Echocardiography Evaluation of Left Ventricular Systolic Function, Systolic Dysfunction, and Ventricular Dyssynchrony

  • Nehzat Akiash
  • Azin Alizadehasl
  • Anita Sadeghpour


The ejection fraction (EF) is the most widely used measure and popular method in evaluating left ventricular (LV) systolic function and is considered a critical prognostic factor in all types of heart diseases.

Precise evaluation of LV volume and systolic function is necessary for defining the optimal timing of surgery in patients with valvular heart diseases such as severe mitral regurgitation and aortic regurgitation.

This section attempts to introduce the different findings that can be obtained from echocardiography in patients with systolic heart failure.


Echocardiography Left ventricular systolic function Systolic dysfunction Ventricular dyssynchrony Speckle-tracking echocardiography Stroke volume Cardiac resynchronization therapy Global longitudinal strain 



Cardiac resynchronization therapy


Ejection fraction


Global longitudinal strain


Heart rate


Inferior vena cava


Left ventricle


Left ventricular outflow tract


Pulmonary arterial pressure


Pulmonary vascular resistance


Right atrium


Right ventricle


Speckle-tracking echocardiography


Stroke volume


Tissue Doppler imaging


Tricuspid regurgitation velocity


Velocity time integral

Supplementary material

Movie 11.1

(related to Fig. 11.4): Left Ventricular ejection fraction measurement using 3DE (AVI 3658 kb)

Movie 11.2

(related to Fig. 11.5): The aneurysm of the LV apex in the 4-chamber view (AVI 20965 kb)

Movie 11.3

(related to Fig. 11.5): Large thrombus into the LV apex (AVI 11881 kb)

Movie 11.4

(related to Fig. 11.5): Large amount of pericardial effusion (AVI 21176 kb)

Movie 11.5

(related to Fig. 11.5): Pleural effusion in the apical 4-chamber and parasternal long-axis views, respectively (AVI 26457 kb)

Movie 11.6

(related to Fig. 11.10): Significant tethering of the mitral valve leaflets (AVI 10406 kb)

Movie 11.7

(related to Fig. 11.10): With severe mitral regurgitation in the apical 4-chamber view (AVI 13842 kb)


