Method	View	Pitfalls
Two-Dimensional Imaging
Fractional shortening	PLAX or PSAX	Geometric Assumptions Based on a single cross section Ignores wall motion in nonmeasured segments
Ejection fraction	(LVEDV − LVESV) × 100/LVEDV	Dependent on load and heart rate (HR)
Modified Simpson’s rule	4-chamber and 2-chamber	Foreshortening of apical views Poor visualization of anterior wall
Area-length method	4-chamber (LV area)2 × 0.85/LV end-diastolic length	Not appropriate for non-symmetrical LV Assumes cylindrical LV shape
Bullet method	Mid-SAX and apical 4- chamber	LV shape assumption
Wall motion score index	PLAX, PSAX, apical 4-, 2-, and 3-chamber Average endocardial thickening score of 16 or 17 segments	Reader and center variability Requires visualization of all segments
Exercise ejection fraction	As above	To detect incipient LV systolic dysfunction Usually eyeballed
Three-dimensional volumes	Full-volume apical view	Resolution is dependent on 2D image quality
Doppler Methods
LV stroke volume	PLAX 2D and apical 5- or 3-chamber	Circular shape assumption of LV outflow tract (LVOT) Error in LVOT measurement Errors are squared
LV dP/dt (mm Hg/s)	MR CW Doppler Σ Δt 1 m/s to 3 m/s, 32/Δt	Load independent Not always feasible
MPI	Apical 5-chamber	Somewhat load dependent No geometric assumption
Tissue Doppler	Apical views Objective data Less dependent on image quality Less dependent on reader expertise	Somewhat load dependent Requires parallel angle of insonation Affected by translation, tethering, and respiration
2D speckle tracking	Longitudinal Strain Not affected by Doppler angle	Requires high frame rate Requires good 2D image resolution Decreased feasibility versus TDI
2D speckle tracking	Radial Strain Not affected by Doppler angle

Key Points

• The most commonly used 2D measurement for volume estimations is the biplane method of disks (modified Simpson’s rule; Figures 1-4 and 1-5). Left-sided contrast agents used for endocardial border delineation are helpful and improve measurement reproducibility for suboptimal studies and correlation with other imaging techniques (Figure 1-6). These agents also help improve diagnosis of left ventricular thrombus (Figure 1-7).

• Left ventricular volumes are increased in systolic heart failure.

Figure 1-4 Reduced endocardial excursion and dilatation of four chambers in the same patient with dilated NICM in the apical 4-chamber view in end-diastole (A) and end-systole (B). Note enlargement of right ventricle and atrium.

Figure 1-5 Reduced endocardial excursion and dilatation of left ventricle and left atrium in the same patient with dilated NICM in the apical 2-chamber view in end-diastole (A) and end-systole (B). Use inspiratory or expiratory breath hold if necessary to define endocardial borders.

Figure 1-6 Apical 4-chamber views in end-diastole (A) and end-systole (B) before (C) and after (D) Definity contrast injection. Note clear delineation of endocardial borders in C and D compared to A and B.

Figure 1-7 Apical 4-chamber views in end-diastole (A) and end-systole (B) before and after (C and D) Definity contrast injection. Note clear delineation of LV apical thrombus (arrows) in C and D after contrast injection.

Limitations

• Difficult to quantify due to endocardial dropout.

• Foreshortening underestimates true LV volumes.

• Ejection fraction is often eyeballed without volume measurement.

Segmental Wall Motion

Key Points

• Segmental wall motion abnormalities are often present in systolic heart failure.

• Dilated ischemic cardiomyopathy (ICM): hypokinetic segments as well as akinetic segments with or without thinning and increased echogenicity suggesting scar formation (Figure 1-8; see also Figures 1-6 and 1-7).

• Dilated non-ischemic cardiomyopathy (NICM): usually global hypokinesis; some segments may be akinetic, dyskinetic, or aneurysmal (see Figures 1-2, 1-4, and 1-5).

• LV thrombus may be present in the apical/distal IVS region or rarely at inferior/lateral aneurysmal segments (see Figure 1-7).

• Reversed IVS motion secondary to prior coronary artery bypass surgery is often present.

• Reversed IVS motion with or without apical and inferoapical dyskinesis occurs in the presence of left bundle branch block or RV pacing.

• Segmental wall motion is often normal in diastolic heart failure.

Figure 1-8 2D measurements for volume calculations using biplane method of disks (modified Simpson’s rule) in apical 4-chamber (A and B) and apical 2-chamber views (C and D) at end-diastole (A and C) and at end-systole (B and D) in a patient with dilated ICM. Papillary muscles should be excluded from the cavity in the tracing. Note thin and echodense basal to midinferior walls (red arrows in C and D) indicating prior inferior wall transmural infarct. Upper-normal LV diastolic (152 mL) and increased LV systolic (99 mL) volumes are present, which are characteristic of dilated ICM.

