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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5229_Библиотеки_им_академика_М_И_Перельмана.pdf
1 General Description of Types and Modes of Pacing
5
Fig. 1.4 ICD
Fig. 1.5 Conduction system pacing
6
1 General Description of Types and Modes of Pacing
References
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Left Ventricle Systolic Function Evaluation in Patients with Implanted Devices
2
Abstract
Echocardiography is the most common method of examination of cardiac
patients. Left ventricle dimension and function evaluation is a cornerstone in patients
with implanted devices. The measurement
includes classical parameters and variables
from advanced techniques such as threedimensional echocardiography and two and
three-speckle tracking echocardiography.
Wall motion abnormalities also need special
attention, according to implanted devices.
2.1 Evaluation of Classical Parameters of Systolic Function in Patients with Implanted Devices
Quantitative assessment of left ventricle (LV)
size and function is essential for the diagnosis,
treatment, and prognosis of heart diseases in any
patient (Lang et al. 2015).
Two-dimensional (2D) echocardiogra-
phy has an established role in LV function
assessment. The limitations are foreshortening,
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-64079-7_2.
malrotation, and angulation; therefore, the measurements may be inaccurate (Lang et al. 2012).
The most used parameters to describe LV
cavity size are linear internal dimensions and
volumes. Measurements are commonly reported
for end-diastole and end-systole and should be
reported indexed to body surface area (BSA).
Linear measurements are representative only
in normally shaped ventricles and should be
avoided in heart failure (HF) patients with
dilated cardiomyopathy (DCM) and cardiac
resynchronization therapy (CRT) (Lang et al.
2015).
2.2 LV Volumes Measurement
According to the guideline’s recommendations
for chamber quantification, LV size should
be assessed by calculating volumes using the
biplane method of disks summation technique
(modified Simpson’s rule) (Lang et al. 2015).
Acquisition will be obtained from the apical
4- and 2-chamber views, focused on the LV
(Fig. 2.1). Contrast agents for endocardial delineation improvement will be used when two or
more contiguous LV segments are poorly visualized in apical views (Mulvagh et al. 2008).
Volumes provided by contrast-enhanced images
are closer to those obtained with cardiac magnetic resonance (CMR) (Hoffmann et al. 2006).
Left ventricle end-diastolic volume (LVEDV)
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
D.-M. Toader, Echocardiographic Evaluation of Patients with Implanted Devices,
https://doi.org/10.1007/978-3-031-64079-7_2
7
8 2 Left Ventricle Systolic Function Evaluation in Patients …
Fig. 2.1 Left ventricle volume measurement by
Simpson method. Left ventricle end-diastolic volume
evaluation at end-diastole—the first frame after mitral
valve closure or the frame where the LV volume is largest: Aa in four-chamber view, Bc in two-chamber view.
will be evaluated at end-diastole—the first
frame after mitral valve closure or the frame
where the largest LV volume is the largest (Fig.
2.1Aa, Bc). Left ventricle end-systolic volume
(LVESV) will be evaluated at end-systole—the
first frame after aortic valve closure or the frame
where the LV volume is smallest (Lang et al.
2015) (Fig. 2.1Aa, Bd).
The guidelines also recommend:
– tracing the endocardial border at the blood
pool interface, between the compacted myocardium and the cavity, using the images with
clear endocardial border definition
– excluding papillary muscles from the LV cav-
ity tracing
– maximizing LV area
– avoiding foreshortening.
Left ventricle end-systolic volume will be evaluated at
end-systole—the first frame after aortic valve closure or
the frame where the LV volume is smallest. Ab in fourchamber view, Bd in two-chamber view
distance between the middle of this line and
the most and the apical point of the LV contour
(Lang et al. 2015).
LV EDVs of 74 mL/m2 for men and 61 mL/
m2 for women and LVESVs of 31 mL/m2 for
men and 24 mL/m2 for women are the upper
limits of the normal range (Lang et al. 2015).
2.3 LVEF
Ejection Fraction (EF) is the primary method for
the global systolic function measurement and
uses LVEDV and LVESV.
