1

KLINGERMETHODFORLEFTVENTRICLEWALLMOTIONANALYSIS
G.Bozzi
Thissystemofcalculationhasbeensetupaccordingtheconcepttheheartfollowsdynamiclaws,notatall
pressureandvolume(staticvariables)asFrankStarlinglawsuggests.Duetodynamics3rdprinciple,theheart
recoilsduringejection,andaorticplanedisplacesdownofabout1.5cm.Asanatomicapexremainsstationary
alloverthecardiaccycle,wehavehypothesizedanatomicshorteningofventricularcavitiesequalsaorticplane
displacement,realizingabalancedaction,asatisfactoryexplanationforunperceivedcardiacactivity.As
angiographiclongaxis(LA)shorteninginthe30RAOprojectionexceedsaorticplanedescent,wealso
hypothesizedtheeffacementofventricularwallsatapicalshell.Theentityofthiseffacementcanbecalculated
subtractingaorticplanedescentfromangiographicshorteningofLAinthe30RAOprojection.
Accordingtothesebasicconcepts,thefollowingsequenceswerestandardized.
1.0Datacollection
1.1Runningcontrastcineventriculography,Identifytheenddiastolic(ED)silhouette.
1.2DrawEDsilhouetterightandleftmarginsonasheetofpaper.
1.3Veryimportant:donotmovethesheetforthesakeofmarkingtheentityofaorticplanedescent.
1.4Goingbackandforth,Identifytheendsystolic(ES)silhouette.
1.5DrawESsilhouetterightandleftmargins.
1.6Overdrawnsilhouettestraceenddiastolicandendsystoliclongitudinalaxes,startingfromapices,looking
forsymmetricalsubdivisionofsilhouettes,nomatterwhereproximalendsend.Thisisquitesimpleproblemin
normalcases,butcanbeacriticalpointinpathologicalcases,becauseLAshoulddividesilhouettesintwo
symmetricalpartsasthoughwallmotionwasnormal;experiencedangiographershavenormallynodifficulties
insolvingthisproblem,whilealgorithmsdonothaveattheirdisposalknowledgeandmentalelasticityour
cerebralcortexhas.

Fig.1.Left:ssilhouettesd
drawnfromffilmofanorm
malcaseand
d(right)comp
puterelaborrationusingK
Klinger
method.

Fig.2.Acaseofanterollateralakyneesis.

Fig.3.Silhou
uettesandth
heirelaborattioninacaseeofcardimyo
opathy.

Criticalnotee.Computerdoes'tperfo
ormdiagnosiss,butonlycaalculations.D
Diagnosisism
madebyangiographer
choosingsilh
houettesedggesandlongaxesextrem
mities,takingintoaccounttwallmovem
mentduringffilmvision.
2.0Datainp
put
2.1Putsheeetofpaperwithsilhouettesoveraggraphictablett,makinglon
ngaxisvertical.

ongaxisofED
Dsilhouetteeends.
2.2Clicklo
2.3Withou
utmovingpaaper,clickequivalentpoin
ntsofESsilho
ouette.
2.4ClickED
DandESaorticplane(i.e.aorticplaneedisplacemeent).
2.5Clickon
nEDrightorlefthalvesilhouettetheepointfromw
whichsegmeentalcalculattionshouldsstart,to
eliminatem
mitralandaorrticvalvemargins.Equivaalentpointon
nESsilhouetttewillbeob
btainedbycalculation.
2.6StartinggfromLAproximalendttotheapex,ttracetherigh
htmarginofEDsilhouettte.
2.7StartinggfromLAproximalendttotheapex,ttracethelefttmarginofEDsilhouette.
2.8RotateethedrawinggtoplaceESSlongitudinaalaxisoverED
Done.
2.9Clickon
nESapex.
2.8StartinggfromLAproximalendttotheapex,ttracetherigh
htmarginofESsilhouettee.
2.9StartinggfromLAproximalendttotheapex,ttracethelefttmarginofESsilhouette..

Fig.4.Graph
hicrepresenttationofthemodel.A:en
nddiastolica
andendsysto
olicsilhouetttesastheyarredrawnfrom
m
thefilmwith
houtmovingthesheetoffpaperduringtracing,wh
hichallowsth
hemeasurem
mentofthea
aorticplane
displacemen
nt(AD).B:en
ndsystolicsillhouetteshowingslices9
912invisible(systolicconcealedapexSCA)dueto
theeffacem
mentofoppossitewalls.Themodelcalcculatesthepeercentarearreductionofsslices120.A
AMddenotess
thedistanceebetweentheproximaleendofthelon
ngitudinalaxxis(LA)andth
hemitralforn
nixor(inthisscase),the
boundarybeetweentheo
outflowtract
t andtheanteerobasalwa
all.Thisallow
wonetoexclu
udefromcon
ntraction
calculationssthenoncon
ntractilevalvu
ularmarginss.AMsisthesystolicequiivalentofAM
Mdandisobttainedby
calculation.edLAm:end
ddiastolicLAmeasured.eedLAc:endd
diastolicLAca
alculated.esLLAm:endsysstolicLA
meannormalcontraction
ncurve1SD.Thealgorith
hmsubdividess
measured.eesLAc:endsyystolicLAcallculated.C:m
theareabettweenmean2SDand+1
10%Intothreeesectors,reepresentingzzonesofincreeasingcontra
action
compromisee(hypokinesiisslight,mild
d,andseveree).Areabetw
ween10%and
d0representtsthezoneoffabsenceof
contraction(akynesis).A
Areaunderba
aselinerepreesentsthezoneofsystoliccexpansion((dyskinesis).

3.0Calculations
3.1Usinglongitudinalaxesendpoints(edLAm&esLAm)andthepointfromwhichcalculationshouldstart
(AMd),thealgorithmrecalculatesthelengthofaxesofEDandESsilhouettes(edLAc&esLAc),andsubdivides
themintotenequalparts,creatingtwentyrectangularslices,apartfromexternalshortside(fig.4).
3.2Subtractingaorticplanedescent(AD)fromangiographicLAshortening,thealgorithmcalculatestheentity
ofsystolicconcealedapex(SCA).Inournormalcases,slices#10and#11arealwaysobliterated.
3.3Percentsystolicreductionofeachoftwentyrectangularareasiscalculated,andeachvalueiscompared
withequivalentpointofournormalcontractioncurve.Theareabetweenmeannormalvaluesminus2
standarddeviations(SD)and+10%(toeliminatetractioneffect),issubdividedintothreepartsdefiningthree
levelsofhypokinesis(slight,mild,andsevere).Areabetween+10%and0definesakinesis,whileunder0
dyskinesisisdiagnosed.
3.4Since"normality"inwallmotionanalysisisanundefinedconcept,andalsoprobablydifferencesamong
sexesandgroupsofageexist,thealgorithmgivestheuserthepossibilitytoaddanynormalcaseintoourown
casuistry(orcasuistries:forexamplemaleandfemaleandinthese,groupsofage:<20;2040;4160;6180;
>80).
3.5StandardDeviations(SD)ofAuthor'snormalcases(N=14).
SLICE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

MEAN
37
51
57
60
63
67
75
86
97
100
100
97
83
70
63
59
56
53
47
38

SD
11
6
4
5
6
7
8
10
5
0
0
5
11
7
5
6
7
8
10
15

Somebodyhascriticizedthesmallnumberofournormalcases.Wehaveselected
ournormalcasesrereadingmorethan1500examsofourCath.Lab.andstopped
after#14asSDdidn'tdecreasefurtheronaftercase#12.