(1) Echocardiography is useful for diagnosing heart failure by assessing ventricular function, sizes, wall thickness, and valve function. It can determine if systolic or diastolic dysfunction is present. (2) Biplane measurements using the Simpson's method and M-mode allow calculation of ejection fraction and evaluation of wall motion abnormalities to identify ischemic or non-ischemic causes. (3) Segmental wall motion analysis can reveal hypokinetic, akinetic, or aneurysmal regions indicating prior infarction or global dysfunction in dilated cardiomyopathy.

1. Non Invasive Diagnosis of HeartNon Invasive Diagnosis of Heart
FailureFailure
D. Rehab Al AshryD. Rehab Al Ashry
MD CardiologyMD Cardiology

2.  A clinical syndrome consisting of a constellation ofA clinical syndrome consisting of a constellation of
symptoms and signs, which are ultimately due tosymptoms and signs, which are ultimately due to
cardiac dysfunction.cardiac dysfunction.
 The diagnosis of HF involves three distinct relatedThe diagnosis of HF involves three distinct related
phases:phases:
First:First: the confirmation that the patient has HFthe confirmation that the patient has HF
Secondly:Secondly: the nature of the underlying cardiacthe nature of the underlying cardiac
dysfunction needs to be determined,dysfunction needs to be determined,
Thirdly:Thirdly: the actual aetiology of the cardiac dysfunction.the actual aetiology of the cardiac dysfunction.
 Unfortunately clinical symptoms and signs are notUnfortunately clinical symptoms and signs are not
sufficiently accurate to diagnose HF. They are oftensufficiently accurate to diagnose HF. They are often
insensitive, or where they are sensitive they lackinsensitive, or where they are sensitive they lack
specificity.specificity.
 Thus, symptoms and signs can be used to alert theThus, symptoms and signs can be used to alert the
clinician to the possible diagnosis of HF.clinician to the possible diagnosis of HF.

3. Diagnostic algorithm for heart failure. Adapted from theDiagnostic algorithm for heart failure. Adapted from the
European Society of Cardiology guidelines:European Society of Cardiology guidelines: Eur Heart JEur Heart J
2005:2005: 2222 ;1527.;1527.

4. Sensitivity and specificity of clinical symptoms andSensitivity and specificity of clinical symptoms and
signs in heart failuresigns in heart failure

5.  Baseline investigationsBaseline investigations
 HaematologyHaematology: anaemia can both cause and: anaemia can both cause and
exacerbate HF.exacerbate HF.
 Renal function and electrolytesRenal function and electrolytes is mandatory beforeis mandatory before
starting therapy.starting therapy.
 Thyroid statusThyroid status should be measured- both hypo- andshould be measured- both hypo- and
hyperthyroidism can cause HF and are commonlyhyperthyroidism can cause HF and are commonly
found in patients being treated with amiodarone.found in patients being treated with amiodarone.
 Liver function testsLiver function tests andand serum sodiumserum sodium are also usefulare also useful
simple baseline prognostic markers.simple baseline prognostic markers.
 FerritinFerritin should always be measured in the patientshould always be measured in the patient
with diabetes and HF to exclude haemochromatosis.with diabetes and HF to exclude haemochromatosis.
 Creatinine kinase (CK)Creatinine kinase (CK) measurement can also alertmeasurement can also alert
clinicians to the presence of a muscular dystrophyclinicians to the presence of a muscular dystrophy
and HF.and HF.

6. 1.1. Markers of Myocardial StretchMarkers of Myocardial Stretch
Natriuretic peptides:Natriuretic peptides:
 The B-type natriuretic peptides (BNP) and NT-proBNP (theThe B-type natriuretic peptides (BNP) and NT-proBNP (the
inactive fragment of proBNP)In both chronic and acute HF,inactive fragment of proBNP)In both chronic and acute HF,
elevated BNP concentrations have a high negativeelevated BNP concentrations have a high negative
predictive accuracy (98–99 % ) for ruling out HF as a causepredictive accuracy (98–99 % ) for ruling out HF as a cause
of the patient’s symptoms. They are therefore very reliable.of the patient’s symptoms. They are therefore very reliable.

7. • Markers of Inflammation:Markers of Inflammation:
C-Reactive ProteinC-Reactive Protein
2.2. Markers of Myocardial Cell Death:Markers of Myocardial Cell Death:
TroponinTroponin
ECG:ECG:
The negative predictive accuracy is not quite as highThe negative predictive accuracy is not quite as high
as with BNP but in most studies it is greater thanas with BNP but in most studies it is greater than
90 %. The ECG may also provide important90 %. The ECG may also provide important
information as to the underlying aetiology andinformation as to the underlying aetiology and
give additional information that may help guidegive additional information that may help guide
future therapy.future therapy.

