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

None

Disclosures

Chamber Quantification Guidelines

What’s new in the document…

Multiple Modalities Described.

• M Mode

• 2 D Linear

• 3 D Volumes

Multiple Modalities Described.

• 2D Contrast

• 3D Contrast

• Strain

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

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

The Left Ventricle

Linear Dimensions

VolumesAdvantages Limitations

Left Ventricular Endocardial Border Tracingsfor Ventricular Volume Determinations

Two Dimensional Left VentricularVolume Calculations

3D Volumes with use of contrastAdvantages Limitations

Volumetric Quantification of Global LeftVentricular Function Compared to MRI

Corsi C et al. Circulation. 2005;112:1161­1170

LV StrainAdvantages Limitations

Normal LV values for size and volumes-2D

Normal LVEF

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

LV Mass- Linear methodAdvantages Limitations

LV mass 2D method

Advantages Limitations

LV mass 3D method

Advantages Limitations

Normal values for LV mass

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

The Right Ventricle

RV Size- Linear measurements

RV -area

Method Advantages Limitations

RV 3D method

RV –wall thickness

Method Advantages Limitations

RV size- normal values

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

RV systolic function RIMP

RV –Global systolic function

RV longitudinal systolic function

RV – tissue Doppler and Strain method

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.

RV function

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

Left atrium and Right atria

LA linear measurements

LA - area

Advantages Limitations

LA volumes

LA- 3D volumes

Advantages Limitations

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.

RA- linear dimensions and area

RA- 2D and 3D volumesAdvantages Limitations

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

The Aorta

The aortic measurements

1. Aortic annulus- hinge point of aortic leaflets.

2. Aortic sinuses of Valsalva

3. Sinotubular junction

4. Proximal ascending aorta

Measuring the aortic annulus

Measuring the Aortic Annulus

Correct Incorrect Incorrect

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

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

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

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)

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)

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.

Thank you for your attentionbullock-palmerr@deborah.org

www.deborah.org

Normal LV values for size and volumes-3D