Limitations

• Requires good image resolution in all parasternal and all apical views.

• Requires technical expertise for interpretation.

LV Function Assessment by Tissue Doppler Imaging (Figure 1-9)

Figure 1-9 TDI velocities at septal annulus (A) and lateral annulus (B) and at the pulmonary veins (C) in a normal male adult age 30 years. A′, late diastolic velocity; D, diastolic pulmonary vein flow velocity; E′, early diastolic velocity; S, systolic pulmonary vein flow velocity; S′, systolic velocity.

Key Points

• Tissue Doppler imaging (TDI) provides more objective data and is less dependent on reader expertise.

• TDI systolic and diastolic velocities can be obtained reliably in basal and mid-myocardial segments by color-coded and pulsed wave (PW) Doppler techniques. Velocity of motion, displacement, and deformation can be measured in the longitudinal, radial, and circumferential planes.

• Global normal strain by TDI echocardiography ranges from 16% to 19%.

Limitations

• TDI systolic and diastolic velocities are age dependent.

• TDI velocities are decreased by increasing wall thickness.

• Requires parallel angle of insonation to area of interest.

• Affected by translational and respiratory motion.

• Significant variability.

• No standardized guidelines.

• Sample volume placement determines measurement precision.

LV Function Assessment by 2D Speckle Tracking (Figure 1-10)

Figure 1-10 Apical 4-chamber (A), 2-chamber (B), and 3-chamber (C) 2D strain maps and segmental strain scores along with bull’s-eye map (D) showing global strain (GS) and segmental strain values in the same patient as in Figure 1-8. Note reduced segmental strain values of −6 to −13% in the basal to midinferior and inferolateral segments consistent with transmural infarction. GS is mildly reduced at −16%. AVC, aortic valve closure.

Key Points

• Normal values for global longitudinal strain: 18.5% to 18.7%.

• Normal values for global radial strain: 47% ± 7%.

• Independent of cardiac translation and angle of insonation.

• Can measure radial, circumferential, and longitudinal strain as well as torsion.

• Less variable than ejection fraction.

• Feasible in approximately 80% of cases.

• Twist is normal in diastolic heart failure (DHF) and markedly reduced in systolic heart failure (SHF) (SHF: 5 ± 2.8, DHF: 13 ± 6.8, control: 14 ± 5.8).

• Circumferential strain is normal in DHF (15% ± 5%) and markedly reduced in SHF (7% ± 3%) (control groups: 20% ± 3%).

• Longitudinal strain is reduced in SHF (−4%) and DHF (−12%).

• Radial strain is reduced in SHF (14% ± 8%) and DHF (28% ± 7%).

• In patients with preserved ejection fraction (50%), regional longitudinal strain of ≤13% compared to other segments identified transmural myocardial infarction (MI) with 80% sensitivity and specificity (see Figure 1-10).

Limitations

• Requires harmonic imaging and high frame rate.

• Subject to image factors, including reverberation artifacts and attenuation.

• Requires technical proficiency in image processing.

Other Methods of Assessment of Left Ventricular Systolic Function

Methods Evaluating Combined Systolic and Diastolic Function

Left Ventricular Diastolic Function

Mitral Inflow PW Doppler

Key Points

• PW sample volume is placed between the tips of the mitral valve leaflets or at the level of the mitral annulus.

• Ensure parallel alignment of the Doppler beam to blood flow.

• In dilated hearts, mitral inflow is often directed posterolaterally.

• Normal mitral inflow comprises an early-filling E wave and a late-filling A wave. Deceleration time of mitral inflow E wave is generally 170 to 180 ms (Figure 1-14).

• There is an age-associated change in mitral inflow pattern (Figures 1-15 and 1-16).

• Four major patterns of mitral inflow are seen with advancing diastolic dysfunction:

• Grade I Diastolic Dysfunction: Mitral inflow filling shows an abnormal relaxation pattern with E/A ratio of less than 1, a prolonged mitral inflow E-wave deceleration time (DT), and a prolonged IVRT.

• Grade II Diastolic Dysfunction: A pseudonormal phase is seen on mitral inflow that looks like a normal inflow filling pattern. This usually reverses to an abnormal relaxation pattern upon Valsalva maneuver (Figure 1-17). Even in the presence of an abnormal relaxation pattern on mitral inflow, a reduction in E/A ratio of greater than 0.5 upon Valsalva maneuver indicated elevated left atrial preload and grade II diastolic dysfunction (Figure 1-18).