8.  Prior myocardial infarction:Prior myocardial infarction:

9. Dilated cardiomyopathyDilated cardiomyopathy::
 Non-specific ST/T wave abnormalities.Non-specific ST/T wave abnormalities.

10.  Restrictive cardiomyopathy:Restrictive cardiomyopathy:
 Amyloid infiltration of the heart….low voltage in theAmyloid infiltration of the heart….low voltage in the
precordial leads and a prolonged PR interval at 20 ms.precordial leads and a prolonged PR interval at 20 ms.
 P mitrale/pulmonale; atrial arrhthymias.P mitrale/pulmonale; atrial arrhthymias.

11.  Hypertrophic cardiomyopathy:Hypertrophic cardiomyopathy:
 Usually abnormal (85%), with ST/T wave abnormalities and LVHUsually abnormal (85%), with ST/T wave abnormalities and LVH
particularly in the midprecordial leads. Prominent inferior or precordial Qparticularly in the midprecordial leads. Prominent inferior or precordial Q
waves are also frequently seen (in up to 50 % ).waves are also frequently seen (in up to 50 % ).

12.  LV non–compaction:LV non–compaction:
 Usually abnormal with abnormalities that include LBBB orUsually abnormal with abnormalities that include LBBB or
RBBB, fascicular block, atrial fibrillation, and ventricularRBBB, fascicular block, atrial fibrillation, and ventricular
tachycardia.tachycardia.

13.  Myocarditis:Myocarditis:
 Nonspecifi cally abnormal: ST/T abnormalities, arrhythmias;Nonspecifi cally abnormal: ST/T abnormalities, arrhythmias;
may mimic STEMI (particularly with pericardial involvement)may mimic STEMI (particularly with pericardial involvement)

14.  Arrhythmogenic RV cardiomyopathy:Arrhythmogenic RV cardiomyopathy:
Epsilon waves or localized prolongation ( > 110 ms) of the QRSEpsilon waves or localized prolongation ( > 110 ms) of the QRS
complex in right precordial leads (V1–V3), VT (usually of RVcomplex in right precordial leads (V1–V3), VT (usually of RV
origin — LBBB morphology)origin — LBBB morphology)

15.  Dystrophinopathies:Dystrophinopathies:
Tall right precordial R waves with an increased R/S ratio; deep qTall right precordial R waves with an increased R/S ratio; deep q
waves in lateral leads; conduction disturbances.waves in lateral leads; conduction disturbances.

16.  Chest X- ray:Chest X- ray:
 The chest radiograph may be suggestive of a cardiac abnormalityThe chest radiograph may be suggestive of a cardiac abnormality
when cardiomegaly (CTR>0.50) is present. Evidence ofwhen cardiomegaly (CTR>0.50) is present. Evidence of
pulmonary venous congestion, bilateral pleural effusions, orpulmonary venous congestion, bilateral pleural effusions, or
interstitial edema.interstitial edema.
 Even patients with severe LVSD can have a normal heart size onEven patients with severe LVSD can have a normal heart size on
chest radiograph.chest radiograph.
 The chest radiograph can also help identify or exclude otherThe chest radiograph can also help identify or exclude other
causes of breathlessness, such as pericardial effusion, bronchialcauses of breathlessness, such as pericardial effusion, bronchial
carcinoma, or emphysema.carcinoma, or emphysema.
 Although an increased CTR may be supportive of a cardiacAlthough an increased CTR may be supportive of a cardiac
abnormality, it need not reflect a reduced LVEF. In the registryabnormality, it need not reflect a reduced LVEF. In the registry
population of the Coronary Artery Surgery Study, two-thirds ofpopulation of the Coronary Artery Surgery Study, two-thirds of
patients with a CTR >0.50 had a normal LVEF. In the absence ofpatients with a CTR >0.50 had a normal LVEF. In the absence of
LVSD, other causes of radiographic cardiomegaly includeLVSD, other causes of radiographic cardiomegaly include
pericardial fat, left ventricular hypertrophy, pericardial effusion,pericardial fat, left ventricular hypertrophy, pericardial effusion,
valvular dysfunction, and right heart dysfunction/dilatation.valvular dysfunction, and right heart dysfunction/dilatation.

