Cardiac Sonographers Training Course
Systolic Function
Determinants of Left Ventricular Function
Contractility
Intrinsic strength of the muscle fibers
Difficult to measure clinically
Dependent on PRELOAD and AFTERLOAD
Preload
Determined by the degree of ventricular filling during diastole
Initial ventricular volume or pressure
Heart Rate
Afterload
Impedance or resistance against which the heart must contract
Directly influences LV shortening
Synergy of LV contraction
M Mode
measurement of the ventricular internal
dimensions and wall thickness throughout the
cardiac cycle
high time resolution
facilitates the recognition of the endocardial
borders
disadvantage of M-mode:
overestimation
beam is oblique with respect to the long or short axis of the ventricle
underestimation
the beam is not centered to the ventricular chamber
avoided by using both the PLAX and the SAX
LV asymmetry
M-mode may not be a representative of overall LVID
Dimensions and volume using M mode
2D guided M-mode in PLAX(parasternal short axis) view
leading edge to leading edge convention
following the most continuous echo line
Dimensions and wall thickness
M-mode beam at mitral chordal level perpendicular to long
axis (long axis view) centered in the short axis view
Tracing the most continuous echo line
Use leading edge to leading edge convention
2D guidance to orient M-mode perpendicular to LV
Measurement of Left Ventricle
End-diastolic dimension (LVEDD)
at the Q wave on ECG from the posterior endocardial surface of IVS to the endocardial
surface of the posterior wall
End-systolic dimension (LVESD)
from peak posterior endocardial surface of the septum to the posterior wall of left ventricle
Interventricular septal thickness (IVST)
at end diastole (onset of QRS on ECG) or end-systole between the anterior and posterior
endocardial surfaces of the interventricular septum
Posterior wall thickness (PWT)
at end diastole (Q wave on ECG) or end-systole
from the endocardial surface to epicardial
surface of the posterior wall of the left ventricle
Normal M mode measurements
IVSd
=
<1.1 cm
LVIDd
=
<5.6 cm
PWTd
=
<1.1 cm
LVIDs
=
variable
Left Ventricular Systolic Function
Fractional shortening
rough measurement of LV systolic function
Percentage of change in LV dimension during systole
Standard measures required: LVEDD
LVESD
normal range is 25% to 45% (95% CI)
Percentage of change in the LV cavity in systole
FS = LVEDD LVESD x 100
LVEDD
Inaccurate in the presence of regional wall motion abnormalities especially at the apex
EJECTION FRACTION
Uncorrected Ejection Fraction
EF% = LVEDD2 LVESD2 x 100
LVEDD2
Corrected Ejection Fraction
% EF = ( 1- %D2 ) % L ) + % D2
%D: fractional shortening of square of minor axis
% L : contractility of the LV apex
15% normal
5% hypokinetic
0% akinetic
-10% aneurysmal
-5% dyskinetic
Circumferential Fiber Shortening
Mean Vcf = LVEDD LVESD
x 100
LVEDD x LVET
Normal : 25- 45%
LVEDD= LV end-diastolic dimen. (cm)
LVESD= LV end-systolic dimen. (cm)
LVET= LV ejection time (seconds)
FS= franctional shortening (no units)
- measure extent of shortening
EPSS WIDENING
or
__FS__
LVET
(Mitral E-point septal separation)
EPSS distance increase due to:
LV dilatation
low flow across the valve
Advantage: independent of LV geometry, size and abnormal wall motion
Limitation: assumption that there is normal mitral valve motion and unimpeded LV inflow
LV Volume M Mode
Stroke volume amount of blood pumped by the heart on each heartbeat
Cardiac output volume of blood pumped by the heart per minute
Both can be calculated using LVED and LVES volumes derived from M-mode
Stroke volume (SV) = LVEDV LVESV
Cardiac Output (CO) =
SV x HR
1000
Cardiac Index (CI)= C O
BSA
LVEDV= end diastolic volume
HR = heart rate
BSA = body surface area
LVESD= end systolic volume
1000 = conversion of cc to liters
Left ventricular volume calculation are based on the assumption that the left ventricle is shaped
like a prolate ellipse
Cubed Method
The ventricle is a prolate ellipse
Minor axes: D1 and D2
Major axis: D3 (L)
V = 4 (3.1416) D1 x D2 x L
3
2
2
2
Assumptions:
LV dilates along the minor axis
LV internal diameter is equal to one of the minor axes of the ellipse
