Quantification of Cardiac Chamber Size
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1 2017 KSE Quantification of Cardiac Chamber Size Division of Cardiology Keimyung University Dongsan Medical Center In-Cheol Kim M.D., Ph.D.
2 LV size and function Internal linear dimensions PLX M-mode tracing 2D-guided linear measurements Good Bad Good Bad Reproducible Temporal resolution Published data Beam oriented Single dimension Perpendicular to the LV long axis Lower FR than M-mode Single dimension
3 LV size and function Volumes (1) A4C A2C A4C PSX Biplane disk summation Area- length Good Bad Good Bad Correct shape distortion Less assumption Apex foreshortening Endocardial dropout Blind shape distortion Partial correction of shape distortion Apex foreshortening Heavy assumption Limited data
4 LV size and function Volumes (2) A4C Endocardial border enhancement 3D data sets Good Bad Good Bad For suboptimal acoustic window Similar with MRI 2D technique limits + Possible LV basal shadowing No assumption Foreshortening independent More accurate Lower temporal resolution Limited data Image quality dependent
5 LV size and function Global longitudinal strain A4C Global longitudinal strain Good Angle independent Established prognostic value Bad Vendor dependent
6 Normal values for 2D Echo of LV size and function Askleios, Flemengho, CARDIA5, CARDIA25, Padua 3D Echo Normal, Echocardiography study Datasets included age, gender, ethnicity, height, weight Exclude : BP > 140/80 mmhg, HTN, DM, FBS > 100mg/dL, BMI > 30 kg/m 2, Cr 1.3 mg/dl, egfr < 60mL/min/1.73m 2, TC > 240 mg/dl, LDL > 130 mg/dl, TG > 150 mg/dl(only normal patients included)
7 Normal ranges and severity partition cutoff for 2DE of LV size, function, mass
8
9 Upper limits of normal value 3DE 2DE EDVi (M) EDVi (F) 79 mm/m 2 71 mm/m 2 74 mm/m 2 61 mm/m 2 ESVi (M) ESVi (F) 32 mm/m 2 28 mm/m 2 31 mm/m 2 24 mm/m 2 LV volume : Scandianvian > White European > Asian EF : Similar
10 Functional assessment of LV End diastole : first frame after mitral valve closure frame with the largest LV dimension or volume End systole : frame after aortic valve closure frame with the smallest LV dimension or volume End-diastole End-systole
11 Fractional shortening (FS) M-mode or 2D guided dimension Limitations : conduction abnormalities, RWMA Ejection Fraction (ES) by 2DE or 3DE EF = (EDV ESV) / EDV Biplane method of disks (modified Simpson s rule) Normal range : 53~73% (age > 20 years, 2DE) Global Longitudinal Strain (GLS) Strain (ε) = (L t - L 0 ) / L 0 GLS (%) = (ML s ML d ) / ML d Should be measured in A4C, A3C, A2C More than 2 segment is suboptimal don t recommend Normal range : < - 20% ML : myocardial length
12 2015 Guideline Segmentation of the Left Ventricle
13 2015 Guideline Wall motion score (2015) 1. Normal or hyperkinetic 2. Hypokinetic 3. Akinetic 4. Dyskinetic (Aneurysm) * Aneurysm : morphologic entity that demonstrates focal dilatation and thinning (remodeling) with either akinetic or dyskinetic systolic deformation Wall motion score (2006) 1. Normal or hyperkinetic 2. Hypokinetic 3. Akinetic 4. Dyskinetic 5. Aneurysmal
14 Quantification of RWMA using Doppler and STE DTI : angle dependent, prone to underestimate Strain (longitudinal strain during LV systole) Strain rate No specific normal range available (upcoming ASE/EACVI consensus document) Tardokinesis (postsystolic shortening or thickening) > 20% of total deformation : consistent sign of regional functional inhomogeneity (ischemia, scar)
15 RWMA without coronary artery disease Myocarditis Sarcoidosis Stress-induced (takotsubo) cardiomyopathy Post operative LBBB RV epicardial pacing RV dysfunction d/t Pr or V overload Conduction delay Abnormal motion of IVS d/t abnormal sequence of myocardial activation Septal bounce - beaking, flash Lateral apical motion during systole - apical rocking
16 Echocardiographic assessment of LV mass M-mode 2D Good Bad Good Bad Fast, widely used Published data Simple Fairly accurate Beam oriented Small error have an impact on accuracy Limitation on asymmetric hypertrophy Perpendicular to the LV long axis Similar with M-mode Normal value less well established
17 Echocardiographic assessment of LV mass Good Partial correction for shape distortions Less dependent on geometrical assumptions Bad Good image quality needed Cumbersome Few normative data
18 Echocardiographic assessment of LV mass
19 Echocardiographic assessment of LV mass 3D based formula Good Direct measure without geometrical assumptions More accurate Higher reproducibility Bad Good image quality needed Normal value less well established Pt s cooperation required
20 LV mass indices RWT = (2 x PWT) / LVEDD
21 Essential imaging windows and views for RV
22 Echocardiographic assessment of RV size RV linear dimension (inflow) RV linear dimension (outflow) Good Bad Good Bad Fast, widely used Published data Simple Fairly accurate RV size may underestimate (crescent) Beam dependent Easily obtainable Simple Fast Dependent on image plane Risk of under- or overestimation Not global RV size
23 Echocardiographic assessment of RV size RV areas (inflow) 3DE RV volumes Good Bad Good Bad Relatively easy to measure Limitation in poor image Foreshortening -> underestimation Not global RV size RV global size Independent of geometric assumption Validated with MRI Dependent on image quality, rhythm, co-op Need training Reference values established in few pub.