17. • Pulmonary edema

18. Non- Invasive imaging modalitiesNon- Invasive imaging modalities which canwhich can
be used:be used:
1.1. Echocardiography.Echocardiography.
2.2. Radionuclide ventriculography.Radionuclide ventriculography.
3.3. Cardiac magnetic resonance (CMR)Cardiac magnetic resonance (CMR)

19. Systolic heart failureSystolic heart failure::
(1)(1) Signs and symptoms of dyspnea, easy fatigue and exerciseSigns and symptoms of dyspnea, easy fatigue and exercise
intolerance,intolerance,
(2)(2) Dilated LV with or without a dilated RV.Dilated LV with or without a dilated RV.
(3)(3) Moderate to severe LV systolic dysfunction associatedModerate to severe LV systolic dysfunction associated
with generalized LV hypokinesis with or without segmentalwith generalized LV hypokinesis with or without segmental
akinesis/dyskinesis.akinesis/dyskinesis.
(4)(4) Diastolic dysfunction that is often proportional to systolicDiastolic dysfunction that is often proportional to systolic
dysfunction but may range from mild to severe.dysfunction but may range from mild to severe.
(5)(5) The RV may be dilated and RV systolic function may beThe RV may be dilated and RV systolic function may be
normal to severely abnormal.normal to severely abnormal.
(6)(6) Atrial enlargement is often proportional to ventricularAtrial enlargement is often proportional to ventricular
enlargement.enlargement.
(7)(7) AV valve regurgitation may range from mild to severe.AV valve regurgitation may range from mild to severe.

20. Diastolic heart failureDiastolic heart failure
1.1. Signs or symptoms of shortness of breath,Signs or symptoms of shortness of breath,
2.2. Normal or mildly abnormal systolic LV functionNormal or mildly abnormal systolic LV function
3.3. Evidence of diastolic LV dysfunction out of proportion toEvidence of diastolic LV dysfunction out of proportion to
systolic dysfunction.systolic dysfunction.

21. Echocardiography triage for cardiac function when heart failure isEchocardiography triage for cardiac function when heart failure is
clinically suggested.clinically suggested.

22.  M-mode and two-dimensional transthoracic echocardiographicM-mode and two-dimensional transthoracic echocardiographic
methods for assessment of left ventricular systolic functionmethods for assessment of left ventricular systolic function
1)1) 2-D echo with Doppler should be performed during initial2-D echo with Doppler should be performed during initial
evaluation of patients presenting with HF to assessevaluation of patients presenting with HF to assess ventricularventricular
functionfunction,, sizesize,, wall thicknesswall thickness,, wall motionwall motion, and, and valve function.valve function.
2)2) LVEF, wihch considered the single most important measurementLVEF, wihch considered the single most important measurement
in HF, help define atiology and type of HF but no correlationin HF, help define atiology and type of HF but no correlation
between symptoms and EF.between symptoms and EF.
 If EF →→ 45–54 →→ Mildly impaired systolic function.If EF →→ 45–54 →→ Mildly impaired systolic function.
 If EF →→ 30–44 →→ Moderately impaired systolic function.If EF →→ 30–44 →→ Moderately impaired systolic function.
 EF →→ <30 →→ Severely impaired systolic function.EF →→ <30 →→ Severely impaired systolic function.
 If EF ≥55% →→ LVH, LA enlargement, and/or other significantIf EF ≥55% →→ LVH, LA enlargement, and/or other significant
structural heart disease (moderate to severe valvular disease,structural heart disease (moderate to severe valvular disease,
abnormal shunt), and presence of elevation of the estimated PASPabnormal shunt), and presence of elevation of the estimated PASP
(derived from Doppler interrogation of the velocity of TR jet)(derived from Doppler interrogation of the velocity of TR jet)
increase the likelihood of a heart failure diagnosis.increase the likelihood of a heart failure diagnosis.
3)3) M-mode is also used to obtain the E point septal separationM-mode is also used to obtain the E point septal separation
(EPSS), an indirect estimation of global LV function.(EPSS), an indirect estimation of global LV function. EPSS > 1EPSS > 1
cm is considered abnormalcm is considered abnormal..

23. Parasternal long axis view of the left ventricle, and the corresponding M-mode trace
showing a thinned and hypokinetic septum of increased echogenicity. This appearance
indicates a previous full thickness infarction. Note also the dilated left ventricular cavi
ty.

24. • M-Mode echocadiogram in a patient with reduced systolic function. The E point
to septal separation (EPSS) is increased at 2 cm

25. Reduced endocardial excursion and dilatation of four chambers in the same patient with
Dilated NICM in the apical 4-chamber view in end-diastole )A) and end-systole) B)

26. 4)4) The biplane method of discsThe biplane method of discs, or, or modifiedmodified
Simpson’s ruleSimpson’s rule, recommended by the, recommended by the
American Society of Echocardiography is oneAmerican Society of Echocardiography is one
of the most commonly applied 2D techniquesof the most commonly applied 2D techniques
for obtaining the left ventricular volumes usedfor obtaining the left ventricular volumes used
in calculating an LVEF. The left ventricularin calculating an LVEF. The left ventricular
endocardial border is traced during end-endocardial border is traced during end-
diastole and end systole in orthogonal planesdiastole and end systole in orthogonal planes
that include the apex (e.g. A4Ch and A2Chthat include the apex (e.g. A4Ch and A2Ch
views). LVEF (EDV − ESV/EDV).views). LVEF (EDV − ESV/EDV).

