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2 Size of the left ventricle | 123sonography

3 . 2 . 2 S i ze o f t h e l ef t v en t r i cl e

Measurement of the size of the ventricle should be a part of every echo report, because it

provides diagnostic clues and prognostic information, and enables the clinician to follow

patients in respect of disease progression (or improvement). Quantification of the size of

the ventricle is not always as easy as it may seem. The endocardial margins must be visible,

the views should be optimal, and foreshortening of the ventricle should be avoided (see

Chapter 2 - How to Image). Various measurements can be performed to determine size: the

diameter of the ventricle, its length, its area, or its volume. I would advise performing several

measurements at distinct time points of the cardiac cycle: the end of diastole and the end

of systole.

The end of diastole is seen when the

ventricle is largest, shortly before the mitral

valve closes and the mitral annulus

descends.

The end of systole is the time when the

ventricle is smallest - shortly before the

mitral valve opens.

3. 2 . 2. 1 Me a s u re m e nt o f d i am e te r

The advantage of measuring diameter is that it can be done rather quickly. The

measurements are reproducible and provide a good estimate of the size of the ventricle.

Management guidelines are frequently based on such measurements. Although poor image

quality and oblique views may render it difficult to perform measurements, the latter should

be part of every exam. Measurements of the left ventricle can be obtained by the MMode or

by 2D methods.

3 . 2 . 2 . 1. 1 M M o d e m e as u r e m e n t s / D i a m e t e r

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MMode still is the most widely used the technique. The reasons are historical. MMode was

the first technique of echocardiography. Millions of publications describe the use of the

MMode to determine the size of the left ventricle. One reason is the fact that the MMode

has a high time resolution, which is an important aspect of this method (see Chapter 1,

Principles of Echocardiography). The disadvantage of the MMode is that we can only

measure the left ventricle in those orientations the mode permits, which is along the

MMode line. This is a major limitation because the conventional MMode line is fixed at the

top of the image. You could circumvent the problem by using the "anatomical MMode" (see

Chapter 1 Technical Principles). However, not all scanners provide this function and the

anatomical MMode also has its limitations (poor temporal and spatial resolution).

To derive MMode diameters, use a parasternal long-axis view and place the mode line such

that it cuts through the right ventricle (the interventricular septum), the cavity of the left

ventricle, and the posterolateral wall. The exact position of the MMode should be adjusted

so that you cut through the ventricle between the papillary muscle and the mitral valve.

Care must be taken to ensure that you are perpendicular to the structures of the left

ventricle, failing which your measurements will overestimate the size of the left ventricle.

This perpendicular position is not always easy to obtain; it depends on the position of the

transducer. Your MMode tracing will be oblique if you image from an intercostal space that

is too low. One way of checking the accuracy of your parasternal view is to look at the

relationship between the aorta and the interventricular septum. If there is an "angle"

between the two, you are usually too low with the transducer. In a considerable number of

patients you will be simply unable to record such a view. If this is the case, don't perform

MMode measurements.

MMode position: The red line depicts correct orientation; the black line shows oblique orientation of the MMode

MMode Measurements of the left ventricle

can only be obtained in about 75% of

patients

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Delineation of the endocardial margins on the MMode tracing is not always easy. As the

MMode line lies between the papillary muscle and the mitral valve we will also traverse

chordae, which may be mistaken for the posterolateral wall. As a rule of thumb, the motion

of these chordae during systole is not as steep as that of the posterolateral wall.

In small ventricles you will have the problem of inward motion (wall and portions of the

papillary muscle) from the sides, which enters the field of view of the MMode. This may

cause the investigator to underestimate end-systolic diameter.

Pitfall of the MMode: In small ventricles with

prominent papillary muscles, these muscles

may lead to "pseudoshortening" of end-

systolic diameter and consequent

overestimation of left ventricular function.

To facilitate interpretation I would suggest you

always look at the reference 2D image. It will

clearly show the structures that pass through the MMode.

If you have difficulties in interpreting the

MMode tracing, look at the 2D reference

image.

Usually you will not only measure the diameter of the ventricles but also the thickness of

the septum and the posterolateral wall. In addition, you may calculate its fractional

shortening. Fractional shortening will be discussed in the section on left ventricular

function. To measure end-diastolic diameter use the section of the MMode in which the

ventricle is largest, shortly before the walls begin to move inward (onset of the QRS

complex). For the end-systolic dimension, pick the region in which the ventricular cavity is

smallest. This usually is at the tip of the T-wave.

In the presence of dyssychrony it becomes difficult to define end diastole and end systole.

