General Considerations, Assessment of Chamber Size and Function

38 cards

Notes

LV linear dimensions (2015 ASE Chamber Quantification)

Measured perpendicular to LV long axis in PLAX or biplane, at end-diastole/systole.
Chordal level (just apical to the mitral leaflet tips).
Timing:
- End-diastole = onset of QRS (or first frame after MV closure).
- End-systole = first frame after AV closure (smallest LV volume).

Reference values

	Men	Women
LVEDd	4.2 – 5.8 cm	3.8 – 5.2 cm
LVESd	2.5 – 4.0 cm	2.2 – 3.5 cm
LVEDVi	34 – 74 mL/m²	29 – 61 mL/m²
LV mass (2D)	≤ 102 g/m²	≤ 88 g/m²
LV mass (M-mode)	≤ 115 g/m²	≤ 95 g/m²
Relative wall thickness (RWT)	≤ 0.42	≤ 0.42

BSA-indexed LV volumes DECREASE with age.

LVEF categories (2015 ASE Chamber Quant)

	Men	Women
Normal	52 – 72 %	54 – 74 %
Mildly abnormal	41 – 51 %	41 – 53 %
Moderately abnormal	30 – 40 %	30 – 40 %
Severely abnormal	< 30 %	< 30 %

LV mass and geometry (Ganau classification)

Combine LV mass index and RWT:

Normal: normal mass, RWT ≤ 0.42.
Concentric remodeling: normal mass, RWT > 0.42 (small hypertensive heart).
Concentric hypertrophy: ↑ mass, RWT > 0.42 (AS, chronic HTN).
Eccentric hypertrophy: ↑ mass, RWT ≤ 0.42 (chronic AR, chronic MR - volume overload).

RWT = 2 · PWTd / LVIDd (normal ~0.34).

2-D "poor man's" LVH criteria (wall thickness alone)

Normal < 1.1 cm
Mild LVH 1.1 – 1.2 cm
Moderate LVH 1.2 – 1.4 cm
Severe LVH > 1.4 cm

Volumes - methods (best to worst)

3-D volumes - no geometric assumption; closest to cMRI; use contrast if endocardium is not clear.
Biplane Simpson's method of disks (A4C + A2C) - best 2D method; include papillary muscles and major trabeculations INSIDE chamber; asymmetric ventricles OK.
Area-length ("bullet") - used when only one apical view is available.
M-mode / linear-derived volume - obsolete (assumes fixed geometric shape).

Foreshortening (missed true apex on TTE apical views) is the main source of underestimation.

2D volumes tend to be smaller than cMRI; contrast volumes are closer to MRI.
3D volumes are also smaller than cMRI but closer than 2D. EF is similar between modalities.

LV mass formula (linear method)

LV mass (g) = 0.8 · [1.04 · ((LVIDd + PWTd + IVSd)³ − LVIDd³)] + 0.6.
Conceptually: volume of a thick-walled ellipsoid minus the inner chamber volume, times specific gravity of muscle (1.05).

Wall stress

Wall stress = (LV pressure × chamber radius) / (2 × wall thickness).
Hypertrophy minimizes wall stress - Laplace-driven.
Pressure overload (AS, HTN) → concentric hypertrophy (↓ radius, ↑ thickness).
Volume overload (AR, MR) → eccentric hypertrophy (↑ radius keeps up with ↑ thickness).

Stroke volume by Doppler

SV (mL) = CSA (cm²) × VTI (cm).
Common sites:
- LVOT: annulus CSA + LVOT PW VTI.
- Mitral annulus + PW inflow VTI.
- Pulmonary annulus + PW RVOT VTI (right-heart SV).

Fractional shortening

FS = (LVIDd − LVIDs) / LVIDd × 100.
Normal 25–45 %. Unreliable when regional wall motion abnormalities exist.
Midwall FS better than endocardial FS in concentric hypertrophy (reflects both endocardial excursion and wall thickening).

dP/dt (from MR CW jet)

dP/dt = 32 / Δt (mmHg/s), where Δt is time to go from 1 m/s to 3 m/s on the MR envelope (seconds).
Normal > 1200 mmHg/s; abnormal < 1000 mmHg/s.

