assessment of systolic function of left ventricle

2. Heart =
longitudinal
Radial
Circumferential
twisting (apex
counter
clockwise base
clockwise

5.  FS
 EF
 SV and cardiac index
 Systolic tissue velocity of the mitral annulus
and myocardium
 Tissue tracking
 Regional wall motion analysis

6.  Percentage change in LV
dimensions with each LV
contraction
 global ventricular function

7.  only at the level being interrogated
 If regional dysfunction is present, which is not in the
interrogation plane-misleading estimate

8.  global LV function
 eyeballing e
 inter-observer variation

9.  volumetric measurements
LVEDV - LVESV
LVEDV
LVEF =

10. 
 LV dimensions from the mid
ventricular level is used to calculate
LVEF
LVEDD2 – LVESD2
LVEDD2
LVEF = x 100

11.  Not a true indicator of systolic function
 Determined by multiple factors
 amount of blood volume ejected with each
cardiac cycle
 difference between the LV end-diastolic
volume and LV end-systolic volume obtained
by the Simpson method

12.  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

13. Calculated as
SV = LVOT area x LVOT TVI(time velocity
integral)

14. 
 The systolic component (S’) of the mitral
annulus correlates well with the LVEF

15.  Mitral anulus displacement -tissue tracking
 Normal mitral annular systolic motion is
>8mm (average 12 + 2 on apical 4 or apical 2
views)
 systolic mitral anulus displacement of < 5 cm
= LVEF (<30%)

16.  8cm/s --cutoff point

Estimation of global left ventricular function from the velocity of longitudinal shortening.
Echocardiography 2002;19(3):177-185

17.  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
 tissue Doppler imaging-- timings of cardiac
events or myocardial movement

18. TDI in systole
TDI in diasystole
Doppler Tissue Velocity

19. Tissue colour Doppler in M-mode

20.  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

21.  The simplest to understand is displacement, defined as
excursion (in millimeters). (product of systolic velocity
and duration of contraction. )
 Strain rate imaging is a newly developed variation of
DTI that provides a high-resolution evaluation of
regional myocardial function.

22.  Strain rate is defined as the instantaneous rate of
change in the two velocities divided by the
instantaneous distance between the two points.
 Positive strain rate represents active contraction and
negative values, relaxation or lengthening between the
two points.
 strain rate has been demonstrated to be a more
sensitive and earlier indicator of regional dysfunction
than many routine techniques.
 Strain rate imaging has tremendous temporal
resolution as well and can be used to demonstrate
subtle phenomena such as postsystolic contraction.

24.  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

25. 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

27.  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)

28.  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%

29. 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

30. 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

32.  . Twist is defined as
(Φapex − Φbase), twist per
unit length as (Φapex −
Φbase)/D, and left
ventricle (LV) torsion T
(circumferential-
longitudinal shear angle)
as (Φapex − Φbase) (ρapex −
ρbase)/2D. Mostly,
counterclockwise
rotation as seen from the
apex is positive.

33. Definition of the normalized twist, where this
twist angle is divided by the distance (D)
between the measured locations of base and
apex . However, to make LV torsion
comparable among differently sized hearts, the
normalized twist should be multiplied by the
mean radius (ρ) of base and apex
T=(ϕapex−ϕbase)×(ρapex+ρbase)2D

34. 1. E-point septal separation
2. Aortic valve opening pattern

35.  magnitude of opening of the mitral valve=E-
wave height, correlates with transmitral flow
and, in the absence of significant MR, with LV
SV
 Mitral valve E point (maximal early opening) -
within 6 mm of the left side of the ventricular
septum
 decreased ejection fraction-distance is
increased

36. Severe systolic dysfunction

38.  stroke volume is
decreased
 gradual reduction in
forward flow in late
systole,
 gradual closing of the
aortic valve in late
systole.
 rounded appearance
of the aortic valve in
late systole

