esh milan 150607 ighc short version tatiana kouznetsova
TRANSCRIPT
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Tatiana Kuznetsova
University of Leuven, Belgium
The InGenious HyperCare European NetworkThe InGenious HyperCare European Network
Excellence in phenotyping:Excellence in phenotyping:
Assessment of left ventricularAssessment of left ventricularfunctionfunction
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OutlineOutlineOutlineOutline
Systolic function
Diastolic function
Echocardiographic protocol (JRP A3)
LVFLVF
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Systolic functionSystolic functionSystolic functionSystolic function
Conventional echocardiography enables the assessment
of LV dimensions, volumes, sphericity index, and severityof mitral regurgitation;
HF due to systolic dysfunction is relatively easy to
diagnose by echocardiography.
(dilated left ventricle with a reduced ejection fraction)
LVFLVF
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Radial function
Longitudinal
Circumferential
Components of regional functionLVFLVF
Without the longitudinal
component, sarcomereshortening would lead to
an EF < 30%.
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Tissue Doppler imagingTissue Doppler imagingTissue Doppler imagingTissue Doppler imaging
Tissue Doppler Imaging (TDI) makes it possible to
specifically evaluate the longitudinal and radialcomponents of regional LV systolic function.
Measurements of myocardial deformation with the
Doppler technique have been validated using
microcrystals and MRI (Urheim S, Circulation 2000;
Edvardsen T, Circulation 2002).
LVFLVF
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Basal segments of
inferior and infero-
lateral walls
AVC MVO
Time
integration
Peak systolic SR End-systolic S
StrainStrain rate
AVC MVO
LVFLVF OffOff--line analysisline analysisOffOff--line analysisline analysis
SPEQLE: Software Package for EchocardiographicQuantification, Leuven; version 4.06
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InterInter--observer differences in percentobserver differences in percent
versus average of two readingsversus average of two readings
InterInter--observer differences in percentobserver differences in percent
versus average of two readingsversus average of two readings
LVFLVF
Bland and Altman, 1986
Mean of 2 readings
LongitudinalStrain
0.16 0.20 0.24 0.28 0.32
-20
-10
0
10
20
14.1%
-1.38%
-16.8%
%
(2
observers
Radial Strain
0.4 0.5 0.6 0.7 0.8 0.9 1.0
-20
-10
0
10
20
18.9%
0.97%
-17.0%
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LongitudinalSandSRbyRWTLongitudinalSandSRbyRWTLongitudinalSandSRbyRWTLongitudinalSandSRbyRWTLVFLVF
Mean values are adjusted; * Pe0.05 ***Pe0.001
Longitudinal Strain
RWT < 0.43 RWT u 0.43
20
21
22
23
24
***%
Strain Rate
RWT < 0.43 RWT u 0.43
1.20
1.25
1.30
1.35
1.40
RWT < 0.43N=335
RWT u 0.43N=75*1/
s
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Regional LV geometryRegional LV geometryRegional LV geometryRegional LV geometryLVFLVF
Wall stress related to:
Pressure
Shape, cavity size
Wall thickness
= P x R / 2WT
Since R curvature is larger in longitudinal
direction, the stress on longitudinal fibres is
higher, they show decreased deformation first.
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Systolic functionSystolic functionSystolic functionSystolic function
TDI, compared with conventional echocardiography, is a more
sensitive method for the detection of LV systolic dysfunction,
particularly in subjects with LV remodelling and normal EF.
Our observations underscore the importance of normal long axis
function in maintaining a coordinated ventricular contraction.
The clinical utility of strain and strain rate in risk stratification or as
therapeutic target remains to be established.
LVFLVF
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Diastolic functionDiastolic functionDiastolic functionDiastolic function
About 50% of patients with new onset of HF do have a normal EF
(HF with preserved EF).
HF with preserved EF is associated with a high mortality rate,
comparable to that of patients with reduced EF.
