Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Assessment of Left Ventricular Systolic Function


Introduction

A major goal of the echocardiographic examination is the assessment of left ventricular (LV) structure and systolic function. This plays a critically important role in the diagnosis, risk evaluation, and management of patients with suspected or established cardiovascular disease. The left ventricle can be assessed qualitatively and quantitatively to define any alterations in cardiac size and geometry by using comprehensive measurements ( Fig. 14.1 ). Established normal values are shown in Tables 14.1–14.3 .

FIG. 14.1, Echocardiographic measures of ventricular systolic function can be categorized using established global and regional systolic function. Global ventricular function parameters include linear and volumetric dimensions , for example, wall thicknesses, ventricular areas, ventricular volumes. From these, traditional measures such as left ventricular ejection fraction (LVEF) and LV mass can be derived. Global hemodynamic measures of global ventricular function obtained on Doppler echocardiography includes stroke volume , cardiac output , rate of rise of pressures within the left ventricle during systole (d P /d T ), and myocardial performance index (MPI) or Tei index. Regional measures of ventricular systolic function include qualitative assessment of regional wall motion, semiquantitative assessment of regional wall motion or wall motion score index (WMSI), tissue Doppler imaging (TDI) techniques to quantify systolic cardiac mechanics and deformation. Speckle tracking imaging (STI) techniques to quantify systolic cardiac mechanics and deformation. ASE, American Society of Echocardiography; CI, cardiac index; CO, cardiac output; d P/ d T, rate of change of pressure during the isovolumetric contraction phase of systole; IVC, isovolumetric contraction; LVEF, left ventricular ejection fraction; SV, stroke volume; TDI, tissue Doppler imaging; WMSI, wall motion score index.

TABLE 14.1
Normal Values for Two-Dimensional Echocardiographic Parameters of Left Ventricular Size and Function According to Gender
From Lang RM, Badano LP, Mor-Avi V, 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(1):1–39.
Parameter Male Female
Mean ± SD 2-SD Range Mean ± SD 2-SD Range
LV internal dimension

  • Diastolic dimension (mm)

50.2 ± 4.1 42.0–58.4 45.0 ± 3.6 37.8–52.2

  • Systolic dimension (mm)

32.4 ± 3.7 25.0–39.8 28.2 ± 3.3 21.6–34.8
LV volumes (biplane)

  • LV EDV (mL)

106 ± 22 62–150 76 ± 15 46–106

  • LV ESV (mL)

41 ± 10 21–61 28 ± 7 14–42
LV volumes normalized by BSA

  • LV EDV (mL/m 2 )

54 ± 10 34–74 45 ± 8 29–61

  • LV ESV (mL/m 2 )

21 ± 5 11–31 16 ± 4 8–24
LV EF (biplane) 62 ± 5 52–72 64 ± 5 54–74
BSA, Body surface area; EDV, end-diastolic volume; EF, ejection fraction; ESV, end-systolic volume; LV, left ventricular; SD, standard deviation.

TABLE 14.2
Reference Limits and Partition Values of Left Ventricular Mass and Geometry
From Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr . 2005;18(12):1440–1463.
Women Men
Reference Range Mildly Abnormal Moderately Abnormal Severely Abnormal Reference Range Mildly Abnormal Moderately Abnormal Severely Abnormal
Linear Method
LV mass (g) 67–162 163–186 187–210 ≥211 88–224 225–258 259–292 ≥293
LV mass/BSA (g/m 2 ) 43–95 96–108 109–121 ≥122 49–115 116–131 132–148 ≥149
LV mass/height (g/m) 41–99 100–115 116–128 ≥129 52–126 127–144 145–162 ≥163
LV mass/height 2.7 (g/m 2.7 ) 18–44 45–51 52–58 ≥59 20–48 49–55 56–63 ≥64
Relative wall thickness (cm) 0.22–0.42 0.43–0.47 0.48–0.52 ≥0.53 0.24–0.42 0.43–0.46 0.47–0.51 ≥0.52
Septal thickness (cm) 0.6–0.9 1.0–1.2 1.3–1.5 ≥1.6 0.6–1.0 1.1–1.3 1.4–1.6 ≥1.7
Posterior wall thickness (cm) 0.6–0.9 1.0–1.2 1.3–1.5 ≥1.6 0.6–1.0 1.1–1.3 1.4–1.6 ≥1.7
Two-Dimensional Method
LV mass (g) 66–150 151–171 172–182 ≥183 96–200 201–227 228–254 ≥255
LV mass/BSA (g/m 2 ) 44–88 89–100 101–112 ≥113 50–102 103–116 117–130 ≥131
Bold italic values are recommended and best validated.
BSA, Body surface area.

TABLE 14.3
Reference Limits and Partition Values of Left Ventricular Function
From Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr . 2005;18(12):1440–1463.
Women Men
Reference Range Mildly Abnormal Moderately Abnormal Severely Abnormal Reference Range Mildly Abnormal Moderately Abnormal Severely Abnormal
Linear Method
Endocardial fractional shortening (%) 27–45 22–26 17–21 ≤16 25–43 20–24 15–19 ≤14
Midwall fractional shortening (%) 15–23 13–14 11–12 ≤10 14–22 12–13 10–11 ≤9
Two-Dimensional Method
Ejection fraction (%) ≥55 45–54 30–44 <30 ≥55 45–54 30–44 <30
Bold italic values are recommended and best validated.

Echocardiography offers several methods for assessment of systolic function. Routine assessment of ventricular systolic function typically begins with a qualitative evaluation. However, more precise quantification methods of global and regional ventricular systolic function are recommended. Linear and volumetric LV measures such as wall thicknesses, mass, and volumes remain clinically useful parameters supported by extensive data. These are based primarily on M-mode, two-dimensional (2D), and Doppler hemodynamic measures ( Figs. 14.1 and 14.2 ).

FIG. 14.2, The cardiac cycle with superimposed events during systole and diastole. During left ventricular systole , ejection of from the left ventricle, through the aortic valve, and into the aorta, occurs. These systolic events can be assessed on the echocardiographic views and Doppler measures depicted. AC, Aortic valve closure; AO, aortic valve opening; IVSd , interventricular septal diameter; LV , left ventricle; MC, mitral valve closure; MO, mitral valve opening.

Traditional M-Mode and 2D-derived measurements, such as left ventricular ejection fraction (LVEF), are still widely used but have important limitations. They are based on comparisons of frames and measures obtained at the beginning and end of the contractile cycle. They are load and heart rate–dependent and do not directly measure dynamic LV myocardial performance. Additionally, the geometric assumptions and derived LV measures have inherent inaccuracies. The advent of real-time three-dimensional (3D) echocardiography, however, has overcome some of these inaccuracies. Nevertheless, continuing challenges such as endocardial border delineation remain.

Recent advances in cardiac deformation imaging, primarily using tissue Doppler and 2D speckle tracking imaging, has made possible the measurement of global and regional LV systolic mechanics. The additional insights they provide about regional LV contractile mechanics have been shown to be more sensitive measures of preclinical and clinical myocardial pathology. An increasing body of data indicates that they provide superior prognostic and incremental information over traditional systolic measures. LV deformation indices, such as velocities, displacement, strain, and strain rate, are now increasing employed in the comprehensive assessment of LV systolic function.

Left Ventricular Systole: Cardiac Cycle and Hemodynamics

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts