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The Latest American Society ofEchocardiography (ASE)
quantification guidelines. What'snew and different for the female
patient?Renee Bullock-Palmer, MD FACC FASE FASNC FSCCT
Director of Non-Invasive Cardiac Imaging,Director of The Women’s Heart Center ,
Deborah Heart and Lung Center
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None
Disclosures
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Chamber Quantification Guidelines
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What’s new in the document…
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Multiple Modalities Described.
• M Mode
• 2 D Linear
• 3 D Volumes
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Multiple Modalities Described.
• 2D Contrast
• 3D Contrast
• Strain
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The quantification guidelines also differentiate thenormal values for men vs. women in the followingareas:
LV size and thickness LV mass LV function RV size RA size Aortic Root Size
Gender Differences
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It is important to make note of these genderdifferences to avoid misdiagnosis in the femalepopulation.
This is especially important as misdiagnosis may resultin misguided treatment of females and thereforeworse outcomes.
Importance of Gender Differences
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The Left Ventricle
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Linear Dimensions
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VolumesAdvantages Limitations
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Left Ventricular Endocardial Border Tracingsfor Ventricular Volume Determinations
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Two Dimensional Left VentricularVolume Calculations
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3D Volumes with use of contrastAdvantages Limitations
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Volumetric Quantification of Global LeftVentricular Function Compared to MRI
Corsi C et al. Circulation. 2005;112:11611170
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LV StrainAdvantages Limitations
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Normal LV values for size and volumes-2D
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Normal LVEF
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LV systolic function should be routinely assessed using 2DE or 3DE bycalculating EF from EDV and ESV.
LVEFs of <52% for men and <54% for women are suggestive of abnormal LV systolic function.
Two-dimensional Speckle Tracking Echo-derived GLS appears to bereproducible and feasible for clinical use and offers incremental prognosticdata over LV EF in a variety of cardiac conditions, although measurementsvary among vendors and software versions.
To provide some guidance, a peak GLS in the range of 20% can be expected in ahealthy person, and the lower the absolute value of strain is below this value,the more likely it is to be abnormal.
Recommendations- LV size and function
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LV Mass- Linear methodAdvantages Limitations
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LV mass 2D method
Advantages Limitations
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LV mass 3D method
Advantages Limitations
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Normal values for LV mass
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In the normally shaped left ventricle, both M-mode and 2D echocardiographicformulas to calculate LV mass can be used. Normal values for these techniquesremain unchanged from the previous guidelines and should be reported indexed toBSA.
Reference upper limits of normal LV mass by linear measurements are 95 g/m2 inwomen and 115 g/m2 in men.
Reference upper limits of normal LV mass by 2D measurements are 88 g/m2 inwomen and 102 g/m2 in men with 2D methods.
Recommendations- LV mass
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The Right Ventricle
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RV Size- Linear measurements
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RV -area
Method Advantages Limitations
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RV 3D method
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RV –wall thickness
Method Advantages Limitations
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RV size- normal values
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RV size should be routinely assessed by conventional 2DE using multipleacoustic windows, and the report should include both qualitative andquantitative parameters.
In laboratories with experience in 3DE, when knowledge of RV volumes maybe clinically important as in the case of congenital heart disease, 3Dmeasurement of RV volumes is recommended.
Although normal 3D echocardiographic values of RV volumes need to beestablished in larger groups of subjects, current published data suggest RVEDVs of 87 mL/m2 in men and 74 mL/m2in women, and RV ESVs of 44 mL/m2 for men and 36 mL/m2 for women as the upper limits of thecorresponding normal ranges.
Recommendations RV size
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RV systolic function RIMP
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RV –Global systolic function
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RV longitudinal systolic function
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RV – tissue Doppler and Strain method
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Journal of the American Society of Echocardiography 2015 28, 139.e14DOI: (10.1016/j.echo.2014.10.003)Copyright © 2015 American Society of Echocardiography Terms and Conditions
Measurement of RV systolic strain by 2D STE. The upper panel demonstrates RV “global” free wallstrain whereby the three segments of the free wall are averaged, and the lower panel demonstrates“global” longitudinal strain of the six segments of the apical fourchamber view: three free wall andthree septal segments. Note that RV longitudinal strain is significantly higher (as an absolute value)than the strain averaged from both septal and free wall segments.
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RV function
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Two-dimensional STE-derived strain, particularly of the RV free wall,appears to be reproducible and feasible for clinical use.
