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Basics of Systolic Function

Vera H. Rigolin, MDProfessor of Medicine

Northwestern University Feinberg School of MedicineMedical Director, Echocardiography Laboratory

Northwestern Memorial HospitalChicago, Illinois

President-Elect, American Society of Echocardiography

Disclosures

• None that pertain to this presentation

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Introduction

• Quantification of LV chamber size and function is the cornerstone of cardiac imaging

• Echo is the most commonly used non-invasive modality

• Standardization of methodology and interpretation is critical to patient care

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Linear Measurements

• Performed in the parasternal long axis view

• Measurement perpendicular to the LV long axis

• Measurement immediately below the MV leaflet tips

• 2D measurements preferred over M-mode

• Accurate in normal hearts, but uni-dimensional nature suboptimal for diseased ventricle

Volumetric Measurements

• Can be made with 2D or 3D echo

• Measurements made by tracing the interface between compacted myocardium and LV cavity

• Apical 4 and 2 chamber views used for 2D biplane measurement

• Contour closed at the mitral valve level by connecting the two opposite sections with a straight line

• LV length defined as the middle of the line at the mitral valve to most distant point of LV contour

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2 D LV Volumes and EF

LV Volumes/EF

– Volumes obtained from apical 4 and 2 chamber views

– EF calculated using modified Simpson’s method or disk summation method

The Echo Manual – 2nd Edition. Oh, JK et al (eds).

Lippincott Williams and Wilkins, 1999

Calculated vs Visual LVEF

• 43 studies were included in meta analysis

• Bland-Altman limits of agreement (95% CI) evaluated for Simpson’s rule and visual EF vs MUGA or cath EF

• Simpson’s rule, LVEF differences ranged from 7% to 25% (median 18%);

• Subjective visual assessment, LVEF differences ranged from 16% to 24% (median 19%).

• Harmonic imaging and contrast not used routinely

McGowen et al. Am Heart J 2003;146:388-397

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Accuracy of LVEF Using Four Different Methods

A=Fund

B=Fund+Cont

C=Harm

D=Harm+Cont

Nahar et al. Am J Cardiol 2000;86:1358-62

Can I Accurately Calculate the EF?

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Can I Accurately Calculate the EF Now?

Simpson’s Biplane EF

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Normal Values for LV Dimensions, volumes and EF

WASE Study – What does a normal echo look like across different ethnic groups?

• Observational, Cross-sectional

• ASE and its international alliance partners and global

partners

• Prospective Enrollment of 1700 healthy volunteers

• Biospecimen: single Echocardiogram

Dr Roberto Lang, WASE PI

Dr Federico Asch, WASE Co-PI

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Case Example

• 58 yr old female diagnosed with HER-2 positive, metastatic breast CA in 2004

• She was initially treated with AC, taxol followed by Trastuzumab

• MUGA EF prior to chemo=61%

• Followup MUGA: EF=34%

• Trastuzumab was stopped

Echo after stopping Trastuzumab

LVEF=36%

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Echo after heart failure treatment

LVEF=55%

Echo 1 yr later with continued Trastuzumab therapy

LVEF=45%

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LV Segments

Coronary Territories

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2D vs 3D Transducers

4 Chamber View

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2D and 3D Echo EF vs MR EF2D echo 3D Echo

Jenkins C et al. J Am Coll Cardiol 2004;44:878-86

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45 year old woman s/p mitral valve repair who also received chemo and XRT for breast cancer

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LV EF and Volumes

3D Echo Normal Values

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Longitudinal VelocityLongitudinal velocity

Systole

IVC

IVR

EA

Velocity

Diastole

Peak Systole

Adapted from Isaaz K. Current Opinions in Cardiology 2002; 17:431-442.

Lateral and Septal most reproducible.

Sa peak systolic myocardial velocity- absolute

Ea early diastolic myocardial velocity- absolute

Aa late diastolic myocardial velocity-absolute

10.8 ± 2.716.0 ± 3.710.9 ± 2.1Posterior

9.0 ± 3.613.2 ± 3.810.4 ± 2.0Anterior

10.1 ± 2.312.5 ± 2.69.3 ± 1.5Septal

9.5 ± 2.616.7 ± 3.910.8 ± 2.0Lateral

Aa (cm/sec)Ea (cm/sec)Sa (cm/sec)

Normal Pulsed DTI Velocities

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Myocardial Deformation Imaging:3 Principle Vectors in Strain

Longitudinal: apical view

Circumferential: parasternal view

Radial: parasternal viewJ Am Coll Cardiol. 2011;58(14):1401-1413.

• Strain is total deformation during the cardiac cycle relative to the initial length at the onset of the cardiac cycle.

– ε = (L - L0)/ L 0

• Strain is dimensionless and expressed in percentages.

Strain (ε)

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Strain ImagingStrain = % change in length of the myocardium

during relaxation and contraction

LALB

Strain =- LALB

LA

=DL

LA

LA = Myocardial length at end diastole

LB = Myocardial length at end systole

Courtesy of Ben Freed, MD

J Am Coll Cardiol. 2011;58(14):1401-1413

Speckle Tracking

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Global Longitudinal Strain

Normal GLS Values

Plana, JC et al. JASE 2014; 27: 911-39

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Twist-Torsion

Rüssel IK et al. J Am Coll Cardiol Imaging 2009;2(5):648-655

Twist-Torsion

• Can be assessed by tissue Doppler or speckle tracking

• Normal heart has pos rotation at base and neg at apex

• The difference between the two represents the total rotation

• Total rotation divided by the distance between the two analyzed segments results in calculation of torsion (the twist in degrees divided by the distance)

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Twist/Torsion in normal (top) and in pt with reduced LVEF (bottom)

Feigenbaum’s textbook of echocardiography, 6th ed

Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.

Tan, Y. T. et al. J Am Coll Cardiol 2009;54:36-46

Peak Apical Rotation and Untwist

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Summary

• Assessment of LV systolic function is the most frequently used tool in echo

• Accurate and reproducible measurements are critical for patient care

• 2D volumes and EF are most common measurements

• 3D echo has advantages over 2D echo

• Strain imaging shows promise

• Greater appreciation to differences in LV size and function according to gender and race

Thank You