Myocardial performance (Tei) index

MPI = (IVCT + IVRT) / ET.
Normal LV Tei < 0.4; RV Tei < 0.4 by PW / < 0.54 by TDI.

Regional wall-motion scoring (17-segment model)

1 = normal or hyperkinetic.
2 = hypokinetic (< 50 % thickening or < 5 mm excursion).
3 = akinetic (no thickening).
4 = dyskinetic (systolic thinning or paradoxical outward motion).
Wall Motion Score Index (WMSI) = sum / number of segments visualized. Normal = 1.

Segmental coronary correlations (17-segment)

LAD: entire septum, anterior wall, anterior half of apex.
RCA (right-dominant): basal-to-mid inferior and inferoseptal walls, inferior apex.
LCx: lateral wall (basal and mid).
Apical segments have overlap; apex is often supplied by all three ("apical crown").

Global longitudinal strain (GLS)

Normal peak GLS is approximately −20 % (more negative = more strain).
Values less negative than −18 % are abnormal.
More sensitive than EF for early systolic dysfunction (e.g., chemotherapy cardiotoxicity: > 15 % relative reduction in GLS = subclinical dysfunction).
Cardiac amyloid - classic apical sparing of longitudinal strain ("bull's eye" cherry on top).
Apical HCM - reduced apical strain (opposite of amyloid).

Contractility markers

Contractility = systolic function independent of loading.
End-systolic volume (ESV) alone is the only routine EF-related parameter LESS load-dependent.
Strain rate ≈ dP/dt in reflecting contractility.
EF, strain, MPI/Tei all remain load-dependent.