24 Echocardiographic assessment of RV size RV wall thickenss RV free wall thickness M-mode or 2DE End-disastole Below TV, approximating the length of anterior TV leaflet Good Easy to perform Bad Single site measurement May overestimate RV wall thickness (Harmonic, M-mode) No definite criteria for thin RV wall
25 Normal values of RV chamber size 2015 Guideline 2005 Guideline
26 Echocardiographic assessment of RV function RIMP (RV index of myocardial performance) = (TCO-ET)/ET, TCO; tricuspid close-open time RV global function - Pulsed Doppler RIMP RV global function - Tissue Doppler RIMP Good Bad Good Bad Prognostic value Less affected by HR Requires matching for R-R interval Unreliable when RAP Less affected by HR Single beat recording(no need R-R interval match) Unreliable when RAP is elevated
27 Echocardiographic assessment of RV function RV FAC (%) = 100 x (EDA ESA) / EDA, FAC; fractional area change RVEF (%) = 100 x (EFV ESV) / EDV RV global systolic function - FAC RV global systolic function - EF Good Bad Good Bad Prognostic value Both longitudinal, radial components of RV contraction Correlates MRI Neglects the contribution of RVOT Not high interobserver variability Less affected by HR Single beat recording(no need R-R interval match) Unreliable when RAP is elevated
28 Echocardiographic assessment of RV function RV longitudinal systolic function - TAPSE RV longitudinal systolic function - Pulsed tissue Doppler S wave Good Bad Good Bad Prognostic value Established with radionuclide EF Angle dependency Partially representative of RV global function Easy to perform Reproducible Established with radionuclide EF Prognostic value Angle dependency Partially representative of RV global function
29 Echocardiographic assessment of RV function RV longitudinal systolic function - Color tissue Doppler S wave RV longitudinal systolic function - GLS Good Bad Good Bad Perform after image acquisition Allows multisite sampling on the same beat Angle dependency Partially representative of RV global function Lower value than pulsed DTI S wave Angle independent Prognostic value Vendor dependent
30 Normal values for parameters of RV function 2006 guideline <15
31 Normal values for parameters of RV function (2012, JACC imaging) JACC Cardiovasc Img. 5(7); 2012:
32 Measurement of RV strain and strain rate RV global free wall strain RV global longitudinal strain
33 RV 3D analysis RV EDV, RV ESV, SV, EF
34 Echocardiographic assessment of LA size Internal linear dimensions - M-mode tracing Internal linear dimensions - 2D-guided linear measurements Good Bad Good Bad Reproducible High temporal resolution Published data Single dimesion Facilitates perpendicular orientation (LA A-P) Lower FR than M- mode Single dimension
35 Echocardiographic assessment of LA size Area - 2D images Good More representative than AP-diameter Bad Need for dedicated view Assumes symmetric shape
36 Echocardiographic assessment of LA size Area-length technique Volume - 2DE Biplane method of disks Volume - 3DE Good Bad Good Bad Assessment of asymmetric LA Robust predictor Geometric assumption Few data on normal No geometrical assumption More accurate Image quality dependent Temporal resolution Limited data on normal Need patient cooperation
37 2015 Guideline Normal value of LA size LA size by Biplane method < 34 ml/m Guideline
38 Echocardiographic assessment of RA size Linear dimensions - 2D-guided measurements Area - 2D view Good Bad Good Bad Easy to obtain Established normal value Single dimesion Assumes symmetrical RA enlargement View dependent More RA size representative Established normal value Need dedicated view (avoid foreshortening) Assumes symmetrical cavity View dependent
39 Echocardiographic assessment of RA size Volume - 2D view Area - 2D view Good Bad Good Bad More RA size representative Assumes symmetrical RA cavity Normal value not well established No geometrical assumption Established normal value Image quality dependent Temporal resolution Need patient cooperation
40 Normal value of RA size 2015 Guideline 2005 Guideline Limited data on a small number of healthy individuals revealed that indexed RA volumes are similar to LA normal values in men (21 ml/m 2 )
41 Sites for measurements of the aortic root and ascending aorta 1. AV annulus (hinge point, virtual ring) - peak systole 2. Sinus of Valsalva (maximal diameter) - end-diastole 3. Sinotubular junction - end-diastole 4. Proximal ascending aorta - end-diastole
42 Measurement of the Aortic root diameter
43 Measurement of the Aortic annulus Correct Incorrect Incorrect The annulus is virtual and only defined by the hinge-points of the three aortic valve leaflets
44 Measurement of the Aortic annulus
45 Aortic root dimensions in normal adults 22-33
46 Measurements of the IVC Subcostal window, supine position IVC diameter measured 1~2cm from the junction of the RA Perpendicular to the IVC long axis Collapsibility index IVC < 2.1 cm, collapse > 50% : RAP 3 mmhg (0~5 mmhg) IVC > 2.1 cm, collapse < 50% : RAP 15 mmhg (10~20 mmhg) IVC < 2.1 cm, collapse < 50% RAP 8 mmhg (5-10 mmhg) IVC > 2.1 cm, collapse > 50% Collapsibility index IVC < 1.7 cm, collapse > 50% : RAP 0~5 mmhg IVC > 1.7 cm, collapse > 50% : RAP 6~10mmHg IVC < 1.7 cm, collapse < 50% RAP 10~15 mmhg IVC > 1.7 cm, collapse < 50%
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