Use the largest and smallest dimensions you find.

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MMode of the left ventricle. The end-diastolic dimension is measured at the onset of the QRS complex, where

the left ventricle is largest

The following table shows the normal dimensions of the ventricle as measured by the

MMode.

Normal (mm) 42 k 59 39 k 53

Mild (mm) 60 k 63 54 k 57

Moderate (mm) 64 k 68 58 k 61

Severe (mm) £ 69 £ 62

LVED diameter k Reference values

Ideally, these measurements should be indexed to the body surface area (BSA)

Normal (cm/m2) 2,2 k 3,1 2,4 k 3,2

Mild (cm/m2) 3,2 k 3,4 3,3 k 3,4

Moderate (cm/m2) 3,5 k 3,6 3,5 k 3,7

Severe (cm/m2) £ 3,7 £ 3,8

LVED diameter/BSA k Reference values

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3 . 2 . 2 . 1 . 2 T w o - d i m e n s i o n a l m e a s u r e m e n t o f t h e l e f t v e n t r i cl e /

D i a m e t er

You can measure the dimensions of the left ventricle in several views. The best and most

widely used one is the four-chamber view. Although the 2D mode and the MMode do not

measure exactly the same diameter, the measurements are quite concurrent.

Use a four-chamber view in which you are able to clearly see the endocardial margin of the

lateral wall and the septum, and measure between these margins - at a level that lies

between the papillary muscle and the mitral valve.

Make sure you measure from the

endocardial surface and not from the

myocardium or pericardium, which usually

has a brighter echo.

You may also use a parasternal view (short and long axis) or a subcostal view, but do not use

a 2-chamber view, because the dimensions of the left ventricle appear smaller on it.

2D measurement of left ventricular diameter on a parasternal long-axis view

2D measurements of left ventricular diameter on the four-chamber view.

Many views may be used to measure the

dimensions of left ventricle.

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The apical views also provide an opportunity to measure the length of the left ventricle.

Although this parameter is clinically less useful, you will need its length to calculate volume

(see section: Volume of the left ventricle) and left ventricular mass.

3. 2 . 2. 2 V ol u me m e as u re m e nts of t he l eft vent ric l e

Volume measurements should be given preference over diameter. Diameter does not

account for the geometry of the entire heart. Let's take the instance of a patient with an

apical aneurysm. Two-dimensional or MMode measurements at the base of the ventricle

will underestimate the true size of the heart. In addition, even a small increment in diameter

is a large increase in volume. This is simple geometry. Many scanners use a formula to

derive volume calculations from MMode measurements. While this gives you a rough idea

of left ventricular volume, it should not be used for the above mentioned reasons.

Formula to derive left ventricular volume using the MMode

Two-dimensional measurements do not

describe the geometry of the ventricle and

are insensitive to differences in volume.

Use volumetric parameters whenever

possible.

It is better to use other methods. Volume may be calculated in three ways:

The area length method

The Simpson method

Three-dimensional volume calculation

3 . 2 . 2 . 2 . 1 A r e a l e n gt h m e t h o d

The area length method is very simple: volume is calculated on the basis of the area of the

left ventricle on a four-camber view, and the length of the ventricle measured from the

mitral annular plane to the apex. All you need to do is trace the endocardium and measure

the length of the ventricle (which is usually done automatically). These values are entered in

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the formula:

Area length formula

You need not memorize the formula. First, most scanners can compute the volume once

you have performed the measurements; second, this method is rarely used today. This is for

a simple reason: the calculation relies on a rather crude geometric assumption. Besides, the

Simpson method is a much better way to approximate volumes.

3 . 2 . 2 . 2 . 2 T h e S i m p so n m e t h o d

The Simpson method is also known as the method of discs ​

because it integrates volume by fitting numerous discs into

the ventricle and sums up their volume. The volume of each

disc is determined by the diameter of the disc and its height.

Simpson Volume = (A1 + A2 +...+An) x h

The measurement is performed the same way as the area length method. You simply trace

the contour of the endocardium on a four-chamber view. Based on your tracing, the system

automatically performs a short-axis segmentation from the base to the apex. On the screen

you will see numerous short-axis lines. Each of these represents the diameter of a disc. The

distance between the lines is the height of the disc. Based on your tracing, the length of the

ventricle is automatically calculated by the scanner.