39. .. .
 M Mode
 Pulse wave tissue
Doppler
 Color Coded Tissue
Doppler

41. PULSED WAVE TISSUE DOPPLER
MITRAL ANNULAR PEAK S WAVE
VELOCITY 7.5 CM/SEC
COLOR CODED TISSUE DOPPLER
MITRAL ANNULAR MEAN S WAVE
VELOCITY 5.4 CM/SEC

42. Diastolic Function

43. rate and time course of blood flow from LA to
LV is determined by
1.Pressure difference along the path
2.Ventricular relaxation
3.Relative compliances of the two chambers
Basic Principle

44. Basic Principle

45. 1.Ventricular relaxation
2.Myocardial compliance and Chamber
Compliance
3. LV-EDP
4.Ventricular Diastolic filling
5.Atrial Pressures and Filling
Parameters of Diastolic Function

46. Ventricular Relaxation
-occurs during IVR and early diastolic filling
-active process involving utilization of energy of the
myocardium.
The measure of Ventricular Relaxation include the
following:
1.Isovolumic relaxation time (IVRT)
2.The maximum rate of pressure decline (- dP/dt)
Parameters of Diastolic Function

47. Parameters of Diastolic Function

48. -dP
dt
-dP/dT
Parameters of Diastolic Function

49. Ventricular Compliance
ratio of change in volume to change in
pressure (dV/dP).
Stiffness -inverse of compliance: the ratio
of change in pressure to change in volume
(dP/dV)
Parameters of Diastolic Function

50. Compliance :
1.Myocardial compliance – isolated myocardium
2.Chamber Compliance – entire chamber
Parameters of Diastolic Function

51. Parameters of Diastolic Function

52. Chamber compliance :
1.Ventricular size and shape
2.Characteristics of the myocardium
3.Extrinsic factors:
a.pericardium
b.RV volume
c.pleural pressure
Parameters of Diastolic Function

53. Factors that affect Diastolic filling
Early filling
•Ventricular Diastolic Function
•Changes in the pressure difference between the
ventricle and atrium due to changes in preload.
•Changes in Transmitral volume flow rate (increased
in MR).
•Change in LA pressure.
Parameters of Diastolic Function

54. Late filling
•Ventricular Diastolic function
•Cardiac rhythm
•Atrial contractile function
•Ventricular end-diastolic pressure
•HR
•Time of atrial Contraction
Parameters of Diastolic Function

55. Left Ventricular Filling

56. Factors that Affect Doppler Left
Ventricular Filling
1.Technical
2.Normal Variations
3.Physiologic
Technical
1.Sample volume location
2.Doppler modality
3.Intercept angle
Left Ventricular Filling

57. Normal Variation
Respiration – Increase filling during inspiration
on the right, increase filling at end of
expiration on the left.
Left Ventricular Filling

58. Normal Variation
Heart rate – Increase
heart rate shortens
diastasis so that the A
velocity more closely
follow the E velocity.
Left Ventricular Filling

59. PR interval
Longer PR interval results in an A
velocity early in diastole.
Left Ventricular Filling

60. Age
As age increase E velocity
diminishes and the
atrial contribution becomes
more prominent with
equalization of the E and
A velocities
age 60 years - reversal of
the E/A ratio
Left Ventricular Filling

61. Physiological Factors
• LA pressure (preload)
• Volume flow rate (MR)
• Left ventricular systolic
function (LV-ESV)
• Atrial contractile function
Left Ventricular Filling

62. Pattern
Impaired Relaxation:
• Prolong IVRT
• Decreased early DT
• Decreased E wave
• Increased A wave
Left Ventricular Filling

63. Pattern
• Reduced Compliance:
• Shorten IVRT
• Increased E wave
• Steep early DT
• Decreased A wave
Reduced Compliance

64. Left Atrial Filling
• Window and Plane – A4C
• Vein interrogated – Right superior
pulmonary vein.
Left Atrial Filling

65. Pattern
1. Small reversal of flow following
atrial contraction (a wave)
2. Systolic filling phase
3. Blunting of flow or brief
reversal at end-systole
1. Diastolic filling phase
Left Atrial Filling

