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  • 1. El pesaje del trabajo es muy alto y la Eur J Echo no estadisponible en HINARI por lo que se brinda informacin enWORD e imgenes en otro file adicional.Se puedereacondicionar con programa convertidorGUIDELINESRecommendations for chamberquantification*Roberto M. Lang, Michelle Bierig, Richard B.Devereux,Frank A. Flachskampf*, Elyse Foster, Patricia A.Pellikka,Michael H. Picard, Mary J. Roman, James Seward,Jack Shanewise, Scott Solomon, Kirk T. Spencer,Martin St. John Sutton, William StewartMed. Klinik 2, Erlangen University, Ulmenweg 18, 91054 Erlangen, GermanyReceived 7 November 2005; accepted 23 December 2005Available online 2 February 2006KEYWORDSStandards;Measurements;Volumes;Linear dimensions;QuantificationAbstract Quantification of cardiac chamber size, ventricular mass and functionranks among the most clinically important and most frequently requested tasks ofechocardiography. Over the last decades, echocardiographicmethods andtechniqueshaveimproved and expandeddramatically, due to the introduction of higherfrequencytransducers, harmonic imaging, fully digital machines, left-sided contrast agents,andother technological advancements. Furthermore, echocardiography due to itsportabilityand versatility is now used in emergency rooms, operating rooms, and intensivecare units. Standardization of measurements in echocardiography has beeninconsistentand less successful, compared to other imaging techniques and consequently,echocardiographic measurements are sometimes perceived as less reliable.Therefore,the American Society of Echocardiography, working together with the EuropeanAssociation of Echocardiography, a branch of the European Society of Cardiology,hascritically reviewed the literature and updated the recommendations for quantifyingcardiac chambers using echocardiography. This document reviews the technicalaspects on how to perform quantitative chamber measurements of morphologyandfunction, which is a component of every complete echocardiographic examination. 2006 The European Society of Cardiology. Published by Elsevier Ltd. All rightsreserved.Abbreviations: LV, left ventricle; LA, left atrium; RA, right atrium; RV, right ventricle; LVID, leftventricular internal dimension;LVIDd, left ventricular internal dimension at end diastole; LVIDs, left ventricular internaldimension at end systole; SWTd, septal wall

2. thickness at end-diastole; PWTd, posterior wall thickness at end-diastole; EBD, endocardialborder delineation; TEE, transesophagealechocardiography; MI, myocardial infarction.* A report from the American Society of Echocardiographys Nomenclature and StandardsCommittee and the Task Force on ChamberQuantification, developed in conjunction with the American College of CardiologyEchocardiography Committee, the AmericanHeart Association, and the European Association of Echocardiography, a branch of theEuropean Society of Cardiology.* Corresponding author. Tel.: 49 9131 853 5301; fax: 49 9131 853 5303.E-mail address: frank.flachskampf@rzmail.uni-erlangen.de (F.A. Flachskampf).1525-2167/$32 2006 The European Society of Cardiology. Published by Elsevier Ltd. Allrights reserved.doi:10.1016/j.euje.2005.12.014IntroductionQuantification of cardiac chamber size, ventricularmass and function ranks among the most clinicallyimportant and most frequently requested tasks ofechocardiography. Standardization of chamberquantification has been an early concern in echocardiographyand recommendations on how tomeasure such fundamental parameters are amongthe most often cited papers in the field.1,2 Overthe last decades, echocardiographic methods andtechniques have improved and expanded dramatically.Improvements in image quality have beensignificant, due to the introduction of higher frequencytransducers, harmonic imaging, fully digitalmachines, left-sided contrast agents, andother technological advancements.Furthermore, echocardiography has become thedominant cardiac imaging technique, which due toits portability and versatility is now used inemergency rooms, operating rooms, and intensivecare units. Standardization of measurements inechocardiography has been inconsistent and lesssuccessful, compared to other imaging techniquesand consequently, echocardiographic measurementsare sometimes perceived as less reliable.Therefore, the American Society of Echocardiography,working together with the European Associationof Echocardiography, a branch of theEuropean Society of Cardiology, has criticallyreviewed the literature and updated the recommendationsfor quantifying cardiac chambers usingechocardiography. Not all the measurements describedin this document can be performed in allpatients due to technical limitations. In addition,specific measurements may be clinically pertinentor conversely irrelevant in different clinic scenarios.This document reviews the technical aspectson how to perform quantitative chamber measurementsand is not intended to describe the standardof care of which