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Stephen Glen ISCHAEMIC HEART DISEASE AND LEFT VENTRICULAR FUNCTION Overview Coronary arteries Terminology to describe contractility Measuring ventricular function Systolic dysfunction Practice cases- LV function Diastolic function RCA LCA Left ventricular territory LAD – anterior wall and apex LCx – posterior and lateral RCA – inferior wall and basal / mid septum Varies between patients – RCA may be dominant and supply large territory, or may be tiny and supply virtually nothing. Mid inferior Basal inferior Mid anterior Mid anterior septum Apical anterior septum Apical posterior Basal anterior septum Describing contractility Normal Hypokinetic (<30% thickening) Akinetic Dyskinetic Aneurysm Scar Wall motion abnormalities PLAX PSAX Q1 – where is the abnormality? Q2. Where is the abnormality? Q3. How would you grade LV function? Q4. Can you guess the EF? Q5. What is this? Q6. Describe the wall motion abnormality Beware the missing apex! Bad and bad, or good and bad? What measurement? Qualitative (eyeball technique) normal or mild / moderate / severe dysfunction Quantitative (give a number) Shortening fraction Ejection fraction (biplane Simpson’s) Wall motion scoring system Shortening fraction LVEDD - LVESD ______________ LVEDD Normal >30% Mild 26-30% Ejection fraction Diastolic – systolic volume _____________________ Diastolic volume Normal >60% male, 55% female Supporting evidence Reliability of reporting left ventricular systolic function by echocardiography: a systematic review McGowan J, Cleland J. Am Heart J 2003;146:388-97 Reviewed 43 studies 95% confidence intervals calculated for each approach: Simpson’s ±7 to ± 25% (median 18%) Wall motion ±13 to ± 20% (median 16%) Subjective ±16 to ± 24% (median 19%) The herceptin problem 10% patients treated with herceptin in FinHer had asymptomatic drop in EF 1 to 4% symptomatic heart failure Most important baseline risk factors are age and EF at baseline In Scotland- funded for contrast and biplane EF Adjuvant docetaxel or vinorelbine with or without trastuzumab for breast cancer. N Engl J Med 2006;354:809-20 Where is the abnormality? First case continued, A2ch First case- both views Q8. How good / bad is LV function? Case 2 A4Ch Q9. Describe LV function Case continued – A2Ch Case summary Case 3- A4Ch Q10. Describe the abnormality Case 3 A4Ch close up Case 3 summary Case 4 PLAX Q11. Describe the abnormality Case 4 PLAX Case 4 A4Ch Q12. Describe the mid septum Case 4 summary Q13. How many arteries are blocked? Case 5 Biplane Case 5 A4Ch Case 5 summary Q14. What segments are abnormal? Case 6 PLAX Case 6 PSAX Case 6 A4Ch Case 6 A2Ch Case 6 summary Q15. Is this normal? Strain rate bullseye summary Strain rate imaging LV multislice with contrast Diastolic function Normal diastolic function Rapid early filling with little atrial contribution • rapid relaxation of ventricle • vigorous elastic recoil (suction) • high ventricular compliance • normal left atrial pressure • high E-wave velocity (E=early) • rapid deceleration time (DT) • low A-wave velocity (A=atrial) Changes with age Older • decreased rate of relaxation of ventricle • fall in elastic recoil (suction) • fall in ventricular compliance • normal LA pressure Slower early filling, more contribution from atrial contraction • reduced E-wave velocity • prolonged deceleration time (DT) • higher A-wave velocity Diastolic Function: Transmitral flow patterns BEST GOOD MODERATE BAD WORST NORMAL PRESSURE INCREASING PRESSURE Moderate diastolic dysfunction • Abnormal relaxation (stiff ventricle) • Elevated left ventricular filling pressure • These balance each other out so mitral inflow looks normal • This is pseudonormal- grade II diastolic dysfunction • normal E-wave velocity • normal DT • normal A-wave velocity Severe diastolic dysfunction High LA pressure leads to early MV opening Rapid early filling of stiff ventricle Pressures equalise rapidly. • high E-wave velocity and short DT Atrial contraction increases LA pressure LV diastolic pressure also rises rapidly • low A-wave velocity Best single measurement? Left atrial volume Mitral annular movement Tissue velocity imaging E/e’ <10 is normal; 10-15 borderline; >15 abnormal (diastolic dysfunction; high LA pressure) E/e’ = 100/4 = 25 Conclusion Assessment of left ventricular function by echo is difficult Requires practice Descriptive may be just as valid as numbers although other specialties like ejection fraction Advanced imaging techniques improve quality and reproducibility