Quantitation of the

Left Heart
Gerard Aurigemma, MD
Division of Cardiovascular Medicine
Department of Medicine
Umass Medical School
Roberto Lang, MD
Eur Heart J Cardiovasc Imaging. 2015 Mar;16(3):233-71. J Am Soc Echocardiogr 2015;28:1-39
Quantitation of the
Left Heart
•Linear Dimensions
•LV Volumes
•LA
•Aorta

5
Quantitation of the
Left Heart
•Linear Dimensions
•LV Volumes
•LA
•Aorta

6
Linear measurements obtained from 2D
echocardiographic images are preferred to 2D-guided
M-mode to avoid oblique sections of the ventricle

Single dimension, i.e., representative

only in normally shaped ventricles
Off-axis Imaging: Elliptical LV
Shape

8
Pitfalls of Linear Measurements

9
 Why End-systolic Dimension?

Importance of LV ESD
• Reflects severity of volume load
• Reflects degree of LV shortening
• Suggests depressed LVEF
• If LVEF is normal it suggests LV remodeling
• Utilized in guidelines for timing of AVR, MVR
Quantitation of the
Left Heart
•Linear Dimensions
•LV Volumes
•LA
•Aorta

11
TEICHHOLZ Formula
Left Ventricular Volumetric Measurement
1 Biplane Disk Summation

Area Length Method

2
15
 Echo v MRI
LV EDV

Wood Echocardiography 2013 16

Limitations of LV Volume
Measurements
• Tracing error / Endocardial definition
• Foreshortening
• Geometrical assumptions

Salgo IS, Lang RM et. al. J Am Soc Echocardiogr 2012;25:80-8

 Sources of error
➢ Latex balloon: ➢ Human ventricles:
Patient A Patient B

• Tracing error is the most

important factor contributing to
True volume: 150 ml LV volume underestimation

• Mor-Avi V. et al, JACC Cardiovasc Img 2008: 1: 413-423

LVV A4c
115 cc
LVV A2c
135 cc
EF 58%
LVL 7.2
cm

19
One ribspace downward later….
LVV A4c
138 cc
LVV A2c
142 cc
LV L 8 cm
EF 58%

20
Clues:
globular LV

discrepancy in
LV lengths

apex is
thickening

21
Foreshortening
A2c A3c

A4c
 A2c A3c

A4c
3
 LV Volumes: 3DE

✓ Advantages
• Avoid image
foreshortening
• No geometric ✗ Disadvantages
assumptions • Low temporal
• More accurate and resolution
reproducible • Less data on
normals
 Use contrast agents
When ≥ 2 contiguous segments are poorly visualized in
apical views consider a contrast agent
 11
A4C
Why is 3D more 10

long axis (cm)

*
accurate? 9

7
2D 3D

Mor-Avi V, Lang RM et al., Circulation

2004. 110: 1814-1818.
The Left Atrium

Reservoir Conduit Booster Pump

15-30% LV SV

Mehrzad et al. Int. J. Mol. Sci. 2014, 15, 15146-15160

LA Linear Dimension
 3D Echo for Assessing the Left Atrium
Assymmetrical LA Remodelling
• LA enlargement does not occur uniformly in all directions

Time
LA volume assessment on 2DE

Single plane
method of disks

Single plane
area-length
Biplane area-length Biplane method of disks

ASE/EACVI Chamber Quantification Guidelines 2015

3D Echo
 LA Volume
Normal Mildly Moderately Severely

LA
Vol/BSA
16-28 29-33 34-39 >40
Lang RM et al; J Am Soc Echocardiogr 2005; 18:1440-1463

Normal Mildly Moderately Severely

LA
Vol/BSA
16-34 35-41 42-48 >48
34
Lang RM et al; J Am Soc Echocardiogr 2015; 28:1-39
 Left atrial volume on 2DE

Accuracy of 2DE is limited:

• View-dependent
• Geometrical assumptions
• Measured on apical views optimized for LV
 Left atrial volume on 2DE
LA
axis

LV
axis

View View
optimized for optimized for
LV LA

LAVi 38.4
LAVi 34.0 mL/m2 mL/m2
Slide from R Lang
LA Function: Three Phases

LV Volume
Conduit

Reservoir
Booster
Left atrial function

• Conduit volume = LV SV – LA max – LA min

• Max = End-systole, just before mitral valve opening
• Min = End-diastole, when the mitral valve closes
• Pre-A = Immediately before atrial systole (p-wave)

Hoit BD. J Am Coll Cardiol 2014;63:493–505

52
53
Aorta
LV OT Measurements
Aortic Root Measurements
(Sinus of Valsalva)