ΕΚΤΙΜΗΣΗ ΤΗΣ ΑΡΙΣΤΕΡΗΣ ΚΟΙΛΙΑΣ ΜΕ ΜΕΘΟΔΟΥΣ ΚΛΑΣΣΙΚΗΣ ΑΓΓΕΙΟΓΡΑΦΙΑΣ

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Oliver Cross
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1 ΕΚΤΙΜΗΣΗ ΤΗΣ ΑΡΙΣΤΕΡΗΣ ΚΟΙΛΙΑΣ ΜΕ ΜΕΘΟΔΟΥΣ ΚΛΑΣΣΙΚΗΣ ΑΓΓΕΙΟΓΡΑΦΙΑΣ Α.-Δ. ΜΑΥΡΟΓΙΑΝΝΗ ΚΑΡΔΙΟΛΟΓΟΣ AIMOΔΥΝΑΜIΚΟ ΕΡΓΑΣΤΗΡΙΟ Γ.Ν.Θ. «Γ.ΠΑΠΑΝΙΚΟΛΑΟΥ» ΘΕΣΣΑΛΟΝΙΚΗ

2 Disclosure Statement of Financial Interest None whatsoever

3 Assessment of LV function* * by angiographic means

4 LT Ventriculography Morphology of LV Qualitative/ semi quantitive assessment of systolic performance IVS integrity Info on valvular competence Pressure measurements Pressure gradients

6 Preferred Right and Left Ventriculographic Views for Specific Conditions Grossman & Baim's Cardiac Catheterization, Angiography, and Intervention, Eighth Edition

7 Clinically Relevant Indicators of Global LV Function EJECTION FRACTION Ratio of SV to EDV [EDV-ESV/EDV] - Simplicity of its derivation - Ability to determine easily - Reproducibly using different imaging techniques - Documentation of its clinical usefulness

Myocardial Fiber Organization Mall and MacCallum s

(circular) and superficial oblique bulbospiral

Cardiac mechanics revisited: the relationship of

8 Myocardial Fiber Organization Mall and MacCallum s suggestion of 4 myocardial bundles, with deep (circular) and superficial oblique bulbospiral tracts Buckberg G. et al. Cardiac mechanics revisited: the relationship of cardiac architecture to ventricular function. Circulation Dec 9;118(24):

9 Normal Contraction of LV: Twist Mechanics Sengupta PP. et al. Twist mechanics of the left ventricle: principles and application. JACC Cardiovasc Imaging.2008 May;1(3):366-76

Estimation of left ventricular volumes in man from biplane

10 The Road to Heaven is Paved with Good Intentions and a LOT of WORK!!!! Wynne J, Green LH, Mann T, Levin D, Grossman W. Estimation of left ventricular volumes in man from biplane cineangiograms filmed in oblique projections. Am J Cardiol Apr;41(4):726-32

11 Area-Length Method For Volume Determination Monoplane V=π/6 LD ²

12 Simpson's Rule for Additive Method of Volume Determination

13 Hemodynamics, Dimensions and Relativity.!!!

14 Optimal ventriculography: biplane

15 Volume calculations: biplane V= 4/3 p [L/2] [M/2] [N/2] = p /6 LMN A RAO = p [L RAO /2] [ M/2]= p [L RAO ][M]/4 A LAO = p [L LAO /2] [N/2]= p [L LAO ][N]/4 V= p /6 Lmax [4A RAO ] [4A LAO ] [p L RAO ][p L LAO ] Usu, Lmax= L RAO => V= 8 A RAO A LAO 3 p L LAO Dodge HT., Sandler H., Ballew DW., Lord JD. Jr. The use of biplane angiocardigraphy for the measurement of left ventricular volume in man. Am Heart J.1960 Nov;60:762-76

16 Regression Equations to Correct for Overestimation in Calculation of Left Ventricular Volumes Grossman & Baim's Cardiac Catheterization, Angiography, and Intervention, Eighth Edition

EF: Drawbacks preload/ afterload/ HR/ synchronicity of contraction Global parameter, major regional differences in contractility presented as an average Given

17 EF: Drawbacks preload/ afterload/ HR/ synchronicity of contraction Global parameter, major regional differences in contractility presented as an average Given EF may have different prognostic importance according to clinical situation Preload increases [AR,MR, Anemia] Afterload increases [AS] EF increases EF decreases