  1. 1.
    Otto CM. The practice of clinical echocardiography. 5th ed. Philadelphia: Saunders; 2017. p. 107–27.Google Scholar
  2. 2.
    Kumar N, Oommen R, Thomson VS, Jose JV. Assessment of left ventricular systolic function by velocity vector imaging. Indian Heart J. 2012;64(2):146–9.CrossRefGoogle Scholar
  3. 3.
    Wang TJ, Evans JC, Benjamin EJ, Levy D, LeRoy EC, Vasan RS. Natural history of asymptomatic left ventricular systolic dysfunction in the community. Circulation. 2003;108(8):977–82.CrossRefGoogle Scholar
  4. 4.
    Mulvagh SL, DeMaria AN, Feinstein SB, Burns PN, Kaul S, Miller JG, et al. Contrast echocardiography: current and future applications. J Am Soc Echocardiogr. 2000;13(4):331–42.CrossRefGoogle Scholar
  5. 5.
    Gutgesell HP. Echocardiographic assessment of cardiac function in infants and children. J Am Coll Cardiol. 1985;5(1 Suppl):95s–103s.CrossRefGoogle Scholar
  6. 6.
    Cameli M, Mondillo S, Solari M, Righini FM, Andrei V, Contaldi C, et al. Echocardiographic assessment of left ventricular systolic function: from ejection fraction to torsion. Heart Fail Rev. 2016;21(1):77–94.CrossRefGoogle Scholar
  7. 7.
    Quinones MA, Waggoner AD, Reduto LA, Nelson JG, Young JB, Winters WL Jr, et al. A new, simplified and accurate method for determining ejection fraction with two-dimensional echocardiography. Circulation. 1981;64(4):744–53.CrossRefGoogle Scholar
  8. 8.
    Wandt B, Bojo L, Tolagen K, Wranne B. Echocardiographic assessment of ejection fraction in left ventricular hypertrophy. Heart. 1999;82(2):192–8.CrossRefGoogle Scholar
  9. 9.
    Gottdiener JS, Bednarz J, Devereux R, Gardin J, Klein A, Manning WJ, et al. American Society of Echocardiography recommendations for use of echocardiography in clinical trials. J Am Soc Echocardiogr. 2004;17(10):1086–119.PubMedGoogle Scholar
  10. 10.
    Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1–39. e14.CrossRefGoogle Scholar
  11. 11.
    Otterstad JE, Froeland G, St John Sutton M, Holme I. Accuracy and reproducibility of biplane two-dimensional echocardiographic measurements of left ventricular dimensions and function. Eur Heart J. 1997;18(3):507–13.CrossRefGoogle Scholar
  12. 12.
    Senni M, Rodeheffer RJ, Tribouilloy CM, Evans JM, Jacobsen SJ, Bailey KR, et al. Use of echocardiography in the management of congestive heart failure in the community. J Am Coll Cardiol. 1999;33(1):164–70.CrossRefGoogle Scholar
  13. 13.
    Dorosz JL, Lezotte DC, Weitzenkamp DA, Allen LA, Salcedo EE. Performance of 3-dimensional echocardiography in measuring left ventricular volumes and ejection fraction: a systematic review and meta-analysis. J Am Coll Cardiol. 2012;59(20):1799–808.CrossRefGoogle Scholar
  14. 14.
    Marwick TH. Methods used for the assessment of LV systolic function: common currency or tower of Babel? Heart. 2013;99(15):1078–86.CrossRefGoogle Scholar
  15. 15.
    Mannaerts HF, van der Heide JA, Kamp O, Stoel MG, Twisk J, Visser CA. Early identification of left ventricular remodelling after myocardial infarction, assessed by transthoracic 3D echocardiography. Eur Heart J. 2004;25(8):680–7.CrossRefGoogle Scholar
  16. 16.
    Marwick TH. The role of echocardiography in heart failure. J Nucl Med. 2015;56(Suppl 4):31s–8s.CrossRefGoogle Scholar
  17. 17.
    Bax JJ, Poldermans D, Schinkel AF, Boersma E, Elhendy A, Maat A, et al. Perfusion and contractile reserve in chronic dysfunctional myocardium: relation to functional outcome after surgical revascularization. Circulation. 2002;106(12 Suppl 1):I14–8.PubMedGoogle Scholar
  18. 18.
    Schinkel AF, Bax JJ, van Domburg R, Elhendy A, Valkema R, Vourvouri EC, et al. Dobutamine-induced contractile reserve in stunned, hibernating, and scarred myocardium in patients with ischemic cardiomyopathy. J Nucl Med. 2003;44(2):127–33.PubMedGoogle Scholar
  19. 19.
