Herbsttagung SGK Neue Echo-Standards, …...Partition values for severity of abnormalities...

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

Vielen Dankfür Ihre Aufmerksamkeit

Kardiologie

Beat Kaufmann

Beat.kaufmann@usb.ch