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Echocardiographic assesment of systolic and diastolic dysfunction

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assessment of systolic function of left ventricle

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Echocardiographic assesment of systolic and diastolic dysfunction

  1. 1. Heart = longitudinal Radial Circumferential twisting (apex counter clockwise base clockwise
  2. 2.  FS  EF  SV and cardiac index  Systolic tissue velocity of the mitral annulus and myocardium  Tissue tracking  Regional wall motion analysis
  3. 3.  Percentage change in LV dimensions with each LV contraction  global ventricular function
  4. 4.  only at the level being interrogated  If regional dysfunction is present, which is not in the interrogation plane-misleading estimate
  5. 5.  global LV function  eyeballing e  inter-observer variation
  6. 6.  volumetric measurements LVEDV - LVESV LVEDV LVEF =
  7. 7.   LV dimensions from the mid ventricular level is used to calculate LVEF LVEDD2 – LVESD2 LVEDD2 LVEF = x 100
  8. 8.  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
  9. 9.  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
  10. 10. Calculated as SV = LVOT area x LVOT TVI(time velocity integral)
  11. 11.   The systolic component (S’) of the mitral annulus correlates well with the LVEF
  12. 12.  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%)
  13. 13.  8cm/s --cutoff point  Estimation of global left ventricular function from the velocity of longitudinal shortening. Echocardiography 2002;19(3):177-185
  14. 14.  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
  15. 15. TDI in systole TDI in diasystole Doppler Tissue Velocity
  16. 16. Tissue colour Doppler in M-mode
  17. 17.  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
  18. 18.  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.
  19. 19.  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.
  20. 20.  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
  21. 21. 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
  22. 22.  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)
  23. 23.  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%
  24. 24. 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
  25. 25. 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
  26. 26.  . 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.
  27. 27. 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
  28. 28. 1. E-point septal separation 2. Aortic valve opening pattern
  29. 29.  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
  30. 30. Severe systolic dysfunction
  31. 31.  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
  32. 32. .. .  M Mode  Pulse wave tissue Doppler  Color Coded Tissue Doppler
  34. 34. Diastolic Function
  35. 35. 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
  36. 36. Basic Principle
  37. 37. 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
  38. 38. 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
  39. 39. Parameters of Diastolic Function
  40. 40. -dP dt -dP/dT Parameters of Diastolic Function
  41. 41. 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
  42. 42. Compliance : 1.Myocardial compliance – isolated myocardium 2.Chamber Compliance – entire chamber Parameters of Diastolic Function
  43. 43. Parameters of Diastolic Function
  44. 44. 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
  45. 45. 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
  46. 46. Late filling •Ventricular Diastolic function •Cardiac rhythm •Atrial contractile function •Ventricular end-diastolic pressure •HR •Time of atrial Contraction Parameters of Diastolic Function
  47. 47. Left Ventricular Filling
  48. 48. 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
  49. 49. Normal Variation Respiration – Increase filling during inspiration on the right, increase filling at end of expiration on the left. Left Ventricular Filling
  50. 50. Normal Variation Heart rate – Increase heart rate shortens diastasis so that the A velocity more closely follow the E velocity. Left Ventricular Filling
  51. 51. PR interval Longer PR interval results in an A velocity early in diastole. Left Ventricular Filling
  52. 52. 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
  53. 53. Physiological Factors • LA pressure (preload) • Volume flow rate (MR) • Left ventricular systolic function (LV-ESV) • Atrial contractile function Left Ventricular Filling
  54. 54. Pattern Impaired Relaxation: • Prolong IVRT • Decreased early DT • Decreased E wave • Increased A wave Left Ventricular Filling
  55. 55. Pattern • Reduced Compliance: • Shorten IVRT • Increased E wave • Steep early DT • Decreased A wave Reduced Compliance
  56. 56. Left Atrial Filling • Window and Plane – A4C • Vein interrogated – Right superior pulmonary vein. Left Atrial Filling
  57. 57. 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
  58. 58. Factors that affect LA filling Pattern Systolic Atrial Filling 1. Age 2. LA size 3. LA pressure 4. LA contractile function Left Atrial Filling
  59. 59. Diastolic Atrial Filling 1. Gradient from PV to LV 2. LV diastolic relaxation 3. LA compliance 4. LV compliance Left Atrial Filling
  60. 60. Impaired Relaxation 1. Prominent reversal 2. Blunting of the diastolic flow Pattern of Left Atrial Filling
  61. 61. Reduced Compliance 1. Prominent reversal 2. Prominent diastolic flow Pattern of Left Atrial Filling
  62. 62.  Mitral Inflow +/- Valsalva  Pulmonary Venous Flow  Tissue Doppler  Color M-mode
  63. 63. Mitral Inflow
  64. 64. Mitral Inflow cm/s E velocity
  65. 65. Mitral Inflow cm/s A velocity
  66. 66. Mitral Inflow cm/s IVRT
  67. 67. Mitral Inflow cm/s A dur
  68. 68. Mitral Inflow cm/s Deceleration time
  69. 69. Mitral Inflow cm/s E velocity A velocity IVRT A dur Deceleration time
  70. 70. Pulmonary Venous Flow
  71. 71. cm/s S velocity Pulmonary Venous Flow
  72. 72. cm/s D velocity Pulmonary Venous Flow
  73. 73. cm/s AR velocity Pulmonary Venous Flow
  74. 74. cm/s AR dur Pulmonary Venous Flow
  75. 75. cm/s D velocity S velocity AR velocity AR dur Pulmonary Venous Flow
  76. 76. Tissue Doppler
  77. 77. Tissue Doppler cm/s E’ velocity
  78. 78. cm/s A’ velocity Tissue Doppler
  79. 79. cm/s E’ velocity A’ velocity Tissue Doppler
  80. 80. 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
  81. 81. PARAMETERS MEASUREMENTS 4. Tissue Doppler a. E’ b. A’ c. E/E’ 5. Color M-mode a. Vp b. E/Vp Diastolic Evaluation
  82. 82. 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
  83. 83. Stage I: Impaired Relaxation Stage II: Pseudo-normalization Stage III: Reversible Restrictive Stage IV: Irreversible Restrictive
  84. 84. E/A < 1.0 Stage I
  85. 85. 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
  86. 86. 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