    Jambrik Z, Monti S, Coppola V, Agricola E, Mottola G, Miniati M, et al. Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. Am J Cardiol. 2004;93(10):1265–70.CrossRefGoogle Scholar
  20. 20.
    Picano E, Frassi F, Agricola E, Gligorova S, Gargani L, Mottola G. Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr. 2006;19(3):356–63.CrossRefGoogle Scholar
  21. 21.
    Natanzon A, Kronzon I. Pericardial and pleural effusions in congestive heart failure-anatomical, pathophysiologic, and clinical considerations. Am J Med Sci. 2009;338(3):211–6.CrossRefGoogle Scholar
  22. 22.
    Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr. 2013;26(9):965–1012. e15.CrossRefGoogle Scholar
  23. 23.
    Ayuela Azcarate JM, Clau Terre F, Ochagavia A, Vicho Pereira R. Role of echocardiography in the hemodynamic monitorization of critical patients. Med Intensiva. 2012;36(3):220–32.CrossRefGoogle Scholar
  24. 24.
    Stein JH, Neumann A, Preston LM, Costanzo MR, Parrillo JE, Johnson MR, et al. Echocardiography for hemodynamic assessment of patients with advanced heart failure and potential heart transplant recipients. J Am Coll Cardiol. 1997;30(7):1765–72.CrossRefGoogle Scholar
  25. 25.
    St John Sutton M. A comprehensive noninvasive hemodynamic assessment of systolic heart failure. Circ Heart Fail. 2010;3(3):337–9.CrossRefGoogle Scholar
  26. 26.
    Abbas AE, Fortuin FD, Schiller NB, Appleton CP, Moreno CA, Lester SJ. A simple method for noninvasive estimation of pulmonary vascular resistance. J Am Coll Cardiol. 2003;41(6):1021–7.CrossRefGoogle Scholar
  27. 27.
    Howard LS, Grapsa J, Dawson D, Bellamy M, Chambers JB, Masani ND, et al. Echocardiographic assessment of pulmonary hypertension: standard operating procedure. Eur Respir Rev. 2012;21(125):239–48.CrossRefGoogle Scholar
  28. 28.
    Lancellotti P, Gerard PL, Pierard LA. Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation. Eur Heart J. 2005;26(15):1528–32.CrossRefGoogle Scholar
  29. 29.
    Lamas GA, Mitchell GF, Flaker GC, Smith SC Jr, Gersh BJ, Basta L, et al. Clinical significance of mitral regurgitation after acute myocardial infarction. Survival and Ventricular Enlargement Investigators. Circulation. 1997;96(3):827–33.CrossRefGoogle Scholar
  30. 30.
    Yiu SF, Enriquez-Sarano M, Tribouilloy C, Seward JB, Tajik AJ. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: a quantitative clinical study. Circulation. 2000;102(12):1400–6.CrossRefGoogle Scholar
  31. 31.
    Ciampi Q, Villari B. Role of echocardiography in diagnosis and risk stratification in heart failure with left ventricular systolic dysfunction. Cardiovasc Ultrasound. 2007;5:34.CrossRefGoogle Scholar
  32. 32.
    Sadeghpour A, Abtahi F, Kiavar M, Esmaeilzadeh M, Samiei N, Ojaghi SZ, et al. Echocardiographic evaluation of mitral geometry in functional mitral regurgitation. J Cardiothorac Surg. 2008;3(1):54.CrossRefGoogle Scholar
  33. 33.
    Schwarzwald CC, Schober KE, Bonagura JD. Methods and reliability of tissue Doppler imaging for assessment of left ventricular radial wall motion in horses. J Vet Intern Med. 2009;23(3):643–52.CrossRefGoogle Scholar
  34. 34.
    ur Rahman H, Khan SB, Noor L, Hadi A, Nawaz T, Shah ST, et al. Assessment of left ventricular systolic and diastolic function by tissue Doppler imaging after acute myocardial infarction. J Ayub Med Coll Abbottabad. 2011;23(2):108–11.PubMedGoogle Scholar
  35. 35.
    Abduch MC, Alencar AM, Mathias W Jr, Vieira ML. Cardiac mechanics evaluated by speckle tracking echocardiography. Arq Bras Cardiol. 2014;102(4):403–12.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Mondillo S, Galderisi M, Mele D, Cameli M, Lomoriello VS, Zaca V, et al. Speckle-tracking echocardiography: a new technique for assessing myocardial function. J Ultrasound Med. 2011;30(1):71–83.CrossRefGoogle Scholar
  37. 37.