27. Two-dimensional
measurements for
volume
calculations using
biplane method of
disks (modified
Simpson’s rule) in
apical four-
chamber (A4C) and
apical two-chamber
(A2C) views
at left ventricular
end-diastole (LV
EDD) and at left
ventricular
endsystole (LV
ESD). Papillary
muscles should be
excluded from the
cavity in the
tracing.

28. 5)5) Segmental Wall MotionSegmental Wall Motion
 Segmental wall motion abnormalities are often present inSegmental wall motion abnormalities are often present in
systolic heart failure.systolic heart failure.
 Dilated ischemic cardiomyopathy (ICM): hypokineticDilated ischemic cardiomyopathy (ICM): hypokinetic
segments as wellsegments as well as akineticas akinetic segments withsegments with or withoutor without
thinningthinning andand increasedincreased echogenicity suggestingechogenicity suggesting scarscar
formationformation..
 Dilated non-ischemicDilated non-ischemic cardiomyopathycardiomyopathy (NICM): usually(NICM): usually
global hypokinesis; some segments may be akinetic,global hypokinesis; some segments may be akinetic,
dyskinetic,dyskinetic, oror aneurysmal.aneurysmal.
 LV thrombus may be present in the apical/distal IVS region orLV thrombus may be present in the apical/distal IVS region or
rarely at inferior/lateral aneurysmal segments.rarely at inferior/lateral aneurysmal segments.
 Reversed IVS motion secondary to prior CABG, occurs in theReversed IVS motion secondary to prior CABG, occurs in the
presence of left bundle branch block or RV pacing.presence of left bundle branch block or RV pacing.
 Regional wall motion abnormalities in heart failure suggestRegional wall motion abnormalities in heart failure suggest
CAD as the etiology. An atypical distribution of regional wallCAD as the etiology. An atypical distribution of regional wall
motion abnormalities that does not correspond to a coronarymotion abnormalities that does not correspond to a coronary
artery distribution may suggest myocarditis or Takotsuboartery distribution may suggest myocarditis or Takotsubo
cardiomyopathycardiomyopathy

29. Diagram of the 2-chamber
view, the 4-chamber
view and short-axis
(SA) planes showing
the name, location and
anatomic landmarks
for selection of the
basal (tips of the mitral
valve leaflets), mid-
cavity (papillary
muscles) and apical
(beyond papillary
muscles but before
cavity ends) short-axis
slices for the
recommended 17-
segment system.

30. 5)5) LV Function Assessment by TDI.LV Function Assessment by TDI.
 TDI systolic and diastolic velocities can beTDI systolic and diastolic velocities can be
obtained reliably in basal and mid myocardialobtained reliably in basal and mid myocardial
segments by color-coded and PW Dopplersegments by color-coded and PW Doppler
techniques.techniques.
 The systolic velocity of the mitral annulus (S)The systolic velocity of the mitral annulus (S)
correlates well with LVEF and SV, withcorrelates well with LVEF and SV, with
important prognostic implications.important prognostic implications.
 Normal reference values ≥ 6 cm/sec.Normal reference values ≥ 6 cm/sec.

31. TDI velocities at septal annulusTDI velocities at septal annulus)) AA)) and lateral annulus (Band lateral annulus (B)) and at theand at thepulmonary veinspulmonary veins
(C(C).). AA′′, late diastolic velocity; D, diastolic, late diastolic velocity; D, diastolic
pulmonary vein flow velocity; Epulmonary vein flow velocity; E′′, early diastolic velocity; S, systolic pulmonary vein, early diastolic velocity; S, systolic pulmonary vein
flow velocity; Sflow velocity; S′′, systolic velocity, systolic velocity

32. 6)6) LV systolic function can be measured from rate of change ofLV systolic function can be measured from rate of change of
pressure gradients between the left ventricle and left atriumpressure gradients between the left ventricle and left atrium
using the initial slope of the mitral regurgitation envelope asusing the initial slope of the mitral regurgitation envelope as
LV dP/dt.LV dP/dt.
 Noninvasive assessment of LV contractility, normal dP/dt isNoninvasive assessment of LV contractility, normal dP/dt is
1000-1200 mmHg/s1000-1200 mmHg/s