• Grade III Diastolic Dysfunction: A markedly increased E-wave velocity is seen with a small A-wave velocity and E/A ratio of greater than 2.0. DT becomes short. This restrictive mitral inflow pattern is reversible upon preload reduction with the Valsalva maneuver or nitroglycerin or diuretic administration (Figure 1-19).

• Grade IV Diastolic Dysfunction: Same as grade III, except no change in filling pattern occurs with preload-reducing maneuvers (Figure 1-20). Advanced systolic dysfunction is often associated with grade IV diastolic dysfunction (Figure 1-21).

Figure 1-14 PW Doppler of mitral inflow showing appropriate filter, gain, scale, and sweep speed settings. The goal is to maximize Doppler signal on the screen to improve temporal and spatial resolution. A discrete electrocardiographic signal is shown at the bottom of the ultrasound panel to allow measurement of time intervals in relation to the QRS complex, such as time from onset of mitral inflow to onset of QRS complex, as well as duration of mitral inflow diastolic filling time as compared to cardiac cycle length measured as R-to-R interval. White arrow indicates deceleration time of E wave.

Figure 1-15 There is an age-associated increase in LV wall thickness, LA size, and LV mass. End-diastolic (A) and end-systolic (B) frames in the PLAX view in a 72-year-old female patient are shown.

Figure 1-16 There is an age-associated increase in mitral inflow A velocity, E-wave DT, pulmonary vein S/D ratio, and E/E′, and there is an age-associated decrease in E/A ratio and TDI E′. Mitral inflow PW Doppler velocities (A), TDI velocities (B), and pulmonary vein Doppler velocities (C) are shown in a 60-year-old male.

Figure 1-17 Mitral inflow PW Doppler (A) and TDI of medial annulus (B) in a 55-year-old female with exertional shortness of breath. Note E/A′ ratio of 13 is inconclusive for left atrial pressure. C, Mitral inflow PW Doppler during Valsalva maneuver; D, pulmonary vein inflow. A greater than 0.5 reduction in E/A ratio, S/D ratio reversal on pulmonary vein flow, and prominent pulmonary vein atrial reversal (white horizontal arrows in D) all indicate elevated left ventricular end-diastolic pressure and left atrial pressure in this patient.

Figure 1-18 Mitral inflow PW Doppler (A) in this 60-year-old male with a history of coronary artery disease shows E and A reversal, suggesting grade I diastolic dysfunction. Evaluation of medial mitral annulus (B) shows E/E′ of 13 (suggesting left atrial pressure is indeterminate). Valsalva maneuver leads to a further reduction in mitral inflow E/A ratio (C) by greater than 25%, suggesting there is elevation of left atrial pressure. Left atrium was markedly enlarged in the apical 4-chamber view (D) with a volume index of 42 mL/m².

Figure 1-19 Left ventricular end-diastolic (A) and end-systolic (B) frames in the PLAX view in a 45-year-old male with a history of uncontrolled hypertension. IVS and posterior wall thicknesses are 1.42 and 1.51 cm, respectively, and LV end-diastolic and end-systolic diameters are 5.6 cm and 4.2 cm, respectively. Mitral inflow PW Doppler (C) shows E/A ratio of 1.6 and DT of 173 ms. Valsalva maneuver (D) decreased E/A ratio to 0.8. TDI of medial mitral annulus (E) showed reduced S′ for age and a markedly reduced E′ with E/E′ ratio of 20. RV-RA gradient (F) was 40 mm Hg, and IVC was dilated with a reduced respiratory variation (G). PAP was estimated at 55 mm Hg. LVEF was 51%. LA volume index was 38 mL/m². These findings of moderate left ventricular hypertrophy, increased LVESD, a 50% reduction in E/A ratio with a preload-reducing maneuver, and an increased E/E′ along with a reduced S′ suggest a combination of systolic and diastolic dysfunction. Diastolic dysfunction is grade III and is predominant in this patient with markedly elevated LVEDP and left atrial pressure. There is mild to moderate pulmonary hypertension secondary to predominant LV diastolic dysfunction.

Figure 1-20 Restrictive cardiomyopathy with grade IV diastolic dysfunction. A and B are mitral inflow before (A) and after (B) Valsalva maneuver. No change in mitral inflow occurs with Valsalva maneuver. Pulmonary vein shows S/D ratio of 0.3 and short pulmonary vein DT. In addition, pulmonary vein A duration is greater than mitral inflow A duration.