(Bhatia R.S., N Engl J Med 2006; Bursi F., JAMA 2006)
Assessment of diastolic function requires conventional and
Tissue Doppler Imaging
LVFLVF
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Transmitral blood flow vs pulsedTransmitral blood flow vs pulsedT
issue DopplerImaging
Tissue Doppler
Imaging
Transmitral blood flow vs pulsedTransmitral blood flow vs pulsedT
issue DopplerImaging
Tissue Doppler
Imaging
EA
Ea Aa
LVFLVF
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LVFLVF
Ea
5 10 15 20 25
-7
-5
-3
-1
1
3
5
7
5.26%
0.72%
-3.83%%
(2
observers
Aa
2.5 5.0 7.5 10.0 12.5 15.0 17.5
-7
-5
-3
-1
1
3
5
7
0.26%
4.48%
-3.96%
%
Mean of 2 readings
InterInter--observer differences in percentobserver differences in percent
versus average of two readingsversus average of two readings
InterInter--observer differences in percentobserver differences in percent
versus average of two readingsversus average of two readings
Bland and Altman, 1986
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Determinants ofTDIvelocitiesDeterminants ofTDIvelocitiesDeterminants ofTDIvelocitiesDeterminants ofTDIvelocities
Stepwise analysis:
Ea: age, BMI, DBP, LVMI; LV length, EF;
Aa: age, HR, DBP, LV length, EF;
Ea/Aa: age, BMI, HR, DBP.
Intrafamilial correlation coefficients (P
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Echocardiographic performance protocolEchocardiographic performance protocolEchocardiographic performance protocolEchocardiographic performance protocolEchoEcho
A single observer performs all echocardiographic examinations by means of
Vivid 7 ultrasound scanner (GE Vingmed, Horten, Norway)
Standardized echocardiography scanning sequence (about 40 min,
page 76-77 MOP JRP A3)
Correct orientation of the ultrasound beam and imaging planes to LV
structure and blood flow is essential
All echocardiographic examinations in a digital format are stored on a local
network for off-line reading by two independent observers (EchoPack, GE
and SPEQLE, University of Leuven)
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Methods to limit echocardiographicMethods to limit echocardiographic
measurement variabilitymeasurement variability
Methods to limit echocardiographicMethods to limit echocardiographic
measurement variabilitymeasurement variability
Use echocardiography central reading laboratory:
a. Minimizenumberofreaders,
b. Monitorreadervariability,c. Rapidcommunication withstudysitesonstudy quality.
Standardized hands-on training of sonographers onsite.
Monitoring of sonographers for technical quality; encode study
quality in database.
American Society of Echocardiography Recommendations for Use of Echocardiography in Clinical
Trials. J Am Soc Echocardiogr 2004;17:1086-1119
EchoEcho
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Methods to limit echocardiographicMethods to limit echocardiographic
measurement variabilitymeasurement variability
Methods to limit echocardiographicMethods to limit echocardiographic
measurement variabilitymeasurement variability
Reading off-line strategies:
1. Batch readwhen possible to minimize systematic temporal drifts;
2. Average multiple beats (minimumof3);
3. Single reader preferable.
Establish acquisition and reader variability:
1. Test-retestofsmallsampleofparticipants,ie,sameparticipant
repeatedoversmallinterval,samemachine,samesonographer,same
reader;
2. Blindduplicatesforinter-reader and intra-reader variability
assessment.
EchoEcho
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Katholieke Universiteit Leuven, B JA Staessen, T Kuznetsova, T Richart
Jagiellonian University Cracow, PL K Kawecka-Jaszcz, K Stolarz, M Loster
Medical University of Gdansk, PL K Narkiewicz, WSakiewicz, A Rojek
Universit degli Studi di Padova, I E Casiglia, V Tikhonoff
Hospital Universitari Valencia, SP E Lurbe, J Alvarez
Institute of Internal Medicine, RU Y Nikitin, S Malyutina, A Ryabikov
EchoEcho--centerscentersEchoEcho--centerscentersJRP A3JRP A3