Cards

basicIII.B-001
State the ASE 2015 normal LVEF ranges for men and women.
→ Men: 52–72%. Women: 54–74%. Mildly abnormal 41–51/53%; moderately abnormal 30–40%; severely abnormal <30%.
basicIII.B-002
State the ASE 2015 LV mass index cutoffs for LVH by 2D echo.
→ Men > 102 g/m², women > 88 g/m². (M-mode cutoffs are slightly higher: men > 115, women > 95.)
basicIII.B-003
How is relative wall thickness (RWT) calculated, and what is the cutoff for concentric geometry?
→ RWT = 2 × PWTd / LVIDd. Concentric geometry: RWT > 0.42. Normal ~0.34.
basicIII.B-004
Classify LV geometry using LV mass index and RWT.
→ Normal: normal mass + RWT ≤ 0.42. Concentric remodeling: normal mass + RWT > 0.42. Concentric hypertrophy: ↑ mass + RWT > 0.42. Eccentric hypertrophy: ↑ mass + RWT ≤ 0.42.
basicIII.B-005
Match geometry to typical etiology: concentric hypertrophy vs eccentric hypertrophy vs concentric remodeling.
→ Concentric hypertrophy: pressure overload (AS, chronic HTN). Eccentric hypertrophy: volume overload (chronic AR, chronic MR). Concentric remodeling: hypertensive heart with small cavity (classically the older woman with HFpEF phenotype).
basicIII.B-006
State the '2D wall thickness only' criteria for LV hypertrophy.
→ Normal < 1.1 cm. Mild LVH 1.1–1.2 cm. Moderate LVH 1.2–1.4 cm. Severe LVH > 1.4 cm.
basicIII.B-007
What is the recommended 2D method for calculating LV volumes?
→ Biplane Simpson's method of disks — from A4C and A2C views. Include papillary muscles and major trabeculations INSIDE the chamber. Foreshortening is the main pitfall.
basicIII.B-008
How do 2D-derived LV volumes typically compare with cMRI-derived volumes? And EF?
→ 2D underestimates volumes compared to cMRI (foreshortening + geometric assumptions). Contrast echo and 3D echo are closer. EF is similar across all modalities.
basicIII.B-009
State the two-part LV mass formula from linear measurements.
→ LV mass (g) = 0.8 × [1.04 × ((LVIDd + PWTd + IVSd)³ − LVIDd³)] + 0.6. Concept: volume of thick-walled ellipsoid minus inner chamber volume, × specific gravity of muscle.
basicIII.B-010
State Laplace's law for LV wall stress and its implications.
→ Wall stress = (LV pressure × chamber radius) / (2 × wall thickness). Hypertrophy minimizes wall stress. Pressure overload → ↑ thickness. Volume overload → ↑ radius (with proportional wall growth = eccentric hypertrophy).
basicIII.B-011
Formula for stroke volume by Doppler at any site?
→ SV (mL) = CSA (cm²) × VTI (cm). Common sites: LVOT (CSA_LVOT × VTI_LVOT), mitral annulus (CSA × VTI_inflow), RVOT for right-heart SV.
basicIII.B-012
Formula for fractional shortening and its normal range?
→ FS = (LVIDd − LVIDs) / LVIDd × 100. Normal 25–45%. Unreliable when regional wall-motion abnormalities are present.
basicIII.B-013
Why is midwall FS a better marker of contractility than endocardial FS in concentric hypertrophy?
→ Midwall FS captures BOTH inward endocardial motion AND wall thickening. In concentric hypertrophy, endocardial FS overestimates function because the thickened wall generates inward endocardial excursion that isn't matched by true contractility.
basicIII.B-014
State the dP/dt formula from the MR CW jet and its normal range.
→ dP/dt (mmHg/s) = 32 / Δt (s), where Δt is the time to travel from 1 m/s to 3 m/s on the MR envelope. Normal ≥ 1200 mmHg/s; abnormal < 1000 mmHg/s.
basicIII.B-015
State the myocardial performance (Tei) index formula and normal values.
→ MPI = (IVCT + IVRT) / ET. Normal LV Tei < 0.4. RV Tei: < 0.43 by PW, < 0.54 by TDI.
basicIII.B-016
Grade the four levels of wall motion in a 4-point scoring system.
→ 1 = normal/hyperkinetic. 2 = hypokinetic (< 50% thickening or < 5 mm excursion). 3 = akinetic (no thickening). 4 = dyskinetic (systolic thinning or paradoxical outward motion). Wall Motion Score Index = sum / segments; normal = 1.
basicIII.B-017
Which coronary artery supplies each LV wall in the 17-segment model?
→ LAD: entire septum, anterior wall, anterior half of apex. RCA (right-dominant): basal-mid inferior and inferoseptal walls. LCx: basal and mid lateral wall. Apex has overlap (all three).
basicIII.B-018
What is a normal peak global longitudinal strain (GLS)?
→ Approximately −20% (more negative = more strain). Values less negative than −18% are abnormal. Note: strain is expressed as a negative number by convention.
basicIII.B-019
What relative reduction in GLS during chemotherapy suggests subclinical cardiotoxicity?
→ A relative reduction > 15% compared to baseline GLS. Detects dysfunction before EF falls.
basicIII.B-020
Describe the classic strain pattern of cardiac amyloid.