Because of the need for additional normative data from large studiesinvolving multivendor equipment, no definite reference ranges arecurrently recommended for either global or regional RV strain orstrain rate.
In laboratories with appropriate 3D platforms and experience, 3DE-derived RV EF should be considered as a method of quantifying RVsystolic function, with the limitations mentioned above. Roughly, anRV EF of <45% usually reflects abnormal RV systolic function, thoughlaboratories may choose to refer to age- and gender-specific values.
Recommendations- RV function
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Left atrium and Right atria
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LA linear measurements
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LA - area
Advantages Limitations
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LA volumes
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LA- 3D volumes
Advantages Limitations
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Left atrium recommendations andvalues
No difference between the 2 groups
• The biplane disk summation technique, which incorporates fewer geometricassumptions, should be the preferred method to measure LA volume in clinical practice.The upper normal limit for 2D echocardiographic LA volume is 34 mL/m2 for bothgenders.
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RA- linear dimensions and area
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RA- 2D and 3D volumesAdvantages Limitations
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The recommended parameter to assess RA size is RA volume, calculatedusing single-plane area-length or disk summation techniques in adedicated apical four-chamber view.
The normal ranges for 2D echocardiographic RA volume are 25 + 7 mL/m2in men and 21 +6 mL/m2 in women.
Right atrium recommendations
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The Aorta
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The aortic measurements
1. Aortic annulus- hinge point of aortic leaflets.
2. Aortic sinuses of Valsalva
3. Sinotubular junction
4. Proximal ascending aorta
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Measuring the aortic annulus
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Measuring the Aortic Annulus
Correct Incorrect Incorrect
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The aortic annulus should be measured at mid systole from inner edge to inner edge.
All other aortic root measurements (i.e., maximal diameter of the sinuses of Valsalva, thesinotubular junction, and the proximal ascending aorta) should be made at end-diastole, in astrictly perpendicular plane to that of the long axis of the aorta using the L-L convention.
Measurements of maximal diameter of the aortic root at the sinuses of Valsalva should becompared with age- and BSA-related nomograms or to values calculated from specificallometric equations.
Accurate measurement of the aortic annulus before TAVI or TAVR is crucial. To date, there isno established gold-standard technique for measuring the aortic annulus before TAVI orTAVR. Although MDCT is emerging as reliable and possibly preferred methods for aorticannulus measurements.
Recommendations – Aortic Root
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Journal of the American Society of Echocardiography 2015 28, 119-182DOI: (10.1016/j.echo.2014.11.015)Copyright © 2015 American Society of Echocardiography Terms and Conditions
Aorta Measurement
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Journal of the American Society of Echocardiography 2015 28, 119182DOI: (10.1016/j.echo.2014.11.015)Copyright © 2015 American Society of Echocardiography Terms and Conditions
Aortic root diameter (vertical axis) in relation to BSA (horizontal axis) inapparently normal individuals aged 1 to 15 (left panel, blue), 20 to 39 (centerpanel, green), and ≥40 (right panel, pink) years. For example, an individualbetween the ages of 20 and 39 years (center panel, green) who has a BSA of2.0 m2 (vertical green line) has a normal root diameter range (2 SDs) between2.75 and 3.65 cm, as indicated by the intersections of the two horizontal greenlines with the green-shaded parallelogram
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Journal of the American Society of Echocardiography 2015 28, 119182DOI: (10.1016/j.echo.2014.11.015)Copyright © 2015 American Society of Echocardiography Terms and Conditions
Surfaces representing aortic diameters at a 1.96 Z score (95% confidence interval)above the predicted mean for age and BSA in male subjects ≥15 years of age.(Adapted from Devereux et al.6)
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Journal of the American Society of Echocardiography 2015 28, 119182DOI: (10.1016/j.echo.2014.11.015)Copyright © 2015 American Society of Echocardiography Terms and Conditions
Surfaces representing aortic diameters 1.96 Z score (95% confidence interval)above the predicted mean value of aortic diameter for age and BSA in femalesubjects ≥15 years of age. (Adapted from Devereux et al.6)
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Summary
Chamber quantification is vital to accurately diagnosepatients to determine appropriate management.
Gender differences should be accounted for whendescribing chamber size and function.
This is especially important for females as failure toaccount for gender differences may lead tomisdiagnosis and misguided treatment of women.
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Normal LV values for size and volumes-3D