2D and M-Mode Calculations and Measurements: Week 4

Question 1

Important points When making Linear measurements

Answer 1

Linear Measurements
 Use parasternal LONG axis (PLAX) view
 Optimise (gains, TGC, FOV): LV should be biggest &
papillary muscle should not visible
 Show clear delineation of endocardial borders
 Measure IVSd, LVIDD, and LVPWd at the same time and
consecutively
 Record measurements diastole and systole from the same
cardiac cycle
 Identify correct phase of cardiac cycle for measuring
 Ensure measurements are perpendicular for each
individual structures

Question 2

LV End-diastolic Linear Measurements
-When should it be taken?

-Where is the Interventricular septum Diastole (IVSd) measured?

-LVID Diastole (LVIDd)
-Should it be inner edge to inner edge?
-Should it be perpendicular?
-Should it be aligned at or below the MV leaflet tips?

Answer 2

LV End-diastolic Linear Measurements
Timing: Perform at end-diastole (defined as the first frame after
mitral valve closure or the frame with the largest LV
dimensions/volume) or at the Peak R wave on the ECG if the valves
cannot be seen.

Interventricular septum Diastole (IVSd)
* Interface RV cavity meets compact endocardium of the septum
and IVS meets LV cavity

LVID Diastole (LVIDd)
* Inner edge to inner edge
* perpendicular to the long axis of the LV
* at or immediately below the level of the mitral valve leaflet tips

LV posterior wall diastole (LVPWd)
* Interface LV compact posterior wall and LV cavity and interface
of the posterior wall and pericardial interface

Question 3

Common pitfalls to avoid

Answer 3

-Trabeculation (including this in the measurement while taking the IVsd)
- LVhypertrophy measurement
-Papillary muscles
-Sigmoid septum

Question 4

LV End-diastolic Linear Measurements
-When should it be taken?

Answer 4

LV End-systolic Linear Measurement
Timing: Perform at end-systole (the frame with the
smallest LV dimensions/volume usually the frame
preceding the initial early diastolic opening of MV) or
at the end of the T wave on the ECG if the valves
cannot be seen.
LVID Diastole (LVIDs)
* Inner edge to inner edge
* perpendicular to the long axis of the LV
* at or immediately below the level of the mitral
valve leaflet tips
.

Question 5

What of the following are limitations of the Bi-plane Disk Summation method?

A. Volumes been overestimated due to foreshortening

B. Volumes can be underestimated due to foreshortening

C. Volumes can be underestimated due to foreshortening

D.Clear endocardial definition

E. Patient with a large body habitus

Answer 5

Correct Answer:
Volumes can be underestimated due to foreshorteningC

Question 6

When performing a systolic linear measurement of the left ventricle (LV) which of the following statements are correct?

A. Parallel to the long axis of the LV.

B. Inner edge to inner edge.

C. Perform measurement at early-systole.

D. Not Selected

E. Perform measurement mid-systole.

Answer 6

Correct answer:

Inner edge to inner edge.

Feedback
Based on your answer
The end-systolic linear measurement should be obtained when the LV cavity is at the smallest, which is generally the frame preceding the initial early diastolic opening of the mitral valve. The caliper measurement should be positioned perpendicular to the long axis of the left ventricle and measurement from the inner edge of the interventricular septum to the inner edge border of the posterior wall. On ECG the end systolic volume will usually be the end of the systolic volume, which is seen at the end of the T wave.

Question 7

When assessing the left ventricle outflow tract (LVOT) the measurement should be parallel to the aortic annulus and measured from the leading edge of the right to the leading edge of noncoronary annulus leaflet insertion point?

A. True

B. False

Answer 7

Correct Answer:
False

Question 8

A patient’s image has been optimised and has clear endocardial definition. Which method is recommended by the ASE guidelines to assess Left ventricular Ejection fraction (LVEF)?