    Nahum J, Bensaid A, Dussault C, Macron L, Clemence D, Bouhemad B, et al. Impact of longitudinal myocardial deformation on the prognosis of chronic heart failure patients. Circ Cardiovasc Imaging. 2010;3(3):249–56.CrossRefGoogle Scholar
  38. 38.
    Bajraktari G, Henein MY. The clinical dilemma of quantifying mechanical left ventricular dyssynchrony for cardiac resynchronization therapy: segmental or global? Echocardiography. 2015;32(1):150–5.CrossRefGoogle Scholar
  39. 39.
    Bax JJ, Bleeker GB, Marwick TH, Molhoek SG, Boersma E, Steendijk P, et al. Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol. 2004;44(9):1834–40.CrossRefGoogle Scholar
  40. 40.
    Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace. 2013;15(8):1070–118.CrossRefGoogle Scholar
  41. 41.
    Cleland J, Freemantle N, Ghio S, Fruhwald F, Shankar A, Marijanowski M, et al. Predicting the long-term effects of cardiac resynchronization therapy on mortality from baseline variables and the early response a report from the CARE-HF (Cardiac Resynchronization in Heart Failure) Trial. J Am Coll Cardiol. 2008;52(6):438–45.CrossRefGoogle Scholar
  42. 42.
    Parameswaran AC, Purushottam B, Amanullah A, Figueredo VM. Distribution of dyssynchrony in subjects with no known cardiac disease and comparison of velocity vector imaging to color-coded tissue Doppler imaging. Echocardiography. 2013;30(2):180–9.CrossRefGoogle Scholar
  43. 43.
    Solomon SD, Foster E, Bourgoun M, Shah A, Viloria E, Brown MW, et al. Effect of cardiac resynchronization therapy on reverse remodeling and relation to outcome: multicenter automatic defibrillator implantation trial: cardiac resynchronization therapy. Circulation. 2010;122(10):985–92.CrossRefGoogle Scholar
  44. 44.
    Verbrugge FH, Verhaert D, Grieten L, Dupont M, Rivero-Ayerza M, De Vusser P, et al. Revisiting diastolic filling time as mechanistic insight for response to cardiac resynchronization therapy. Europace. 2013;15(12):1747–56.CrossRefGoogle Scholar
  45. 45.
    Wu VC-C, Takeuchi M. Three-dimensional echocardiography: current status and real-life applications. Acta Cardiol Sin. 2017;33(2):107–18.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Edner M, Kim Y, Hansen KN, Nissen H, Espersen G, La Rosee K, et al. Prevalence and inter-relationship of different Doppler measures of dyssynchrony in patients with heart failure and prolonged QRS: a report from CARE-HF. Cardiovasc Ultrasound. 2009;7:1.CrossRefGoogle Scholar
  47. 47.
    van der Hulst AE, Delgado V, Blom NA, van de Veire NR, Schalij MJ, Bax JJ, et al. Cardiac resynchronization therapy in paediatric and congenital heart disease patients. Eur Heart J. 2011;32(18):2236–46.CrossRefGoogle Scholar
  48. 48.
    Galderisi M, Cattaneo F, Mondillo S. Doppler echocardiography and myocardial dyssynchrony: a practical update of old and new ultrasound technologies. Cardiovasc Ultrasound. 2007;5:28.CrossRefGoogle Scholar
  49. 49.
    Pitzalis MV, Iacoviello M, Romito R, Massari F, Rizzon B, Luzzi G, et al. Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony. J Am Coll Cardiol. 2002;40(9):1615–22.CrossRefGoogle Scholar
  50. 50.
    Delgado V, Ypenburg C, van Bommel RJ, Tops LF, Mollema SA, Marsan NA, et al. Assessment of left ventricular dyssynchrony by speckle tracking strain imaging: comparison between longitudinal, circumferential, and radial strain in cardiac resynchronization therapy. J Am Coll Cardiol. 2008;51(20):1944–52.CrossRefGoogle Scholar
  51. 51.
    Marcus GM, Rose E, Viloria EM, Schafer J, De Marco T, Saxon LA, et al. Septal to posterior wall motion delay fails to predict reverse remodeling or clinical improvement in patients undergoing cardiac resynchronization therapy. J Am Coll Cardiol. 2005;46(12):2208–14.CrossRefGoogle Scholar
  52. 52.
