Stephen Glen ISCHAEMIC HEART DISEASE AND LEFT VENTRICULAR FUNCTION
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1 Stephen Glen ISCHAEMIC HEART DISEASE AND LEFT VENTRICULAR FUNCTION
2 Overview Coronary arteries Terminology to describe contractility Measuring ventricular function Systolic dysfunction Practice cases- LV function Diastolic function
3 RCA LCA
4 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.
5 Mid inferior Mid anterior Basal inferior
6 Apical anterior septum Mid anterior septum Basal anterior septum Apical posterior
7 Describing contractility Normal Hypokinetic (<30% thickening) Akinetic Dyskinetic Aneurysm Scar
8 Wall motion abnormalities PLAX PSAX
9 Q1 where is the abnormality?
10 Q2. Where is the abnormality?
11 Q3. How would you grade LV function?
12 Q4. Can you guess the EF?
13 Q5. What is this?
14 Q6. Describe the wall motion abnormality
15
16 Beware the missing apex!
17 Bad and bad, or good and bad?
18 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
19 Shortening fraction LVEDD - LVESD LVEDD Normal >30% Mild 26-30%
20 Ejection fraction Diastolic systolic volume Diastolic volume Normal >60% male, 55% female
21 Supporting evidence Reliability of reporting left ventricular systolic function by echocardiography: a systematic review McGowan J, Cleland J. Am Heart J 2003;146: 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%)
22 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
23 Where is the abnormality?
24 First case continued, A2ch
25 First case- both views Q8. How good / bad is LV function?
26 Case 2 A4Ch Q9. Describe LV function
27 Case continued A2Ch
28 Case summary
29 Case 3- A4Ch Q10. Describe the abnormality
30 Case 3 A4Ch close up
31 Case 3 summary
32 Case 4 PLAX Q11. Describe the abnormality
33 Case 4 PLAX
34 Case 4 A4Ch Q12. Describe the mid septum
35 Case 4 summary Q13. How many arteries are blocked?
36 Case 5 Biplane
37 Case 5 A4Ch
38 Case 5 summary Q14. What segments are abnormal?
39 Case 6 PLAX
40 Case 6 PSAX
41 Case 6 A4Ch
42 Case 6 A2Ch
43 Case 6 summary Q15. Is this normal?
44 Strain rate bullseye summary
45 Strain rate imaging
46 LV multislice with contrast
47
48 Diastolic function
49 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)
50 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 Changes with age
51 Diastolic Function: Transmitral flow patterns BEST GOOD MODERATE BAD WORST NORMAL PRESSURE INCREASING PRESSURE
52 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
53 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
54 Best single measurement? Left atrial volume
55 Mitral annular movement
56 Tissue velocity imaging
57 E/e <10 is normal; borderline; >15 abnormal (diastolic dysfunction; high LA pressure) E/e = 100/4 = 25
58 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
59
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