Myocardial structure

Myocardium

The myocardial thickness usually refers to measurements of the thickness of the compact LV myocardium, obtained at end-diastole. Papillary muscles and trabeculations are excluded from measurement of the thickness of the compact LV myocardium (Kawel-Boehm et al. 2020).

For standardized myocardial segmentation and nomenclature, using basal, mid-cavity and apical as part of the name defines the location along the long axis of the ventricle from the apex to base. With regard to the circumferential location, the basal and mid-cavity slices should be divided into 6 segments of 60 each. As the left ventricle tapers as it approaches the true apex, it is believed appropriate to use just 4 segments for the apex. The apical cap represents the true muscle at the extreme tip of the ventricle where there is no longer cavity present, which is defined as segment 17 in the 17-segment model. The attachment of the right ventricular wall to the left ventricle should be used to identify and separate the septum from the left ventricular anterior and inferior free wall. The figure below shows the location and the recommended names on a bull’s-eye display (American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging: et al. 2002).

<figure> <img src="/latex/images/myocardium/AHA_segment1.png" id="fig:AHA_segment1" alt="Segmentation of the Region of Interest (ROI) in the short-axis view. left panel: Six segments are used for the basal and mid-levels in the 16 segment model, as well as for the apical level in the 18-segment model. Right panel: Four segments for the apical level in the 16-segment model. The red dot marks the anterior insertion of the right ventricular free wall, which defines the border between antero-septal and the anterior segment (Voigt et al. 2015)." /><figcaption aria-hidden="true">Segmentation of the Region of Interest (ROI) in the short-axis view. left panel: Six segments are used for the basal and mid-levels in the 16 segment model, as well as for the apical level in the 18-segment model. Right panel: Four segments for the apical level in the 16-segment model. The red dot marks the anterior insertion of the right ventricular free wall, which defines the border between antero-septal and the anterior segment <span>(Voigt et al. 2015)</span>.</figcaption> </figure>

<figure> <img src="/latex/images/myocardium/AHA_segment2.png" id="fig:AHA_segment2" alt="Schematic diagram of the different LV segmentation models. Left panel: 16-segment model. Central panel: 17-segment model. Right panel: 18-segment model. In all diagrams, the outer circle represents the basal segments, the mid one the segments at the mid-papillary muscle level, and the inner circle the apical level. In the 17-segment model, an additional segment, apical cap, is added in the center of the Bull’s eye (Voigt et al. 2015)." /><figcaption aria-hidden="true">Schematic diagram of the different LV segmentation models. Left panel: 16-segment model. Central panel: 17-segment model. Right panel: 18-segment model. In all diagrams, the outer circle represents the basal segments, the mid one the segments at the mid-papillary muscle level, and the inner circle the apical level. In the 17-segment model, an additional segment, apical cap, is added in the center of the Bull’s eye <span>(Voigt et al. 2015)</span>.</figcaption> </figure>

Wall Thickness (WT)

  • Definition: The perpendicular distance between the endocardial and epicardial surfaces of the myocardium measured at end-diastole.

  • Acquisition Type: SAX, LAX

  • Reference Range:

    The septal wall thickness is significantly greater than in the other segments in both the end-diastolic and end-systolic phases (Cho et al. 2019). When progressing from the base to the apex, there is a gradual decrease in systolic wall thickening (Le Ven et al. 2016; Cho et al. 2019).

