Echocardiographic evaluation of lv function

ECHOCARDIOGRAPHICECHOCARDIOGRAPHIC
EVALUATION OF VENTRICLEEVALUATION OF VENTRICLE
FUNCTION.FUNCTION.
Children Hospital 1.Children Hospital 1.
Cardiology Department.Cardiology Department.
Gio an.Gio an.

INTRODUCTIONINTRODUCTION
 Doppler ultrasound is the mainstay of diagnosisDoppler ultrasound is the mainstay of diagnosis
examination.(2D,M-mode).examination.(2D,M-mode).
 Differences between children and adult:Differences between children and adult:
 Myocardial function changes during heartMyocardial function changes during heart
mature.mature.
 CHD leads to nongeomatric shapes.CHD leads to nongeomatric shapes.
 Pathophysiology of CHDPathophysiology of CHD  difficult indifficult in
interpretations.interpretations.
 One functional ventricle.One functional ventricle.

LEFT VENTRICULAR SYSTOLICLEFT VENTRICULAR SYSTOLIC
FUNCTIONFUNCTION
 Left ventricular dimension:Left ventricular dimension: HF with increased end-HF with increased end-
diastolic and end-systolic dimension.diastolic and end-systolic dimension.
 Dimension-Derived Indices.Dimension-Derived Indices.
 Shortening fraction.Shortening fraction.
 Ejection fraction.Ejection fraction.
 Doppler-Derived Indices.Doppler-Derived Indices.
 Aortic velocity curve.Aortic velocity curve.
 Mitral regurgitation velocity curve.Mitral regurgitation velocity curve.
 Stress velocity Index.Stress velocity Index.
 Doppler tissue imaging (DTI) and Strain Rate Imaging.Doppler tissue imaging (DTI) and Strain Rate Imaging.

The Frank–Starling relationshipThe Frank–Starling relationship

Dimension-Derived Indices: M-modeDimension-Derived Indices: M-mode
Shortening fractionShortening fraction
[LVEDD-LVESD][LVEDD-LVESD]
 SF=SF= ×100×100
LVEDDLVEDD
 Limitation:Limitation:
 LV not entirely uniform or symmetric.LV not entirely uniform or symmetric.
 Regional different in wall motion and wallRegional different in wall motion and wall
thickening.thickening.
 Flattened interventricular septum.Flattened interventricular septum.
 AR or MR, SF normalAR or MR, SF normal deterioratingdeteriorating
function.function.

Ejection fractionEjection fraction
[LVEDV-LVESV][LVEDV-LVESV]
 LVEF=LVEF= ×100×100
LVEDVLVEDV
 Limitation: ~FSLimitation: ~FS
 Changes in ventricular loading condition.Changes in ventricular loading condition.
 LV not entirely uniform or symmetric.
 Regional different in wall motion and wall
thickening.
 Flattened interventricular septum.

LV VOLUMELV VOLUME
 Normal LV: Prolate ellipse.Normal LV: Prolate ellipse.
 Equal short axis.Equal short axis.
 Long axis= 2 short axis.Long axis= 2 short axis.
LV volume:LV volume:
4/34/3ππ×LVID×LVID/2×LVID/2.×LVID×LVID/2×LVID/2.
LV volume:LV volume: π/3π/3×LVID×LVID33
..
 LV enlarge: spherical.LV enlarge: spherical.
 LV=(7.0/(2.4+LVID)LV=(7.0/(2.4+LVID)×(LVI D)×(LVI D)33
).).

 WALL THICKNESS (H/r ratio).WALL THICKNESS (H/r ratio).
H/r ratio=2H/r ratio=2×PWT/ LVI D in diast ole.×PWT/ LVI D in diast ole.
 LV MASS:LV MASS: Teicholz formulae.Teicholz formulae.
LV mass =(LV volume-LV cavit yLV mass =(LV volume-LV cavit y
volume)×Densit y.volume)×Densit y.
=1.055×((PWT+LVI D+I VST)=1.055×((PWT+LVI D+I VST) 33
-(LVI D)-(LVI D)33
).).
 Not e:Not e:
 PWT: Post er ior wall t hickness.PWT: Post er ior wall t hickness.
 LVI D: LV int er nal diamet er.LVI D: LV int er nal diamet er.
 I VST: I nt ervent r icular sept al t hickness.I VST: I nt ervent r icular sept al t hickness.

Dimension-Derived Indices: 2DDimension-Derived Indices: 2D
BULLET-SHAPED PROLATE -ELLIPSE ANY LV SHAPE.
LV CAVITY VOLUME

LV CAVITY VOLUME: 2DLV CAVITY VOLUME: 2D
5/6 ×SAX CAVITY AREA×LAX LENGTH
SAX CAVITY AREA:
Area in short axis view , at the high papillary
muscle level.
APICAL LAX LENGTH:
A line connecting the midpoint of MV
annulus to the apical endocardial
border/apical 4C view.
FORMULA
d
S

 The apical area/length formulaThe apical area/length formula
LV= 0.85 × LAX area1×
LAX area2 / LAX length
LAX area1: apical four chamber cavity area.
LAX area2: apical two chamber cavity area.
LAX length: apical length.
Disadvantage: Regions of akinesis or dyskinesis.

