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Echo assessment of lv systolic function and swma

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Echo assessment of lv systolic function and swma

  1. 1. Fuad Farooq
  2. 2.  Assessment of ventricular systolic function, theessential part of all echocardiographyexaminations
  3. 3.  2D echo allows visualization of theendocardium and it’s thickening, by whichglobal and regional ventricular systolicfunctions are assessed Quantitative assessment of global systolicfunction is usually based on changes inventricular size and volume
  4. 4.  Fractional shortening of LV Ejection fraction Stroke volume and cardiac index Systolic tissue velocity of the mitral annulusand myocardium Tissue tracking Regional wall motion analysis
  5. 5.  Percentage change in LV dimensions with eachLV contraction Reflects global ventricular functionLVED - LV end-diastolic dimensionLVES - LV end-systolic dimension
  6. 6.  Assesses ventricular function only at the levelbeing interrogated If regional dysfunction is present, which is not in theinterrogation plane, it may result in a misleadingestimate of global ventricular function
  7. 7.  Expression of global LV function Strong predictor of clinical outcome in almostall major cardiac conditions Determined visually by eyeballingechocardiographic images of the LV Considerable inter-observer variation but withexperienced readers variation is less than 5%
  8. 8.  Measured quantitatively by using volumetricmeasurements from M-mode, 2D and 3DechocardiogramsLVEDV - LVESVLVEDVLVEF =
  9. 9.  EF can also calculated from LV dimensionsmeasured with M-mode Measurement of LV dimensions from the midventricular level is used to calculate LVEFLVEDD2 – LVESD2LVEDD2Add 15% for normal, 5% for hypokinetic apex, 0% forakinetic apex, -5% for dyskinetic apex, and -10% forapical aneurysmLVEF = x 100
  10. 10.  Not a true indicator of systolic function Determined by multiple factors Provides the amount of blood volume ejectedwith each cardiac cycle
  11. 11.  Stroke volume can be measured as thedifference between the LV end-diastolicvolume and LV end-systolic volume obtainedby the Simpson method
  12. 12.  The difference should be equal to SV across theLVOT if there is no valvular regurgitation If there is MR, regurgitant volume needs to besubtracted to obtain stroke volume across theLVOT
  13. 13. Calculated asSV = LVOT area x LVOT TVI(time velocityintegral)
  14. 14.  Cardiac output is calculated as:CO = SV x HR Cardiac index is calculated as:COBody Surface Area (BSA)CI =
  15. 15.  Tissue Doppler imaging records the velocity ofmyocardial tissue The systolic component (S’) of the mitralannulus correlates well with the LVEF
  16. 16.  Value of 8cm/s was selected as a cutoff point Vinereanu et al. have reported (80%sensitivity, 89% specificity) for the same cutoffpoint of S’ measured at the medial mitralannulus and (80% sensitivity, 92% specificity)for S’ measured at the lateral mitral annulusEstimation of global left ventricular function from the velocity of longitudinal shortening.Echocardiography 2002;19(3):177-185
  17. 17.  Systolic contraction of the ventricles isperformed optimally when regionalcontractions are coordinated All walls should contract within 20 to 30milliseconds of each other Disrupted by conduction delay, atrialfibrillation, or a pacemaker
  18. 18.  Assessed best with tissue Doppler imaging Reliably provide timings of cardiac events ormyocardial movement
  19. 19. TDI in systoleTDI in diasystole
  20. 20. Tissue colour Doppler in M-mode
  21. 21.  It is byproduct of tissue Doppler imaging Basoapical views of each ventricular segmentare displayed as seven color bands, with eachcolor representing a particular distance thetissue moves during systole Tissue tracking provides a rapid assessment ofsystolic motion
  22. 22.  Mitral anulus displacement can be determinedinstantaneously with tissue tracking Normal mitral annular systolic motion is>8mm (average 12 + 2 on apical 4 or apical 2views) A systolic mitral anulus displacement of lessthan 5 mm determined by tissue trackingcorrelates well with a severe decrease in theLVEF (<30%)
  23. 23.  Normal ventricular contraction consists ofsimultaneous myocardial thickening andendocardial excursion toward the center of theventricle Regional contractility or wall motion of the LV isgraded by dividing the LV into segments In 2002, a 17-segment model was recommended bythe American Society of Echocardiography LV is divided into three levels - basal, mid orpapillary and apicalCirculation, 2002;105: 539-542
  24. 24. Basal1.Anteroseptum2. Anterior3. Lateral4. Inferolateral5. Inferior6. InferoseptumMid1.Anteroseptum2. Anterior3. Lateral4. Inferolateral5. Inferior6. InferoseptumApical1. Anterior2. Lateral3. Inferior4. SeptalApical cap
  25. 25.  Numerical score is assigned to each wallsegment on the basis of its contractility asassessed 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)
  26. 26.  On the basis of this wall motion analysisscheme, a wall motion score index (WMSI) iscalculated to semiquantitate the extent ofregional wall motion abnormalitiesNormal WMSI is 1WMSI > 1.7 may suggest perfusion defect > 20%
  27. 27. Qualitative estimation errors due to: Underestimation of EF due to endocardial echodropout and seeing mostly epicardial motion Underestimation of EF with enlarged LV cavity; alarge LV can eject more blood with less endocardialmotion Overestimation of EF with a small LV cavity Significant segmental wall motion abnormalities
  28. 28. NormalAbnormal
  29. 29. Myocardial performance indexTEI index = IVRT + IVCTLVET IVCT - Isovolumic contraction time IVRT - Isovolumic relaxation time LVET - LV ejection time Normal in 0.39 +/- 0.05
  30. 30. 1. E-point septal separation2. Aortic valve opening pattern
  31. 31.  The magnitude of opening of the mitralvalve, as reflected by E-wave height, correlateswith transmitral flow and, in the absence ofsignificant mitral regurgitation, with leftventricular stroke volume Mitral valve E point (maximal early opening) iswithin 6 mm of the left side of the ventricularseptum In the presence of a decreased ejectionfraction, this distance is increased
  32. 32. Severe systolic dysfunction
  33. 33.  If left ventricular forward stroke volume isdecreased, there may be a gradual reduction inforward flow in late systole, which results ingradual closing of the aortic valve in latesystole. This results in a rounded appearance ofthe aortic valve in late systole

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