Chamber Quantitation Guidelines: What is New?
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1 Chamber Quantitation Guidelines: What is New? Roberto M Lang, MD J AM Soc Echocardiogr 2005; 18:
2 Approximately 10,000 citations iase in itune Cardiac Chamber Quantification: What is New? Database Deformation Imaging RT3DE 2
3 Eur Heart J Cardiovasc Imaging Mar;16(3): J Am Soc Echocardiogr 2015;28:1-39 In Chinese.. 3
4 Partition Values for Severity of Abnormalities Cutoffs based on SD Data readily exist Echo parameters are not normally distributed Asymmetric distribution Cutoffs based on percentile values (95 th ) Cutoffs based on outcomes or prognosis Cutoffs based on consensus LV EF, LA, LA size and LV mass Normal Reference Values for 2DE Seven data bases (Asklepios, Flemengho, Cardia5, Cardia 25, Padua 3D Echo Normal, Norre Study) No contrast studies Age, gender, ethnicity, height and weight Nl BP, no diabetes, nl BMI, creatinine, glomerular filtration rate, cholesterol, LDL and triglicerides 4
5 Left Ventricle and Left Atrium Eye ball How do we Assess LV Function? Qualitative Assessment Subjective Experience dependent Lack of standardization Large inter- and intraobserver variability 5
6 Left Ventricular Linear Measurement Left Ventricular Volumetric Measurement TEICHHOLZ Formula 6
7 Left Ventricular Volumetric Measurement 1 Biplane Disk Summation Area Length Method 2 7
8 Left Ventricular Ejection Fraction Normal Mild Moderate Severe 2015 > < > <30 8
9 LV Ejection Fraction Male Normal Mildly Moderately Severely LVEF <30 Female Normal Mildly Moderately Severely LVEF <30 3 9
10 Why is 3D More Accurate? long axis (cm) A4C * 7 2D 3D Mor-Avi V, Lang RM et al., Circulation : Validation by MRI EDV, ESV Excellent correlation (r²>0.85) but RT3DE underestimates volumes Jacobs LD, et al. Eur Heart J 2005; 27:460-8 Sugeng L, et al. Circulation 2006; 114: Jenkins C, et al. J Am Soc Echocardiogr 2007; 20:962-8 Soliman OI, et al. Am Soc Echocardiogr 2007; 20:
11 Sources of error Latex balloon: Human ventricles: Patient A Patient B True volume: 150 ml Tracing error is the most important factor contributing to LV volume underestimation Mor-Avi V. et al, JACC Cardiovasc Img 2008: 1: LV Volumes: 3DE Advantages Avoid image foreshortening No geometric assumptions More accurate and reproducible Disadvantages Low temporal resolution Less data on normals 11
12 2D Methods Linear Method Cubed Formula Area Length Truncated ellipsoid Men Women LV Mass/BSA RWT, cm Septal WT, cm PWT, cm Men Women LV mass/bsa, g/m Direct measurement without geometrical assumptions about cavity shape and hypertrophy distribution More accurate that the linear or the 2D measurements Higher inter-measurement and test/retest reproducibility Better discriminates small changes within a patient 3D Methods Normal values less well established Dependent on image quality Patients cooperation required 12
13 Lang RM, JASE 2005; 18: RWT = 2PW TH / LVIDd LV Global Longitudinal Strain Peak GLS in the range of -20% can be expected in a healthy person Low Flow AS Cardio-oncology Valvular Regurgitation 13
14 LV Global Longitudinal Strain LV Segmentation: Regional Deformation Quantitative assessment of the magnitude of regional LV deformation is not recommended lack of reference values suboptimal reproducibility considerable intervendor measurement variability
15 1. Normal or Hyperkinetic 2. Hypokinetic (reduced thickening) 3. Akinetic (absent or negligible thickening 4. Dyskinetic (systolic thinning or stretching) 15
16 LV Volume 3/30/2017 The Left Atrium Reservoir Conduit Booster Pump 15-30% LV SV Mehrzad et al. Int. J. Mol. Sci. 2014, 15, Left atrial function 3DE Conduit Reservoir Booster 16
