Echo assessment of lv systolic function and swma
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This document discusses various techniques for assessing left ventricular systolic function using echocardiography, including: - Visual assessment of endocardial motion and wall thickening to evaluate global and regional function - Quantitative measures like fractional shortening, ejection fraction, and volumes - Tissue Doppler imaging of mitral annular velocities - Tissue tracking and strain imaging to evaluate timing and extent of myocardial contraction - Wall motion scoring to characterize regional abnormalities
Echo assessment of lv systolic function and swma
- 1. Fuad Farooq
- 2. Assessment of ventricular systolic function, the essential part of all echocardiography examinations
- 3. 2D echo allows visualization of the endocardium and it’s thickening, by which global and regional ventricular systolic functions are assessed Quantitative assessment of global systolic function is usually based on changes in ventricular size and volume
- 4. Fractional shortening of LV Ejection fraction Stroke volume and cardiac index Systolic tissue velocity of the mitral annulus and myocardium Tissue tracking Regional wall motion analysis
- 5. Percentage change in LV dimensions with each LV contraction Reflects global ventricular function LVED - LV end-diastolic dimension LVES - LV end-systolic dimension
- 7. Assesses ventricular function only at the level being interrogated If regional dysfunction is present, which is not in the interrogation plane, it may result in a misleading estimate of global ventricular function
- 8. Expression of global LV function Strong predictor of clinical outcome in almost all major cardiac conditions Determined visually by eyeballing echocardiographic images of the LV Considerable inter-observer variation but with experienced readers variation is less than 5%
- 9. Measured quantitatively by using volumetric measurements from M-mode, 2D and 3D echocardiograms LVEDV - LVESV LVEDV LVEF =
- 11. EF can also calculated from LV dimensions measured with M-mode Measurement of LV dimensions from the mid ventricular level is used to calculate LVEF LVEDD2 – LVESD2 LVEDD2 Add 15% for normal, 5% for hypokinetic apex, 0% for akinetic apex, -5% for dyskinetic apex, and -10% for apical aneurysm LVEF = x 100
- 13. Not a true indicator of systolic function Determined by multiple factors Provides the amount of blood volume ejected with each cardiac cycle
- 14. Stroke volume can be measured as the difference between the LV end-diastolic volume and LV end-systolic volume obtained by the Simpson method
- 16. The difference should be equal to SV across the LVOT if there is no valvular regurgitation If there is MR, regurgitant volume needs to be subtracted to obtain stroke volume across the LVOT
- 17. Calculated as SV = LVOT area x LVOT TVI(time velocity integral)
- 19. Cardiac output is calculated as: CO = SV x HR Cardiac index is calculated as: CO Body Surface Area (BSA) CI =
- 20. Tissue Doppler imaging records the velocity of myocardial tissue The systolic component (S’) of the mitral annulus correlates well with the LVEF
- 22. Value of 8cm/s was selected as a cutoff point Vinereanu et al. have reported (80% sensitivity, 89% specificity) for the same cutoff point of S’ measured at the medial mitral annulus and (80% sensitivity, 92% specificity) for S’ measured at the lateral mitral annulus Estimation of global left ventricular function from the velocity of longitudinal shortening. Echocardiography 2002;19(3):177-185
- 23. Systolic contraction of the ventricles is performed optimally when regional contractions are coordinated All walls should contract within 20 to 30 milliseconds of each other Disrupted by conduction delay, atrial fibrillation, or a pacemaker
- 24. Assessed best with tissue Doppler imaging Reliably provide timings of cardiac events or myocardial movement
- 25. TDI in systole TDI in diasystole
- 26. Tissue colour Doppler in M-mode
- 27. It is byproduct of tissue Doppler imaging Basoapical views of each ventricular segment are displayed as seven color bands, with each color representing a particular distance the tissue moves during systole Tissue tracking provides a rapid assessment of systolic motion
- 28. Mitral anulus displacement can be determined instantaneously with tissue tracking Normal mitral annular systolic motion is >8mm (average 12 + 2 on apical 4 or apical 2 views) A systolic mitral anulus displacement of less than 5 mm determined by tissue tracking correlates well with a severe decrease in the LVEF (<30%)
- 29. Normal ventricular contraction consists of simultaneous myocardial thickening and endocardial excursion toward the center of the ventricle Regional contractility or wall motion of the LV is graded by dividing the LV into segments In 2002, a 17-segment model was recommended by the American Society of Echocardiography LV is divided into three levels - basal, mid or papillary and apical Circulation, 2002;105: 539-542
- 30. Basal 1.Anteroseptum 2. Anterior 3. Lateral 4. Inferolateral 5. Inferior 6. Inferoseptum Mid 1.Anteroseptum 2. Anterior 3. Lateral 4. Inferolateral 5. Inferior 6. Inferoseptum Apical 1. Anterior 2. Lateral 3. Inferior 4. Septal Apical cap
- 33. Numerical score is assigned to each wall segment on the basis of its contractility as assessed visually: 1= Normal (>40% thickening with systole) 2= Hypokinesis (10-30% thickening) 3= Severe hypokinesis to akinesis (<10% thickening) 4= Dyskinesis (out of phase) 5= Aneurysm (thinned and bulging outwards)
- 34. On the basis of this wall motion analysis scheme, a wall motion score index (WMSI) is calculated to semiquantitate the extent of regional wall motion abnormalities Normal WMSI is 1 WMSI > 1.7 may suggest perfusion defect > 20%
- 35. 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
- 36. Normal Abnormal
- 37. Myocardial performance index TEI index = IVRT + IVCT LVET IVCT - Isovolumic contraction time IVRT - Isovolumic relaxation time LVET - LV ejection time Normal in 0.39 +/- 0.05
- 38. 1. E-point septal separation 2. Aortic valve opening pattern
- 39. The magnitude of opening of the mitral valve, as reflected by E-wave height, correlates with transmitral flow and, in the absence of significant mitral regurgitation, with left ventricular stroke volume Mitral valve E point (maximal early opening) is within 6 mm of the left side of the ventricular septum In the presence of a decreased ejection fraction, this distance is increased
- 42. If left ventricular forward stroke volume is decreased, there may be a gradual reduction in forward flow in late systole, which results in gradual closing of the aortic valve in late systole. This results in a rounded appearance of the aortic valve in late systole