measurements should be performedin individual clinical studies. However,evaluation of chamber size and function is a componentof every complete echocardiographic 3. examination and these measurements may havean impact on clinical management.General overviewEnhancements in imaging have followed technologicalimprovements such as broadband transducers,harmonic imaging and left-sided contrastagents. Nonetheless, image optimization stillrequires considerable expertise and attention tocertain details that are specific to each view(Table 1). In general, images optimized for quantitationof one chamber may not necessarily be optimalfor visualization or measurement of othercardiac structures. The position of the patient duringimage acquisition is important. Optimal viewsare usually obtained with the patient in the steepleft-lateral decubitus position using a cut-out mattressto permit visualization of the true apex whileavoiding LV foreshortening. The patients left armshould be raised to spread the ribs. Excessivetranslational motion can be avoided by acquiringimages during quiet respiration. If images areobtained during held end-expiration, care mustbe taken to avoid a Valsalva maneuver, whichcan degrade image quality.Digital capture and display of images on theechocardiographic system or on a workstationshould optimally display images at a rate of atleast _30 frames/second. In routine clinical practicea representative cardiac cycle can be used formeasurement as long as the patient is in sinusrhythm. In atrial fibrillation, particularly whenthere is marked RR variation, multiple beatsshould be used for measurements. Averaging measurementsfrom additional cycles may be particularlyuseful when R-R intervals are highly irregular.When premature atrial or ventricular contractionsare present, measurements should be avoided inthe post-ectopic beat since the length of the preceding cardiac cycle caninfluence ventricularvolume and fiber shortening.Harmonic imaging is now widely employed inclinical laboratories to enhance the images especiallyin patients with poor acoustic windows.While this technology reduces the drop-out ofendocardial borders, the literature suggests thatthere is a systemic tendency for higher measurementsof LV wall thickness and mass and smallermeasurements of internal dimensions and volumes.3,4 When analyzing serial studies on a givenpatient, differences in chamber dimension potentiallyattributable to imaging changes from thefundamental to the harmonic modality are probablysmaller than the inter and intra-observer variabilityof these measurements. The best techniquefor comparing serial changes in quantitation is todisplay similar serial images side-by-side andmake the same measurement on both images by 4. the same person, at the same time.5 It is importantto note that most measurements presented in thismanuscript are derived from fundamental imagingas normative values have not been establishedusing harmonic imaging.Left-sided contrast agents used for endocardialborder delineation (EBD) are helpful and improvemeasurement reproducibility for suboptimal studiesand correlation with other imaging techniques.While the use of contrast agents has beenreviewed elsewhere in detail,6 a few caveats regardingtheir use deserve mention. The mechanicalindex should be lowered to decrease the acousticpower of the ultrasound beam, which reduces bubbledestruction. The image should be focusedon the structure of interest. Excessive shadowingmay be present during the initial phase of bubbletransit and often the best image can be recordedseveral cardiac cycles following the appearanceof contrast in the left ventricle. When less than80% of the endocardial border is adequately visualized,the use of contrast agents for EBD is stronglyrecommended.7 By improving visualization of theLV apex, the problem of ventricular foreshorteningis reduced and correlation with other techniquesimproved. Contrast enhanced images should belabeled to facilitate the reader identification ofthe imaging planes.Quantitation using transesophageal echocardiography(TEE) has advantages and disadvantagescompared to transthoracic echocardiography(TTE). Although visualization of many cardiacstructures is improved with TEE some differencesin measurements have been found between TEEand TTE. These differences are primarily attributableto the inability to obtain from the transesophagealapproach the standardized imagingplanes/views used when quantifying chamber dimensionstransthoracically.8,9 It is the recommendationof this writing group that the same rangeof normal values for chamber dimensions and volumesapply for both TEE and TTE. In this manuscript,recommendations for quantification usingTEE will primarily focus on acquisition of imagesthat allow measurement of cardiac structuresalong imaging planes that are analogous to TTE.In addition to describing a parameter as normalor abnormal (reference values), clinical echocardiographersmost often qualify the degree ofabnormality with term