SIMPSON RULE METHOD OF DISKS (MOD)
Single plane =∑ L/n ×(πd/2)2
l
d
Biplane =∑ L/n ×(πd1/2)2
× πd2/2)2

LV mass/hypertrophy: 2DLV mass/hypertrophy: 2D
LV mass =(LV volume-LV cavit yLV mass =(LV volume-LV cavit y
volume)×Densit y.volume)×Densit y.
CAVITY VOLUME

Doppler-Derived IndicesDoppler-Derived Indices
 LV dP/dt.LV dP/dt.
 Normal meanNormal mean
>1200mmHg/sec>1200mmHg/sec
 Limitation:Limitation:
Changes inChanges in
ventricularventricular
loading condition.loading condition.
4 mmHg
36 mmHg
MR DOPPLER IMAGE

Velocity
Aortic velocity curve.
Time
Peak
Velocity time intergral (VTI)
AT
ET
Limitation:
- Heart rate
-Loading condition
-Cross section model
-Angular deviation

AORTIC VELOCITY CURVE.
At: Acceleration time.
VTI: Velocity time integral
during At.
CSA: Cross section area of
LVOT.
VTI
LV Force=(1.055 × CSA×VTI of At) ×(peak velocity/acceleration time).
LV acceleration (dP/dt)=V Peak of LVOT /At.

Stress velocity IndexStress velocity Index
 Velocity of circmferential fiber shortening (Vcf):Velocity of circmferential fiber shortening (Vcf):
Evrage rate of chang of the LV circumference inEvrage rate of chang of the LV circumference in
diameter per second.diameter per second.
[LVEDD-LVESD][LVEDD-LVESD]
 Vcf=Vcf= = SF/LVET= SF/LVET
LVEDD × LVETLVEDD × LVET
 Normal value:Normal value:
 Neonate: 1.5 ±0.04 cir/sec.Neonate: 1.5 ±0.04 cir/sec.
 2-10 years: 1.3 ±0.03 cir/sec.2-10 years: 1.3 ±0.03 cir/sec.
 Normalize Vcf for HR: Vcf/√RRNormalize Vcf for HR: Vcf/√RR
 Neonate: 1.28 ±0.22 cir/sec.Neonate: 1.28 ±0.22 cir/sec.
 Children: 1.08 ±0.14 cir/sec.Children: 1.08 ±0.14 cir/sec.

Stress velocity IndexStress velocity Index
Rate corrected
Vcf
LV end systolic wall stress
(g/cm2)
+2sd
-2sd
Vcfc high for σ
es
Vcfc low for σ
es
Normal range value.

Doppler Tissue ImagingDoppler Tissue Imaging
 Pulse- wave Doppler velocities directlyPulse- wave Doppler velocities directly
of underlying myocardium.of underlying myocardium.
 Site:Site:
Mitral annular DTI.Mitral annular DTI.
Septal DTI.Septal DTI.

COLOR DTICOLOR DTI
Color TDI from the apical four-chamber view.

STRAIN RATE IMAGINGSTRAIN RATE IMAGING
 Regional elongation and shortening ofRegional elongation and shortening of
myocardial tissue segments.myocardial tissue segments.
∆r
v(r)
v(r+∆r)

LEFT VENTRICULARLEFT VENTRICULAR
DIASTOLIC FUNCTIONDIASTOLIC FUNCTION
 Doppler derived indicesDoppler derived indices
Mitral inflow doppler.Mitral inflow doppler.
Pulmonary venous Doppler.Pulmonary venous Doppler.
 Color M-mode flow propagationColor M-mode flow propagation
velocity.velocity.

Doppler derived indicesDoppler derived indices

Doppler derived indicesDoppler derived indices
E
A PVs
PVd
PVa

Flow propagation velocityFlow propagation velocity
 Mitral inflow filling waves during propagationMitral inflow filling waves during propagation
from base to apex.from base to apex.
- Less effected by heart
rate, LA pressure and
loading condition.

Echocardiographic evaluation of lv function

ASSESSMENT OF LVASSESSMENT OF LV
DYSFUNCTION.DYSFUNCTION.
 Myocardial performance index.Myocardial performance index.
Normal value:Normal value:
LV indexLV index::
0.35 ±0.03.0.35 ±0.03.
RV index:RV index:
0.32 ±0.030.32 ±0.03
RelativelyRelatively
independentindependent
of changes inof changes in
preloadpreload
afterload. andafterload. and
heart rate.heart rate.

ASSESSMENT OF RIGHTASSESSMENT OF RIGHT
VENTRICLE FUNCTIONVENTRICLE FUNCTION
 Importance:Importance:
 TGA with atrial switch procedure.TGA with atrial switch procedure.
 TOFTOF
 SV with morphology of RV.SV with morphology of RV.
 LimitationLimitation
 Asymmetric and and creentic geomatric shape ofAsymmetric and and creentic geomatric shape of
RV.RV.
 New approaches:New approaches:
 RV MPI, RV dP/dt, DTI, acoustic quantifiacationRV MPI, RV dP/dt, DTI, acoustic quantifiacation
and 3D echo.and 3D echo.

Echocardiographic evaluation of lv function

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