herbsttagung sgk neue echo-standards, …...partition values for severity of abnormalities...
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Herbsttagung SGKNeue Echo-Standards, praktische UmsetzungPD Dr. Beat Kaufmann, Kardiologie
Basel, 12.11.2015
Kardiologie
Kardiologie
J Am Soc Echocardiogr 2015;28:1-39
Chamber quantification guidelines: What is new?
Kardiologie
Database
Strain imaging
3-D Imaging
Normal reference values for 2DE
Kardiologie
• 7 databases (Asklepios, Flemengho, Cardia 5, Cardia
25, Padua 3D Echo Normal, Norre)
• No contrast studies
• Age, gender, ethnicity, height, weight
• Normal blood pressure, no diabetes, normal BMI,
normal renal function, normal cholesterol/triglycerides
Partition values for severity of abnormalities
Kardiologie
• Cut-offs based on SD
• Data readily exist
• Echo parameters are not normally distributed
• Asymmetric distribution
• Cut-offs based on percentile values (95th)
• Cut-offs based on outcome or prognosis
• Cut-offs based on experience-consensus
Partition values are given for selected parameters:
LVEF, LA size, LV mass
How to assess left ventricular function?
Kardiologie
Eye-balling
Qualitative Assessment
• Subjective
• Experience dependent
• Lack of standardisation
• Large inter- and intraobserver variability
Left ventricular linear measurement
Kardiologie
No longer recommended!
Recommended
• Perpendicular to the long axis
• Interface wall/cavity wall/pericardium
• Limitations
Left ventricular linear measurements: Uncertainties/Limitations
Kardiologie
• Measurements insensitive to small changes
• Highly dependent on image quality and observer expertise
• Exclusion/Inclusion of trabeculae
Septo-marginal
parts of the
moderator band
Left ventricular linear measurements: Uncertainties/Limitations
Kardiologie
• Measurements insensitive to small changes
• Highly dependent on image quality and observer expertise
• Exclusion/Inclusion of trabeculae
LV dimensions
Kardiologie
Male Female
Parameters
LV internal dimension
Mean
±SD
2SD
Range
Mean
±SD
2SD
Range
Diastolic dimension, mm 50.2±4.1 42.0 – 58.4 45.0±3.6 37.8 – 52.2
Systolic dimension, mm 32.4±3.7 25.0 – 39.8 28.2 ± 3.3 21.6 – 34.8
Left ventricular volumetric measurement
Kardiologie
Fractional shortening and
Teichholz should no longer be used!
End-diastolic volume=7/(2·4+EDD) x EDD3
End-systolic volume=7/(2·4+ESD) x ESD3
Left ventricular volumetric measurement
Kardiologie
Biplane disk summation
• Corrects for shape distortions
• Less geometrical assumptions
• Apex frequently foreshortened
• Blind to shape distortions not visualized in
AP4 and AP2
Area length method
• Partial correction for shape distortion
• Apex frequently foreshortened
• Relies heavily on geometric assumptions
• Limited published data on normal population
( )
Kardiologie
Left ventricular volumetric measurement
Biplane disk summation
Male Female
Parameters
LV volumes normalized to BSA
Mean
±SD
2SD
Range
Mean
±SD
2SD
Range
LV end-diastolic volume, mL/m2 54±10 34 – 74 45±8 29 – 61
LV end-systolic volume, mL/m2 21±5 11 – 31 16 ± 4 8 – 24
LV ejection fraction
Kardiologie
Preload
Afterload
Contractility
Heart rate
Ejection fraction
LV volumes by 3D
Kardiologie
Upper limits of normal:
EDV:
•79 ml/m2 for men
•71 ml/m2 for women
ESV:
•32 ml/m2 for men
•28 ml/m2 for women
Kardiologie
LV ejection fraction
Normal Mildly Moderately Severely
LVEF - Male 52-72 41-51 30-40 <30
LVEF - Female 54-74 41-53 30-40 <30
Normal Mildly Moderately Severely
LVEF - Male/Female >55 54-45 30-44 <30
2005:
2015:
Kardiologie
LV ejection fraction TIME-CHF trial
0 10 20 30 40 50 60 70 80
0
10
20
30
40
50
60
70
80
EF core lab biplane [%]
EF
recru
itin
g c
en
tre [
%]
n=413
y = 0.71x + 10.4
r2 = 0.62
p<0.0001
Kaufmann BA et al. Int J Cardiovasc Imaging. 2012
LV ejection fraction TIME-CHF trialBland-Altmann Analysis
Kardiologie
0 10 20 30 40 50 60 70 80
-40
-30
-20
-10
0
10
20
30
Average EF [%]
∆E
F (
EF
recru
itin
g
cen
tre –
EF
bip
lan
e)
[%]
Bias: 0.2%
95% CI: -17.4 – 17.8
Kaufmann BA et al. Int J Cardiovasc Imaging. 2012
Kardiologie
LV ejection fraction TIME-CHF trialRe-Assignment
0 10 20 30 40 50 60 70 80
0
10
20
30
40
50
60
70
80
EF core lab biplane [%]
EF
recru
itin
g c
en
tre [
%]
Re-assignment:
21.7%
Kaufmann BA et al. Int J Cardiovasc Imaging. 2012
LV Global Longitudinal Strain
Kardiologie
Bild Fedeli
• Decrease sector
• Start analysis in AP3Ch
• Peak GLS in the range of -20% can
be expected to be normal – no
formal recommendations
• Cardio-Oncology
• Prognosis in valvular regurgitation
• Inter-Vendor and Inter-Software
differences
• Endocardial vs Midwall vs Average
Importance of LA size
Kardiologie
Normal LA
• There has been no long-term filling pressure elevation
Dilated LA
•There has been chronic pressure overload
Causes of LA enlargement
•Mitral valve disease
•Atrial myopathy
•Diastolic dysfunction
LA linear dimension
Kardiologie
The LA does not enlarge symmetrically!
