Nephrol Dial Transplant (1996) 11: 1328-1331
Nephrology
Images in Nephrology
Left ventricular disorders detected by M-mode echocardiography in
chronic uraemia
P. S. Parfrey1, P. Collingwood2, R. N. Foley1 and A. Bahrle3
'Division of Nephrology and 2Department of Radiology, The Health Sciences Centre, St John's, Newfoundland, Canada,
3
Division of Cardiology, Department of Internal Medicine, Heidelberg, Germany
Introduction
Echocardiographic assessment of patients with end-
stage renal disease is useful in the evaluation of left
ventricular structure and function, as well as in the
detection of pericardial effusion and coexisting cardiac
lesions. Imaging may be undertaken by 2-dimensional,
M-mode and Doppler echocardiography. Two-
dimensional echocardiography provides anatomical
information by real-time imaging of the heart in mul-
tiple tomographic planes. M-mode produces a unidi-
mensional image, with a single spatial dimension on
the ordinate and time on the abscissa. Doppler echocar-
diography provides information about blood flow vel-
ocity within the cardiac chambers, across valves, and
in the great vessels, from which a haemodynamic
assessment of the heart can be made.
M-mode echocardiography
M-mode assessment of the left ventricle is a useful,
reproducible, and reliable method of quantifying left
ventricular chamber size in systole and diastole and of
measuring left ventricular wall thickness. From the left
ventricular dimensions it is possible to assess systolic
function, left ventricular mass, and left ventricular
volume.
Fractional shortening, a measure of systolic function,
is calculated as follows:
LVEDD-LVESD
xlOO
LVESD
Where LVEDD = left ventricular end diastolic dia-
meter (mm).
LVESD = left ventricular end systolic diameter
(mm).
Left ventricular hypertrophy can be detected by
measuring LV mass index:
0.00083 [(LVEDD-HVS + PW) 3 -(LVEDD) 3 ] + 0.6
BSA
1996 European Dialysis and Transplant Association-European Renal Association
Dialysis
Transplantation
Where IVS = LV interventricular septal wall thickness
in diastole (mm)
PW = LV posterior wall thickness in diastole
(mm)
BSA = body surface area.
Left ventricular volume can be quantified as follows:
(LVEDD)3x 0.001047
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BSA
Although M-mode assessment should not be used
in isolation, when obtained in accordance with the
American Society of Echocardiography recommenda-
tions [1], it provides a standardized method for
assessing and following left ventricular structure and
function.
In haemodialysis patients the interrater reproducibil-
ity of left ventricular measurements is high [2].
However, the LV end-diastolic volume increases
between dialyses, as plasma volume increases [2]. This
is associated with changes in systolic function and in
the calculation of LV mass index. Consequently echo-
cardiography should be performed when the patient is
considered to be at 'dry weight' or euvolaemic, prefer-
able the day immediately after haemodialysis. The
importance of performing echocardiography when a
dialysis is euvolaemic is demonstrated by the observa-
tion that the calculation of LV mass index can differ
by about 25 g/m2 when comparing echocardiographic
results obtained before and after haemodialysis [2].
Normal left ventricle
Figure 1 shows M-mode assessment of the left ventricle
according to the American Society of Echo-
cardiography recommendations. Measurements are
taken from leading edge to leading edge. Diastolic
thicknesses of the inner ventricular septum and poster-
ior wall are demonstrated with corresponding internal
chamber diameter in diastole and systole. The LV
septal wall thickness in diastole is 11 mm
(normal < 12 mm), the LV posterior wall thickness in
diastole is 9 mm (normal < 12 mm), the LV end-
diastolic diameter is 51 mm (normal < 57 mm) and the
Left ventricular disorders detected by M-mode echocardiography in chronic uraemia 1329

Fig. 1. Long-axis parasternal echocardiogram of a normal left ventricle (LV) with normal LV systolic function, normal wall thickness
(< 12 mm) and normal cavity dimension (LV end-diastolic diameter<56 mm). On the left the M-mode echocardiogram, on the right the
two-dimensional echocardiogram. Note the echoes immediately anterior to the posterior LV wall, which are echoes from the mitral valve
apparatus (posterior chordae) and should be differentiated from the endocardial echoes.