Figure 1-21 This 53-year-old male with a history of drug abuse, including cocaine, has dilated NICM. LVEF was calculated at 13%. The patient was on a ventilator at the time of echocardiogram. Mitral inflow (A) and TDI of medial (B) and lateral (C) mitral annulus are shown. Note a markedly restrictive mitral inflow pattern with E/A ratio of 4.6, a very short DT (100 ms), and markedly reduced systolic and diastolic mitral annular velocities, suggesting advanced systolic and diastolic dysfunction. E/E′ is 53.

Pulmonary Vein PW Doppler

Key Points

• A color flow–guided 2- to 3-mm PW Doppler sample volume from an apical 4-chamber position is placed 1 to 3 cm deep within the right superior pulmonary vein.

• Place the sample volume further into the pulmonary vein for a crisp atrial reversal signal.

• Sometimes better signals are obtained from apical 2- or 3-chamber views.

• Normal pulmonary vein inflow is composed of an early systolic-filling S wave and a diastolic-filling D wave. The DT of the D wave is greater than 170 to 180 ms.

• Four major patterns of pulmonary inflow are seen with advancing diastolic dysfunction:

• Grade I Diastolic Dysfunction: Pulmonary inflow filling shows an S-dominant pattern. D-wave DT is normal and atrial reversal is minimal (see Figure 1-16).

• Grade II Diastolic Dysfunction: A prominent pulmonary vein atrial reversal is seen with an S-dominant pattern.

• Grade III Diastolic Dysfunction: S/D ratio reversal is present. Atrial reversal is usually prominent, and pulmonary vein atrial duration is greater than mitral inflow A duration. The DT of the D wave is less than 170 ms (see Figure 1-17).

• Grade IV Diastolic Dysfunction: Same as grade III, except atrial reversal is often not seen due to mechanical atrial failure (see Figure 1-20).

• In the presence of atrial fibrillation, marked blunting of the pulmonary vein S wave with or without mitral regurgitation (MR) is the rule.

TDI of Mitral Annulus

Key Points

• The TDI PW Doppler sample volume is placed at the medial (or septal) corner and then at the lateral corner of the mitral annulus in the apical 4-chamber view.

• Doppler beam alignment should be parallel to myocardial/annular motion.

• In patients with excessive respiratory excursion of the annulus, record these velocities during breath hold after expiration.

• Filters are set to exclude high-frequency signals, and the Nyquist limit is adjusted to a velocity range of 15 to 30 cm/s to eliminate the signals produced by transmitral flow and measured at sweep speed of at least 100 mm/s.

• The myocardial early motion wave shows a progressive decline in amplitude with increasing stage of diastolic dysfunction (see Figures 1-16 through 1-19 and 1-21).

• A markedly diminished early diastolic velocity (E′) is observed in patients with advanced restrictive cardiomyopathy.

Limitations

• Load dependent in patients with severe volume overload, such as end-stage renal and liver disease.

• Septal E′ may be less reliable in the presence of normal systolic function or in the presence of right ventricular diastolic dysfunction.

Color M-Mode Velocity Propagation

• Place the M-mode cursor, guided by color Doppler ultrasonography, in the middle of the LV aligned through the center of the mitral ring to the apex.

• Keep the color sector as narrow as possible.

• Use the zoom function to enlarge the image and maximize the sweep speed.

• The aliasing velocity is set to 0.5 to 0.7 m/s and the sweep speed at 100 to 200 mm/s.

• The color scale may be reduced to emphasize low-velocity flow, particularly in patients with poor LV function. Recording during held breathing or only at the end-expiratory phase can eliminate respiratory motion artifacts.

Key Points

• More user dependent than TDI.

• Color Doppler of LV inflow is obtained in the apical 4-chamber view.

• Color Doppler is considered less load dependent than mitral inflow. Using the slope of the first aliasing contour, progressive LV diastolic dysfunction leads to progressive shortening of the slope. The normal value is considered to be greater than 50 cm/s.

• Because of the physiologic beat-to-beat variability of the PW TDI data, an averaged value from a few cardiac cycles should be obtained.

Assessment of Left Atrium

Assessment of Linear Dimensions

An increase in atrial size most commonly is related to increased wall tension as a result of increased filling pressure.

Linear Diameters

Left Atrial Volume

• LA volume is more reliable than linear dimensions due to asymmetrical LA enlargement (Figure 1-25; see also Figure 1-24).

• Avoid foreshortening.

• Maximize LA length.

• Avoid confluences of the pulmonary veins and left atrial appendage.

Figure 1-25 Measurement of left atrial volume from biplane method of disks (modified Simpson’s method) using apical 4-chamber view at ventricular end-systole and maximum LA size. Four- and 2-chamber views are used for measurement.

