Visuall estimation
Vi ti ti
2D
3D
Contrast 2D, 3D
MRI (gold standard)

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 Inter and intraobserver variability is 5%
Reliability 78%

Visual estimation usually

underestimates the EF
Especially
p y in p
patients with
near normal LVEF

(J Am Soc Echocardiogr 2010;23:258-64.)

2010;23:258 64.)

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 LV SSystolic
t li Function
F ti
Eyeball
Eyeball Assessment

Experienced operator
Quick and easy
Subjective
Subtle findings overlooked

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Linear and 2D measurements of LVEF

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Repeat the same measurement
p
for apical 2 chamber view
 Area /lenght method

If apical endocardial border can not be deliniated

V = (5x(area)(lenght))/6

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LV quantification methods Utility/advantages Limitations

Linear
M
M-mode
d Reproducible
R d ibl Single
Si l didimension
i may nott b be
High frame rates representative in distorted
Wealth of accumulated ventricles
data Most representative
p in normally
y
shaped ventricles
Beam orientation
frequently off-axis
2 D guided
2-D id d Assures orientation
A i t ti L
Lower fframe rates
t than
th in i M-mode
M d
perpendicular Single dimension only
to ventricular long-axis
Volumetric
Biplane Simpsons Corrects for shape distortions Apex frequently foreshortened
Minimizes mathematical Endocardial dropout
assumptions
Relies on only two planes
Little accumulated data on normal
population
Area length
g Partial correction for shape
p Based on mathematical
distortion assumptions
Little accumulated data

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2D echocardiography underestimates
the volumes by 30-40%
30 40%
and EF by about 5%

Incomplete endocardial resolution

(in routine examination 10-15%,
in critically ill patients 25
25-30%
30% )

Need more quantification

Defibrillator or biventricular pace implantation
Timing of surgery for valvular heart disease
Follow up of the patients using cardiotoxic drugs
J Am Coll Cardiol 1998;32:14261432.
J Am Coll Cardiol 2001;38:867875.
European Heart Journal (2009) 30, 98106

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Contrast Echocardiography for Evaluation of
L ft Ventricular
Left V ti l S Systolic
t li FFunction
ti
Contrast agents used Conraindications (for optison and definity)
SonoVue Right-to-left, bidirectional, or transient right-
to-left cardiac shunts;
Optison Hypersensitivity to perflutren; and
Luminity hypersensitivity to blood, blood products,
Definity or albumin
((applies
pp to Optison
p only)
y)
The intra-arterial injection of ultrasound
Monitoring of vital signs, contrast agents.
electrocardiography and cutaneous
electrocardiography,
oxygen saturation (for 30 minutes)
Is required in patients with
pulmonary
p y hypertension
yp ((degree
g not
specified) or unstable cardiopulmonary J Am Soc Echocardiography 2008; 1; 409-

conditions.

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 J Am Soc Echocardiography 2008; 1; 409-

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 A significant impact of CE on
management was observed:
Additional diagnostic procedures were
avoided in 32.8% of patients and
d
drug managementt was altered
lt d iin
10.4%,
with a total impact
(procedures avoided,
avoided change in drugs
drugs,
or both) observed in 35.6% of patients.

J Am Coll Cardiol 2009;53:80210

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Contrast echocardiography is used in difficult to image
patients
ti t tot enable
bl iimproved d endocardial
d di l visualization
i li ti and d
assessment of left ventricular (LV) structure and function
when 2 contiguous segments are not seen on noncontrast
images

LV border is obscured by true myocardial structures

(trabeculations, irregularities, papillary muscles)
C t t echocardiography
Contrast h di h nott only
l iimprove th
the iimage
quality but also shows the true cavity

Contrast echocardiography increase the image quality in all

levels of expertise

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3D acquisition modes
Narrow angle
Zoom
Wide angle (used for volume measurements)
 Full Volume
trace the endocardial border with a
semiautomated detection process

Triplane
manually tracing of 3 apical planes
obtained from a single R-R interval
Test-retest variability of EF

EF compared to MRI

J Am Coll Cardiol 2004;44:87886

Follow up of the AMI patients
3D measurements are correlated with MRI
better than 2D measurements
Am J Cardiol 2007;99:300306
For the estimation of the LV volumes and EF
MRI > 3D conrast > 3D > 2D conrast > 2D
European Heart Journal (2009) 30, 98106

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3D vs MRI
3D underestimates volumes
Imaging tecnique
Trabeculation

RT 3DE overcome the geometric

RT-3DE
limitations of 2D echocardiography.
The major advantage of RT-3DE
RT 3DE is to
quantitate LV volume without any pre-
established assumption of LV geometry

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Feasable in 80% of the patients
Time needed for analysis 5 minutes
Changes clinical decision making in 10-15 % of the patients
(especially in patients with EF between 25-50%)
Heart 2008 94: 440-445

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 L ft Vetricular
Left V ti l L Longitudinal
it di l
Function
M Mode
Pulsed wave tissue Doppler
Colour coded tissue Doppler

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M mode AVPD (atrioventricular plane displacement)
N>10mm (avarage of 4
4-6
6 annular sites)
Related to EF

Echocardiography 2006; 23:846852.

Am J Physiol Heart Circ Physiol 2007; 292:H1452
292:H1452H1459
H1459

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Pulsed wave tissue Doppler Colour coded tissue Doppler
Mitral annular peak Mitral annular mean
S wave velocity S wave velocity
7.5 cm/sec 5.4 cm/sec

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 Pulsed wave Doppler Colour coded tissue
Doppler imaging

Colour coded images of

High temporal resolution
myocardial velocities on
Myocardial velocities are gray scale picture
higher than colour coded
Images should be obtained
images
at high
g frame rate
M
Myocardial
di l velocities
l iti off (>100frame/sec)
different segments can
Myocardial velocities can
not be obtained at the
be obtained at the same
same cardiac cycle
cardiac cycle

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TEACHING COURSE 2010
Left Ventricular Longitudinal Function

Simple, reproducible,quickly performed, feasable even

with suboptimal image quality
Early
E l markerk off subtle
btl systolic
t li d
dysfunction
f ti
Predictor of adverse clinical outcome in heart failure
patients
TD records absolute velocities (effected by tethering,
and overall translational and rotational motion of the
heart)