Bahaa M. Fadel, MD, FACC King Faisal Specialist Hospital & Research Center
No longer the lesser companion of the Left!
RV dysfunction associated with increased mortality in many conditions: Coronary artery disease Valvular heart disease Dilated cardiomyopathy Pulmonary hypertension
Easier to manage and treat LV dysfunction than RV dysfunction Horton KD. J Am Soc Echocardiogr 2009;22:776 Forfia P. AJRCCMI 2006;174:1034-41
Right Ventricle
Structure: Cavity size: Normal or
Dilated? Wall: Normal or thickened?
Function: Normal or abnormal? Systolic Diastolic
No RV assessment is complete without:
IVC size & Collapsibility index
High RVEDP
Severe TR
Pulmonary regurgitation
RVOT Doppler
PHTN
Stiff RV
Hepatic vein Doppler
SVC Doppler
TV Doppler
TR
Reduced TAPSE
Constriction RV annulus TDI
Left Ventricle & Right Ventricle: The Full Moon vs. the Crescent LV
RV
Simple
Complex; does not fit simple models
Shape
Ellipsoid
Sagitally triangular Coronally crescentic
Trabeculations
Minimal
Prominent
6-9
2-5
64-109
17-34
3 (Circ, Rad, Long)
2 (Long, Circ)
Complex
Simpler
Geometry
Wall thickness (mm) Muscle mass (g) Wall layers (fiber orientation) Myocyte arrangement
Deformation
Longitudinal Circumferential Radial Rotational
Longitudinal Less so circumferential
Circulation
High impedence systemic
Low impedence pulmonary
Vascular resistance (dyne-sec.cm5)
Systemic = 1100
Pulmonary = 70
130/75 (85)
25/9 (15)
≼ 55%
≼ 45%
Pressure pump
Volume pump
Better to pressure overload
Better to volume overload
Quantitative Assessment
Qualitative Assessment
Afterload pressure (mmHg) Ejection fraction Type of pump Adaptation to disease states
Difficult image acquisition due to anterior location behind sternum
Difficult to trace endocardium due to trabeculations
Cannot image entire cavity in a single view
No geometric assumptions can be made to measure volume
Haddad F. Circulation 2008;117:1436-48
Views for Evaluation of RV
Apical 5-chamber
PSA at mitral valve Subcostal 4-chamber
PLA
PSA at pap muscles Apical 4-chamber
PLA RVOT
PLA RV inflow RV focused apical 4-ch
Apical coronary sinus
Modified apical 4-ch
Subcostal short-axis
PSA at basal RV
PSA at PA bifurcation
ASE/EAE Guidelines. J Am Soc Echocardiogr 2010:23:685-713
Qualitative Assessment “A quick look” “Eyeballing the RV” RV diameter: ○ RV < LV (usually < 2/3) → normal size ○ RV = LV → at least mildly dilated ○ RV > LV → moderately or severely dilated
“Sharing of the apex”
by the RV often implies enlargement
Quantitative Assessment RV Chamber Dimensions
End-diastolic area
End-systolic area
ASE/EAE Guidelines. J Am Soc Echocardiogr 2010:23:685-713
Indexed RV Dimensions
Willis J. J Am Soc Echocardiogr 2012:25:1259-67
RV Systolic Function Qualitative visual assessment Surface-to-volume ratio: RV > LV Longitudinal function: RV > LV Radial function: RV < LV
Smaller inward motion of RV required to eject same stroke volume than LV
Easier to visually underestimate RV systolic function + Complex RV geometry
Need for quantification
Haddad F. Circulation 2008;117:1436-48
Fractional Area Change FAC =
End diastolic area – End systolic area End-diastolic area
X 100
Simple and fast Trace endocardium beneath trabeculations and papillary muscles Surrogate for RVEF: some correlation by CMR Normal FAC > 35% Does not account for function of anterior, inferior wall or RVOT Prognostic value: independent predictor of outcome following MI and PE End -diastole
End -systole
FAC 33% Area = 24 cm2
Area = 16 cm2
AnavekarNS. Echocardiography 2007;24:452-6 Nass N. Am J Cardiol 1999;83:804-6 Zornoff LA. J Am Coll Cardiol 2002;39:1450-5
TAPSE - TAM Tricuspid Annular Plane Systolic Excursion Tricuspid Annular Motion
Advantages
Rapid to obtain Easy to measure Reproducible Less dependent on good image quality than other systolic parameters Easy to compare to prior and future studies TAPSE ≤ 16 mm has high specificity but low sensitivity to distinguish abnormal from normal subjects Tamborini G. Int J Cardiol 2007;115:86-9
Normal > 16 mm
Baseline TAPSE = 20 mm
1 month post-MVR TAPSE = 10 mm
TAPSE - TAM Keep in mind Not meant to provide information on RVEF More sensitive than EF to detect early impairment in RV function Prognostic value
RVEF by CMR
Tricuspid Annular Plane Systolic Excursion Tricuspid Annular Motion
