1. Fuad Farooq

2.  Assessment of ventricular systolic function, the
essential part of all echocardiography
examinations

3.  2D echo allows visualization of the
endocardium and it’s thickening, by which
global and regional ventricular systolic
functions are assessed
 Quantitative assessment of global systolic
function is usually based on changes in
ventricular size and volume

4.  Fractional shortening of LV
 Ejection fraction
 Stroke volume and cardiac index
 Systolic tissue velocity of the mitral annulus
and myocardium
 Tissue tracking
 Regional wall motion analysis

5.  Percentage change in LV dimensions with each
LV contraction
 Reflects global ventricular function
LVED - LV end-diastolic dimension
LVES - LV end-systolic dimension

7.  Assesses ventricular function only at the level
being interrogated
 If regional dysfunction is present, which is not in the
interrogation plane, it may result in a misleading
estimate of global ventricular function

8.  Expression of global LV function
 Strong predictor of clinical outcome in almost
all major cardiac conditions
 Determined visually by eyeballing
echocardiographic images of the LV
 Considerable inter-observer variation but with
experienced readers variation is less than 5%

9.  Measured quantitatively by using volumetric
measurements from M-mode, 2D and 3D
echocardiograms
LVEDV - LVESV
LVEDV
LVEF =

11.  EF can also calculated from LV dimensions
measured with M-mode
 Measurement of LV dimensions from the mid
ventricular level is used to calculate LVEF
LVEDD2 – LVESD2
LVEDD2
Add 15% for normal, 5% for hypokinetic apex, 0% for
akinetic apex, -5% for dyskinetic apex, and -10% for
apical aneurysm
LVEF = x 100

13.  Not a true indicator of systolic function
 Determined by multiple factors
 Provides the amount of blood volume ejected
with each cardiac cycle

14.  Stroke volume can be measured as the
difference between the LV end-diastolic
volume and LV end-systolic volume obtained
by the Simpson method

16.  The difference should be equal to SV across the
LVOT if there is no valvular regurgitation
 If there is MR, regurgitant volume needs to be
subtracted to obtain stroke volume across the
LVOT

17. Calculated as
SV = LVOT area x LVOT TVI(time velocity
integral)

19.  Cardiac output is calculated as:
CO = SV x HR
 Cardiac index is calculated as:
CO
Body Surface Area (BSA)
CI =

20.  Tissue Doppler imaging records the velocity of
myocardial tissue
 The systolic component (S’) of the mitral
annulus correlates well with the LVEF

22.  Value of 8cm/s was selected as a cutoff point
 Vinereanu et al. have reported (80%
sensitivity, 89% specificity) for the same cutoff
point of S’ measured at the medial mitral
annulus and (80% sensitivity, 92% specificity)
for S’ measured at the lateral mitral annulus
Estimation of global left ventricular function from the velocity of longitudinal shortening.
Echocardiography 2002;19(3):177-185

23.  Systolic contraction of the ventricles is
performed optimally when regional
contractions are coordinated
 All walls should contract within 20 to 30
milliseconds of each other
 Disrupted by conduction delay, atrial
fibrillation, or a pacemaker

24.  Assessed best with tissue Doppler imaging
 Reliably provide timings of cardiac events or
myocardial movement

25. TDI in systole
TDI in diasystole

26. Tissue colour Doppler in M-mode

27.  It is byproduct of tissue Doppler imaging
 Basoapical views of each ventricular segment
are displayed as seven color bands, with each
color representing a particular distance the
tissue moves during systole
 Tissue tracking provides a rapid assessment of
systolic motion

28.  Mitral anulus displacement can be determined
instantaneously with tissue tracking
 Normal mitral annular systolic motion is
>8mm (average 12 + 2 on apical 4 or apical 2
views)
 A systolic mitral anulus displacement of less
than 5 mm determined by tissue tracking
correlates well with a severe decrease in the
LVEF (<30%)

29.  Normal ventricular contraction consists of
simultaneous myocardial thickening and
endocardial excursion toward the center of the
ventricle
 Regional contractility or wall motion of the LV is
graded by dividing the LV into segments
 In 2002, a 17-segment model was recommended by
the American Society of Echocardiography
 LV is divided into three levels - basal, mid or
papillary and apical
Circulation, 2002;105: 539-542

30. Basal
1.Anteroseptum
2. Anterior
3. Lateral
4. Inferolateral
5. Inferior
6. Inferoseptum
Mid
1.Anteroseptum
2. Anterior
3. Lateral
4. Inferolateral
5. Inferior
6. Inferoseptum
Apical
1. Anterior
2. Lateral
3. Inferior
4. Septal
Apical cap

33.  Numerical score is assigned to each wall
segment on the basis of its contractility as
assessed visually:
1= Normal (>40% thickening with systole)
2= Hypokinesis (10-30% thickening)
3= Severe hypokinesis to akinesis (<10% thickening)
4= Dyskinesis (out of phase)
5= Aneurysm (thinned and bulging outwards)

34.  On the basis of this wall motion analysis
scheme, a wall motion score index (WMSI) is
calculated to semiquantitate the extent of
regional wall motion abnormalities
Normal WMSI is 1
WMSI > 1.7 may suggest perfusion defect > 20%

35. Qualitative estimation errors due to:
 Underestimation of EF due to endocardial echo
dropout and seeing mostly epicardial motion
 Underestimation of EF with enlarged LV cavity; a
large LV can eject more blood with less endocardial
motion
 Overestimation of EF with a small LV cavity
 Significant segmental wall motion abnormalities

36. Normal
Abnormal

37. Myocardial performance index
TEI index = IVRT + IVCT
LVET
 IVCT - Isovolumic contraction time
 IVRT - Isovolumic relaxation time
 LVET - LV ejection time
 Normal in 0.39 +/- 0.05

38. 1. E-point septal separation
2. Aortic valve opening pattern

39.  The magnitude of opening of the mitral
valve, as reflected by E-wave height, correlates
with transmitral flow and, in the absence of
significant mitral regurgitation, with left
ventricular stroke volume
 Mitral valve E point (maximal early opening) is
within 6 mm of the left side of the ventricular
septum
 In the presence of a decreased ejection
fraction, this distance is increased

41. Severe systolic dysfunction

42.  If left ventricular forward stroke volume is
decreased, there may be a gradual reduction in
forward flow in late systole, which results in
gradual closing of the aortic valve in late
systole. This results in a rounded appearance of
the aortic valve in late systole