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LV end-systolic diameter is 26 mm (normal <40 mm). normal systolic function, LV mass index and LV
The fractional shortening is [(51 — 26) H- 51 ] x 100 = volume.
49%. LV mass is 0.00083 [(51 + 11 + 9 ) 3 - ( 5 1 ) 3 ] + 0.6 =
187 g. With body surface area of i .7 m2 LV mass index Left ventricular disorders
(51)3 x 0001047
is 110 g/m 2 . LV volume is — - =82 ml/m 2
Left ventricular disease may be manifest as systolic
Thus this patient has a normal echocardiogram with dysfunction, concentric LV hypertrophy, or LV dilata-

Fig. 2. LV dilatation with normal systolic function in the long-axis parasternal view on M-mode (left) and two-dimensional (right)
echocardiogram. AIVSD. anterior interventricular septum in diastole; PIVSD, posterior interventricular septum in diastole; AIVSS, anterior
interventricular septum in systole; PIVSS, posterior interventricular septum in systole; ENDOD, endocardial margin of the posterior wall
in diastole; EPID, epicardial margin of the posterior wall in diastole; ENDOS, endocardial margin of the posterior wall in systole; EPIS,
epicardial margin of the posterior wall in systole.
1330
tion [3]. Systolic dysfunction is defined as fractional
shortening ^25%; concentric hypertrophy as LV mass
index > 131 g/m2 in males and >100g/m 2 in females
[4] with normal LV volume and normal fractional
shortening; and LV dilatation as LV volume > 90 ml/m2
[5] with normal systolic function.
The left ventricular disorders identified by echocardi-
ography have adverse clinical consequences [3]. All
three disorders are associated with high risks for sub-
sequent episodes of heart failure [3]. The median
survival in patients with systolic dysfunction on start-
ing dialysis therapy is only 38 months and significantly
worse than those with a normal echocardiogram. The
late survival (after 2 years of therapy) in those with
.UEDD= 47 nV. LUPU= 18
Fig. 3. Concentric LV hypertrophy in the long-axis parasternal view
with marked thickening of the septal and posterior wall and normal
systolic function on M-mode (left) and two-dimensional (right)
echocardiogram.
Fig. 4. Global systolic dysfunction with LV dilatation on M-mode (left) and two-dimensional (right) echocardiogram in the long-axis
parasternal view. Note that the walls move poorly. The LV diameter varies little from diastole to systole. Opening of the mitral valve is
decreased with a typically increased distance between the interventricular septum and the anterior mitral valve leaflet.
P. S. Parfrey et al.
concentric LV hypertrophy and LV dilatation is shorter
than those with a normal echocardiogram. In patients
with concentric LV hypertrophy on starting dialysis
therapy, the greater the degree of hypertrophy the
higher the risk for late mortality [6]. In patients with
LV dilatation on starting dialysis therapy, the greater
the degree of LV dilatation the higher the risk for late
mortality, and the higher the mass to volume ratio the
lower the risk [6].
Left ventricular dilatation
Figure 2 is an M-mode image of LV dilatation in which
the anatomic boundaries are identified. The LV inter-
ventricular septal diameter in diastole is 10 mm, the
LV posterior wall thickness is 11 mm, the LV end-
diastolic diameter is 63 mm, and the LV end-systolic
diameter is 38 mm. The fractional shortening is 40%,
LV mass index 151 g/m2, and LV volume 110 ml/m2.
Thus the patient has LV dilatation with LV hyper-
trophy and normal systolic function.
Concentric LV hypertrophy
Figure 3 demonstrates concentric LV hypertrophy on
M-mode echocardiography. The LV interventricular
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septal thickness in diastole is 18 mm, as is the LV
posterior wall thickness. The LV end-diastolic diameter
is 47 mm and the LV end-systolic diameter is 26 mm.
The fractional shortening is 45%, the LV mass index
228 g/m2, and the LV volume 64 ml/m2. Thus this
patient has concentric LV hypertrophy with normal
systolic function and normal LV volume.
Systolic dysfunction
Figure 4 demonstrates a patient with global decrease
in left ventricular contractility and severe LV dilatation.
Left ventricular disorders detected by M-mode echocardiography in chronic uraemia
The interventricular wall thickness in diastole is 10 mm,
as is the LV posterior wall thickness. The LV end-
diastolic diameter is 75 mm and the LV end-systolic
diameter is 66 mm. The fractional shortening is 12%,
LV mass index 213 g/m2, and the LV volume
260 ml/m 2 . Thus the patient has systolic dysfunction
with LV hypertrophy and LV dilatation.
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