Download Left ventricular function

Stephen Glen
ISCHAEMIC HEART DISEASE AND
LEFT VENTRICULAR FUNCTION
Overview
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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