both minor axes are equal
major axis to minor axis ratio 2:1
Regression Formula
LVV = __ 7_
x D3
2.4 + D
Factors affecting Quality
Theoretical resolution (transducer frequency)
Overall technical quality of the derived M-mode trace
Inconsistency in measurements due to operator variability in the selection of measured
interface
2DE examination
Visualization of the entire heart
The assessment of global and segmental left ventricle is further enhanced
2D Echo is used when:
spatial orientation for measurement is important (ie. LVOT diameter)
structures of interest cannot be aligned perpendicular to the ultrasound beam (ie. pul valve
annulus)
assessing LV systolic function in the presence of regional wall motion abnormalities
2D measurements are performed from inner edge to inner edge
Major axis of LV:(apical 4-chamber view) from apical endocardium to the middle of the mitral
valve annulus
Minor axis: (apical 4 chamber view and various parasternal views)
Technical Considerations:
Image maximization
Both AV valves imaged
Avoid aorta and coronary sinus
Selection of precise time in cardiac cycle for measurements
End-diastolic frame is the largest LV cavity just after MV closure at ECG R wave
End-systolic frame is the smallest cavity just before MV opening
Use the apical 2 chamber and apical 4 chamber views
2 methods are recommended by ASE
Modified Simpsons method
single plane area-length method
Potential Limitations
Require high-quality images (endocardial definition)
Require no major shape distortion
Beam orientation (avoid oblique measurements)
Limited frame rate of 2D imaging
Foreshortening of long axis of LV
Influence of loading conditions
Modified Simpsons Rule
paired apical view are measured: apical 2 chamber
and 4 chamber
divides ventricular length into twenty equal sections
Volumes approximate angiographic data
Advantage: independent of the geometrical shape of
the ventricle
Computed by most echo machines
Single Plane Method
when only one apical view is able to assessed
the ventricle is considered symmetrical
Volume = 0.85 x A2
L
A = area of the ventricle L = long axis of the ventricle
Three variables used most frequently
Fractional shortening
percent change in LV dimension with systolic contraction
Ejection fraction
stroke volume as percent of end-diastolic LV volume
cardiac output
product of stroke volume and heart rate
SUBJECTIVE ESTIMATION OF EJECTION FRACTION (EYE BALLING)
done in real time viewing
estimate of the percent reduction of the intraventricular area in systole and diastole using
the short axis view
Regional Wall Assessment
Three Levels:
Basal
Mid
Apex
16 segments in total
Scoring System:
Based on Contractility of Individual Segments:
1=normal
2=hypokinesis
3=akinesis
4=dyskinesis
5=aneurysmal
Wall Motion Score Index (WMSI):
Sum of Wall Motion Scores
Number of Visualized Segments
WMSI>1.7 usually indicates perfusion defect of >20%
Doppler Echo
Assumption for accurate measurement
Accurate cross sectional flow area measurement
Laminar Flow
Spatially flat flow velocity profile
Parallel intercept angle
Velocity and diameter measurement at the same
anatomic site
Doppler assessment of LV function
Flow through the LVOT
Velocity time integral = flow through a single point
Therefore: Area x VTI = flow through LVOT
Stroke volume
Flow through a single point x area = stroke volume
Area of a circle = (D/2)2
= r2
Flow LVOT= (DLVOT/2)2 x VTILVOT
Spectral envelope of pulse wave Doppler - sample
volume in LVOT
dp/dt using MR jet
Maximum rate of LV pressure generation measured
invasively
MR spectral envelope can be used for similar calculation
LA pressure not usually contributory
Influenced by heart rate and preload
MR spectral envelope
Measure time between 1m/sec and 3 m/sec
36 - 4 = 32 mm Hg/time
Correlates with cath lab value
> 1343 mm Hg/sec predicts normal LVEF after MVR
32 mm Hg/ 12 msec
dP/dt = 2,666 mm Hg/sec
Tissue
Doppler
Myocardial motion characterized by low velocity and high amplitude
Spectral measurement has high temporal resolution
Lateral annular velocity measured in apical 4 chamber correlates with LVEF
Systolic tissue Doppler velocity in normal and abnormal
Normal
Abnormal
Sm 12cm/s
Sm 6cm/s
