제43회 한국심초음파학회 추계학술대회 (KSE 2017)

Assessement of
Regional Walll Motion

양산부산대학교병원
박용현
Regional Wall Motion

Endocardial motion
+
Systolic thickening
Regional Motion vs. Thickening

Regional motion is influenced by

 regional flow  regional thickening
 cardiac translation & rotation during
systole
 cardiac motion during respiration
 loading conditions
Normal Hypokinesis
 Regional Wall Motion Abnormalities
Segmental motion LV wall thickening in systole Score

Normokinesia > 35-40% 1

Hypokinesia 10-30% 2

< 10%
Akinesia 3
or no inward movement

Dyskinesia Moving outward 4

Aneurysm Bulging outward (& diastole) 5

벽운동 지수 (Wall Motion Score Index)

각분절의 벽운동 점수의 합

=
관찰한 심실 분절 개수의 합
Regional Wall Motion Abnormalities
Standard score Optional score Score

Hyperdynamic 0

Normokinesia 1

Mildly hypokinetic 1.5

Hypokinesia 2

Severely hypokinetic 2.5

Akinesia 3

Dyskinesia 4

Aneurysm 5

Akinetic with scar 6

Dyskinetic with scar 7
Radial wall motion analysis with anatomical M-mode
 The most common cause
of RWMA

Coronary Artery Disease

 Infarction / Scar

Angina

ECG Changes

Visibly Abnormal
Wall Motion

Diastolic Dysfunction
Relaxation Abnormalities
Perfusion Abnormality
Normal
Function

Magnitude of Ischemia / Flow Reduction

 Wall Motion Analysis Method
Regional
Qualitative
“Eyeball” assessment
Normal-hypokinetic-akinentic-dyskinetic
Presence of scar/aneurysm
Semiquantitative
Wall motion score/score index
Quantitative
Fractional shortening / Radial shortening
Cavity/fractional cavity area change
Chordal centerline analysis
Doppler tissue based
Wall velocity, Myocardial displacement
Strain / Strain rate, Torsion
Akinesis Dyskinesis
 WMA in Hibernation
• WMA in pts with angina
= hibernating myocardium
 Reduced perfusion  reduced function

• The LV wall in the ischemic region is usually

thick due to ischemia induced edema.

• Depending on the severity of ischemia the

region is hypokinetic or akinetic
 Anatomical M-mode
- tool for regional wall motion analysis -

R-wave T-wave P-wave

Post-systolic contraction = sensitive marker of myocardial ischemia
 WMA in Stunning
• Normal regional perfusion with reduced
regional function

• The appearance is similar with hibernation

• In stunning there is usually no wall

thickening, because there is no edema.

• During stress we can observe akinesia and

wall thinning.
 WMA in AMI
• Acute loss of blood supply
 Blood volume at rest is reduced
 In the early stage of an acute myocardial infarction
the infarcted wall is thinned ; there is regional
akinesia

• If the infarct vessel is reperfused by TL or PCI,

reactive hyperemia will result in local edema
 increased thickness of akinetic regional
myocardium.
 Extent of Infarct Thickness &
Percentage of Systolic Thickening
40
Total 827 segments
P < 0.001
of 13 dogs model
30 Conclusion : myocardial infarction involving
Systolic thickening (%)

more than 20% of the wall thickness result

in lack of regional systolic contraction
20
P < 0.001

10
N= P = 0.27 (NS)
535 84
0
18 40 69 81

-10
0 1 - 20 21 - 40 41 - 60 61 - 80 81 - 100
-20 Infarct thickness (%)

Circulation 1981;63:739-46.
If there is regional systolic contraction,
there is viable myocardium

Endocardium
Systolic contraction of Increase in regional
myocardila wall layers thickness in wall
(M-mode analysis) layers relative to total
wall thickness (%)

Epicardium 60%

27%

10%
3%
Systole
Epicardium Endocardium

By Myers et al. Circulation 1986; 74: 164-172

Transmural Extent before Revascularization and the
Likelihood of Increased Contractility after
Revascularization.

