Measurement of Left Ventricular Wall Thickness ...circ.ahajournals.org/content/circulationaha/45/3/602.full.pdf · Measurement of Left Ventricular Wall Thickness and Mass by Eehocardiography

Measurement of Left Ventricular WallThickness and Mass by Eehocardiography

By BART L. TROY, M.D., JOAQUIN POMBO, M.D.,

AND CHARLES E. RACKLEY, M.D.

SUMMARYEchocardiographic measurements of minor axis and wall thickness and calculations

from these two measurements of left ventricular end-diastolic volume and mass were

performed in 24 patients and compared with angiocardiographic measurements of thesame variables in corresponding patients. The echo-measured left ventricular end-diastolic chamber dimension (Dd) correlated closely with the angiographic minor axisin the AP plane (correlation coefficient 0.87 and SE -+-0.45 cm) and with the minoraxis from the lateral film (r 0.91, SE +0.39 cm). Similar correlations were foundbetween measurements by these methods of wall thickness (r = 0.89, SE +1.3 mm),of end-diastolic volume (r 0.94, SE ±30.6 cc), and of left ventricular mass (r 0.88,SE +49.19 g). The reproducibility of this method was established by independentrecordings and measurements of echo Polaroid films by two observers. The percentsystolic wall thickening, as determined by echocardiography, identified subjects withejection fractions greater or less than 0.50. Echocardiography offers a reliable andreproducible method for measuring left ventricular wall thickness and mass. Finally,ultrasound may provide an accurate method for measuring systolic wall thickening inman.

Additional Indexing Words:Chamber dimensions UltrasoundWall thickness

Ventricular mass Ventricular volume

ALTHOUGH interest in the thickness ofthe left ventricle was recorded as long

ago as 1724 in pathologic examinations,1observations on human left ventricular wallthickness and mass in living man have awaitedthe development of quantitative angiocardiog-raphy.2-1 This measurement of left ventricularwall thickness has been related to chamber

From the University of Alabama Medical Center,Myocardial Infarction Research Unit, Birmingham,Alabama.

Supported in part by Contract PH 43-67-1441 withthe National Institutes of Health, VRS Grant RD2219, and U. S. Public Health Service Grant HE11310.

Address for reprints: Charles E. Rackley, M.D.,Professor of Medicine, University of Alabama MedicalCenter, 1919 Seventh Avenue South, Birmingham,Alabama 35233.

Received June 16, 1971; revision accepted forpublication October 25, 1971.

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dimensions and pressure in order to calculatedynamic events of the myocardium through-out the cardiac cycle.6 In chronic heartdisease the left ventricular mass has beencompared with chamber size, mechanicalwork, wall forces, and function of theventricle in an effort to understand themechanism of cardiac hypertrophy.Y 9 Suchstudies have suggested that hypertrophy is amajor compensatory mechanism for the failingmyocardium. Unfortunately, the angiographicestimation of left ventricular wall thicknessand mass requires cardiac catheterization, andtherefore the frequency of such measure-ments in the course of chronic heart disease islimited. Recent studies employing echocardi-ography have produced estimations of leftventricular volume10-12 and limited observa-tions on wall thickness and mass.1") 13, 14 In thepresent investigation echocardiography was

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MEASUREMENTS BY ECHOCARDIOGRAPHY

utilized to measure left ventricular wallthickness and mass and changes in the wallthroughout the cardiac cycle, and thesemeasurements were compared with thoseobtained from biplane angiocardiography.

MethodsEchograms were recorded with a Smith Kline

Ekoline #20 which has a cathode-ray tube withtwo display modes. The A mode displays motionand the intensity of the reflected echo signalswithout respect to time. This allows setting of thetime gain control so that echoes from deeperstructures, such as the posterior wall, can beamplified selectively, with or without amplifyingmore proximal structures such as the mitral valveor the interventricular septum. The B modedisplays the amount of motion in relation to time.The echo records reported in this study arePolaroid pictures of the B mode display (see fig.1.)The technic used in obtaining these Polaroid

pictures was similar to that describedpreviously.1' A 12-mm (0.05-inch) diametercrystal transducer, emitting pulsed ultrasound of2.25 MHz, was placed parasternally, usually inthe left fourth or fifth intercostal space. In a rarepatient with low diaphragms, a lower intercostalspace was sometimes selected. The ultrasoundbeam was directed posteriorly with the examinerobserving the A mode of the cathode-ray tube forthe general location of cardiac structures. Gener-

ally, the first characteristic motion seen was themitral valve, especially the anterior leaflet.15Anteriorly, the motion of the interventricularseptum could be seen," requiring only a slightchange in position of the transducer. Thetransducer was then directed more laterallyand/or inferiorly to detect the motion of theposterior leaflet of the mitral valve. Usually, theposterior wall could be seen just behind theposterior leaflet or slightly lateral and inferior toit. In other patients the posterior wall was locatedfirst and the septum identified in a reverse fashionor by moving the transducer medially to recordthe interventricular septum while simultaneouslyretaining the posterior wall image. After appro-priate adjustments of gain, reject, and sensitivity,a Polaroid picture was taken of the B mode suchas in figure 1.The transducer is positioned in the left

parasternal region because this is where theultrasound beam traverses the most undistortedpathway into the heart. In areas of the chest otherthan the parasternal region and in the parasternalregion in certain patients with chronic obstructivelung disease, the lung separates the heart and thechest wall. In these cases echograms of necessaryquality cannot usually be taken since the airtissue interfaces in lung scatter the echobeam.15 16 If recordings cannot be obtained witha patient supine, the semilateral, lateral, or sittingposition at 30 or 450 may result in ac-ceptableechograms, presumably by bringing the heart incloser contact with the chest wall. Similarly,

Figure 1

Ant echocardiographic Polaroid picture. From anterior to posterior are seen chest wall, rightventricle, interventricular septum, left ventricular chamber, and posterior wall of the leftventricle. Dd is the end-diastolic, and D. the end-systolic left ventricular chamber dimension.


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pictures may be taken in certain patients at end-tidal expiration when films cannot be made atother phases of respiration.

Appr-eciation of the characteristic motion ofcardiac structures, the correct angulation of thetransducer, the proper settings of the echocardio-graphic machine, and the optimal position of thepatient all require practice and experience on thepart of the operator. Thus, several months ofexperience may be necessary for proficiency. Ininitial attempts of the present study, success inobtaining pictures for the measurement of wallthickness and mass was Inot tabulated; however,echograms in the last nine cases requiredexamination of 15 patients.

Twenty-four patients with valvular and/ormyocardial disease were studied by echocardiog-raphy and biplane angiocardiogr-aphy. The onlycriterion for echocardiography was that a patientbe scheduled for left ventricular volume and massstudies at cardiac catheterization.

Figure 1 shows a negative print of a Polaroidfilm of a typical echogram which is a timeexposure of the reflected pulsed ultrasoundsignals on an oscilloscope. All Polaroid pictures

The formula for the calculation of enid-diastolicleft ventricular chamber volume from the echo-cardiogram is

(D,,) (D,,) (2D )LVCV 4/3 ~2 2 2 (1)

where LVCV = end-diastolic left ventricularchamber volumne in ml anid Dd 2 = one half theleft ventr-icular end-diastolic chamber dimensions.This is a derivation of the ellipsoid formula usedin calculation of angiographic volumes,2 in whichthe echo diameter is assumed to equal the minordiameter measured from the anteroposterior orlateral angiocardiograms and the major diameteris assumed to be twice the minor diameter.Therefore, the left ventricular volume can becalculated by cubing the echo minor diameter.12Such values for left ventricular volume aresystematically slightly smaller than those derivedfrom the above echo formula and can be correctedbv a factor of 1.047.The additioni of the wall thickness measure-

ment at end-diastole to the end-diastolic diameterallows the calculation of the total left ventricularvolume.

(2)LV(C+M) V7-4/3 I7T 2+2 T 2)(2 +WT,)( 2 +WT,)

were of similar quality to figure 1 and allowed therequisite measurements to be made. From the topto the bottom of the film in figure 1 are seen,sequentially, chest wall, part of the rightventricle, interventricular septum, left ventricularchamber, and the posterior wall of the leftventricle. The distance from the left side of theiniterventricular septum to the endocardium of theposterior wall is the chamber diameter. Thisdimension at end-diastole is labeled Ddl and atend-systole D,. Wall thickness is the distancefrom the endocardium to the epicardium of theposterior wall. WVT( represents the end-diastolicwall thickness and WT, the enid-svstolic wallthickness. In the three patients with atrialfibrillation, six or more cycles were averaged forthese measurements to be made. The two basicmeasurements D, and WT(1 are niecessary for thecalculation of left ventricular mass in the methodreported.Echograms from each patient were read inde-

pendently by two observers. Each pair of valueson the 24 patients studied was averaged and thenplotted against corresponding angiographic data.In addition, there were 10 patients who had twoechograms taken at different times by eachexaminer. The measurement scale was determinedby a film of dots which vertically were 1 cm apartanid horizontally 1 sec apart.

where LV (C + M) V = end-diastolic left ven-tricular chamber plus muscle volume in ml;Dd/2 = one half the left ventricular end-diastolicchamber dimension; and WT1 = left ventricularend-diastolic wall thickness.The volume of the left ventricular mu-scle and

its mass are then calculated.

LVMV LV (C + M) V - LVCV (3)

where LVMV left ventricular muscle voluime innil; LV (C + M) V - end-diastolic left ventricu-lar chamber plus muscle volume in ml; LVCV -

enid-diastolic left ventricular chamber volume inml.

LV7M -= LVMV x 1.05 (4)

where LVM = left ventricular mass in g;LNVMV - left ventricular muscle volume; and1.05 - specific gravity of heart muscle.

In 14 of the 24 echo films, not onily end-diastolic wall thickness (WTd) but also end-systolic wall thickness (WT,) was measured asshown in figure 1. From these two measurementsof WT, and W/TS, the percent thickening of theventricular wall with systole was calculated, andthis value was compared with the angiographical-1v determined ejection fraction.

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The 24 patients had left ventricular biplaneangiography during diagnostic cardiac catheteri-zation with informed consent in accordance withthe regulations of the Human Use Committee.Left ventricular quantitative angiography anddeterminations of chamber dimensions, ejectionfraction, wall thickness, and mass were performedby previously described imethods.2 5

Results

Reproducibility of Echo Measurements

Reproducibility was established in twoways: (1) by independent measurement ofthe same echograms and (2) by independentmeasurements of echograms taken at differenttimes in the same patient. The same echopictures in 24 patients were read independent-ly by two examiners. The results given in table1 demonstrate agreement, as seen in the

following standard errors: for Dd + 0.24 cm,for WTd + 1.25 mm, for end-diastolic vol-ume 29.2 cc, and for left ventricular mass41 g. The second method for establishingreproducibility was independent measurementof films taken at different times (8 hours to 30days apart) in 10 patients by two differentexaminers. The standard errors, seen in table2, are as follows: for Dd +(0.17 cm, forWTTd 1.16 mm, for end-diastolic vol-ume + 19.0 cc, and for mass 36 g.

Echocardiographic and AngiocardiographicData

The echocardiographic and angiographicdata for the 24 patients are presented in table3. Table 1 contains the individual echoreadings from which the average echo data intable 3 were calculated. Comparative plots of

able 1

Measurements and Calculations from the Same Echograms by Two Observers Independently

Dd(cm)

Case * t Diff

Wall thickness LVEDV LV mass(mm) (cc) (g)

* t Diff * t Diff * t Diff

1 4.50 4.60 0.102 6.70 7.30 0.603 6.70 6.75 0.054 5.00 4.90 0.105 6.00 6.70 0.706 6.00 6.10 0.107 6.05 6.05 08 6.60 6.30 0.109 4.95 4.80 0.1510 5.20 5.10 0.1011 6.10 6.10 012 5.00 4.65 0.3513 7.10 6.80 0.3014 6.90 6.90 015 5.00 5.25 0.2316 6.30 6.30 017 5.20 5.20 018 3.80 4.00 0.2019 5.40 5.30 0.1020 5.10 5.10 021 6.40 6.30 0.1022 7.00 7.00 023 4.70 4.60 0.1024 6.10 6.20 0.10Mean difference 0.1458Standard error 0.2391

.5.08.07.58.08.59.07.08.06.37.09.07.0

10.012.09.010.020.08.53.a5.5

10.56.06.57.0

4.0 1.0 91 978.5 0.5 301 3898.5 1.0 201 308

10.0 2.0 125 188

9.0 0.5 216 3018.0 1.0 216 2274.5 2.5 221 2217.5 0.5 287 2758.0 1.5 121 111

8.0 1.0 141 1336.5 2.5 227 2276.0 1.0 125 1019.0 1.0 358 314

10.0 2.0 329 3298.0 1.0 125 145

10.0 0 250 25020.0 0 141 14110.0 1.5 55 643.5 0 157 1496.0 0.5 133 1339.5 1.0 262 2506.5 0.5 343 3437.0 0.5 104 978.0 1.0 227 238

1.01.24

6 70 58 1288 251 216 657 233 273 407 146 185 39

85 218 287 6911 234 211 230 181 113 6812 245 221 2410 113 137 248 134 151 170 242 167 75

24 125 99 2644 360 287 730 423 341 8220 168 150 18

0 290 290 00 521 521 09 97 130 338 181 174 70 99 108 9

12 315 272 430 201 218 177 102 107 5

11 182 217 3515.38 33.529.20 40.72

*Bart L. Troy, M.D.tJoaquin F. Pombo, M.D.


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Table 2

Measurements and Calculations from Different Echograms Recorded atPatient by Two Observers Independently

Different Times in the Same

Dd \Vall thickness LVEDV LV mass Time(cm) (mm) (cc) (gm) between

Subject * t Diff * t Diff * t Diff * t Diff echograms

1 7.10 6.9C35 0.1.3 12.0 9.3 2.3 338 336 22 446 328 118 1 hotir2 4.30 4.60 0.10 3.0 3.0 0 91 97 6 70 74 4 3 days3 3.23 3.40 0.13 9.0 8.3 0.3 143 137 12 184 181 3 1 dav4 6.60 6.70 0.10 6.7 6.6 0.1 287 301 14 202 204 2 7 days3 6.10 5.7. 0.3.3 7.0 7.0 0 227 190 37 182 164 18 3 days6 6.70 6.30 0.20 8.0 6.3 1.3 301 273 26 231 189 62 2 days7 4.80 4.9.3 0.135 6.3 6.3 0 111 121 10 106 113 7 1 dav8 3.30 3..10 0.20 7.0 4.3 2.3 149 133 16 139 80 39 30 days9 7.10 6.80 0.30 10.0 9.3 0.3 338 314 44 360 314 46 1 day10 6.00 6.10 0.10 6.0 8.0 2.0 216 227 11 149 211 62 2 days

MXIean difference 0.18 0.96 19.8 38.1Standard error 0.17 1.16 19.0 36.0

*Bart L. Troy, MI.D.tJoaquin F. Pombo, M1.1).

echo and angiographic left ventricular end-diastolic minor axes, wall thickness, and end-diastolic volume and mass are seen in figures 2through 6, respectively.The average echo end-diastolic chamber

dimension, Dd, is compared with the angio-graphic minor axis on the AP films in table 3and figure 2. The correlation coefficient, r, is0.87 with a standard error of + 0.46 em. WhenDd is compared with the angiographic minoraxis in the lateral film (in table 3 and fig. 3),the r is 0.91 with a standard error of + 0.39Cm.The average echo posterior wall thickness

was compared with the angiographic free wallthickness in table 3 and figure 4. Thecorrelation coefficient between them is 0.89with a standard error of + 1.3 mm.A comparison of echo and angiographic left

ventricular end-diastolic volume is in table 3and figure 5. The r value is 0.94 with astandard error of + 30.6 ml.