Angiographic wall motion score 1= normal 2= moderate hypokinesis 3=severe

18 Regional Left Ventricular Wall Motion Regional dyssynergy more sensitive marker of CAD Quantification of regional wall motion abnormalities Angiographic wall motion score 1= normal 2= moderate hypokinesis 3=severe hypokinesis 4=akinesis 5=aneurysm/dyskinesis Normal score is 5 RAO or RAO/LAO ventriculography

19 The Centerline Method Sheehan FH. et al. Advantages and applications of the centerline method for characterizing regional ventricular function. Circulation.1986 Aug;74(2):

20 Changes In Diastolic Properties Of The Regional Myocardium During Ischemia Sasayama S. et al. Changes in diastolic properties of the regional myocardium during pacing-induced ischemia in human subjects. J Am Coll Cardiol.1985 Mar;5(3):

21 Wall Stress Grossman W, Jones D, McLaurin LP. Wall stress and patterns of hypertrophy in the human left ventricle. J Clin Invest Jul;56(1):56-64

22 Normal Average Values of Left Ventricular Parameters obtained by Angiocardiography Grossman & Baim's Cardiac Catheterization, Angiography, and Intervention, Eighth Edition

23 Pressure Volume Loops: ESPVR or Maximum Elastance Nearly independent of loading conditions aortic dicrotic notch pressure as ESPR & Minimum LV chamber volume Pacing/ IVC balloon occlusion/ Drugs PV loops at different loads

24 ESPVR: How Does It Translate? McKay RG. et al. Instantaneous measurement of left and right ventricular stroke volume and pressure-volume relationships with an impedance catheter. Circulation.1984 Apr;69(4):703-10

25 Evaluation of Left Ventricular Systolic Performance: Normal Values of Some Isovolumic and Ejection Phase Indices Grossman & Baim's Cardiac Catheterization, Angiography, and Intervention, Eighth Edition

26 Evaluation of Left Ventricular Diastolic Performance: Normal Values for Some Indices of Relaxation and Filling Grossman & Baim's Cardiac Catheterization, Angiography, and Intervention, Eighth Edition

27 Appropriateness: Use of Left Ventriculography test is not ordered decision made by the interventionalist adds contrast -(small risk of worsening renal function) adds radiation -(minimal risk of cancer)

of this invasive test. Witteles RM. et al. Am Heart J.

28 Variation in LVgram Use New clinical practice guidelines should be considered to decrease the overuse of this invasive test. Witteles RM. et al. Am Heart J Apr;163(4): Use and overuse of left ventriculography.

A single center's experience ( and one's own) although there are certain clinical

e STEMI we very rarely perform an LT VG, let alone all other invasive measurements!

almost always perform an LT VG and calculate gradients when AoS is present, even if there

29 A single center's experience ( and one's own) although there are certain clinical scenarios where a plain old ventriculography is considered conditio sina qua non - i.e STEMI we very rarely perform an LT VG, let alone all other invasive measurements!!! LT VG ONLY WHEN NO INFORMATION ON GLOBAL LV FUNCTION AVAILABLE tout au contraire we almost always perform an LT VG and calculate gradients when AoS is present, even if there is ample non invasive data which consequently proves that (all) interventionalists are egotistical maniacs.!!!

30 In conclusion one should not forget that all measurements were standardized in the Cath. Lab. time consuming and above all INVASIVE - still, fundamental in basic research no perfect much between different modalities but good correlation exists modalities often complementary acquire information by means available What I CANNOT do: give ANY information on TISSUE and METABOLISM

31 what I CAN DO and others CANNOT is FIX IT!!!

32 Καλά Χριστούγεννα

10/7/2013. Systolic Function How to Measure, How Accurate is Echo, Role of Contrast. Thanks to our Course Director: Neil J.

10/7/2013. Systolic Function How to Measure, How Accurate is Echo, Role of Contrast. Thanks to our Course Director: Neil J. Systolic Function How to Measure, How Accurate is Echo, Role of Contrast Neil J. Weissman, MD MedStar Health Research Institute & Professor of Medicine Georgetown University Washington, D.C. No Disclosures