Ellipsoid Method

Biplane area-length method is calculated using the formula:

where A₁ is the LA area on 4-chamber view, A₂ is the LA area on apical 2-chamber view, and L is the shorter of the major axes. Length (L) is measured from the back wall to a line across the hinge points of the mitral valve (see Figure 1-24).

Simpson’s Method (Method of Disks)

The volume of the LA is calculated from the sum of the volumes of a series of stacked oval disks whose height is h and whose orthogonal minor and major axes are D₁ and D₂ (see Figure 1-25), using the formula:

Noninvasive Assessment of Left Atrial and Left Ventricular Filling Pressures

Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure [LVEDP] > 16 mm Hg or mean pulmonary capillary wedge pressure > 12 mm Hg) or noninvasively by TDI (E/E′ > 15). Multiple other parameters, including the mitral inflow E/A ratio, its reduction with the Valsalva maneuver, E-wave deceleration time, the pulmonary vein S/D ratio, the pulmonary vein D-wave DT, mitral inflow and pulmonary vein inflow duration, and E/velocity of propagation, can be used for assessing left atrial pressure (Table 1-2).

TABLE 1-2 ASSESSMENT OF CARDIAC FILLING PRESSURES

Mitral regurgitation	To evaluate LA filling pressure [SBP − 4(MR velocity)²]
Tricuspid regurgitation	To evaluate pulmonary artery systolic pressure [4 × (tricuspid insufficiency jet velocity)² (m/s)]
Pulmonary regurgitation	Pulmonary artery diastolic pressure [4 × (pulmonary insufficiency jet velocity)² (m/s)] plus right atrial pressure
Left atrial pressure	Mitral inflow E-wave DT < 160 ms
	Mitral inflow E/A > 2.0
	Pulmonary vein S < pulmonary vein D
	Pulmonary vein a_dur 30 ms > mitral inflow a_dur
	Mitral inflow E/A > 0.5 with Valsalva maneuver
	E/E′ > 15
	E/Vp > 2.0
	Pulmonary vein D wave DT < 160 ms

a_dur, atrial wave velocity duration; D, diastolic wave; E, mitral inflow early-filling wave; E/A, mitral inflow early-to-late diastolic velocity ratio; E/E′, ratio of mitral inflow early filling wave to myocardial early diastolic velocity; E/Vp, ratio of mitral inflow early-filling wave to early propagation velocity by color M-mode; S, systolic wave; SBP, systolic blood pressure.

To evaluate dP/dt: Σ Δt from 1 m/s to 3 m/s, 32/Δt

If TDI yields an E/E′ ratio suggestive of diastolic LV dysfunction (15 > E/E′ > 8), additional noninvasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of the mitral valve or pulmonary veins, echocardiographic measures of LV mass index or left atrial volume index, electrocardiographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma levels of natriuretic peptides are elevated, diagnostic evidence of diastolic LV dysfunction also requires additional noninvasive investigations such as TDI, blood flow Doppler of the mitral valve or pulmonary veins, echocardiographic measures of LV mass index or left atrial volume index, or electrocardiographic evidence of atrial fibrillation.

Assessment of Right Ventricle

Right Ventricular Size

Qualitative

• RV smaller than LV—normal.

• RV cavity area similar to that of LV—moderate enlargement, RV may share the apex of the heart.

• RV cavity area exceeds that of LV and RV is apex forming—severe RV enlargement.

Quantitative

• Midcavity diameter at end-diastole—PLAX view, SAX view (Figure 1-26), apical 4-chamber view (Figure 1-27).

• Obtain a true non-foreshortened apical 4-chamber view, oriented to obtain the maximum RV dimension. RV longitudinal diameter can be measured from this view.

Figure 1-26 PLAX (A) and PSAX (B) views showing dilated right ventricle.

Figure 1-27 Assessment of right ventricular systolic function by fractional shortening. Endocardium is traced in the apical 4-chamber view, including trabeculation in end-diastole (A) and end-systole (B). Images demonstrate a decreased percent fractional area change (%FAC) of 30%; less than 35% indicates RV systolic dysfunction.

Right Ventricular Systolic Function

Given the complex geometry of the RV and the lack of standard methods for assessing RV volumes, RV systolic function is generally estimated qualitatively in clinical practice. Nevertheless, a number of echocardiographic techniques may be used to assess RV function. These are listed in Table 1-3.