33. Left Ventricular Diastolic FunctionLeft Ventricular Diastolic Function
 No single echocardiographic parameter is sufficiently accurate andNo single echocardiographic parameter is sufficiently accurate and
reproducible to be used in isolation to make a diagnosis of LV diastolicreproducible to be used in isolation to make a diagnosis of LV diastolic
dysfunction. Therefore, a comprehensive echocardiographic examinationdysfunction. Therefore, a comprehensive echocardiographic examination
incorporating all relevant two-dimensional and Doppler data isincorporating all relevant two-dimensional and Doppler data is
recommended.recommended.
1.1. Mitral Inflow PW DopplerMitral Inflow PW Doppler
2.2. Pulmonary Vein PW Doppler.Pulmonary Vein PW Doppler.
3.3. TDI of Mitral Annulus.TDI of Mitral Annulus.
Mitral Inflow PW DopplerMitral Inflow PW Doppler
PW sample volume is placed between the tips of the mitral valve leaflets or atPW sample volume is placed between the tips of the mitral valve leaflets or at
the level of the mitral annulus.the level of the mitral annulus.
 Normal mitral inflow comprises an early-filling E wave and a late-filling ANormal mitral inflow comprises an early-filling E wave and a late-filling A
wavewave
 Deceleration time of mitral inflow E wave is generally 170 to 180 ms.Deceleration time of mitral inflow E wave is generally 170 to 180 ms.
 FourFour major patterns of mitral inflow are seen with advancing diastolicmajor patterns of mitral inflow are seen with advancing diastolic
dysfunction:dysfunction:
 Grade I Diastolic Dysfunction:Grade I Diastolic Dysfunction: Mitral inflow filling shows an abnormalMitral inflow filling shows an abnormal
relaxation pattern withrelaxation pattern with E/A ratio of less than 1E/A ratio of less than 1, a, a prolonged mitralprolonged mitral inflowinflow
E-wave deceleration time (DT), and aE-wave deceleration time (DT), and a prolonged IVRTprolonged IVRT..

34.  Grade II Diastolic Dysfunction:Grade II Diastolic Dysfunction: A pseudonormal phase isA pseudonormal phase is
seen on mitral inflow that looks like a normal inflow fillingseen on mitral inflow that looks like a normal inflow filling
pattern. This usually reverses to an abnormal relaxationpattern. This usually reverses to an abnormal relaxation
pattern upon Valsalva maneuver.pattern upon Valsalva maneuver.
 Grade III Diastolic Dysfunction:Grade III Diastolic Dysfunction: A markedly increased E-A markedly increased E-
wave velocity is seen with a small A-wave velocity andwave velocity is seen with a small A-wave velocity and E/AE/A
ratio of greater than 2.0ratio of greater than 2.0.. DT becomes shortDT becomes short. This restrictive. This restrictive
mitral inflow pattern ismitral inflow pattern is reversiblereversible upon preload reduction withupon preload reduction with
the Valsalva maneuver or nitroglycerin or diureticthe Valsalva maneuver or nitroglycerin or diuretic
administration.administration.
 Grade IV Diastolic Dysfunction:Grade IV Diastolic Dysfunction: Same as grade III, except noSame as grade III, except no
change in filling pattern occurs with preload-reducingchange in filling pattern occurs with preload-reducing
maneuvers.maneuvers.
 Advanced systolic dysfunction is often associated with gradeAdvanced systolic dysfunction is often associated with grade
IV diastolic dysfunction.IV diastolic dysfunction.

35.  PW Doppler sample volume from an apical 4PW Doppler sample volume from an apical 4--chamber position is placed 1chamber position is placed 1
to 3 cm deep within theto 3 cm deep within the right superior pulmonary vein.right superior pulmonary vein.
 Normal pulmonary vein inflow is composed of anNormal pulmonary vein inflow is composed of an early systolic-filling Searly systolic-filling S
wavewave and aand a diastolic filling D wavediastolic filling D wave. The DT of the D wave is. The DT of the D wave is greater thangreater than
170 to 180 ms170 to 180 ms..
 Four major patterns of pulmonary inflow are seen with advancing diastolicFour major patterns of pulmonary inflow are seen with advancing diastolic
dysfunction:dysfunction:
1.1. Grade I Diastolic Dysfunction:Grade I Diastolic Dysfunction: Pulmonary inflow filling shows an S-Pulmonary inflow filling shows an S-
dominant pattern. D-wave DT is normal and atrial reversal is minimaldominant pattern. D-wave DT is normal and atrial reversal is minimal
2.2. Grade II Diastolic DysfunctionGrade II Diastolic Dysfunction: A prominent pulmonary vein atrial reversal: A prominent pulmonary vein atrial reversal
is seen with an S-dominant pattern.is seen with an S-dominant pattern.
3.3. Grade III Diastolic Dysfunction:Grade III Diastolic Dysfunction: S/D ratio reversal is present. AtrialS/D ratio reversal is present. Atrial
reversal is usually prominent, and pulmonary vein atrial duration is greaterreversal is usually prominent, and pulmonary vein atrial duration is greater
than mitral inflow A duration. The DT ofthan mitral inflow A duration. The DT of the D wave isthe D wave is less than 170 ms.less than 170 ms.
4.4. Grade IV Diastolic Dysfunction:Grade IV Diastolic Dysfunction: Same as grade III, except atrial reversal isSame as grade III, except atrial reversal is
often not seen due to mechanical atrial failureoften not seen due to mechanical atrial failure.. In the presence of atrialIn the presence of atrial
fibrillation, marked blunting of the pulmonary vein S wave with or withoutfibrillation, marked blunting of the pulmonary vein S wave with or without
mitral regurgitation (MR) is the rule.mitral regurgitation (MR) is the rule.
Pulmonary Vein PW DopplerPulmonary Vein PW Doppler

