HAMED OEMAR
Measurement of end-diastolic LV internal diameter
(LVIDd) made by properly-oriented M-Mode
techniques in the Parasternal Long Axis View (PLAX):
A. Are identical to those made from 2D images
B. Are larger than those made from 2D images
C. Are less discrepant from 2D measures with advancing age
D.Are identical if trailing edge to leading edge convention is
used
E. Are completely unreliable compared to 2D measurements
In males, the geometric pattern of left ventricular
”concentric remodeling”is present when
A. LVMI <115 g/m2 and RWT <0.42
B. LVMI >115 g/m2 and RWT >0.42
C. LVMI <115 g/m2 and RWT >0.42
D. LVMI >115 g/m2 and RWT <0.42
E. LVMI <115 g/m2 and RWT <0.34
Volumetric Measurement of LV Simpson’s Method are
superior to Linear technique
A. Small errors in linear measurements
are greatly influnce techniques.
B. Complex mathematical modeling of
precision
C. Linear measurement is for M-mod and
have decreased accuracy when applied
to 2DE
C. Volumetric techniques directly
measure volumes, whereas linear
techniques measure only length
and width
D. Volumetric techniques correct for
shape distortions better than linear
techniques.
Ventricular Chamber Size
▪ Chamber Dimensions
▪ Chamber Volume
Ventricular Muscle Mass
▪ Ventricular Wall Thickness
▪ Myocardial Hypertrophy
▪ Ventricular Geometry
Ventricular Function
▪ Systolic
▪ Diastolic
M-Mode
▪ 2D guided M-mode in PLAX view
▪ Leading edge to leading edge convention
2-Dimensional
▪ Useful in cases of off-axis M-mode
▪ Requires good endocardial definition
STANDARD M-MODE ASSESSMENT
Use “leading edge” to “leading edge” convention
2D guidance to orient M-mode perpendicular to LV
NORMAL M-MODE
IVSd = <1.1 cm
LVIDd = <5.6 cm
PWTd = <1.1 cm
LVIDs = variable
Measured in freeze-frame
▪ End-diastole –
▪ First frame after mitral valve closure or
▪ Framein which LV diameter is the largest
▪ End-systole –
▪ First frame after aortic valve closure or
▪ Framein which LV dimension is smallest
Ideally in PLAX view
▪ PSAX only if positioned perpendicular
What Criterion
did I use?
IVSd
LVIDd
PWTd
LVIDs
End Diastole
nd Systole
La ng R, et a l. J Am Soc Ec ho (2015)
La ng R, et a l. J Am Soc Ec ho (2015)
Measurement of systolic function
▪ Calculated from M-mode dimensions
LVIDd - LVIDs
= X 100
LVIDd
▪ Normal >25%
▪ Inherently limited
▪ Assessing 3D function using 1dimensional measurement
▪ Inaccurate in presence of regional wall motion
abnormalities especially at the apex
More accurate assessment of LV size
LV Ejection Fraction (%) can be calculated
2D Techniques – based on geometric assumptions
▪ Simple assumptions - easier to use but less accurate
▪ Complex assumptions - more accurate but less easy to use
3D Techniques – very accurate
▪ As yet, infrequently utilized in clinical practice
• All are based on assumption of symmetry
• Neglects focal abnormalities
• More complex geometric models are the
most
accurate
• Rotational Ellipse
• Prolate Ellipse - Bullet shape
On-line LV Volume Calculation
Simpson’s Method of Disks
Most accurate LV volume
▪ Particularly with abnormal LV shape
Apical 4 Chamber + Apical 2 Chamber
▪ Biplane approximation is best
La ng R, et a l. J Am Soc Ec ho (2015)
Use LV Volumes
▪ LVEDV = End Diastolic Volume
LVESV = End Systolic Volume
