esh milan 150607 ighc short version tatiana kouznetsova

8/3/2019 ESH Milan 150607 IGHC Short Version Tatiana Kouznetsova

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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



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





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



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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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

esh milan 150607 ighc short version tatiana kouznetsova

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