36. TDI of Mitral AnnulusTDI of Mitral Annulus
 The myocardial early motion wave shows a progressiveThe myocardial early motion wave shows a progressive
decline in amplitude with increasing stage ofdecline in amplitude with increasing stage of diastolicdiastolic
dysfunctiondysfunction
 A markedly diminished early diastolic velocity (EA markedly diminished early diastolic velocity (E′′) is) is
observedobserved inin patients with advanced restrictivepatients with advanced restrictive
cardiomyopathy.cardiomyopathy.

37. Classification of diastolic function by Doppler/tissue, Doppler echocardiography, and
correlating left ventricular and left atrial abnormalities.

38. There is an age-associatedThere is an age-associated increaseincrease in mitral inflow A velocity, E-wave DT, pulmonaryin mitral inflow A velocity, E-wave DT, pulmonary
vein S/D ratio, and E/Evein S/D ratio, and E/E′′, and there is an age-associated decrease in E/A ratio and TDI E, and there is an age-associated decrease in E/A ratio and TDI E
′′. Mitral inflow PW Doppler velocities (A), TDI velocities (B), and pulmonary vein. Mitral inflow PW Doppler velocities (A), TDI velocities (B), and pulmonary vein
Doppler velocitiesDoppler velocities ))C) are shown in 60C) are shown in 60 year-old male. year-old male.

40. Restrictive cardiomyopathy with grade IV diastolic dysfunctionRestrictive cardiomyopathy with grade IV diastolic dysfunction.. A and B are mitral inflowA and B are mitral inflow
beforebefore)) AA)) and after (Band after (B)) Valsalva maneuverValsalva maneuver.. No change in mitral inflow occurs with ValsalvaNo change in mitral inflow occurs with Valsalva
maneuvermaneuver.. Pulmonary vein shows S/D ratio of 0.3 and short pulmonary vein DT. In addition,Pulmonary vein shows S/D ratio of 0.3 and short pulmonary vein DT. In addition,
pulmonary vein Apulmonary vein A duration is greater than mitralduration is greater than mitralinflow A duration.inflow A duration.

41. Echo features of hypertrophic cardiomyopathy. Concentric LVH, with narrowing of LVOT, biventricular
hypertrophy. SAM of the MV detected readily by M-mode. Significant LVOT obstruction, with
velocity reaching 6 m/s.

42. Noncompaction cardiomyopathy. Echocardiogram showing prominent apicalNoncompaction cardiomyopathy. Echocardiogram showing prominent apical
trabeculations and recesses (arrowheads). Note thin epicardial layer (thintrabeculations and recesses (arrowheads). Note thin epicardial layer (thin
arrows).arrows).

43. Echo features of amyloidosisEcho features of amyloidosis.. Echocardiogram in 4-chamber apical viewEchocardiogram in 4-chamber apical view
shows LVH with linear “speckling” of septumshows LVH with linear “speckling” of septum ((arrowarrow)), RV free wall, RV free wall
hypertrophy, and LA enlargementhypertrophy, and LA enlargement.. LVEF 63%LVEF 63%..

