Stephen Glen ISCHAEMIC HEART DISEASE AND LEFT VENTRICULAR FUNCTION

Stephen Glen ISCHAEMIC HEART DISEASE AND LEFT VENTRICULAR FUNCTION

Overview Coronary arteries Terminology to describe contractility Measuring ventricular function Systolic dysfunction Practice cases- LV function Diastolic function

RCA LCA

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.

Mid inferior Mid anterior Basal inferior

Apical anterior septum Mid anterior septum Basal anterior septum Apical posterior

Describing contractility Normal Hypokinetic (<30% thickening) Akinetic Dyskinetic Aneurysm Scar

Wall motion abnormalities PLAX PSAX

Q1 where is the abnormality?

Q2. Where is the abnormality?

Q3. How would you grade LV function?

Q4. Can you guess the EF?

Q5. What is this?

Q6. Describe the wall motion abnormality

Beware the missing apex!

Bad and bad, or good and bad?

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

Shortening fraction LVEDD - LVESD LVEDD Normal >30% Mild 26-30%

Ejection fraction Diastolic systolic volume Diastolic volume Normal >60% male, 55% female

Supporting evidence Reliability of reporting left ventricular systolic function by echocardiography: a systematic review McGowan J, Cleland J. Am Heart J 2003;146:388-97 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%)

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

Where is the abnormality?

First case continued, A2ch

First case- both views Q8. How good / bad is LV function?

Case 2 A4Ch Q9. Describe LV function

Case continued A2Ch

Case summary

Case 3- A4Ch Q10. Describe the abnormality

Case 3 A4Ch close up

Case 3 summary

Case 4 PLAX Q11. Describe the abnormality

Case 4 PLAX

Case 4 A4Ch Q12. Describe the mid septum

Case 4 summary Q13. How many arteries are blocked?

Case 5 Biplane

Case 5 A4Ch

Case 5 summary Q14. What segments are abnormal?

Case 6 PLAX

Case 6 PSAX

Case 6 A4Ch

Case 6 A2Ch

Case 6 summary Q15. Is this normal?

Strain rate bullseye summary

Strain rate imaging

LV multislice with contrast

Diastolic function

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)

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

Diastolic Function: Transmitral flow patterns BEST GOOD MODERATE BAD WORST NORMAL PRESSURE INCREASING PRESSURE

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

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

Best single measurement? Left atrial volume

Mitral annular movement

Tissue velocity imaging

E/e <10 is normal; 10-15 borderline; >15 abnormal (diastolic dysfunction; high LA pressure) E/e = 100/4 = 25

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