N Engl J Med 2000; 343:1445-1453

 Factors that influence RWMA
 Tethering or hyperkinetic effect

 Cardiac rotation and translation

 Cardiac position change during breathing

 Condition of preload or afterload

Normal

Tethered
Infarction Systolic Contour

5% Involvement 5% Involvement

20% Involvement
Total Apparent Involvement
= 20% + 10% = 30%
 Regional Wall Motion Abnormalities

Segmental analysis of LV walls in a parasternal short-and long-axis

views at 3 different levels.
J Am Soc Echocardiogr 2005;18:1440-1463.
 Regional Wall Motion Abnormalities

Typical distribution of the right and left coronary arteries.

J Am Soc Echocardiogr 2005;18:1440-1463.

 Dominance of Coronary Artery
Right dominance : 85%

Definition 1 :
the coronary artery which reaches the crux of the heart and then gives off the PDA

Definition 2 : ( Allows for codominance )

the artery which gives off the PDA as well as a large posterolateral branch
 Wrap Around Short LAD/Large RCA
Left Dominance
LAD with Apical Extension
 Detection of RWMA

From multiple windows and planes

 Cases

1. LAD territory
2. LCX territory
3. RCA territory
4. LAD+LCX territory
5. LAD+RCA territory
6. 3 Vessels Disease
7. RV infarction
 Right Ventricular Infarction

• Mostly occurred in patients with inferior MI

: 1/3 of inferior MI ( occlusion of proximal RCA )

• Isolated RV infarction or RV infarction in anterior MI

is very rare.

• shows dilatation RV cavity and global or regional RV

contractile dysfunction.
 Prognostic Implications of RWMA

The more extensive the wall motion abnormality is,

the greater is the likelihood of complications such as
CHF, arrhythmia and death.

Isolated, single-vessel CAD;

Compensatory hyperkinesis of the remaining segments
Protect against the overall adverse impact of
RWMA

Multivessel CAD;
Failure to develop compensatory hyperkinesis
Worse prognosis
Lack of compensatory hyperkinesis
in AMI

(1) reduced contractile reserve or reduced

blood flow reserve in the noninfarcted beds

(2) three-vessel disease 75%

(3) ant. MI : mortality 68%

Am J Cardiol 1986;58:394
 심초음파를 이용한 예후평가
20
심근경색 6개월 후 사망률(%) 심부전 협심증

(<30%)

생존심근영역
10
(30-39%)

심근허혈영역
(40-49%)
(50-59%)
(60%)

0
20 30 40 50 60 70
심초음파로 구한 좌심실 구혈율(%)
Circulation 1994;88:416
Problems & Solvings(?) in RWMA
• Image dependent (Echo window)

: contrast echoCG, raise hand-power

• Operator dependent

: avoid foreshortening, get exact plane for RWMA

• Acute or Chronic ?

: history, wall thickness, echogenecity

• Reversible or Irreversible ?

: parametric imaging, comprehensive evaluation…

 Non-ischemic RWMA
• Conduction system abnormalities
Left bundle branch block
Ventricular pacing
Premature ventricular contractions
Ventricular preexcitation (Wolf-Parkinson-White syndrome)
• Abnormal septal motions
Right ventricular volume and/or pressure overload
Pericardial constriction ( septal bouncing )
• Miscellaneous
Post-cardiac surgery
Stress-induced cardiomyopathy, Sarcoidosis
Posterior compression (Ascites, Hiatal hernia, Pregnancy)
Congenital absence of the pericardium
LBBB vs. ischemic wall motion abnormality

Ischemic WMA LBBB RV paced

Distal septum, apex, Proximal /Mid Distal septum, often

Max location and ant. wall anterior septum inferior septum

Thickening Absent or thinning Partially preserved Partially preserved

Duration Usually monophasic Multiphasic Multiphasic

Abnormal
Common Uncommon Uncommon
geometry
Temporal
No Yes Yes
dyssynchrony
Feigenbaum’s Echocardiography 7th edition
 Conclusion
• Knowledge of ischemic heart disease is essential in
the evaluation of ischemic RWMA.

• Try to characterize RWMA, whenever possible :

ischemia, hibernation, stunning, acute infarct and
scars

• DDx. of ischemic RWMA from non-ischemic RWMA

is needed.

• Despite of growing data in parametric imaging, 2D

imaging is fundamental for the evaluation of RWMA.