    StudyImaging ModalityCohort SizeLevelRegionGenderReference Value (mm)Note
    (Kawel-Boehm et al. 2020)SAX387BasalAnteriormale(7.8, 1.3)
    467BasalAnteriorfemale(6.4, 1.1)
    900BasalAnteroseptalmale(9.0, 1.4)
    1114BasalAnteroseptalfemale(7.6, 1.2)
    387BasalInferoseptalmale(8.8, 1.2)
    467BasalInferoseptalfemale(7.3, 1.0)
    387BasalInferiormale(7.9, 1.2)
    467BasalInferiorfemale(6.4, 1.0)
    900BasalInferiorlateralmale(7.7, 1.2)
    1114BasalInferiorlateralfemale(6.3, 1.1)
    387BasalAnterolateralmale(7.5, 1.2)
    467BasalAnterolateralfemale(6.1, 1.0)
    387Mid-cavityAnteriormale(6.7, 1.2)
    467Mid-cavityAnteriorfemale(5.6, 1.0)
    387Mid-cavityAnteroseptalmale(7.4, 1.3)
    467Mid-cavityAnteroseptalfemale(6.1, 1.0)
    387Mid-cavityInferoseptalmale(7.9, 1.2)
    467Mid-cavityInferoseptalfemale(6.6, 1.0)
    387Mid-cavityInferiormale(7.0, 1.2)
    467Mid-cavityInferiorfemale(5.8, 1.0)
    387Mid-cavityInferiorlateralmale(6.5, 1.4)
    467Mid-cavityInferiorlateralfemale(5.3, 1.0)
    387Mid-cavityAnterolateralmale(6.6, 1.2)
    467Mid-cavityAnterolateralfemale(5.5, 1.1)
    387ApicalAnteriormale(6.5, 1.2)
    467ApicalAnteriorfemale(5.9, 1.3)
    387ApicalSeptalmale(6.8, 1.3)
    467ApicalSeptalfemale(5.8, 1.1)
    387ApicalInferiormale(6.1, 1.1)
    467ApicalInferiorfemale(5.2, 1.0)
    387ApicalLateralmale(6.2, 1.1)
    467ApicalLateralfemale(5.6, 1.0)
    LAX131BasalAnteriormale(8.2, 1.3)
    169BasalAnteriorfemale(7.0, 1.1)
    131BasalInferiormale(8.2, 1.3)
    169BasalInferiorfemale(6.7, 1.1)
    131BasalSeptalmale(9.1, 1.3)
    169BasalSeptalfemale(7.3, 1.1)
    131BasalLateralmale(7.6, 1.3)
    169BasalLateralfemale(6.0, 1.1)
    131Mid-cavityAnteriormale(6.0, 1.3)
    169Mid-cavityAnteriorfemale(4.9, 1.1)
    131Mid-cavityInferiormale(7.7, 1.3)
    169Mid-cavityInferiorfemale(6.5, 1.1)
    131Mid-cavitySeptalmale(8.3, 1.3)
    169Mid-cavitySeptalfemale(6.8, 1.1)
    131Mid-cavityLateralmale(6.6, 1.3)
    169Mid-cavityLateralfemale(5.3, 1.1)
    131ApicalAnteriormale(5.1, 1.3)
    169ApicalAnteriorfemale(4.2, 1.1)
    131ApicalInferiormale(5.8, 1.3)
    169ApicalInferiorfemale(5.0, 1.1)
    131ApicalSeptalmale(5.8, 1.3)
    169ApicalSeptalfemale(5.0, 1.1)
    131ApicalLateralmale(5.5, 1.3)
    169ApicalLateralfemale(4.6, 1.1)

    Other reported normal values can be found in (Dawson et al. 2011), (Kawel et al. 2012), (Le Ven et al. 2016)and (Cho et al. 2019)

    Note: Thickness for segment 2 and 3 are lower than the reference range

  • Clinical Associations: An increased LV wall thickness (≥15) in one or more myocardial segments is considered abnormal and indicative of HCM (Pantazis et al. 2015). LV myocardial thickness can also be altered in hypertensive heart disease, dilated cardiomyopathy (DCM), and myocardial infarction (MI) (Kawel et al. 2012). The increased LV wall thickness can manifest differently across etiologies: in hypertensive heart disease, it typically presents as mild concentric hypertrophy (≥13) secondary to chronic afterload elevation; in cardiac amyloidosis, symmetric and pronounced thickening is predominant; whereas cardiac sarcoidosis often exhibits basal interventricular thinning alongside nonspecific variable abnormalities (Méndez et al. 2018).

  • ICC: Note: 0.46 (segment 2) - 0.86 (segment 9)

Fractal Dimension (FD)

Trabeculations are strut-like myocardium structures that connect to each other to form a complex meshwork. They line the luminal part of every cardiac chamber and can comprise a small part of the wall. The role of trabeculations become particularly debated when they are excessive in the LV. While excessive trabeculation can be observed in different types of cardiomyopathies and congenital heart diseases, it also occurs in a substantial fraction of ostensibly healthy population cohorts (Visoiu et al. 2025).

<figure> <img src="/latex/images/myocardium/trabeculation.png" id="fig:trabeculation" alt="Organization of trabecular layer in normal and excessively trabeculated hearts. (A) Normal anatomy of heart, showing persistence of trabeculations architecture as a meshwork, distributed longitudinally throughout the left ventricle, including on the septal surface. (B) Macroscopic appearance of an ex-planted heart with excessive trabeculation, in the short-axis section, showing organization of trabeculations as a meshwork. (C) 3D reconstructed model of the trabecular and compact layers, showing the complexity of the trabecular meshwork, distributed both transversely and longitudinally (Visoiu et al. 2025)." /><figcaption aria-hidden="true">Organization of trabecular layer in normal and excessively trabeculated hearts. (A) Normal anatomy of heart, showing persistence of trabeculations architecture as a meshwork, distributed longitudinally throughout the left ventricle, including on the septal surface. (B) Macroscopic appearance of an ex-planted heart with excessive trabeculation, in the short-axis section, showing organization of trabeculations as a meshwork. (C) 3D reconstructed model of the trabecular and compact layers, showing the complexity of the trabecular meshwork, distributed both transversely and longitudinally <span>(Visoiu et al. 2025)</span>.</figcaption> </figure>