LVEF by Biplane Method of Disks (modified
Simpson’s rule)
LVEF = LVEDV − LVESV/LVEDV
At the mitral valve level, the contour is closed
by connecting the two opposite sections of the
mitral ring with a straight line. LV length is the
The average value of ejection fraction is
53–73% (52–72% for men, 54–74% for women)
(Lang et al. 2015; Potter 2018).
2.3 LVEF
9
Another LV systolic function assessment
parameter is Global Longitudinal Strain
(GLS), derived from 2D speckle tracking echo-
cardiography (2D STE). GLS represents the
change in the length of cardiac fiber within a
certain direction: longitudinal, circumferential,
and radial planes, relative to its baseline length
(Tops et al. 2017; Negishi and Negishi 2015).
Strain (%) = (Lt – Lo) / Lo o Lt is the length
at time t, Lo is the length at time 0 (Potter
2018). PW of the LVOT should be used to time
the aortic valve opening and closure (Fig. 2.2a).
Longitudinal and circumferential shortening
have a negative value (Fig. 2.2b), while radial
thickening has a positive value (Fig. 2.2c, d)
(Potter 2018; Negishi and Negishi 2015).
Peak global LV strain measurement involves
averaging 3 standard apical views GLS values. The three, four, and two apical LV-focused
views should be acquired by optimizing endocardial borders. The acquisition should be performed at a frame rate of 60–90 Hz. Heart rate
variation should not vary more than five bpm.
(Potter 2018).
Strain is a frame-by-frame automatic tracking of acoustic markers throughout the cardiac
cycle. The operator can manually adjust the
segments that failed to track correctly. After
tracing the endocardial border, the time–longitudinal strain curves for the apical four-chamber
(A4ch), two-chamber (A2ch), and three-chamber (A3ch) views will be obtained. The left ventricle is divided into six segments in each apical
view. The final bull’s eye plot will display the
regional longitudinal strain value for every 17
segments, and the LV averaged GLS (Tops et al.
2017) (Fig. 2.3). Peak GLS is a negative num-
ber, and average values range from 15.9% to
22.1% (Potter and Marwick 2018). Normal values usually differ depending on the vendor or
the software version, but generally, the cut-off is
− 20%. A smaller absolute number represents a
pathological value (Negishi and Negishi 2015)
(Fig. 2.4).
Fig. 2.2 Speckle tracking strain curves in a patient with
CRT: a Aortic valve timing, b longitudinal strain curve in
apical three-chamber view, c circumferential strain curve
at the mitral valve level, d radial strain curve at the mitral
valve level
10 2 Left Ventricle Systolic Function Evaluation in Patients …
Fig. 2.3 BE display obtained after tracing the endocardial border in apical three-, four-, and two-chamber view
Fig. 2.4 BE in a patient with CRT vs BE in a healthy individual
The peak strain can be measured as peak
systolic strain, peak strain at end-systole (in the
moment of aortic valve closure), or peak strain
during the cardiac cycle regardless of timing
(Negishi and Negishi 2015).
The strain has three main components: longitudinal (LS) (motion from base to apex) (Fig.
2.5), circumferential (CS) (change in radius of
the short axis, perpendicular to the radial and
long axis) (Fig. 2.6) and radial (RS) (wall thickening and thinning) (Fig. 2.7). Analysis can be
performed either for individual segments or the
entire LV. The radial strain data have generally
shown an increased variability compared with
longitudinal and circumferential strain (Chan
et al. 2006a; Oxborough et al. 2012) because the
2.3 LVEF
Fig. 2.5 Global longitudinal strain in a, apical tree-chamber view, b apical four-chamber view, c apical two-chamber
view, and d BE display in a patient with DCM and CRT
11
lower lateral resolution produces lateral dropout and out-of-plane motion of the LV basal
segments (Geyer et al. 2010). Nonuniform segmental thickness of the scar area could produce
variability of the region of interest during stain
analysis, with variability in strain parameters
(Biaggi et al. 2011). Myocardial shear strain in
the circumferential longitudinal plane provides
the twist and torsion (Geyer et al. 2010) (Fig.
2.8). LV wall strain will impair according to the
involved myofiber.
The damage to the subendocardium, the most
sensitive layer with longitudinally oriented fibers, will decrease the longitudinal strain (Fig.