66. Factors that affect LA filling Pattern
Systolic Atrial Filling
1. Age
2. LA size
3. LA pressure
4. LA contractile function
Left Atrial Filling

67. Diastolic Atrial Filling
1. Gradient from PV to LV
2. LV diastolic relaxation
3. LA compliance
4. LV compliance
Left Atrial Filling

68. Impaired Relaxation
1. Prominent reversal
2. Blunting of the diastolic flow
Pattern of Left Atrial Filling

69. Reduced Compliance
1. Prominent reversal
2. Prominent diastolic flow
Pattern of Left Atrial Filling

70.  Mitral Inflow +/- Valsalva
 Pulmonary Venous Flow
 Tissue Doppler
 Color M-mode

71. Mitral Inflow

72. Mitral Inflow
cm/s
E velocity

73. Mitral Inflow
cm/s
A velocity

74. Mitral Inflow
cm/s
IVRT

75. Mitral Inflow
cm/s
A dur

76. Mitral Inflow
cm/s
Deceleration time

77. Mitral Inflow
cm/s
E velocity
A velocity
IVRT
A dur
Deceleration time

78. Pulmonary Venous Flow

79. cm/s S velocity
Pulmonary Venous Flow

80. cm/s
D velocity
Pulmonary Venous Flow

81. cm/s
AR velocity
Pulmonary Venous Flow

82. cm/s
AR dur
Pulmonary Venous Flow

83. cm/s
D velocity
S velocity
AR velocity
AR dur
Pulmonary Venous Flow

84. Tissue Doppler

85. Tissue Doppler
cm/s
E’ velocity

86. cm/s
A’ velocity
Tissue Doppler

87. cm/s
E’ velocity
A’ velocity
Tissue Doppler

88. PARAMETERS MEASUREMENTS
1. Mitral Valve inflow
a. E wave velocity
b. A wave velocity
c. E/A ratio
d. Deceleration Time
e. A wave duration
f. IVRT
2. Mitral Valve inflow with reduced
preload a. E wave velocity
b. A wave velocity
c. E/A ratio
3. Pulmonary Venous flow
a. S wave
b. D wave
c. A reversal velocity
d. A reversal duration

89. PARAMETERS MEASUREMENTS
4. Tissue Doppler
a. E’
b. A’
c. E/E’
5. Color M-mode
a. Vp
b. E/Vp
Diastolic Evaluation

90. E/A ratio 1.0 to 1.5
Deceleration time 160 to 240 ms
IVRT 76 +/- 13 > 40 yr
69 +/- 12 < 40 yr
Valsalva maneuver Preserved E/A ratio
Pulmonary a wave flow reversal < 35 cm/s
Mitral A wave duration Greater than pulmonary A
reversal duration
Pulmonary S wave velocity Greater or equal to pulmonary
D wave velocity.
Cardiac structure and function. Normal

91. Stage I: Impaired Relaxation
Stage II: Pseudo-normalization
Stage III: Reversible Restrictive
Stage IV: Irreversible Restrictive

92. E/A < 1.0
Stage I

93. 1.0 < E/A < 2.0
• AR < 0.35
• AR dur < A dur
• No E/A reversal
• Vp > 45
• E/Vp < 1.5
• E/E/ < 10
• AR > 0.35
• ARdur > A dur + 30 ms
• E/A reversal
• Vp < 45
• E/Vp >1.5
• E/E/ > 10
Valsalva
PV inflow
Tissue Doppler
Color M-Mode
Valsalva
PV inflow
Tissue Doppler
Color M-Mode
Normal Stage II

94. E/A > 2.0
• E/A reversal
• Decrease E/
• Decrease E/ / A/ < 1
Valsalva
Tissue Doppler
Valsalva
Tissue Doppler
Stage III Stage IV
• No E/A reversal
• Decrease E/
• Decrease E/ / A/ > 1