<figure> <img src="/latex/images/myocardium/trabeculation_example.png" id="fig:trabeculation_example" alt="End-diastolic thickness (in mm) of trabeculation: 3 slices representing base, mid and apex are selected from within the entire LV stack; trabeculated myocardial thickness is measured per slice; segment 17 excluded from analysis (Kawel-Boehm et al. 2020)." /><figcaption aria-hidden="true">End-diastolic thickness (in mm) of trabeculation: 3 slices representing base, mid and apex are selected from within the entire LV stack; trabeculated myocardial thickness is measured per slice; segment 17 excluded from analysis <span>(Kawel-Boehm et al. 2020)</span>.</figcaption> </figure>

Due to the large variability, trabecular phenotypes of the ventricular myocardium are hard to measure. Nevertheless, the fractal method provides a sensitive mathematical solution. There may be added clinical utility in the use of the fractal dimension to measure endocardial complexity and to identify pathologic patterns of trabeculation (Captur et al. 2013).

<figure> <img src="/latex/images/myocardium/fractal_dimension.png" id="fig:fractal_dimension" alt="Example analysis of a single slice belonging to a left ventricular non-compaction (LVNC) case. (a) Dashed line across the 4-chamber view marks the slice location. Automatic thresholding, binarization and edge-detection are followed by fractal analysis. (b) In the box-counting method, a series of grids of boxes of progressively smaller size are laid over the ROI, and the boxes containing detail are counted. The same set of calibres is applied to the ROI in four orientations. In this pictorial representation, only box sizes are shown, but the complete analysis for this slice actually involves 55 box sizes. Each orientation generates a separate natural logarithmic plot of box-count (y axis) against scale (x axis, calculated from box/image size) (c) The slope of the line-of-best-fit across the points represent a fractal dimension (FD). The mean value from the four plots is the slice FD. FD for this slice is 1.34 (Captur et al. 2013)." /><figcaption aria-hidden="true">Example analysis of a single slice belonging to a left ventricular non-compaction (LVNC) case. (a) Dashed line across the 4-chamber view marks the slice location. Automatic thresholding, binarization and edge-detection are followed by fractal analysis. (b) In the box-counting method, a series of grids of boxes of progressively smaller size are laid over the ROI, and the boxes containing detail are counted. The same set of calibres is applied to the ROI in four orientations. In this pictorial representation, only box sizes are shown, but the complete analysis for this slice actually involves 55 box sizes. Each orientation generates a separate natural logarithmic plot of box-count (y axis) against scale (x axis, calculated from box/image size) (c) The slope of the line-of-best-fit across the points represent a fractal dimension (FD). The mean value from the four plots is the slice FD. FD for this slice is 1.34 <span>(Captur et al. 2013)</span>.</figcaption> </figure>

<figure> <img src="/latex/images/myocardium/fractal_dimension_examples.png" id="fig:fractal_dimension_examples" alt="Fractal dimension measured using a semi-automatic level-set segmentation with bias field correction; all slices of the LV short axis stack are analyzed except for the apical slice (Kawel-Boehm et al. 2020)." /><figcaption aria-hidden="true">Fractal dimension measured using a semi-automatic level-set segmentation with bias field correction; all slices of the LV short axis stack are analyzed except for the apical slice <span>(Kawel-Boehm et al. 2020)</span>.</figcaption> </figure>

  • Definition: The extent of how completely the complex structure fills space (Captur et al. 2013).

  • Acquisition Type: SAX

  • Reference Range:

    • Global fractal dimension:

      StudyCohort SizeReference ValueNote
      (Kawel-Boehm et al. 2020)30(1.246, 0.005)black ethnicity
      75(1.228, 0.002)white ethnicity
      180(1.205, 0.031)Singaporean Chinese

    • Maximal apical fractal dimension:

      StudyCohort SizeReference ValueNote
      (Kawel-Boehm et al. 2020)30(1.235, 0.03)black ethnicity, measured for the apical third
      75(1.253, 0.025)white ethnicity, measured for the apical third
      180(1.278, 0.045)Singaporean Chinese, measured for the apical half
      163(1.203, 0.06)BMI ≥ 30kg/m<sup>2</sup>, measured for the apical half
      206(1.194, 0.06)BMI ≥ 25kg/m<sup>2</sup> and  < 30kg/m<sup>2</sup>, measured for the apical half
      163(1.169, 0.07)BMI < 25kg/m<sup>2</sup>, measured for the apical half

  • Clinical Associations: Elevated fractal dimension (FD) is observed in patients with left ventricular non-compaction (LVNC) (Captur et al. 2013; Cai et al. 2016) and is also associated with hypertension, particularly in the apical region (Captur et al. 2015).