Left ventricular mass by both methods iscompared in table 3 and figure 6. The r valueis 0.88 with a standard error of ± 49 g.

Echocardiographic Dynamic Wall Thickness

Table 4 presents the echo wall thickness atend-diastole and end-systole, the calculatedecho percent systolic wall thickening, and the

angiographic ejection fraction in the corre-sponding patient. While wall thickness mea-surements are usually easily possible at end-diastole, it was more difficult to identifyclearly both endocardium and epicardiumsimultaneously at end-systole. Thus, it waspossible to measure end-systolic wall thicken-ing by echo in only 14 of 24 patients. A plot ofangiographic ejection fraction versus echocar-diographic percent systolic wall thickening isseen in figure 7. The percent systolic wallthickening varied from 3 to 100%, the range ofejection fraction from 0.11 to 0.65, and thecorrelation coefficient was 0.87. The datademonstrate that a systolic wall thickening of60% or greater is associated with an ejectionfraction greater than 0.50.

DiscussionSince the echocardiographic estimation of

left ventricular chamber volume, wall thick-ness, and mass is based on two assumptions,the validity of these assumptions must beexamined. The first assumption is that theecho chamber diameter is representative ofthe anteroposterior and lateral diameters ofthe left ventricle. The minor semiaxes byangiographic technics have been shown to besimilar.2 3 17 18 These findings support the useof the ellipsoid as an appropriate geometric


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The echocardiographic left ventricular end-diastolicchamber dimension, D d' is plotted against the angio-graphic minor diameter on the anteroposterior film.

figure for the left ventricle and further permitthe technic of single-plane quantitativeangiography. Dd correlated with both antero-posterior and lateral angiographic minor axes.Therefore, Dd can be used to represent both

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The angiographic thickness of the free wall of the leftventricle is compared with the echocardiographicthickness of the posterior wall.

minor axes, or Dd1/2 for both minor semiaxes,in the echo formula. The second assumptionfor echocardiographic measurement of cham-ber volume is that the major axis or length ofthe left ventricle is twice the minor axis.Observations to support this assumption havederived from previous studies in echocardi-ography,12 from uniplanar cineangiography in

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Figure 6Angiocardiographic and echocardiographic left v(

tricuilar masses are conmpared.

the right anterior oblique position,1'' and frcanalysis of data from large films taken at 612 films/see in both the anteroposterior a

lateral projections.18 Experimental and cliniPobservations suggest that under certain con(

tions the chronically enlarged left ventri(may alter the relationship between the minand major diameters from an ellipsoid tospheroid.19-21 If the geometric shape of t

ventricle should change to a spheroid and if

Table 4

Wall Thickening by Echo Compared with Anggraphic Ejection Fraction

Echo w-all thickness (mm) Percent wvall AngiograpEnd- End- thickening ejectio]

Subject diastole systole with systole fractioi

volume should be calculated from the equa-tion for an ellipsoid, then the calculatedventricular volume would be considerablygreater than the actual volume. However, inthe five patients in the present study with verylarge angiographically determined left ven-tricular end-diastolic volumes (from 316 to396 cc), the echo technic did not consistentlyoverestimate the left ventricular end-diastolicvolume.There are certain conditions in which

discrepancies could be expected between theecho and angiographic measurements of wall

600 thickness at end-diastole. Angiographic wallthickness at end-diastole is measured alongthe free wall of the left ventricle over a 4-cm

en- long segment of myocardium.4 In echocardi-ography the thickness of the posterior wall ofthe left ventricle is measured. An increase in

)m thickness of either the endocardium or peri-to cardium could give a spuriously increasednd myocardial wall thickness. A pericardial effu-cal sion could produce such a change on angio-di- cardiography, but the echo should detect thecle fluid separate from the ventricular wall. Bothior

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The relationship between the angiographic ejectionfraction and the echocardiographic percent systolicthickening of the posterior wall of the left ventricleis presented. Subjects with systolic wall thickening of60% or greater have ejection fraction greater than 0.50.

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technics would give high values for wallthickness with pericardial thickening in theabsence of fluid.

