Basics of LV Systolic

Function, Remodeling,
and LVH
Gerard Aurigemma, MD
Division of Cardiovascular Medicine
Department of Medicine
Umass Medical School
 LV Systolic Function
Anatomic Considerations
The Left Ventricle Job Description
generate stroke volume
The Left Ventricle Job Description
generate stroke volume
The Left Ventricle Job Description
generate stroke volume
The EF: Getting it done for
(at least) half a century

• Outcome data
• Easy index to
compare between
modalities
• Internally normalized
Preferred EF Method: Simpson’s Biplane
MOD

SV= EDV-ESV
208-113=95 cc
SV/EDV= EF
95 / 208 =46%

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LV Ejection Fraction
Male Normal Mildly Moderately Severely

LVEF 52-72 41-51 30-40 <30

Female Normal Mildly Moderately Severely

LVEF 54-74 41-53 30-40 <30

 Left Ventricular Ejection
Fraction
Normal Mild Moderate Severe

2015 >52 51-41 40-30 <30

2005 >55 54-45 44-30 <30
Limitations of the EF
•Load
•Pump function
•Regional function
 Afterload = Wall stress
Afterload proportional to
heart size and pressure and
inversely to wall thickness
 = p x r / th
Meridional
Circumferential Heart remodels to
Radial normalize load per unit
myocardium
 Normal Pressure Volume

EF normal normal normal

LVH absent present present

Geometry normal concentric eccentric

condition HTN, AS, HCM AR, MR, DCM

= P x r / Th
LV Remodeling
Aortic Stenosis
Prototype afterload
excess lesion

“no bad
myocytes…only bad
loading conditions”

Contractility preserved
even with markedly
reduced EF
Afterload reduction and EF
AVR=afterload
reduction

Carabello et al Circulation 1980

58 year old man

Class III HF
Untreated HTN

Treated HTN
Asymptomatic
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 Normal Pressure Volume

EF normal normal normal

LVH absent present present

Geometry normal concentric eccentric

condition HTN, AS, HCM AR, MR, DCM

= P x r / Th
Normal vs spherical ventricle

Severe AR
 Sphericity index
• Short axis/long axis

• Spherical ventricle is at mechanical

disadvantage

• Aortic regurgitation, dilated CM most

common causes of increased sphericity
index
 EF does not
equal SV
LVIDd EF SV

normal 5 65 81

LVH 4.4 75 63

DCM 7.5 20 84
85% x = small SV
Longitudinal Velocity
Longitudinal velocity

Systole Diastole

IVC Peak Systole

Velocity
IVR
A
E
 Normal Pulsed DTI Velocities
Sa (cm/sec) Ea (cm/sec) Aa (cm/sec)
Lateral 10.8 ± 2.0 16.7 ± 3.9 9.5 ± 2.6
Septal 9.3 ± 1.5 12.5 ± 2.6 10.1 ± 2.3
Anterior 10.4 ± 2.0 13.2 ± 3.8 9.0 ± 3.6
Posterior 10.9 ± 2.1 16.0 ± 3.7 10.8 ± 2.7
Sa peak systolic myocardial velocity- absolute
Ea early diastolic myocardial velocity- absolute
Aa late diastolic myocardial velocity-absolute

Adapted from Isaaz K. Current Opinions in Cardiology 2002; 17:431-442.

Lateral and Septal most reproducible.
 Tei index
index of
myocardial
performance

• LV--0.39 +/- 0.05

• Values differ depending on
whether tissue Doppler or
pulsed Doppler is used
• Values higher with TDI

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dP/dT Mean Rate Method
• Record MR velocity using CW
• Select 2 points at 1M/s and 3M/s
(P = 36mmHg - 4mmHg)
• Measure the time between the
two points ( T)
• Value below 600 is associated
with poor prognosis
MR dP/dT = <4* (32)-4*(12)>/dT
=32 mmHg/ 71 ms
=452 mmHg / s
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Limitations of the EF
•Load
•Pump function
•Regional function
 Echo and CAD
• Regional wall motion abnormalities at rest may not be seen
until the luminal diameter stenosis exceeds 85%
– with exercise, a coronary lesion of 50% can result in regional
dysfunction
• Echocardiography can overestimate the amount of ischemic
or infarcted myocardium, as wall motion of adjacent regions
may be affected by:
– Tethering
– Disturbance of regional loading conditions
– Stunning
• Wall thickening and motion should be considered
• Regional wall motion abnormalities may occur in the absence
of CAD
 Regional function
• “a normal overall LV EF may belie
important regional dysfunction”
me, personal communication

37
Diagnostic Role in Acute MI
• Regional wall motion
abnormality
– Occurs within 5-10
beats of acute
coronary ligation
– Rate and amplitude
of endocardial
excursion decreased
– Reduced wall
thickening or wall
thinning
1. Normal or
Hyperkinetic
2. Hypokinetic
(reduced
thickening)
3. Akinetic
(absent or
negligible
thickening
4. Dyskinetic
(systolic
thinning or
stretching)
25 year old man with
chest pain

Troponin I 7
46
47
48
51
Which of the following patients has the acute MI?
A B C

1.Patient A
2.Patient B
3.Patient C
4.All of the above
5.None of the above
 What is the diagnosis?
1. LAD territory infarction with
a septal aneurysm
2. LAD ischemia but no
aneurysm
3. Volume loaded LV due to left
sided valve disease
4. None of the above
Violent LBBB
 Courtesy Rick
Grimm, Cleveland
Clinic Foundation
Impact of Contrast on Wall Motion
Contrast agents can improve endocardial
delineation when ≥2 contiguous segments are
poorly visualized
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Limitations of the EF
•Load
•Pump function
•Regional function
LV Global Longitudinal Strain
Peak GLS in the range
of -20% can be expected
in a healthy person
Growing evidence to suggest that
myocardial deformation ues provide
incremental value in Ischemic heart disease
1. Cardiomyopathies (hypertrophic, infiltrative,
HFrEF and HFpEF)
2. Diastolic dysfunction
3. Subclinical dysfunction in
– Valvular heart disease
– Chemotherapy induced myocardial dysfunction
 Strain: Definition
% change in parameter
EF = volume strain =
EDV-ESV / EDV x 100
Longitudinal strain = change
in length divided by original
length
Led-Les / Led x 100
Longitudinal

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LV mass, volumes, and function
• Linear measurements
• Volume measurements
• LV remodeling and function

70
55 year old woman with DM and
resistant HTN

MC
BSA 2
Height 61”
 Lang RM, JASE 2005; 18: 1440-63

RWT = 2PW TH / LVIDd

LV data
• LVIDd 4.2 cm
• IVSTd 1.4 cm
• PWTd 1.4 cm
• RWTd 0.64
• LV mass 239 g
• LVMi 119 g/M2
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LV data
• LVIDd 4.2 cm
• IVSTd 1.4 cm
• PWTd 1.4 cm
• RWTd 0.64
• LV mass 239 g
• LVMi 119 g/M2
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Assumes prolate ellipsoid shape

assume D1 = D2 = L/2

/
LV volume =  3 (LVIDd)3
 Concept: subtract inner shell
volume from outer shell volume

Outer shell= (5 +1+1)3

Inner shell= 53
Shell volume=343-125=118 ml
Shell volume*1.04 g/ml=122 g
LV data
• LVIDd 4.2 cm
• IVSTd 1.4 cm
• PWTd 1.4 cm
• RWTd 0.64
• LV mass 239 g
• LVMi 119 g/M2
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 81% 90%
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