2.9). Involvement of the mid myocardium with
circumferential fiber or subepicardial layer with
oblique fiber alignment results in impairment
of CS (Fig. 2.10) and RS (Fig. 2.11) and twist
mechanics (Fig. 2.12). Acute transmural damage
or a disease affecting all three layers will damage
all vectors of mechanics (Mor-Avi et al. 2011).
The strain rate represents the change of strain
over time (Potter and Marwick 2018) (Fig. 2.13).
Systolic dyssynchrony index (SDI) is calculated by STE averaging values from A-3ch,
A4ch, and A-2ch view. For each view, SDI is
quantified by calculating the standard deviation
of time to peak systolic strain of six segments
(Fig. 2.14) (Kusumoto et al. 2018).
Myocardial work evaluates LV performance,
incorporating afterload into strain measurement.
The method uses cuff systolic blood pressure,
providing a more load-independent measurement
than GLS. Measured parameters are: myocardial work efficiency, global work index (GWI),
global constructive work (GCW), global wasted
work (GWW), global work efficiency (GWE).
Myocardial work efficiency = GCW/[GCW +
GWW]) (Fig. 2.15) (Kusumoto et al. 2018).
Three-dimensional transthoracic echocardiographic (3DE TTE) LV assessment is more
accurate than 2D echocardiography (Yoshitani
et al. 2009) and includes volumes, ejection
fraction, shape, and regional and global strain
(Lang et al. 2012). Depending on image quality and availability, 3D LV evaluation is recommended when feasible (Lang et al. 2015). The
most important contribution of 3D echocardiography is the LV quantification (Monaghan
2006). The advantage of 3D echocardiographic
12 2 Left Ventricle Systolic Function Evaluation in Patients …
Fig. 2.6 Circumferential strain: a the mitral valve level, b papillary muscles level, c apical level in a patient with
dilated cardiomyopathy and CRT
volume measurements is that they do not rely on
geometric assumptions (Monaghan 2006). This
is the method of choice in patients with good
image quality (Dorosz et al. 2012).
spatial resolution. This approach will increase
the accuracy of end-systole identification
(Lang et al. 2012). Acquisitions of multiple
narrow volumes of data over up to seven car-
diac cycles, stitched together, ECG gated, will
Acquisition modes for 3D LV analyses are:
create a single volumetric data set. The breath
hold will minimize the risk of stitch artifacts
1. “Full volume” LV-focused acquisition will
allow LV volume measurement. Multiplebeat 3D echocardiography image acquisition should include the entire left ventricle
within the pyramidal data set, maximizing the
temporal resolution without compromising
(Nucifora et al. 2009; Jenkins et al. 2009).
The pyramidal data set should include LV,
and the settings should reveal a good endocardial border. The volume/frame rate should be
15 Hz or higher (Nucifora et al. 2009; Jenkins
et al. 2009).
2.3 LVEF
13
Fig. 2.7 Radial strain: a the mitral valve level, b papillary muscles level, c apical level in a patient with dilated car-
diomyopathy and CRT
2. Simultaneous multi-plane imaging.
2001) and the LV functional measurements:
volumes, ejection fraction, and mass (Lang
Display modes are:
– Simultaneous orthogonal two or three
orthogonal planes display: coronal, sagittal,
and transverse. This mode provides multiple
et al. 2012).
3D LVQ is a semiautomated quantification software used for edge detection and tracing. This
algorithm allows:
visualizations of the same segment within
a single cardiac cycle, useful for ventricular function analysis (Yoshitani et al. 2009)
(Fig. 2.16).
– Surface rendering technique allows visualiza-
tion of the surface of structures (Fenster et al.
– The calculation of cavity contours and evalu-
ation of changes during the cardiac cycle,
resulting in a volume-versus-time curve.
– Surface-rendered cavity cast display with
volume computation.
14 2 Left Ventricle Systolic Function Evaluation in Patients …
Fig. 2.8 Twist, twist rate in a patient with dilated cardiomyopathy and CRT
Fig. 2.9 Decrease global longitudinal strain in patient with CRT: a healthy volunteer, b a patient with dilated cardio-
myopathy and CRT