44.  Transoesophageal echocardiographyTransoesophageal echocardiography::
 TEE is not needed in routine diagnostic assessmentTEE is not needed in routine diagnostic assessment
unless the transthoracic ultrasound window isunless the transthoracic ultrasound window is
inadequate (e.g. because of obesity, chronic lunginadequate (e.g. because of obesity, chronic lung
disease, ventilated patients) and an alternativedisease, ventilated patients) and an alternative
modality [e.g. cardiac magnetic resonance (CMR)modality [e.g. cardiac magnetic resonance (CMR)
imaging] is not available or applicable.imaging] is not available or applicable.
 TEE is, however, valuable in patients with complexTEE is, however, valuable in patients with complex
valvularvalvular
 disease (especially mitral disease and prostheticdisease (especially mitral disease and prosthetic
valves), suspected endocarditis, and in selectedvalves), suspected endocarditis, and in selected
patients with congenital heart diseasepatients with congenital heart disease
 TEE is also used to check for thrombus in the leftTEE is also used to check for thrombus in the left
atrial appendage of patients with AF.atrial appendage of patients with AF.

45.  Stress echocardiography:Stress echocardiography:
 This technique may also be useful in evaluating patients withThis technique may also be useful in evaluating patients with
suspected severe aortic stenosis, reduced EF, and a lowsuspected severe aortic stenosis, reduced EF, and a low
transvalvular gradient.transvalvular gradient.
 Diastolic stress testing is an emerging procedure to identify HF-Diastolic stress testing is an emerging procedure to identify HF-
PEF in patients with HF symptoms during physical activity,PEF in patients with HF symptoms during physical activity,
normal EF, and inconclusive diastolic function parameters atnormal EF, and inconclusive diastolic function parameters at
rest.rest.

46. Challenges in assessment of diastolic functionChallenges in assessment of diastolic function
1.1. Tachycardia makes evaluation of diastolic function difficult.Tachycardia makes evaluation of diastolic function difficult.
Pulmonary vein flow may be most helpful in this setting.Pulmonary vein flow may be most helpful in this setting.
2.2. In the presence of a prosthetic mitral valve, mitral stenosis, orIn the presence of a prosthetic mitral valve, mitral stenosis, or
significant mitral annular calcification, pulmonary vein flow is mostsignificant mitral annular calcification, pulmonary vein flow is most
reliable in assessing diastolic function.reliable in assessing diastolic function.
3.3. Atrial fibrillation is another common condition that makes assessmentAtrial fibrillation is another common condition that makes assessment
of diastolic function difficult due to a loss of mechanical atrialof diastolic function difficult due to a loss of mechanical atrial
function and highly variable cycle length.function and highly variable cycle length.
4.4. Significant mitral regurgitation causes S-wave blunting. InSignificant mitral regurgitation causes S-wave blunting. In
addition, increased forward flow increases the E wave. Henceaddition, increased forward flow increases the E wave. Hence
assessment of diastolic function in the presence of significant MRassessment of diastolic function in the presence of significant MR
remains challenging.remains challenging.

47. Methods Evaluating Combined Systolic andMethods Evaluating Combined Systolic and
Diastolic FunctionDiastolic Function
 TheThe myocardial performance index is defined as the summyocardial performance index is defined as the sumofof
IVCT andIVCT and IVRT divided by ET.IVRT divided by ET.
 It is useful in patients with primary myocardial systolicIt is useful in patients with primary myocardial systolic
dysfunction.dysfunction.
 The myocardialThe myocardial performanceperformance indexindex has prognostic value inhas prognostic value in
various clinical settings because itvarious clinical settings because it seems to beseems to be independent ofindependent of
heart rate.heart rate.

48. PW Doppler velocity curves of mitral inflow and left ventricular outflow.
A is time from cessation to onset of mitral inflow( shown as1; B is the left
ventricular ET from Onset to cessation of LV ejection( shown as2
Myocardial performance index is) A−B)/B.

49. ASSESSMENT OF RIGHT ASSESSMENT OF RIGHT
VENTRICULAR FUNCTION VENTRICULAR FUNCTION

50. Measurement of tricuspid annular plane systolic excursionMeasurement of tricuspid annular plane systolic excursion
(TAPSE)(TAPSE)

51. Tissue Doppler imaging of the tricuspid annulus in a patient withTissue Doppler imaging of the tricuspid annulus in a patient with
normal right ventricular systolic functionnormal right ventricular systolic function

52. The measurement of fractional area change (end-diastolic area minus end-The measurement of fractional area change (end-diastolic area minus end-
systolic area, divided by end-diastolic area) in a normal subject, and a patientsystolic area, divided by end-diastolic area) in a normal subject, and a patient
with severe RV systolic dysfunction.with severe RV systolic dysfunction.