    Chung ES, Leon AR, Tavazzi L, Sun JP, Nihoyannopoulos P, Merlino J, et al. Results of the predictors of response to CRT (PROSPECT) trial. Circulation. 2008;117(20):2608–16.CrossRefGoogle Scholar
  53. 53.
    Gorcsan J 3rd. Echocardiographic assessment of ventricular dyssynchrony. Curr Heart Fail Rep. 2008;5(1):31–7.CrossRefGoogle Scholar
  54. 54.
    Cho EJ, Caracciolo G, Khandheria BK, Steidley DE, Scott R, Abhayaratna WP, et al. Tissue Doppler image-derived measurements during isovolumic contraction predict exercise capacity in patients with reduced left ventricular ejection fraction. JACC Cardiovasc Imaging. 2010;3(1):1–9.PubMedGoogle Scholar
  55. 55.
    De Backer J, Matthys D, Gillebert TC, De Paepe A, De Sutter J. The use of Tissue Doppler Imaging for the assessment of changes in myocardial structure and function in inherited cardiomyopathies. Eur J Echocardiogr. 2005;6(4):243–50.Google Scholar
  56. 56.
    Kadappu KK, Thomas L. Tissue Doppler imaging in echocardiography: value and limitations. Heart Lung Circ. 2015;24(3):224–33.CrossRefGoogle Scholar
  57. 57.
    Mundigler G, Zehetgruber M. Tissue Doppler Imaging: myocardial velocities and strain—are there clinical applications? J Clin Basic Cardiol. 2002;5(2):125–32.Google Scholar
  58. 58.
    Dandel M, Lehmkuhl H, Knosalla C, Suramelashvili N, Hetzer R. Strain and strain rate imaging by echocardiography – basic concepts and clinical applicability. Curr Cardiol Rev. 2009;5(2):133–48.CrossRefGoogle Scholar
  59. 59.
    Marwick TH. Measurement of strain and strain rate by echocardiography: ready for prime time? J Am Coll Cardiol. 2006;47(7):1313–27.CrossRefGoogle Scholar
  60. 60.
    Marwick TH, Yu C-M, Sun JP, editors. Myocardial imaging: tissue Doppler and speckle tracking. Malden: Wiley-Blackwell; 2007.Google Scholar
  61. 61.
    Van de Veire NR, Bleeker GB, De Sutter J, Ypenburg C, Holman ER, van der Wall EE, et al. Tissue synchronisation imaging accurately measures left ventricular dyssynchrony and predicts response to cardiac resynchronisation therapy. Heart. 2007;93(9):1034–9.CrossRefGoogle Scholar
  62. 62.
    Sadeghpour A, Kyavar M, Behzadnia N, Maddadi S, Parsaei M, Maleki M, et al. Left ventricular systolic dyssynchrony in patients with hypertrophic cardiomyopathy: the prevalence and its relation to syncope. Iran Cardivasc Res J. 2010;4(4):152–8.Google Scholar
  63. 63.
    Delgado-Montero A, Tayal B, Goda A, Ryo K, Marek JJ, Sugahara M, et al. Additive prognostic value of echocardiographic global longitudinal and global circumferential strain to electrocardiographic criteria in patients with heart failure undergoing cardiac resynchronization therapy. Circ Cardiovasc Imaging. 2016;9(6):e004241.CrossRefGoogle Scholar
  64. 64.
    Badano LP, Lang RM, Zamorano JL. Textbook of real-time three dimensional echocardiography. New York: Springer; 2011.CrossRefGoogle Scholar
  65. 65.
    Marsan NA, Bleeker GB, Ypenburg C, Van Bommel RJ, Ghio S, Van de Veire NR, et al. Real-time three-dimensional echocardiography as a novel approach to assess left ventricular and left atrium reverse remodeling and to predict response to cardiac resynchronization therapy. Heart Rhythm. 2008;5(9):1257–64.CrossRefGoogle Scholar
  66. 66.
    Rabben SI. Technical principles of transthoracic three-dimensional echocardiography. In: Badano L, Lang RM, Zamorano JL, editors. Textbook of real-time three dimensional echocardiography. London: Springer; 2010. p. 9–24.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Nehzat Akiash
    • 1
  • Azin Alizadehasl
    • 2
  • Anita Sadeghpour
    • 3
  1. 1.Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical SciencesAhvazIran
  2. 2.Echocardiologist, Echocardiography and Cardiogenetic Research CentersCardio-Oncology Department, Rajaie Cardiovascular Medical and Research CenterTehranIran
  3. 3.Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical ScienceTehranIran

Personalised recommendations