TABLE 1-3 ASSESSMENT OF RIGHT VENTRICULAR FUNCTION

Measurement	Location	Normal Values
TAPSE M-mode apical 4-chamber view	Tricuspid annulus	≥16 mm
Peak tricuspid valve (TV) annular velocity in systole (S_a) TDI apical 4-chamber view	Systole at lateral and medial TV annulus	≥10 cm/s
Fractional area change (FAC) 2D—apical 4-chamber view	FAC = (EDA − ESA)/EDA	>35%
Isovolumic acceleration (IVA) Tissue Doppler—lateral tricuspid annulus	IVA = TV peak isovolumic annular velocity/time to peak velocity	2.2 m/s²
RV dP/dt	Tricuspid regurgitant jet by CW Doppler—time for the TR velocity to increase from 0.5 m/s to 2 m/s ΔP = (4V₂² − 4V₁²) = 15/Δt	>400 mm Hg/s
Myocardial performance index (MPI) PW Doppler RV inflow and outflow	MPI = (time interval of TV closure − ET)/ET	≤0.4

EDA, end-diastolic area; ESA, end-systolic area.

Global RV Function

• Fractional area change (see Figure 1-27).

• RV ejection fraction (RVEF)—by 3D methods.

• Myocardial performance index (Figure 1-28).

• RV dP/dt (Figure 1-29).

Figure 1-28 Calculation of right ventricular myocardial performance index (MPI) by PW Doppler: MPI = (TST − ET)/ET. Total systolic time (TST) is measured from the end of the tricuspid inflow A wave to the tricuspid inflow E wave (arrow in A). The TST encompasses IVCT, ET, and IVRT. In the PW Doppler method, the TST can also be measured by the duration of the TR CW Doppler signal. ET is measured from PW Doppler of RVOT (arrow in B). MPI of greater than 0.4 indicates RV systolic dysfunction. TAPSE is obtained by M-mode of the lateral tricuspid annulus (orange arrow in C). Normal distance between systole and diastole should be greater than 16 mm. Peak systolic velocity of the lateral tricuspid annulus is measured by placing PW TDI sample volume at the lateral tricuspid annulus (D). Peak S′ of tricuspid should be >10 cm/s.

Figure 1-29 Right ventricular dP/dt can be estimated from the ascending limb of the TR CW Doppler signal using the time for the TR velocity to increase from 0.5 m/s to 2 m/s (arrow). ΔP = 4[V₂² − V₁²]. dP/dt = Δt from V₁ to V₂/ΔP. If Δt is 55 ms, RV dP/dt is 273 mm Hg/s.

Regional RV Function

• Tricuspid annular plane systolic excursion (TAPSE) (see Figure 1-28).

• Doppler-derived velocities of the annulus (systolic annular motion [Sm]) (see Figure 1-28).

• TDI-derived and two-dimensional strain.

• Myocardial acceleration during isovolumic contraction.

Assessment of Filling Pressure by Continuous Wave (CW) Doppler Signals (Table 1-4)

Assessment of Left Atrial Pressure

LA systolic pressure can be obtained by subtracting the peak systolic LV-LA gradient, calculated from the peak MR velocity (4V²), from the systolic blood pressure, assuming there is no aortic stenosis or subclavian stenosis (Figure 1-30).

TABLE 1-4 ASSESSMENT OF CARDIAC FILLING PRESSURES

LA pressure	LV systolic pressure − LV-LA systolic gradient
	SBP − 4(peak mitral regurgitation jet velocity)² (m/s)
Peak PA pressure	RV systolic pressure + right atrial pressure
	[4 × (tricuspid insufficiency jet velocity)² (m/s)] + RA pressure
End-diastolic PA pressure	PA-RV late diastolic pressure gradient + RV diastolic pressure
	[4 × (late pulmonary insufficiency jet velocity)² (m/s)] + RA pressure
Mean PA pressure	PA-RV early diastolic pressure gradient + RV diastolic pressure
	[4 × (early pulmonary insufficiency jet velocity)² (m/s)] + RA pressure
LV end-diastolic pressure	Aortic diastolic pressure − end-diastolic aortic-LV pressure gradient
	Diastolic blood pressure − [4 × (late aortic insufficiency jet velocity)² (m/s)]

Figure 1-30 CW Doppler of MR in a patient with NICM in sinus rhythm (A) and in a patient with NICM and atrial fibrillation (B). Multiple measurements are averaged in a patient in atrial fibrillation to obtain peak and mean MR velocity. Subtracting the systolic LV-LA gradient, obtained from peak velocity (4V²), from the systolic blood pressure gives an assessment of left atrial pressure.

Limitation

• Peak MR velocity may not be visible in the presence of trace or mild MR.

The ascending limb of the MR signal can be used to calculate LV dP/dt (32/Δt, where t = time in ms between MR velocity of 1 m/s and 3 m/s).

Limitation

• Usually needs presence of mild to moderate regurgitation from MR signal on CW Doppler.