LVEDV – LVESV
EF (%) = X 100
LVEDV
Can use any LV volume technique
▪ Simpson’s Method of Discs is preferred
La ng R, et a l. J Am Soc Ec ho (2015)
3-D Volumes and EF
Left Ventricular Hypertrophy
▪ “Abnormal” increase in LV mass
▪ Important prognostic indicator
Basic concept for measurement:
LV Mass = Mass of Ca rdia c Muscle
Cardiac Muscle Mass = Volume of Muscle * Specific Gravity of Muscle
Ca rdia c Muscle Ma ss = (LV Volepi - LV Volendo) * 1.05 g/ cm 3
Using Rotational Ellipse:
▪ [(IVSd+LVIDd+PWTd)3 - (LVIDd)3] x 1.05
Using Area-Length:
▪ [(5/6 x Areaepi x Lepi) - (5/6 x Areaend x Lend)] x 1.05
Simpson’s Method
▪ NOT USED!!! Cannot define all epicardial surfaces
Adaptive response
▪ Volume and/or Pressure overload
▪ Wall thickening normalizes LV wall stress
▪ Optimizes myocardial oxygen consumption
Increase in Myocyte mass
▪ No change in myocyte number
Abnormal myocardium
▪ Fetal / alternate protein isomers
▪ Abnormal subcellular organelles
▪ Decreased capillary density
Abnormal systolic / diastolic function
▪ Subclinical initially
▪ Ultimately leads to CHF
LVH Criteria
What qualifies as “Abnormal”?
Gender M-Mode 2D
Derived Derived
Ma le >115 g/ m 2 >102 g/ m 2
Fema le >95 g/ m 2 >88 g/ m 2
Based on 2D wall thickness only:
▪ Normal = < 1.1 cm
▪ Mild LVH = 1.1 - 1.2 cm
▪ Moderate LVH = 1.2 - 1.4 cm
▪ Severe LVH = > 1.4 cm
2 x PWT
LVIDLVID
RWT = Nl ≈ 0.34
LVID
WTWT
> 0.45 ≤ 0.34
NORMAL VS SPHERICAL VENTRICLE
Severe AR
Subdivide LV:
▪ series of discs
▪ finite thickness
▪ measurable area
Disc volume =
▪ ∏ * r2 * h
Sum of disc volumes =
LV volume
Hemodynamic (Doppler) Assessment
▪ World Renowned talk by Itzhak Kronzon
Global Longitudinal Strain (and other strain)
▪ Fabulously explained by Steve Lester
Diastolic Function and Dysfunction
▪ Exquisitely delineated by Gerry Aurigemma, Miguel
Quiñonez, Natesa Pandian
Three-Dimensional (3D) Evaluation
▪ Brought to you by – Sunil Mankad
Measurement of end-diastolic LV internal diameter
(LVIDd) made by properly-oriented M-Mode
techniques in the Parasternal Long Axis View (PLAX):
A. Are identical to those made from 2D images
B. Are larger than those made from 2D images
C. Are less discrepant from 2D measures with advancing age
D. Are identical if trailing edge to leading edge convention is
used
E. Are completely unreliable compared to 2D measurements
A. Incorrect - M-mode imaging and 2D imaging represent different
modalities, and measurements derived will not be identical
B. Correct - Due to angulation of the ventricle in the PLAX, subtle
degrees of obliquity results in LVIDd measurements that are between 6
and 12 mm larger than measured directly on 2D images.
C. Incorrect - The heart typically angulates to a more apex-upward
orientation with age in the parasternal long axis view, M-Mode derived
measurements become MORE discrepant over time.
D. Incorrect – LEADING edge to leading edge measurements are
conventional on M-mode. Even if trailing edge to leading edge
measurement is made on M-mode, inherent differences in edge
detection and technique result in non-identical measurements
E. Incorrect – M-mode imaging affords extremely accurate spacial
resolution. Performed properly in correct orientation, M-mode
measurements are extremely accurate and reliable.
