A New Method to Rapidly Evaluate LVEF from a Contractility Polar Map. Lebeau et al.

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Conrad Nichols
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1 A New Method to Rapidly Evaluate LVEF from a Contractility Polar Map Lebeau et al.

2 Good afternoon It is my pleasure to present to you a new method to rapidly evaluate LVEF from a contractility polar map in trans thoracic Echocardiography

4 2 This method was developped as a tool to teach cardiology resident and technician how to quantitate LVEF in TTE

5 Part 1 Scientific data supporting LVEF from WMSI A new tool for estimating left ventricular ejection fraction derived from wall motion score index Ref.: Lebeau R. and all, CJC Vol. 19 No 4 March 2003 Part 2 Semi quantitative visual estimation of LVEF from WMSI map - How to do it - Study and results

6 3 The first part of my presentation will concentrate on the scientific data supporting the evaluation of the LVEF from WMSI as published in the CJC in March 2003 The second part will focus on the visual estimation of the LVEF from the WMSI map, the data behind this rapid method and how to do it

7 LVEF = systolic function Commonly use in management of cardiac patients. Direct correlation between survival and number of hospitalisations post myocardial infarction. Important in decision making for therapeutics - Treatment (ICD) - Cardiac insufficiency - Post myocardial infarction

8 4 The LV systolic function is commonly used in evaluation of cardiac patient There is a direct correlation between number of hospitalisation post MI, survival and LVEF Knowledge of LVEF is necessary in therapeutic decision making such as ICD candidate or therapy for heart failure

9 LVEF / ECHO 1. Mmode: - Teichholz - Quinones 2. 2D : - Planimetric Simpson biplane - Visual estimate 3. Doppler and Mmode : Dumesnil 4. Wall motion score index (Rifkin 1990, r:0.91) (Berning 1994, r:0.93)

10 5 Several methods can be use to assess LVEF, Some using the m-mode such as the Teichholz, Quinones, Other using 2D data such as the Simpson biplane. and visual estimate. The doppler and m-mode allow us to use the Dumesnil technique. As will be shown, the WMSI and the visual method from the WMSI can also be useful

11 Long axis 4 chambers 2 chambers 4 chambers 2 chambers

12 6 The polar map is done by evaluating the wall motion in short axis at 3 differents level : the mitral valve, the papillary muscle level and at the apical level. It can all be done in the short axis view but the long axis view and apical (4C - 2C) can also be used.

14 7 This graph represent the 16 segments of the polar map and the coronary blood supply to each segment The territory supplie by the LAD, by the Cx and by the RCA are described here.

15 Normal(N) = 1 x 8 = 8 Hypokinesia(H) = 2 Akinesia(A) = 3 x 8 = 24 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 Total = 2

16 8 The WM score is calculated from this polar map by adding all 16 segments. Each segment gets : 1 point if it is normokinetic, 2 point for HK, 3 for AK, 4 for DK and 5 if aneurysmal In this example there are 8 normal segments so we have 8 points, 8 akinetic segments, therefore 24 points. The WMS is therefore = 32 and the WMSI 32/16 = 2.

17 Clinical characteristics of the patients Age (years) Sex 21 to 88 (mean 69) 140 men 103 women 243 pts LV dimension Diastolic 40 to 79 (mean 56) Systolic 20 to 70 (mean 42)

18 9 In our study, we compared the LVEF mesured by RNA and to the WMSI obtained by echo. 243 patients were studied, 140 men and 103 women ranging from 21 to 88 years old. The LV dimension in diastole range from 40 to 79 mm and from 20 to 70 mm in systole. The polar map by echo and the LVEF in nuclear medicine were obtained within 3 days of each other in all 243 patients.

19 Methods 150 pts WMSI vs LVEF-RNA Regression Equation: LVEF-RNA = 92,8 25,8 * WMSI

20 Using the LVEF mesured by RNA and the WMSI from the echo, a regression equation was established. This was done with the data from the first 150 patients.

21 Regression Equation LVEF-RNA = 92,8 25,8 x WMSI 92,8-25,8 x 1,0 = 67 (WMS=16) 92,8-25,8 x 1,6 = 53 (WMS=25) 92,8-25,8 x 2,1 = 40 (WMS=33) 92,8-25,8 x 2,6 = 27 (WMS=41) 92,8-25,8 x 2,9 = 15 (WMS=48) WMS WMSI EF (%) WMS WMSI EF (%) 16 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,0 15

22 This regression equation allowed us to derive a LVEF from the WMSI and to design this EF table, where each WMSI correspond to a LVEF

23 Methods 150 pts LVEF -WMSI vs LVEF-RNA Regression Equation: 243 pts LV function Echo - NM LVEF-RNA = 92,8 25,8 * WMSI 93pts Regression Equation vs LVEF-RNA 243pts