53. Restrictive cardiomyopathies versus constrictive Restrictive cardiomyopathies versus constrictive
pericarditispericarditis

54. Radionuclide ImagingRadionuclide Imaging
 Precise measurements of LV function are necessary.Precise measurements of LV function are necessary.
 When slight changes of LV function are important such as duringWhen slight changes of LV function are important such as during
administration of cardiotoxic drugs.administration of cardiotoxic drugs.
 It can be useful when less precise modalities produce conflicting data and aIt can be useful when less precise modalities produce conflicting data and a
management decision needs to be made based on the LVEF, such asmanagement decision needs to be made based on the LVEF, such as
placement of a prophylactic internal cardiac defibrillator.placement of a prophylactic internal cardiac defibrillator.
 It can be done safely in patients who have metal prosthesis who would not beIt can be done safely in patients who have metal prosthesis who would not be
candidates for cardiac magnetic resonance imaging (CMR)..candidates for cardiac magnetic resonance imaging (CMR)..
 To evaluateTo evaluate ::
-Assessment of myocardial viability and hibernation in ischemic heart-Assessment of myocardial viability and hibernation in ischemic heart
disease.disease.
-valvular or congenital cardiac disorders,-valvular or congenital cardiac disorders,
-cardiomyopathy, and other cardiac disorders-cardiomyopathy, and other cardiac disorders
 Radioisotopes Injected IntravenouslyRadioisotopes Injected Intravenously
 3D images of the Heart3D images of the Heart
 Use Single Photon Emitting Computerized TomographyUse Single Photon Emitting Computerized Tomography ((SPECTSPECT)) permitspermits
simultaneous evaluation of regional and global ventricular function as well assimultaneous evaluation of regional and global ventricular function as well as
perfusion. However, severe perfusion abnormalities can preclude accurateperfusion. However, severe perfusion abnormalities can preclude accurate
assessment of left ventricular function and volume, resulting in anassessment of left ventricular function and volume, resulting in an
underestimation of ejection fraction.underestimation of ejection fraction.
 A gamma camera is used to capture the photon particles emitted from theA gamma camera is used to capture the photon particles emitted from the
radioisotopesradioisotopes ((same as Computerized Tomographysame as Computerized Tomography))

55. Cardiac Magnetic Resonance ImagingCardiac Magnetic Resonance Imaging
 Echocardiographic examinations are limited by poor acoustic windows.Echocardiographic examinations are limited by poor acoustic windows.
 Compared with echocardiography, CMR has superior visualization of theCompared with echocardiography, CMR has superior visualization of the
RV, isolated right ventricular myopathies.RV, isolated right ventricular myopathies.
 With its superior delineation of myocardial anatomy, CMR can assess forWith its superior delineation of myocardial anatomy, CMR can assess for
specific etiologies of systolic dysfunction including infarction,specific etiologies of systolic dysfunction including infarction,
arrythmogenic right ventricular dysplasia, and myocarditis.arrythmogenic right ventricular dysplasia, and myocarditis.
 When ECG is unclear, avoid dangers of Angiogram, repeated exposure toWhen ECG is unclear, avoid dangers of Angiogram, repeated exposure to
radiation,radiation,//or use of Ionicor use of Ionic--based dyebased dye
 Used to diagnoseUsed to diagnose --Heart muscle damage after MIHeart muscle damage after MI
-Birth defects of the heart.-Birth defects of the heart.
-Heart tumors and growths.-Heart tumors and growths.
 ShowShow -- Amount of dead heart cells after MI.Amount of dead heart cells after MI.
-Heart Valve Disorders.-Heart Valve Disorders.
-Pericardial Effusions.-Pericardial Effusions.
-Fibrosis of Heart.-Fibrosis of Heart.
-Congenital Heart Abnormalities-Congenital Heart Abnormalities
 NO RADIATIONNO RADIATION:: RadioRadio--magnetic waves.magnetic waves.
 Special dye given as IV in special testsSpecial dye given as IV in special tests ((commonly Gadoliniumcommonly Gadolinium))

56. Cardiac Magnetic Resonance ImagingCardiac Magnetic Resonance Imaging
 CMR is particularly useful in the diagnosis of pericardialCMR is particularly useful in the diagnosis of pericardial
disease through characterization of pericardial anatomy anddisease through characterization of pericardial anatomy and
detection of restricted motion at the pericardial–myocardialdetection of restricted motion at the pericardial–myocardial
interface using tagging techniques.interface using tagging techniques.

57. Panels A–D: MRI study at
baseline demonstrates slight
apical hypokinesis in end-
systolic phase (arrows in D,
C = end-diastolic phase). In
A and B, short-axis delayed-
enhanced MR images show
multiple foci in the sub-
epicardium and the midwall
(arrows in A and B) and the
acute ECG shows ST-
elevation (arrows). At 3-
months follow-up (E–H),
systolic function normalized
(G and H) and delayed-
enhancement demonstrates
resolution of inflammatory
foci (E and F, identical
location as in A and B) with
ECG normalization (F/u. (
Magnetic Resonance Imaging