좌심실수축기능평가 Cardiac Function

Basic Echo Review Course 좌심실수축기능평가 Cardiac Function Seonghoon Choi Cardiology Hallym university

LV systolic function Systolic function 좌심실수축기능 - 심근의수축으로심실에서혈액을대동맥으로박출하는기능 실제임상에서 LV function 의의미 1Diagnosis systolic (and diastolic) dysfunction, etiology for symptoms 2Assessing response to treatment 3Assessing risk and prognosis need for intervention like as defibrillation, valve surgery, medicine, CRT etc. and timing of intervention

Systolic function by echo: important marker of risk Post-MI CHF LVEF < 35% GISSI-2 SOLVD Registry Data Volpi A, et al, Circulation 1993;88:416 Quinones et al : JACC 2000;1237-1244

심장주기 Aorta pr. LV pr. LA pr. LV volume ICT ET IRT ICT = 등용적수축기 (Isovolumic Contraction Time) ET = 좌심실박출기 (Ejection Time) IRT = 등용적이완기 (Isovolumic Relaxation Time)

Visual assessment Qualitative assessment Subjective Experience dependent Lack of standardization Large inter- and intra-observer variability

LV systolic function index 수축기능 분획단축률 Fractional shortening (FS) 좌심실구혈률 Ejection fraction (EF) 일회박출량 / 심박출량 Stroke volume / cardiac output Ejection acceleration time in LVOT(LVOT ACC) dp/dtmax Mitral annular systolic wave (Sm) by TDI Mitral E point septal separation (EPSS) Tei index (Index of myocardial performance, IMP) LV global longitudinal Strain

LV linear measurement Parasternal long-axis view Perpendicular to LV long axis Below level of MV leaflet tips in diastole Leading edge to edge

Fractional shortening (FS) LVEDd: 이완기내경 LVEDd LVESd LVESd: 수축기내경 LV FS = (LVIDd - LVIDs) / LVIDd x 100%

Fractional shortening Normal >30% (25-45%) Severe LV dysfunction <15% Limitation 1. measures only transverse myocardial function, 2. describes the contractility of two walls only(infero-lateral and interventricular septum) 3. conclusions about overall LV function are made based on contractility of basal segments, that usually function properly (even in a significant LV systolic dysfunction) 4. completely useless when any regional wall motion abnormalities are present 5. inadequate M-mode cross-section (oblique orientation of the ultrasound beam with respect to the long axis of LV, incorrect crosssection level).

LV ejection fraction stroke volume as a percent of enddiastolic volume. LVEF = LVSV/LVEDV x 100% = (LVEDV - LVESV)/LVEDV x 100%

LVEF : Linear method(m-mode) LVEDd: 이완기내경 LVEDd LVESd LVESd: 수축기내경

LVEF : Linear method(m-mode) Limit 1. excessive geometric simplification, 2. completely useless when any regional wall motion abnormalities are present, 3. inadequate M-mode cross-section (oblique orientation of the ultrasound beam with respect to the long axis of LV, incorrect cross-section level). M-mode 로측정한 EF 는권장되지않는다

LVEF: Modified Simpson method ai bi Disc ( 전부 20) L 20 V = /4Σaibi L/20 i=1 A4C A2C

LVEF: Modified Simpson method 4 chamber view 좌심실이완말기용적 : 103 ml 이완말기 2 chamber view 수축말기 좌심실추축말기용적 : 39 ml 좌심실구혈률 (EF): 62 % = (103-39)/103X100(%) 이완말기 수축말기

LVEF: Modified Simpson method Limit 1. Inadequate endocardial border definition, even if optimal image quality (usually anterior and lateral endocardium are inadequately visualized), 2. Suboptimal image quality (especially when significant obesity or COPD are present), 3. Useless when excessive regional wall motion abnormalities or left ventricular geometric alterations are present (e.g. post-infarction aneurysm).

좌심실구혈률 (LVEF) 법의장단점

Potential problems with LVEF Load dependency Measurement issues Measurement issues Endocardial dropout : overestimation of volume Foreshortening of the ventricle : underestimation of volume, less effect on EF Geometric assumptions : influence EF measure when LV distorted Regional dysfunction Regional dysfunction : over or underrepresented with some methods Paradoxical septal motion, other discoordinations of contraction Underestimation of EF Heart rate effects Heart rate effects : tachycardia reproducibility

LVEF: 삼차원심초음파법

3D Echo versus CMR Soliman O et al. Am J Cardiol 2008;102:778-783

Ejection acceleration time in LVOT (LVOT ACC) LV ejection curve max. velocity and acceleration time (time from the beginning to the maximum) Global LV systolic function Apical 3 chamber view, PW sample volume at LVOT & 1cm distally of AV valve (increasing sweep speed) LVOT ACC = Vmax (m/s) / ACT (s) Normal range: 8-14 m/s 2 Systolic dysfunction causes the decrease in LVOT ACC. Load-undependent and greatly correlates with hemodynamic variables.

Ejection acceleration time in LVOT (LVOT ACC)

Mitral_dP/dt Doppler mitral regurgitation (MR) curve - Instantaneous pressure difference between LV and LA in systole In LV systolic dysfunction, LV pressure falls / LA pressure Pressure difference Rate of increase in velocity of MR jet Apical View, MR jet with CW

dp/dt max Mitral regurgitation jet CW Doppler dp / dt (mmhg/sec) = P x 1,000 / T = 4 (V 3 2 - V 12 ) x 1,000 / T dt = 4 (3 2 1 2 ) x 1,000 / T = 32,000 / T 정상 > 1,200 mmhg/sec 중증수축기능저하 1 3 MR Jet V 1 = 1 m/sec V 3 = 3m/sec < 800 mmhg/sec 이하 T

Rapid Rate dp/dt max Slow Rate dp/dt 1047 mmhg/s Normal dp/dt 668 mmhg/s Depressed T T

Mitral Annular Systolic Velocity LV RV S LA RA E A Close correlation between S and LVEF S > 7.5 cm/s: Predict LVEF > 50% (sensitivity: 79%, specificity: 88%)

Tei Index a b 등용적수축기 ICT 수축기 ET 등용적이완기 IRT 수축기능및이완기능모두의종합기능평가지표

LV Global Longitudinal Longitudinal Strain WNL Peak GKS in range of -20% Can be used in low flow AS, cardiooncology, Valvular regurgitation

LV function in poor echo quality Contrast Echo Non-endocardial border delineation method - Iso-volumic indices mitral-dp/dt - Ejection phase indices Tei index FS(M-dode)

Contrast Echo LVEF 2D biplane = 46.1% Contrast M-mode = 73.6% Contrast biplane = 60.2%

LV systolic function index 수축기능 분획단축률 Fractional shortening (FS) 좌심실구혈률 Ejection fraction (EF) Ejection acceleration time in LVOT(LVOT ACC) dp/dtmax Mitral annular systolic wave (Sm) by TDI Mitral E point septal separation (EPSS) Tei index (Index of myocardial performance, IMP) LV global longitudinal Strain

Summary LV systolic function is single most important cardiac performance measurement. Quantitation of LVEF rather than qualitative evaluation like as 2D biplane Simpson method. Semi-quantitative global systolic measurement like as LVOT ACC, dp/dtmax, mitral annular systolic wave (Sm), Mitral E point septal separation (EPSS), Tei index, LV global longitudinal Strain. Use contrast in poor echo window.