24 In the susbsequent 93 patients, the LVEF obtained with regression equation (EF Table) was compared to the RNA LVEF

25 Results

26 In the first 150 patients, the correlation between WMSI and RNA EF was 0.82 The correlation between the LVEF obtained by regression equation, in the subsequent 93 patients and RNA was 0.86 Correlation for the whole group of 243 patients was 0.88 If we exclude 20 outliers. (Difference of EF more than 12 % between the two techniques). The correlation between WMSI and RNA EF was 0.92

27 Results

28 In various subgroup including patients with dyskinesis (DK), aneurysm (AN), atrial fibrillation (AF), the correlation remains good. Interobserver and intraobserver variability was good.

29 LVEF-RNA vs other technics LVEF-RNA Teichholz Quinones Simpson Dumesnil Standard score Score plus : 9pts % 9pts % 9pts % 9pts % 9pts % 9pts > 61 % 54 pts mild HK = 1,5 moderate HK = 2,0 severe HK = 2,5

30 We compared the WMSI with other techniques in 54 pts with LVEF ranging from 10-61% We also compared the LVEF by RNA to the LVEF obtained in echo using the Teichholz, Quinones, Simpson,Dumesnil and our score technique. We also use the "score plus" technique where mild HK got 1.5 point, moderate HK 2 points and severe HK 2.5 points

31 WMSI-LVEF vs RNA (54 pts) Results Teichholz Quinones Dumesnil Simpson (r = 0,43) (r = 0,50) (r = 0,83) (r = 0,82) Standard score (r = 0,85) Score plus (r = 0,83) mild HK = 1,5 moderate HK = 2,0 severe HK = 2,5

32 The result in 54 patients showed the best correlation with the Simpsons and Dumesnil technique. The correlation with our score (the standard and the modified "score plus") was equally good with a r value of 0.85 and 0.83

33 Normal(N) = 1 x 8 = 8 Hypokinesia(H) = 2 Akinesia(A) = 3 x 8 = 24 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 Total = 2

34 This is a typical LAD infarct The WMS score is equal 32 WMSI is equal 2.0

35 Estimation of left ventricular ejection fraction according to wall motion score index WMS WMSI EF (%) WMS WMSI EF (%) 16 1, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,0 15

36 The WMSI is 2 and the LVEF is 41% using our regression equation and EF table

37 Normal(N) = 1 x 8 = 8 Hypokinesia(H) = 2 Akinesia(A) = 3 x 8 = 24 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 Total = Normal(N) = 0 Hypokinesia(H) = 1 Akinesia(A) = 2 Dyskinesia(D) = 3 Aneuvrysm(AN) = 4

38 If we want to use a fast calculation system We begin our calculation at 16 then adding 1 for every HK segment and 2 for every akinetic segments going in a clockwise rotation. The normal segment get no additional points

39 Fast calculation Normal(N) = 1 Hypokinesia(H) = 2 Akinesia(A) = 3 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 Normal(N) = 0 Hypokinesia(H) = 1 Akinesia(A) = 2 Dyskinesia(D) = 3 Aneuvrysm(AN) = 4

40 The total score is 32 / 16 The LVEF is 41% Try to do a Biplane Simpson in (4C-2C) in 5 seconds.

41 The goal of our study is to have a visual estimation not dependant of EF table.

42 Part 2 Semi quantitative visual estimation of LVEF from WMSI map - How to do it - Study and results

43 I developped a semiquantitative visual estimation of LVEF from the WMSI map even if we don t do the score calculation

45 This is done by pattern recognition and it is easy to do and is possible since there is a linear correlation between WMSI and LVEF obtained in nuclear medicine

$fraction according to wall motion score$

46 Estimation of left ventricular ejection fraction according to wall motion score index

47 This linear correlation is confirm by the EF table. In this table of LVEF we can have 3 subgroup, those with high EF, those with intermediate or low EF The premise behind this rapid method is that if all segments are normal the LVEF is greater or equal to 60% If all are HK, it is 40% If all are AK, it is equal or less than 20%

49 This drawings represent several possibility For example, if all segment are HK the LVEF is 40% If half of the segments are NK and half HK the LVEF is 50% (mild hypokinesia) If half of the segments are HK and half AK the LVEF is 30% (severe hypokinesia)

50 Method A + N = H, H (3 + 1) = (2 + 2) D + H = A, A (4 + 2) = (3 + 3) D + N + N = H, H, H AN + N = A, A (5+1) = (3+3) AN + H + H = A, A, A AN + N + N + N = H, H, H, H

51 The way to do this simplification. If you have one normal segment and one akinetic segment, it is equal to 2 Hk segments. A dyskinetic segment and one hypokinetic segments equal 2 akinetic segments.