Right ventricular hypertrophy can present aproblem in angiocardiography by contributingto the left border of the heart on theanteroposterior projection. Thus, a left ven-tricular angiogram would show an increasedthickness of the left ventricular free wall sincethe outer part of the apparent wall thick-ening on the angiogram would consist ofthe right ventricle. Right ventricular angiocar-diography would be necessary to solve thisproblem in measurement of wall thickness.4 Inthe present series, in patient 9 who had mitralstenosis, the right ventricular pressure of70/40 mm Hg may indicate right ventricularhypertrophy, which may account for the echomeasurement of the posterior wall being 3 mmless than the angiographic thickness of thelateral wall of the left ventricle.Another discrepancy between echo and

angiographic wall thickness could exist in thepresence of an aneurysm of the lateral wall ofthe left ventricle. If the aneurysm did notinvolve the posterior wall, the posterior wallthickness measured by echo would be expect-ed to be thicker than the lateral wall thicknessmeasured by angiography. An additionalproblem could arise from the development ofa mural thrombus in an aneurysm in thelateral wall of the left ventricle. The lateralwall thickness observed on angiography wouldproject as spuriously larger than the posteriorwall visualized by echo.

Previous investigations bave reported mea-surements on the percent systolic wallthickening by cineangiography and by largefilm biplane angiography. Subjects withnormal ventricular function displayed a great-er percentage of thickening of the ventricularwall from diastole to systole than patients withdepressed ventricular function. These clinicalstudies described a range of systolic wallthickening from 25 to 100%. In the presentstudy the echocardiographic range of systolicwall thickness was 3 to 100% and suggests thatthe echo and angiographic technics are

including equivalent structures in the mea-surement of systolic wall thickness. Further-moore, the correlation between percent systolicwall thickness and ejection fraction suggeststhat systolic change in wall thickness may be ameasure of left ventricular function.

Variations in the amount of systolic wallthickening have been reported from experi-mental and clinical studies. Direct methods ofmeasuring the percent thickening of theventricular wall in animals describe lowervalues than observed in angiographic studiesin man and animals. 22 27 Mitchell, Wilden-thal, and Mullins examined the direct andangiographic methods by inserting inert beadsinto the heart beneath the endocardial layerand by positioning tantalum clips oppositethese beads on the epicardium.2S Measure-ments of systolic wall thickening averaged 30%from the beads and 60% from the angiograms.Thus, the discrepancies from the two methodsmust be explained by the infolding of thetrabeculae which is included in the angio-graphic wall thickness but not in the methodemploying the beads. Although the interpre-tation of these findings remains debatable, theinfolding of the trabeculae does in part reflectthe extent of thickening of the ventricularwall.The correlation between echocardiographic

and angiocardiographic measurements of mi-nor diameter and wall thickness and the calcu-lations of left ventricular end-diastolic volumeand mass support the validity of the echomethod. Reproducibility has been confirmedby independent measurements of two observ-ers. Finally, a relationship between the per-cent echo systolic wall thickening and theangiographic ejection fraction has been de-scribed, which differentiates patients with anejection fraction of greater or less than 0.50.These studies suggest that the measurement ofsystolic wall thickening by echocardiographymay be a reliable method for determining thechanges in left ventricular wall thickness inthe intact human heart.

References1. WEPFER JJ: Historiae Apoplecticorium. Amster-

dam, Janssmio-Waesbergios, 1724, p 666.

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3. DODGE HT, SANDLER H, BAXLEY WA, HAWLEYRR: Usefulness and limitations of radiographicmethods for determining left ventricular vol-ume. Amer J Cardiol 18: 10, 1966

4. RACKLEY CE, DODGE HT, COBLE YD JR, HAYRE: Method for determining left ventricularmass in man. Circulation 29: 666, 1964

5. KENNEDY JW, REICHENBACH DD, BAXLEY WA,DODGE HT: Left ventricular mass: Comparisonof angiocardiographic measurements with au-

topsy weights. Amer J Cardiol 19: 221,1967

6. SANDLER H, DODGE HT: Left ventricular tensionand stress in man. Circ Res 13: 91, 1963

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