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EVALUATION OF SYSTOLIC FUNCTION

EVALUATION OF SYSTOLIC FUNCTION. ECHOCARDIOGRAPHY/ANGIOGRAPHY DEEPAK NANDAN. “SYSTOLE”- CONTRACTION “DIASTOLE”-TO SEND APART. Systolic function is affected by preload afterload,contractility and heart rate. Asynchronous systolic contraction also may affect systolic function.

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EVALUATION OF SYSTOLIC FUNCTION

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  1. EVALUATION OF SYSTOLIC FUNCTION ECHOCARDIOGRAPHY/ANGIOGRAPHY DEEPAK NANDAN

  2. “SYSTOLE”- CONTRACTION • “DIASTOLE”-TO SEND APART

  3. Systolic function is affected by preload afterload,contractility and heart rate. • Asynchronous systolic contraction also may affect systolic function

  4. LV SYSTOLIC FUNCTION • Quantitative echo • LV VOLUME • LV MASS • EJECTION INDICES STROKE VOLUME EJECTION FRACTION FRACTIONAL SHORTENING VELOCITY OF CIRCUMFERENCIAL FIBRE SHORTENING

  5. Quantify LV function -MODES • M-Mode • Modified Simpson’s Method • Single plane area-length method • Velocity of Circumferential Shortening • Mitral Annular Excursion • E-point to septal separation • Rate of rise of MR jet • Index of myocardial performance • Subjective assessment

  6. M-Mode Quantification • Use Parasternal Short-Axis or Long-Axis views to measure LVEDD and LVESD • May take several measurements at different levels and calculate average • Assumes that no significant regional wall motion abnormalities are present

  7. Uncorrected (LVEDD)² - (LVESD)² LVEF = ----------------- X 100 (LVEDD)² If apical contractility is normal Corrected LVEF = Unc LVEF +(100 – Unc LVEF) X 15%) 5% hypokinetic, 0% akinetic, -5% dyskinetic, -10% aneurysm

  8. Global Myocardial Function • Fractional shortening (FS) • Assumes symmetric contraction • Ejection fraction (EF)

  9. M-MODE-LINEAR MEASUREMENTS

  10. INDIRECT M-MODE MARKERS • EPSS • GRADUAL CLOSURE OF AORTIC VALVE • MEAN Vcf-rate of shortening of LV

  11. EPSS

  12. Mitral Annular Excursion toward LV Apex • M-mode tracings in systole • The magnitude of systolic motion is proportional to the longitudinal shortening of the LV • Normal mitral annular systolic motion is 8mm+ (average 12 +/- 2 on apical4 or apical 2 views) • If motion is < 8 mm, the EF is likely < 50%

  13. Velocity of Circumferential shortening • Vcf is the mean velocity of LV shortening through the minor axis • Vcf = FS/ET • ET is the time between LV isovolumetric contraction and isovolumetric relaxation • Measure by obtaining M-mode of AV opening to AV closure, aortic flow by doppler, or by an external pulse recording of carotid artery • NL values are > 1.0 c/s • Slow Vcf may suggest diminished systolic function

  14. 2-D MEASUREMENTS

  15. Ejection Fraction • Quantitative - accuracy, reproducibility limited - assumes shape of LV cavity - best in symmetric ventricles

  16. SIMPSONS RULE\ RULE OF DISC

  17. Simpson’s Rule – the biplane method of disks LV-ED LV-ES • Volume left ventricle - manual tracings in systole and diastole - area divided into series of disks - volume of each disc(πr2x h ) summed = ventricular volume LV-ED LV-ES A4C A2C

  18. LEFT VENTRICULAR MASS

  19. TEICHOLZ /CUBED FORMULA

  20. LV Mass Quantification • 2D M-Mode method using parasternal short axis view or parasternal long axis view • Assumes that LV is ellipsoid (2:1 long/short axis ratio) • Measurements made at end diastole • ASE approved cube formula: • LV mass (g) = 1.04 [(LVID + PWT + IVST)3 - (LVID)3] X 0.8 + 0.6 LV mass index (g/m2) = LV mass / BSA • Small errors in M-Mode cause large errors in mass values. Can have off axis/tangential cuts due to motion.

  21. LV Mass Quantification • LV mass = 1.04[(IVS + LVID + PWT)3 – (LVID)3] – 13.6 g NL LV mass index for males: 93±22g/m2 NL LV mass index for females: 76±18g/m2

  22. LV MASS BY 2-D

  23. RWT = 2(PWT/LVID)

  24. REGIONAL LEFT VENT FUNCTION

  25. Regional Myocardial Function • Assessment of motion of regions of the myocardium • Useful for detection of myocardial ischemia • Leads to decreased or paradoxical motion of the wall in affected areas • Regions can be roughly mapped to coronary arteries

  26. NONISCHEMIC RWMA

  27. DIFF ISCHEMIC VS NONISCHEMIC

  28. LBBB

  29. DOPPLER EVALUVATION OF GLOBAL LVF

  30. SCHEMATIC REP OF ASSESSMENT OF LV VOL

  31. Stroke Volume and Cardiac Output • Flow = Cross sectional area (CSA) x Average velocity • Average velocity not usually measured directly • VTI = velocity-time integral • Area under the velocity curve for a single beat • Represents ‘stroke distance’ • SV = VTI * CSA

  32. Stroke Volume Measurement Measurement of VTI Measurement of CSA

  33. Pitfalls in Echo Calculation of CO • Accurate measurement of CSA • Weakest link in the calculation • VTI very good for assessing change in cardiac output with therapy, by following changes in VTI, since CSA is largely invariant in an individual • Measures forward flow only • Regurgitant fraction not considered • May over-estimate systemic cardiac output • Echocardiographic window in mechanically ventilated patients may be poor

  34. WALL STRESS

  35. LEFT VENTRICULAR dp/dt

  36. CW doppler to measure rate of rise of MR jet may correlate to LVEF A slow rate of rise may indicate poor systolic function Must have MR present, and good doppler study present (more difficult with eccentric jets)

  37. INDEX OF MYOCARDIAL PERFORMANCE

  38. Index of Myocardial Performance Uses systolic and diastolic time intervals to evaluate global ventricular performance Systolic dysfunction causes prolonged isovolumetric contraction time (ICT) and a shortened ejection time (ET). IMP = (ICT + IRT)/ET

  39. Index of Myocardial Performance • Normal LV: 0.39 +/- 0.05 • LV, DCM: 0.59 +/- 0.10 • Normal RV: 0.28 +/- 0.04 • Primary PulmHtn: 0.93 +/- 0.34 • Use PW of AV inflow signal, or CW to get AV regurgitant signal • Also need to measure interval between AV closure and opening (AVco) • PW or CW to capture semilunar outflow signal to measure ejection time (ET) IMP = (AVco – ET)/ET

  40. Summary • LV Mass Quantification: M-mode, Area-length method, Truncated ellipsoid method, and Subjective assessment. • LV Volume Quantification: M-mode, Subjective assessment • LV Function Quantification: Modified Simpson’s and Subjective Assessment by region.Also by M-mode, Single plane area length method, Velocity of Circumferential Shortening, Mitral Annular Excursion, EPSS, Rate of Rise of MR jet, Index of myocardial performance, etc

  41. ANGIOGRAPHIC ASSESSMENT OF LV FUNCTION

  42. LV PRELOAD • Amout of passive tension or strectch on the ventricular walls prior to systole • This load determines end diastolic sarcomere length and force of contraction • This inturn decides stroke volume and cardiac output

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