52 Normal(N) = 1 Hypokinesia(H) = 2 Akinesia(A) = 3 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 WMS-EF = 41%

53 Normal(N) = 1 Hypokinesia(H) = 2 Akinesia(A) = 3 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 WMS-EF = 41%

54 Normal(N) = 1 Hypokinesia(H) = 2 Akinesia(A) = 3 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 WMS-EF = 41%

55 This map represent a typical anterior. If we have one akinetic and one normal segment we can scratch them off and replace them by 2 HK segments.

56 Normal(N) = 1 Hypokinesia(H) = 2 Akinesia(A) = 3 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 APPR = 40%

57 In this graph we would end up with all 16 segments being HK and a LVEF of 40% The LVEF by the standard method is 41% and 40% by semi quantitative visual estimate.

58 Normal(N) = 1 Hypokinesia(H) = 2 Akinesia(A) = 3 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 WMS-EF = 53%

59 This map represent a typical inferior infarct. Again we combine one akinetic and one normal segment and replace them with 2 HK segments.

60 Normal(N) = 1 Hypokinesia(H) = 2 Akinesia(A) = 3 Dyskinesia(D) = 4 Aneuvrysm(AN) = 5 APPR = 50%

61 In this graph we would end up with all 8 normal segments and 8 HK segments a LVEF of 50% The LVEF by the standard method is 53% and 50% by semi quantitative visual estimate.

63 We gave 243 polar map to our participants and asked them to derive the LVEF.

65 It was also done in 100 polars maps with the 17 segments model.

66 16 segments model (243pts) observers RNA Echocardiographers (2) r: 0,87 S.D.: 12 Sonographers (3) r: 0,86 S.D.: 13 Fellows (3) r: 0,85 S.D.: 14 Outsiders (3) r: 0,86 S.D.: segments model (100pts) observers RNA Echocardiographers (2) r: 0,88 S.D.: 8 Outsiders (3) r: 0,88 S.D.: 8

67 The results are in the table The echocardiographer had a correlation of 0.87 compared to RNA The sonographers 0.86 The fellows 0.85 The outsider, one 16 y.o high school student, a university student in business and one in psychology also have a good correlation with RNA showing that even without medical formation you can succes in this test.

68 Conclusion Semiquantitative visual estimation of LVEF is a simple, rapid and safe method to evaluate and teach to fellows in cardiology

69 In conclusion, the semivisual estimation of LVEF is simple, rapid, accurate and easy method to teach to residents and technicians in transthoracic echocardiography.

70 If you want to test you ability to do this rapid semiquantitative evaluation of LVEF, you will find 100 cases on our internet site Thank you!

84 Comments 1. If you use mild hypokinesia, you can use a score of 1.5. If you use severe hypokinesia, you can use a score of 2.5. The maximal LVEF with the score technique is 67 % and the minimal is 15 %. You can use the biplane Simpson method for hyperkinetic state. If you use the 17 segment model, use only the first 16 segments in the calculation. 2. Lebeau Score D : for our anesthesiologists we compared a third method to RNA. Using 243 patients from our study A new tool for estimating LVEF derived from WMSI ( Lebeau. R. and all, Canadian Journal of Cardiology Vol 19, no4, mars 2003 (p.397) we found a new score derived from the WMSI regression formula (score-d).: Normal = 4 %, Mild Hypokinesia= 3.3 %, Moderate Hypokinesia=2.5 %, Severe Hypokinesia=1.8 % and Akinesia=1 % for each of the 16 segments model (R=0.89) and 17 segments model (R=0.90) to evaluated the LVEF. We simply add the total % score of the 16 or 17 segments model. N.B. Dyskinetic segment = -1% and aneurysmal segment = -2%. The lowest LVEF reported should be 15%. 3. Test yourself : compare your visual, Simpson Biplane and score method ( WMSI and score D) in ten of your patients.

85 References LEBEAU R, SERRI K, MORICE MC, HOVASSE T, UNTERSEEH T, PIÉCHAUD JF, GAROT J., Assessment of left ventricular ejection fraction using the wall motion score index in cardiac magnetic resonance imaging, Arch Cardiovasc Dis Feb;105(2):91-8. Epub 2012 Feb 22. Lebeau R, Potter BJ, Sas G, et al. Performance of a simplified wall motion score index method for non-cardiologists to assess left ventricular ejection fraction. ISRN Emergency Medicine Volume 2012: article ID Lebeau R, Di Lorenzo M, Sauvé C et al. Two-dimensionnel echocardiographic estimation of right ventricular ejection fraction by wall motion score index. Canadian Journal of Cardiology. Pulsus Group Inc. Volume 20,no2, February 2004 p

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