Assessment of Left Ventricular End-Diastolic Pressure

The LV-aortic end-diastolic pressure gradient can be calculated from the end-aortic regurgitation velocity as 4V². This gradient is then subtracted from the diastolic blood pressure to get the LVEDP (Figure 1-31).

Figure 1-31 CW Doppler AI pressure half-time (PHT) in a patient with trace aortic regurgitation (A) and a patient with moderate aortic regurgitation (B). Pressure half-time (time for pressure gradient between aorta and LV to decrease to half in diastole) is longer when AI is insignificant and shortens when AI is significant.

Limitation

• End-diastolic aortic insufficiency (AI) velocity may not be visible in the presence of trace or mild aortic regurgitation or when aortic regurgitation is very eccentric.

LA pressure and LVEDP can also be calculated from a number of other Doppler parameters listed in Table 1-4.

Assessment of Right Ventricular and Right Atrial Pressures

The RV-RA gradient can be obtained from the peak tricuspid regurgitation (TR) velocity (4V²) from the TR signal (Figure 1-32; see also Figures 1-19 and 1-29). Peak RV systolic pressure (peak pulmonary artery pressure [PAP] in the absence of pulmonic valve stenosis) can be estimated by adding right atrial pressure to the RV-RA gradient. RA systolic pressure is estimated from the size and respiratory variability of the inferior vena cava (IVC) (Table 1-5).

Figure 1-32 Peak RV-PA systolic pressure is obtained from the peak velocity of CW Doppler TR envelope. Pressure is obtained by Bernoulli equation as 4 × V². Normal resting values are usually a peak TR gradient of up to 2.8 m/s or a peak systolic pressure less than 35 mm Hg and less than 43 mm Hg during exercise.

TABLE 1-5 ASSESSMENT OF RIGHT ATRIAL PRESSURE

IVC Diameter	Collapsibility Index	Estimated RA Pressure
≤2.1 cm (normal)	>50% (normal)	3 mm Hg (normal)
>2.1 cm (dilated)	>50% (normal)	8 mm Hg (mildly elevated)
>2.1 cm	<50%	15 mm Hg
>2.1 cm	None	>15 mm Hg

Limitation

• Peak TR velocity may not be visible in the presence of trace TR.

Assessment of Right Ventricular End-Diastolic Pressure

The RV–pulmonary artery (PA) end-diastolic pressure gradient can be calculated from the end pulmonary insufficiency (PI) velocity as 4V² (Figure 1-33). RA pressure is then added to this gradient to obtain RV end-diastolic pressure.

Figure 1-33 Doppler echocardiographic determination of PA diastolic pressure. CW Doppler signal of pulmonic regurgitation (PI) is shown in A. White arrow points to the velocity at end PI corresponding to the PA-RV diastolic pressure gradient. PA diastolic pressure is calculated as the sum of the RA pressure and the gradient between the PA end-diastolic pressure and the RV end-diastolic pressure, by application of the modified Bernoulli equation to the end-diastolic velocity of the pulmonary regurgitation Doppler signal. Mean PAP is PA systolic pressure + (2PADP)/3. Mean PA pressure can also be estimated from PW Doppler of the RVOT (B). Acceleration time is measured from the onset of ejection to peak ejection (white lines in B). Mean PAP = 79 − (0.45 × acceleration time); in patients with acceleration times less than 120 ms, mean PAP = 90 − (0.62 × acceleration time).

RA pressure is estimated from the IVC (see Table 1-5; see also Figure 1-19) and TR jet shape (Figure 1-34).

Figure 1-34 RV dilatation, often associated with systolic heart failure, may be associated with significant functional TR and elevated right atrial pressure. A cutoff sign (“V” sign) on the upstroke of the TR envelope (white arrows) indicates equalization of right ventricular and right atrial pressure in early systole as a result of elevation of right atrial pressure.

Summary of Echocardiographic Findings

Echocardiographic findings in systolic and diastolic heart failure are summarized in Tables 1-6 and 1-7.

TABLE 1-6 TWO-DIMENSIONAL ECHOCARDIOGRAPHIC FINDINGS IN SYSTOLIC AND DIASTOLIC HEART FAILURE

Echo Parameter	Systolic Heart Failure	Diastolic Heart Failure
LV size	Dilated	Normal
Wall thickness	Normal or increased	Usually increased
LV mass	Significantly increased	Normal to severely increased
LVEF	Moderate to severly reduced	Preserved
LV trabeculation	Often increased	Normal
LV thrombus	May be present	Absent
Atrial size	Usually enlarged	Enlarged disproportionate to LV size
Right ventricular size	Often enlarged	Normal to mildly enlarged
Right ventricular systolic function	Often reduced	Usually normal
Inferior vena cava	Normal to dilated	Dilated with reduced respiratory variation
Hepatic veins	Variable	Often dilated
Pleural effusion	Often present	Often absent
Pericardial effusion	Usually absent	Usually absent
Atrial fibrillation	May be present	Often present

