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QUANTIFICATION OF THE LEFT VENTRICULAR FUNCTION BY DIFFERENT METHODS Prof.E.Srbinovska Kostovska MD, PHD, FESC Nothing to declare Quantification of LV function Part of routine echocardiography examination TTE is the most common used technique for quantitative estimation Huge impact on clinical decisions making and follow up provide important prognostic information Why assessment of LV function Determinants of left ventricular performance M - mode echocardiography EF – quantitative approach of LV function, defined by the fraction of volume ejected during each ventricular contraction M-mode echocardiography provide an adequate measurement of LV function in the presence of normal geometry and symmetric function Linear line has to be perpendicular to the long axis of the left ventricle Linear measurement obtain - 2D guided M mode measurements - EF (%)= (LVEDd-LVESd)/LVEDd*100 Underestimation/overestimation of LV dimension - Pericardial tamonada or constriction - RV overload - LBBB - Non-compaction cardiomyopathy - Muscular bend Muscular bend Intraventricular dyssinchrony Other M-mode measurements Fractional shortening (%) > 25% in men and > 27%in women In normal geometry and symmetric function Distance between the E point of the anterior mitral leaflet and the basal portion of the interventricular septum MAPSE – mitral annular plane systolic function Quantitative assessment of LV longitudinal function Directly proportional to systolic function Two dimensional echocardiography assessment of the LV Qualitative assessment Normal, Hyper-dynamic, depressed Depressed- mild, moderate, severe Quantitative assessment Biplane method of disk (modified Simpson.s rules) Area length method Normal value and severity partition cut-off values for 2D derived LV EF(%) 2D echocardiography Noncompaction cardiomyopathy Stoke volume – N 50-80ml - afterload dependant parameter 2D echocardiography – biplane Simpson's methods ( LVEDvol-LVESvol) 3D echocardiography full volume echocardiography Doppler echocardiography LVOT tract area LVOT time velocity integral 3D echocardiography Highly accurate and reproducible of global and regional assessment of the left ventricle Do non rely on geometrical assumption Two approaches used for 3D LV quantification 3D guided biplane technique Direct volume calculation based on semiautomated detection of endocardial surface, followed by calculation of volume 3D echocardiography 3D measurements are comparabile with MRI Sugeng Circ.2006; 114:654 Doppler Evaluation - dp/dt of the MR * represent LV contractility Limitation- Eccentric jets - Load dependent ( in patients wit hypertension Normal value > 1200 mmHg/s and Ao stenosis can be normal even in impaired LV Impaired < 1000 mmHg/s - heart rate dependant Tissue Doppler imaging – measures myocardial motion velocity - Global longitudinal systolic function ( S < 0,6m/s) - Regional function by velocity – placing the sample volume in the region of interest - Angle dependent Normal velocity range in TDI Tissue Doppler imaging Tissue Doppler imaging Left vetricular dyssinchrony Myocardial performance index TEI index MPI = IVCT+IVRT/ EF Reflects global systolic and diastolic LV performance Systolic dysfunction causes a prolonged IVCT Diastolic dysfunction prolongs IVRT N value > 0,4 Myocardial performance index TEI index TDI Doppler echocardiography 2D speackle tracking (STI) Technique for quantification of multidirectional myocardial strain Speckles are natural acoustic markers that occur as small and bright elements in conventional gray scale The speckles are back scattered from the structures smaller than a wavelength of ultrasound. Speckles are distributed all through the myocardium on the ultrasound image Arch Cardiol Mex. 2011;81:114-125 Speacle tracking vs TDI Deformation from myocardial tissue markers Angle independent Strain in 3 spatial directions Myocardial velocity Angle dependency Strain along beam direction only 2D speckle tracking (STI) - longitudinal deformation - circumferential deformation - radial deformation Longitudinalen strain 2D biplane EF and 2D Spackle tracking estimated GLVSS -reflects different aspects of systolic LV function Accuracy of LV EF biplane (Simpson role): - imaging quality dependence - variability of EF to inaccurate border tracking - load dependant - insensitivity to early disease Benefits of 2D Spackle tracking estimated GLVSS: - calculated directly by the software - when endocardial border is not well defined - less load dependent in terms of EF - subclinical LV heart failure - LBBB and tethering effects of adjanced myocardial segments There is a good correlation between GLVSS and LVEF calculated using the 2D biplane method (Simpson's rule) Strain – calculates contractility of the myocardium Early stage of dysfunction EF – describes myocardial pump function Tasce et al.Cardiovascular Ultrasound 2007, 5-27 GLVSS is compared to EF from both methods, echo and angiography, but also to other hemodynamic echo parameters GLVSS was significantly lower in patients with EF below 50: (–18;3: vs –9;5:, p<0.01). A strong correlation was observed between EF and GS with good reproducibility. Stephanie BretteAutomated Function Imaging (AFI)- A New Onboard and Clinically Applicable Method of LV Global Function Assessment by Speckle Tracking. Circulation. 2006;114:II_364 Regional systolic function Regional systolic function LV diastolic function LV diastolic function Valsalva maneuver Progression of Dyastolic Dysfunction Diastolic function algorithm LA filling pressure and grading diastolic dysfunction Conclusion For more accurate assessment of LV function ( systolic, diastolic, longitudinal,….regional) we have to use all echocardiographic modalities