→ Apical sparing of longitudinal strain with reduced basal and mid strain — the 'cherry-on-top' bullseye pattern.
basicIII.B-021
Which parameter of systolic function is essentially load-independent?
→ End-systolic volume (ESV). EF, strain, MPI/Tei, and dP/dt all remain load-dependent to varying degrees. Strain rate is a reasonable analogue for contractility.
basicIII.B-022
State the ASE 2015 upper limit for LVEDVi in men and women.
→ Men: 74 mL/m². Women: 61 mL/m².
basicIII.B-023
What is the End-systolic volume (ESVi) prognostic threshold for post-MI mortality?
→ ESV < 95 mL after MI: ~10% 5-year mortality. Larger ESV predicts higher mortality (30% for markedly dilated ventricles).
basicIII.B-024
How does exercise typically change EDV, ESV, and EF in a normal heart?
→ EDV unchanged or slightly decreased. EF increases. ESV decreases (more complete emptying, higher contractility with catecholamines).
basicIII.B-025
What is the M-mode measurement convention for LV chamber dimensions?
→ Leading-edge to leading-edge. In 2D, use inner-edge to inner-edge (white-black interface). M-mode values are typically slightly larger than 2D values.
basicIII.B-026
What is pulsus alternans and what does it signify on echo?
→ Beat-to-beat variation in the systolic velocity or stroke volume with alternating strong and weak beats — a marker of severely impaired myocardial function.
basicIII.B-027
Why does the RV normally have a lower EF than the LV even though right- and left-sided stroke volumes match?
→ Right heart EDV is larger than left heart EDV. Because SV/EDV = EF, the same stroke volume comes from a larger baseline volume, giving a lower EF (typically ≥ 45% is normal for RV).
basicIII.B-028
Why must LV volumes be measured with the true apex included?
→ Foreshortening — imaging that cuts off the apex — underestimates LV length and volume. Use extended focus, off-axis views, or 3D to avoid it. It is the single biggest source of TTE volume underestimation vs cMRI.
basicIII.B-029
How does 3D echo compare to 2D biplane Simpson's for LV volume measurement?
→ 3D reduces geometric assumptions and foreshortening — volumes are LARGER than 2D biplane and closer to cMRI (though still slightly smaller than cMRI). EF values are similar across modalities.
basicIII.B-030
State the ASE definition of LV concentric remodeling vs concentric hypertrophy.
→ Both have RWT > 0.42. Concentric remodeling: NORMAL LV mass index. Concentric hypertrophy: INCREASED LV mass index (> 102 g/m² men, > 88 g/m² women).
basicIII.B-031
Which strain reduction defines subclinical cardiotoxicity from chemotherapy?
→ A relative reduction in global longitudinal strain > 15% from baseline. Detects dysfunction before LVEF declines.
basicIII.B-032
How does the RVOT PW envelope's mid-systolic notching relate to pulmonary hypertension?
→ Mid-systolic notching of the RVOT/PA velocity envelope indicates severe pulmonary hypertension — transient reversal of the RVOT-PA gradient from poor PA compliance.
basicIII.B-033
What is Simpson's biplane method's main limitation and how do you avoid it?
→ Foreshortening — cutting off the true LV apex on apical views underestimates volume. Avoid by using extended-focus or off-axis views to visualize the true apex, or use 3D echo.
basicIII.B-034
Name three techniques to improve endocardial border definition when calculating LV volumes.
→ 1) Harmonic imaging. 2) LV opacification with IV contrast (when ≥ 2 basal/mid segments poorly seen). 3) Reduce depth to focus on LV. 4) Use appropriate gain and TGC.
basicIII.B-035
How does 3D echo directly measure LV mass?
→ By directly measuring the volume of myocardium between the endocardial and epicardial surfaces × specific gravity of muscle (1.05). No geometric assumption is required. Correlates well with cMRI.
basicIII.B-036
How is the LV shape ('sphericity index') described in dilated cardiomyopathy?
→ DCM: LV becomes more spherical (short-axis/long-axis ratio approaches 1). Normal LV is more elliptical (short/long axis ratio ~0.5). Sphericity worsens as remodeling progresses.
basicIII.B-037
For LVOT PW measurement, why should the sample volume be 2–3 mm proximal to the aortic valve?
→ Placing the PW too close captures the acceleration into the AV. Placing too far captures LV inflow. 2–3 mm proximal gives a clean laminar signal. An audible AV closure click on the trace indicates the sample volume is at the valve level.
basicIII.B-038
Which single measure of contractility is preload- AND afterload-independent?
→ End-systolic elastance (Ees) — the slope of the end-systolic pressure-volume relationship. Not routinely measured on echo. Strain rate is a practical noninvasive analogue.