  • ICC: 0.63

Noncompacted to Compacted Myocardium Ratio (NC/C Ratio)*

Left ventricular non-compaction (LVNC) is an unclassified cardiomyopathy characterized by an extremely thick endocardial layer with prominent trabeculation and a thin epicardial layer. It is widely known that the major clinical manifestations of LVNC are heart failure, thrombo-embolism and arrhythmia (Choi et al. 2016).

(Petersen et al. 2005) suggests to use 17 segment model, where a segment is regarded as non-compacted if the visual appearance clearly suggests the presence of two myocardial layers with different degrees of tissue compaction. In each of the three diastolic long-axis views, the segment with the most pronounced trabeculations is chosen for measurement of the thickness of the non-compacted and the compacted myocardium perpendicular to the compacted myocardium. The ratio of non-compacted to compacted myocardium (NC/C ratio) in diastole is calculated for each of the three LAX views, and only the maximal ratio is used for analysis. The apex (segment 17) is excluded because the compacted myocardium is generally thinner in this area.

In order to diagnose LVNC especially in cases with apical involvement, (Choi et al. 2016) categories the distribution of trabeculation into three patterns: the global, apical and non-apical types. The global type is defined as having over ten two-layer segments in total. The apical type is defined as involving more than three segments in the apical level (segments 13 through 17). The non-apical type is any trabeculation that doesn’t meet the definitions of the global or apical types. Then during the measurement, mid-septum and mid-lateral wall thickness in diastole are also measured. If the apical trabeculation is present, the trabeculated thickness is measured perpendicular to the apex in diastole.

In addition to the most prominent trabeculation to compacted measured in three long-axis views, the ratios of the thickness of apical trabeculation to that of compacted myocardium in the apical lateral segments (apex/C ratio), the apical trabeculation to the septal wall thickness (apex/septum ratio), the apical trabeculation to the mid-lateral wall thickness (apex/mid-lateral ratio), as well as the trabeculated myocardium to the mid-septal wall thickness (NC/septum ratio) are calculated. The maximal ratio from the long-axis views is used for analysis. These ratios, especially the apex/C ratio and NC/septum ratio, can be supplemental diagnostic tools for LVNC (Choi et al. 2016).

<figure> <img src="/latex/images/myocardium/NC_C_ratio.png" id="fig:NC_C_ratio" alt="Measurement of LVNC. Illustration of described method for measuring the trabeculated LV area in a patient with isolated LVNC. The trabeculated LV area is measured on an end-diastolic frame of each short-axis slice. (a) An endocardial border and non-compacted layer border are drawn to include the trabeculated area, and the papillary muscles are excluded from the measurement. The most prominent non-compacted to compacted ratio in three long axis views are measured, along with the mid-septal and mi-lateral walls, and the apical trabeculation thickness in diastole. All measurements are performed perpendicular to the epicardium. (b) A, apical trabeculation; C, compacted myocardium; ML, mid-lateral wall; NC, non-compacted area; S, mid-septal wall (Choi et al. 2016)" /><figcaption aria-hidden="true">Measurement of LVNC. Illustration of described method for measuring the trabeculated LV area in a patient with isolated LVNC. The trabeculated LV area is measured on an end-diastolic frame of each short-axis slice. (a) An endocardial border and non-compacted layer border are drawn to include the trabeculated area, and the papillary muscles are excluded from the measurement. The most prominent non-compacted to compacted ratio in three long axis views are measured, along with the mid-septal and mi-lateral walls, and the apical trabeculation thickness in diastole. All measurements are performed perpendicular to the epicardium. (b) A, apical trabeculation; C, compacted myocardium; ML, mid-lateral wall; NC, non-compacted area; S, mid-septal wall <span>(Choi et al. 2016)</span></figcaption> </figure>

<figure> <img src="/latex/images/myocardium/NC_C_ratio_examples.png" id="fig:NC_C_ratio_examples" alt="Maximal non-compacted (NC, red lines) / compacted (C, orange lines) wall thickness ratio. Measurements are in mm, and the maximal NC/C parameter is highlighted in blue (Kawel-Boehm et al. 2020)." /><figcaption aria-hidden="true">Maximal non-compacted (NC, red lines) / compacted (C, orange lines) wall thickness ratio. Measurements are in mm, and the maximal NC/C parameter is highlighted in blue <span>(Kawel-Boehm et al. 2020)</span>.</figcaption> </figure>

  • Definition: The ratio of non-compacted to compacted myocardium (Petersen et al. 2005).

  • Acquisition Type: SAX, LAX

  • Reference Range:

    StudyCohort SizeReference ValueNote
    (Choi et al. 2016)31(1.40, 0.39)23 males, 8 females., average age 55.4 years

  • Clinical Associations: A maximum ratio of NC/C ratio greater than 2 or 2.3 is considered diagnostic for LVNC (Petersen et al. 2017; Méndez et al. 2018).

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