TABLE 1-7 DOPPLER ECHOCARDIOGRAPHIC FINDINGS IN SYSTOLIC AND DIASTOLIC HEART FAILURE

Echo Parameter	Systolic Heart Failure	Diastolic Heart Failure
Mitral regurgitation	None to severe	None to moderate
Diastolic MR	May be present	May be present
Diastolic MR	Often due to first-degree atrioventricular block (AVB)	Often due to elevated LVEDP
MR peak velocity	Often reduced	Normal to elevated
MR dP/dt	Reduced	Often normal
Tricuspid regurgitation	None to severe	None to moderate
Tricuspid regurgitation	Often due to first-degree AVB	Often due to elevated LVEDP
Diastolic TR	May be present	May be present
Pulmonary artery pressure	Elevated proportionate to LV systolic dysfunction and/or MR	Elevated disproportionate to LV systolic dysfunction and/or MR
Mitral inflow	Grade I–IV diastolic dysfunction	Often grade II–IV diastolic dysfunction
Mitral inflow	Grade often concordant to LV systolic function	Grade often disconcordant to LV systolic function
Color M-mode	Propagation velocity (Vp) variable	Vp usually <45 cm/s and E/Vp > 1.5
Tricuspid inflow	Variable	Often restrictive filling
Pulmonary vein (PV) pattern	Grade I–IV	Often grade III–IV
Pulmonary vein (PV) pattern	May show systolic reversal with severe MR	Diastolic dominant pattern prominent atrial reversal with PV a_dur > mitral inflow a_dur
TDI E′	Often reduced	Often reduced
Septal annulus TDI S′	Markedly reduced	Mildly reduced
Mitral annulus	Dilated	Normal to moderately dilated
Tricuspid annulus	Dilated	Normal to moderately dilated
Tricuspid annulus TDI	S′ reduced	S′ often normal
Hepatic veins	Variable	S/D ratio <0.5, prominent atrial and ventricular reversal with inspiration and expiration

Infiltrative Cardiomyopathy

While abnormalities in systolic function can be detected by TDI and speckle tracking, infiltrative cardiomyopathy manifests as a pure form of diastolic dysfunction on a conventional echocardiogram and initially presents as isolated diastolic heart failure (Figures 1-35 through 1-37).

Figure 1-35 PLAX (A and B), apical 4-chamber (C and D), and subcostal (E and F) views in end-diastole and end-systole in a 45-year-old male with amyloid cardiomyopathy. Note a marked increase in LV and RV wall thickness, ground-glass appearance of LV and RV myocardium, normal to small LV end-systolic dimensions, marked left atrial enlargement, and small circumferential pericardial effusion, all hallmarks of restrictive cardiomyopathy from an infiltrative process.

Figure 1-36 PLAX M-mode view (A), apical 4-chamber view in end-systole (B), and apical 2-chamber view in end-systole (C) in the same patient with infiltrative cardiomyopathy. Note again marked left ventricular hypertrophy on M-mode as well as ground-glass appearance of myocardium (A). Measurement of left atrial volume by area-length method revealed that the left atrial volume was severely increased at 68 mL/m².

Figure 1-37 Mitral inflow (A), pulmonary vein inflow PW Doppler (B), TDI of medial (C) and lateral (D) mitral annulus, TR envelope (E), and subcostal view showing a dilated IVC (F) in the same patient with infiltrative cardiomyopathy. Note a pseudonormal-appearing mitral inflow with a DT of 213 ms. However, the pulmonary vein shows S/D ratio reversal with a ratio of 0.8. In addition, pulmonary vein atrial duration (white arrow in B) is greater than mitral inflow a duration in A (black braces in A and B) and E/E′ is 21 and 25 at the medial and lateral annulus, respectively. These findings suggest grade III LV diastolic dysfunction and elevated left atrial pressure. IVC is dilated with reduced respiratory variation, suggesting RA pressure is approximately 15 mm Hg. This gives a PAP of 37 + 15 mm Hg = 52 mm Hg. Pulmonary hypertension in this patient is secondary to diastolic heart failure.

Concomitant Systolic and Diastolic Dysfunction

In systolic heart failure, diastolic dysfunction is present parallel to the grade of systolic dysfunction. Figure 1-38 illustrates a patient with a large anterior acute MI complicated by LV aneurysm formation along with LV thrombus. Following bypass surgery, LV systolic function improved after a year. This was associated with an improvement in diastolic function grade.