Echocardiography:

LV Systolic Function
David M. Whitaker, MD
 “I need a stat echo…”

LVEF – most common reason for echo

2nd most common – pericardial effusion

3rd most common - RVSP

 The “early days”

Before there was 2D echo  M-mode

M-mode was a useful tool but with many

limitations

Offered superior temporal resolution

 M-mode

LV function was determined using linear

measurements

Even as 2D echo advanced, linear measurements

still made to assess LV function
Linear Measurements
 M-mode

Early limitations related to “quality” of echo image

– difficulty separating blood pool from endocardial
interface

Improvements in gray scale technology improved

this
 Other M-mode Limits

Ice Pick evaluation

Leaves out potential regional wall motion

abnormalities

May overestimate or underestimate overall LV

function
 Other M-mode Limits

Because the M-mode line often intersects the LV

in a tangential fashion – the minor axis is often
overestimated

Could argue that for a given pt the degree of

overestimation remains constant and thus could
be used for serial evaluation
 More Linear M-mode

Other measurements for LV performance

Rates of systolic wall thickening of post wall
Calculation of velocity of circumferential shortening
(which assumes the LV is a perfect circle)
Descent of the base measurement
 Descent of the Base

During ventricular contraction – base moves

toward apex

Magnitude of this motion directly proportional to

systolic function

Same principle that TDI is based on

Indirect Markers of LVEF

Increased E-point septal separation

Gradual end systolic closure of the aortic valve

E-point Septal Separation

Magnitude of MV opening (E wave height)

correlates with transmitral flow and with LV stroke
volume – if MR is not bad

Internal dimension of LV  diastolic volume

So… the ratio of the mitral excursion to LV size

reflects the EF
E-point Septal Separation

Normally the MV E-point within 6 mm of the LV

septum

In severely depressed EF, this distance is

increased…
 Aortic Valve Closing
Pattern

If the LV stroke volume is decreased, there may

be a gradual reduction in forward flow in late
systole

Results in “gradual” closing of the AV in late

systole

M-mode will show a rounded closure rather than

the box cars
 2D Measurements

A number of 2D views are used to provide LV function

Some rely exclusively on area measurement

Others rely on calculation of volume from the image

 2D Measurements

All the general formulas based on the assumption

that ventricle will adhere to a predictable shape

If there are regional wall motion abnormalities, the

accuracy of these methods decreases
 Simplified Method

Get minor axis measurements in diastole and

systole at base, mid and distal LV.

Combine these with assessment of the apex to get

EF
 Simpsons Method

A.k.a. the “Rule of Disks”

Requires apical 4 or 2 chamber view, outlining the

endocardial border in diastole and systole

Ventricle is mathematically divided along its long

axis into a series of disks of equal height
 Simpsons Method

Individual disk volume is calculated

Height x disk area

Height = total length of LV / # of disks

Disk surface area determined for LV diameter at that

point

Adding the disk volumes give LV volume

 Simpsons Method

Tangential or foreshortened imaging of LV apex

will most often overestimate EF

If the LV is assymetric, a bi-plane determination

improves accuracy
 Simpsons Method

Determine the stroke volume

(LV diastolic – LV systolic)

EF = stroke volume / end diastolic volume

 LV Mass

Determined using a number of echo formulas and

algorithms

Carries significant prognostic importance in all

forms of heart disease
LV Mass – Earliest Method

Teichholz Method or Cubed Formula

Based on M-mode measurement of septal and
posterior wall thickness as well as LV internal
dimension measurement
Again, symmetric geometry is assumed that LV is
a sphere
Calculates outer dimensions of sphere, then inner
dimension. The difference = presumed LV volume
 Cubed Formula

LV Mass =

(IV septum + LV interior + post wall)3 ---

(LV interior)3

This gives volume of stylized sphere of

myocardium which, multiplied by SG of muscle
(1.05 g/cm3) estimates LV mass
 Abnormal LV Mass

Conentric Remodeling

Contentric Hypertrophy

Eccentric Hypertrophy
After 100 Echos