LA foreshortening
Kardiologie
Measurement of LA Volume
Kardiologie
Difference between Biplane Area length
and Biplane Simpson‘s:
Ca. 4ml
Lester SJ et al. J Am Coll Cardiol. 2008;51(7):679-689
Kardiologie
3D Measurement of LA Volume
No normative data!
Buechel R et al. J Am Soc Echocardiogr 2013;26:428-35.
LA Volume normal values (2D)
Kardiologie
Normal Mildly Moderately Severely
20051
LA Vol/BSA (ml/m2) 16-28 29-33 34-39 >40
20152
LA Vol/BSA (ml/m2) 16-34 35-41 42-48 >48
1 Lang RM et al. J Am Soc Echocardiogr 2005;18:14402 Lang RM et al. J Am Soc Echocardiogr 2015;28:1
LV Mass
Kardiologie
Cubed formula
LV mass = 0.8x1.04x[(IVS+LVID+PWT)3- LVID3] +0.6g
2D based formulas
Area length
Truncated ellipsoid
Men Women
LV Mass/BSA (g/m2) 49-115 43-95
Men Women
LV Mass/BSA (g/m2) 50-102 41-88
LV Mass
Kardiologie
Cubed formula
LV mass = 0.8x1.04x[(IVS+LVID+PWT)3- LVID3] +0.6g
2D based formulas
Area length
Truncated ellipsoid
• Cube formula has a 20% correction factor that is historical
• Cube formula overestimates mass in basal septal hypertrophy
• 2D based formulas underestimate mass in basal septal hypertrophy
• Correction for BSA may mask hypertrophy in obese patients
Aorta
Kardiologie
Hinge pointsHinge point
plane
≈virtual ring
Hinge points
Measurement of aortic anulus
Kardiologie
• mid-systole (anulus rounder, larger)
• Inner edge to inner edge
• Do include calcifications within the lumen
25mm
Measurement of the aortic root and theascending aorta
Kardiologie
•End-diastole
•Leading edge to leading
edge
•For ascending aorta give
distance from closure line of
aorta
Kardiologie
Measurement of the aortic root and theascending aorta
Sinus of valsalva
Kardiologie
Measurement of the aortic root and theascending aorta
Ascending aorta
Normal echocardiography vs. absence of disease!
Biaggi P et al. J Am Soc Echocardiogr 2009;22:720-725.
Kardiologie
Right ventricular anatomy
• Complex crescent shape
• Thin-walled, compliant chamber
• Low pulmonary
resistance/afterload
• Sensitive to changes in afterload
• RV dilatation
• RV hypertrophy
Kardiologie
Right apical views
Apical 4 chamber RV focused 4 chamber Modified 4 chamber
Kardiologie
RV linear dimensions/area
Parameter Normal range
RV basal diameter (mm) 25-41
RV mid diameter (mm) 19-35
RV longitudinal diameter (mm) 59-83
RVOT PLAX diameter (mm) 20-30
RVOT prox. diam. (mm) 21-35
RVOT dist. diam. (mm) 17-27
RV EDA indexed to BSA (cm2/m2)
Men 5-12-6
Women 4.5-11-5
Kardiologie
RV area/fractional area change
Parameter Normal range
RV basal diameter (mm) 25-41
RV mid diameter (mm) 19-35
RV longitudinal diameter (mm) 59-83
RVOT PLAX diameter (mm) 20-30
RVOT prox. diam. (mm) 21-35
RVOT dist. diam. (mm) 17-27
RV EDA indexed to BSA (cm2/m2)
Men 5-12-6
Women 4.5-11-5
RV fractional area change (%) ≥35
FAC (%) = (RV EDA –RV ESA) / RV ESA x 100
Kardiologie
Right ventricular longitudinal systolicfunction
TAPSE
Pulsed tisse
doppler s‘
wave
GLS of the
RV free
wall
≥17mm
≥9.5cm/s
≤ -20%
Kardiologie
Right ventricular wall thickness
• End-diastole
• Distance ≈ anterior
tricuspid leaflet
• Exclude trabeculae
• <5mm
Kardiologie
Right atrial size
•4-chamber only
•Disc summation
Women Men
Right atrial volume (ml/m2) 21±6 (<34) 25±7 (<40)
Kardiologie
Inferior vena cava
• Measure in subcostal view 1-2 cm from the junction
to the RA
• <2.1cm, >50% collapse 3mmHg
• >2.1cm, <50% collapse 15mmHg
• Intermediate scenarios 8mmHg