The Simpson method also makes geometric assumptions. It considers the discs to be

circular (defined by the diameter). Actually the cross-section of the ventricle is not round,

especially in the presence of pathologies. To obtain a better approximation, you may use

the Simpson method on a two-chamber view as well. By using this second view you will

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now have two diameters lying perpendicular to each other. This permits the discs to be

oval-shaped, which better fits the geometry of the ventricle. This approach is also known as

the Biplane Simpson Method. The latter is the most commonly used method to quantify left

ventricular volumes and ejection fraction. You should use it as often as possible. However,

you should be aware of its numerous limitations and the fact that it is actually not as

accurate as many consider it to be. Compared to MRI the calculated volumes may be

significantly smaller. Why is this so and what are the difficulties?

Foreshortening: Remember that we usually do not see the very apical part of the ventricle.

This means we tend to underestimate the true volume of the ventricle. As foreshortening

does not occur on MRI, the measurements obtained with MRI are generally greater.

Foreshortened left ventricle: note that the ventricle appears short and that the apex has a qround shape . o

Mistakes associated with tracing the endocardial margins. It may be difficult to see the

endocardial surface, especially in case of poor image quality. Besides, the inner surface of

the heart is by no means smooth. It is full of trabeculae, especially at the apex.

Tracing the endocardium - Tips:

Use the best images you can get.

Avoid foreshortening.

Scroll back and forth between frames; it is easier to detect margins on a moving image.

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Use an ECG tracing to define end-systolic and end-diastolic frames.

Exclude the papillary muscles when you trace.

Use left ventricular contrast agents in case of poor image quality

The biplane Simpson method is still based on geometric assumptions: Geometric

deviations, which are not seen on the four- or two-chamber view, are ignored when using

this method. For example, if you have an aneurysm in the posterolateral wall you will simply

not account for the increased volume when using the Simpson method. This limitation is

important when using Simpson-derived volumes to compute ejection fraction (see section

Ejection Fraction).

Given these limitations, use the method only in those patients in whom you can trust the

measurements.

3 . 2 . 2 . 2 . 3 T h r e e - d i me n s i o n a l v o l u m e c a l c u l a t i o n

The advent of 3D echo has made it possible to compute volumes of the ventricle without

having to apply geometric assumptions. Numerous approaches have been introduced. In

general it requires the acquisition of a full volume set and delineation of endocardial

margins. This is usually done by the use of a semiautomatic algorithm. The user either

defines certain anatomic landmarks (such as the apex, the mitral annulus, LVOT etc), or

roughly traces the endocardial margin on reference views. As three-dimensional

echocardiography utilizes many (reconstructed) views to calculate volumes, it is practically

free of geometric assumption. However, only high-end scanners provide 3D capabilities.

You will read more about 3D echo in the section on left ventricular function.

Three-dimensional echocardiography can

be combined with contrast

echocardiography. This approach

enhances identification of endocardial

margins.

Normal (mL) 67 k 155 56 k 104

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Mild (mL) 156 k 178 105 k 117

Moderate (mL) 179 k 200 118 k 130

Severe (mL) £ 201 £ 131

LV Diastolic Volume (four chamber view) k Reference Values

Normal (mL) 22 k 58 19 k 49

Mild (mL) 59 k 70 50 k 59

Moderate (mL) 71 k 82 60 k 69

Severe (mL) £ 83 £ 70

LV Systolic Volume (four chamber view) k Reference Values

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Add a comment...

Post to Facebook Posting as Bogdan Teo (Not you?) Com m ent

Am aranath Lakshm inarayanasetty · Doctor at Self-Employed

more logical explanation,thanks
Reply · Like · Follow Post · September 12 at 4:48pm

‫ · رﯾﺎض ﻛﺎظم ﻣﺣﻣد‬Samaw ah, Al Muthanna, Iraq

I hope I w ill meet you someday tommy. Thank yo tommy
Reply · 1 · Like · Follow Post · July 28 at 9:40pm

Shiva Mathur · Loreto Convent, Lucknow

very important information.
Reply · Like · Follow Post · June 2 at 4:43pm

Mônica De Mônico Magalhães · Works at Hospital Madre Regina Prottman

I am very impressed w ith how you made a complex issue become a "no brainer" one. Thanks so much
for that.
Reply · Like · Follow Post · May 31 at 12:56am

Dr-Aym an Tantaw y · Follow · Top Commenter · Works at Assistant lecturer of cardiology

Very nice
Reply · Like · Follow Post · May 6 at 2:34am

Ram esh Sharm a · CMC

Excellent Tommy!
Reply · Like · Follow Post · March 13 at 3:30am

Thom as Binder · Top Commenter · Vienna, Austria

Thanks Ramesh
Reply · Like · April 8 at 12:42pm

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