17 Left atrial function Conduit volume = LV SV LA max LA min Max = End-systole, just before mitral valve opening Min = End-diastole, when the mitral valve closes Pre-A = Immediately before atrial systole (p-wave) Hoit BD. J Am Coll Cardiol 2014;63: Left atrial function 2DE 2D Speckle-tracking analysis Reservoir function Conduit function Booster function Singh A, Addetia K Lang RM ASE
18 Diastolic Dysfunction Hypertension Ischemia Sleep Apnea Mitral /aortic valve disease Volume/Pressure Overload LA Enlargement Clinical Outcomes 3D Echo for Assessing the Left Atrium LA size has a powerful prognostic value in a variety of clinical conditions: atrial fibrillation systolic heart failure diastolic dysfunction chronic coronary artery disease myocardial infarction mitral regurgitation systemic hypertension stroke hypertrophic cardiomyopathy renal failure Tsang, T.S.M. et al. J Am Coll Cardiol
19 Assesment of Left Atrial Size/Volumes Diameters - M-mode - 2D guided Area - 4Ch TIME EVOLUTION Volume - Calculated from 2D - Measured by 3D 19
20 3D Echo for Assessing the Left Atrium Assymmetrical LA Remodelling LA enlargement does not occur uniformly in all directions Time LA Linear Dimension 20
21 LA Volume Left atrial volume on 2DE Accuracy of 2DE is limited: View-dependent Geometrical assumptions Measured on apical views optimized for LV 21
22 Left atrial volume on 2DE LA axis LV axis View optimized for LV View optimized for LA LAVi 34.0 ml/m 2 LAVi 38.4 ml/m 2 LA volume assessment on 2DE Single plane method of disks Single plane area-length Biplane area-length Biplane method of disks ASE/EACVI Chamber Quantification Guidelines D Echo 22
23 Left atrial volume on 2DE Biplane volume: 82 ml 3D volume: 88 ml A4C Standard views A2C 3DE-derived views Biplane volume: 87 ml A4C Atrial-focused views A2C Left atrial volume on 2DE LA volumes obtained from non-foreshortened LAfocused views correlated highly with those obtained from conventional A4C views (r=0.94), but were larger (Bland Altman bias 7 ml, limits of agreement ±19 ml). V. Mor-Avi, Addetia K and Lang RML work in progress 23
24 LA Volume LA Vol/BSA Normal Mildly Moderately Severely >40 Lang RM et al; J Am Soc Echocardiogr 2005; 18: LA Vol/BSA 34 Normal Mildly Moderately Severely >48 Lang RM et al; J Am Soc Echocardiogr 2015; 28:1-39 2DE vs. 3DE for LA Volume Quantification 3DE Mor-Avi V,Lang RM et al.: Real-time 3D echocardiographic quantification of left atrial volume: Multicenter study for validation with magnetic resonance imaging. JACC Imaging
25 Left atrial function Conduit volume = LV SV LA max LA min Max = End-systole, just before mitral valve opening Min = End-diastole, when the mitral valve closes Pre-A = Immediately before atrial systole (p-wave) Hoit BD. J Am Coll Cardiol 2014;63: Left atrial function 2DE 2D Speckle-tracking analysis Reservoir function Conduit function Booster function Singh A, Addetia K Lang RM ASE
26 Aorta Aortic Annulus Measurements NCC LCC RCC When: mid-systole: slightly larger and rounder Where: mid right coronary cusp and the edge of the commissures between the LCC and NCC from inner edge to inner edge 26
27 Sinuses of Valsalva (Enddiastole) Sino-tubular junction (Enddiastole) Maximal diameter of the proximal Asc Ao (Enddiastole) Leading edge to leading edge 27
28 Aortic Root Measurements (Sinus of Valsalva) 28
29 Summary 1. Reference ranges for left ventricular volumes and ejection fraction as well as LA volumes have changed in the recent guidelines due to the use of large echo databases. 2. Left ventricular wall motion scoring has changed to a 4-grade system. 3. Three-dimensional echocardiography is recommended for measurement of left and right ventricular volumes if possible. Summary 4. If global longitudinal strain is being used to follow patients, it should be using the same vendors machine and analysis package. Lang et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am. Soc. Echocardiogr. 2015;28:
30 30
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