A.Simpsons Bi-plane measurement

B.3D LV volume

C. Area-length measurement

D. LVEDD linear measurement

E. Simpsons Single- plane measurement

Answer 8

Correct Answer:
3D LV volume

Question 9

Score

Wall Motion

1

Normal or hyperkinetic

2

Hypokinetic (reduced thickening)

3

Akinetic (absent or negligible thickening, e.g. scar)

4

Dyskinetic (systolic thinning or stretching, e.g., aneurysm)

A patient presents to the echo lab with a dyskinetic apical anterior and apical septal segments, the apical inferior and apical lateral LV segments are also akinetic. The remaining LV segments are normal. Using a 16-segment model, which is the regional wall motion score index?

A. 1.625

B. 1.75

C. 0.625

D. 24

Answer 9

Correct answer:

1.625

To calculate the regional wall motion score index (WMSI) using the given scoring system and the patient’s presentation, we sum up the scores for each segment and then divide by the total number of segments assessed.

Given the patient’s presentation:

Dyskinetic apical anterior and apical septal segments: Each receives a score of 4.
Akinetic apical inferior and apical lateral LV segments: Each receives a score of 3.
Remaining LV segments (assumed to be normal): Each receives a score of 1.
Total score = (4 + 4 + 3 + 3 + 1 + 1 + 1 + 1 + 1 + 1 + 1 + 1 + 1 + 1 + 1 + 1) = 24

Number of segments assessed = 16

Regional WMSI = Total score / Number of segments assessed
= 24 / 16
= 1.5

Therefore, the regional wall motion score index is 1.5. (Closest to 1.625)

Question 10

Describe the posterior to anterior LA linear measurement.

Answer 10

TIMING: END SYSTOLE (LARGEST LA DIMENSIONS!) PRECEEDS EARLY OPENING OF THE MV OR T WAVE

LEADING EDGE TO LEADING EDGE.

PERPENDICULAR TO THE LONG AXIS OF THE LEFT ATRIA

MEASURE FROM SINIS OF VALSALVA OF THE AORTIC ROOT TO THE POSTERIOR LEFT ATRIA WALL

Question 11

BASICS OF MEASURING

Answer 11

-Current guidelines state measurements should be taken in 2D PLAX
-Largest ventricle as possible
- Clear delineation of endocarditis borders by adjusting dynamic contrast,range
-Same cycle

Question 12

Calculating relative wall thickness / LV geometry

Answer 12

RwT = ( 2xPWd ) / LVd
Then match it to the LV mass index box ( refer to photo)
<0.42 Nirmal >0.42 concentric remodeling etc

Question 13

LVOT diameter linear measurement zoom PLAX
when to measure in cycle?
Inner edge to inner edge?
Measure from where to where?
How many mm from valve plane?
Parallel to aortic valve annulus?

Answer 13

Mid systole

Measure from the Rcc to the Ncc leaflet insertion points

3-10mm from the valve plane

Parallel to the aortic valve annulus

Question 14

Using the LVOT diameter we can calculate what?

Answer 14

LVOT Cross sectional area
CSA= pi x (D/2) ²
CSA (CM²) = 0.785 X D²

EXAMPLE
LVOTd = 2.0cm
CSA=0.785×2.0²
CSA=3.14CM²

Question 15

Proximal RVOT linear measurement - PLAX
When to measure in cycle?

Answer 15

First frame after mitral valve closure or frame with largest RV dimensions or peak R wave on the ECG

Measured from the interface of the compacted anterior RV wall and RV cavity to the interface of the septal-aortic junction

Question 16

PSAX Proximal and distal RVOT Measurements
When in cycle to measure?

Answer 16

Timing: preform at end diastole (defined as the first frame after tricuspid valve closure or the frame with the largest RV dimension)or at the peak R wave on the ECG if the valves cannot be seen
-Measure at level of AV leaflets . Interface of the compacted myocardium anterior RV wall and RV cavity to the blood/tissue interface.
-Measured at the level of the AV leaflets. Inner edge to inner edge proximal to PV