Left Ventricular Deformation and Vortex Analysis in Heart Failure: From Ultrasound Technique to Current Clinical Application

Figure 1. Strain curves and bull’s eye in a patient with heart failure and reduced ejection fraction. Scheme 3. 4-, and 2-chamber views are not homogeneous, indicating that left ventricular segments do not contract all at the same time, and also the degree of systolic shortening is greater in some segments and impaired in others. At the bottom right, the bull’s eye displays a reduced value of global longitudinal strain. All images were obtained using an Esaote Mylab echo-scanner.

Figure 2. Intracardiac flow dynamics in a patient with dilated cardiomyopathy. Different maps were used to represent flow properties. The vector flow map (A) shows that the flow circulates along the posterolateral wall and is rotating anteriorly at the level of the left ventricular apex. In the circulation map (B) this translates into the formation of a single large vortex, that rotates clockwise (blue color) at the mid-apical portion of the left ventricle. The steady-streaming flow map of one heartbeat (C) shows the streamlines and the color map of the vorticity field. All images were obtained using the HyperDoppler software of an Esaote Mylab X8 echo-scanner without contrast injection.

Figure 3. Intracardiac flow analysis of a normal subject (A) and (B) and a patient with dilated cardiomyopathy (C) and (D). In the normal subject, during diastole, left ventricular (LV) filling occur mainly along a longitudinal axis (panel (A), red arrow). Panel (B) shows the intensity-weighted polar histogram representing the distribution and intensity of the LV hemodynamic forces occurring during the entire heartbeat. The hemodynamic forces (in red) are aligned along the LV base–apex direction according with the normal emptying–filling process of the LV. In the cardiomyopathy patient, LV filling is abnormal, with flow circulating along the posterolateral wall and rotating anteriorly at the level of the left ventricular apex (panel (C), red arrow). The intensity-weighted polar histogram (panel (D)) shows a dispersed distribution of the intraventricular hemodynamic forces. Images were obtained using the HyperDoppler software of an Esaote Mylab X8 echo-scanner without contrast injection.

Figure 4. Left ventricle (LV) color-coded polar maps of longitudinal myocardial strain. Panels on the left: map of strain amplitude. Clear pink and blue colors identify the most dysfunctional areas. Panels on the right: map of time-to-peak strain (dyssynchrony map). The red color represents the latest contracting myocardial areas. Basal and mid myocardial segments of inferior, posterior, lateral, and anterior walls (demarcated by the blue lines) are potential sites for LV pacing. (A,B) Patient with viable myocardium at the basal lateral wall, which is the site with latest contraction delay (optimal pacing site, yellow arrow). (C,D) The posterior wall is the most dyssynchronous, as indicated by the red color on the dyssynchrony map, but it is not the optimal pacing site because of the very low contraction amplitude. The best site for LV pacing is the lateral wall, although it is not the most delayed (yellow arrow).