50%
1.5
TAPSE (cm)
Disadvantages
Angle dependency Can be load-dependent Can be reduced while RVEF is still normal and vice versa
Kjaergaard J. Eur J Echocardiogr 2006;7:430-8 Forfia P. AJRCCMI 2006;174:1034-41
FAC = 20%
TAPSE = 18 mm
TAPSE - TAM Keep in mind Not meant to provide information on RVEF More sensitive than EF to detect early impairment in RV function Prognostic value
RVEF by CMR
Tricuspid Annular Plane Systolic Excursion Tricuspid Annular Motion
50%
1.5
TAPSE (cm)
Disadvantages
Angle dependency Can be load-dependent Can be reduced while RVEF is still normal and vice versa
Kjaergaard J. Eur J Echocardiogr 2006;7:430-8 Forfia P. AJRCCMI 2006;174:1034-41
FAC = 20%
TAPSE = 18 mm
Some Issues
Cutting off RV on PSA
Reverberations preventing visualization of lateral wall
Not visualizing RV apex
RV side of septum
RV dimensions are highly dependent on probe rotation in 4-chamber view may result in underestimation of RV width ASE/EAE Guidelines. J Am Soc Echocardiogr 2010:23:685-713
Normal
dP/dt Rate of pressure rise V = 0.5 m/sec
0.013 sec
V = 2 m/sec
Derived from TR signal Index of RV contractility Normal > 400 mmHg/sec Load-dependent Problems:
Severe TR Diastolic TR
Anconina J. Am J Cardiol 1993;71:1495-7
dP/dt = 15/0.013 = 1154 mmHg/sec
Poor RVEF
V = 0.5 m/sec 0.092 sec
V = 2 m/sec
dP/dt = 15/0.092 = 163 mmHg/sec
RV index of Myocardial Performance RIMP (Tei index)
ď&#x201A;&#x17E;
Global index of RV systolic and diastolic function Normal < 0.4
MPI =
IVCT + IVRT = ET
Normal < 0.55
TCO - ET ET Tei C. J Am Soc Echocardiogr 1996;9:838-47 Yoshifuku S. Am J Cardiol 2003;91:527-31
RV index of Myocardial Performance RIMP (Tei index)
What is it supposed to measure? Mixes apples and oranges (systolic and diastolic indices) These should be assessed separately
Varies with pressure and volume status Pulmonary hypertension? RV dysfunction? Both?
Measurement may include pre-systolic time Diastolic TR - elevated RVEDP or long PR interval
Falsely normal if RA pressure is elevated Should not be used as sole parameter of RV function
RV index of Myocardial Performance RIMP (Tei index)
Severe PHTN
30-year old female Vasoreactive pulmonary hypertension Severe PHTN
PostIloprost
Systolic PA pressure (mmHg)
100
40
RV-EF(%) by CMR
25
42
RV-SV (ml)
46
63
TAPSE (mm)
6
10
RV dp/dt
800
1200
RIMP (Tei index)
0.4
0.6
Fadel BM. Echocardiography 2013; in press
Post-Iloprost
Tissue Doppler Imaging
<40
4059
≥60 years
S’
E’ A’ Normal S’ > 10 cm/sec
Lindqvist P. Echocardiography 2005;22:305-14
Alam M. J Am Soc Echocardiogr 1999;12:618-28 Meluzin J. Eur Heart J 2001;22:340-8
Tissue Doppler Imaging Advantages
Simple Reproducible for annulus and basal RV segment Can be analyzed off-line More sensitive than EF to detect early impairment in RV function If S’ < 10 cm/sec: should suspect abnormal RV function especially in young patients
Disadvantages
S’ = displacement rather than shortening velocity Angle-dependent Load-dependent Affected by TR Not meant to provide information on function of entire RV
ASE/EAE Guidelines. J Am Soc Echocardiogr 2010:23:685-713
Speckle tracking Use software for LV No data Limitations similar to those of fractional area change
Follow-up March 2012
72-year old female with rectal cancer Presented with acute pulmonary embolism
January 2013
Final Words
Should push to quantify RV dimensions and systolic parameters in your lab M-mode and 2D RV quantification are not the best but better than qualitative assessment Due to complex 3D geometry, standardized 2D echocardiographic measurements of RV dimensions and function do not correlate well with RV volumes and EF especially in abnormal RV Taylor the study to your patient Obtain RV-focused 4-chamber view and additional images in patients who require more detailed assessment of RV Be aware of pitfalls
What are RV size and function?
RVOT Prox = 37 mm
RVOT Prox = 55 mm
16-year old male BSA = 1.5 m2 TOF repair followed by PV homograft + TV repair
TAPSE = 9 mm
Sâ&#x20AC;&#x2122; = 5 cm/sec RV basal diam = 40 mm RV mid diam = 37 mm RV longit diam = 79 mm RV area = 24 cm2
FAC = 33%
RV: Usual Views
RV: Additional Views
A 1.0 m/sec
PR
TVC
TVO
Normal PVO
A
PVC
TVC
E
AT ET
PVO
PVC
RVOT
PEP
TR 2.2 m/sec
Q
ECG B 3.0 m/sec
PR PEP
TVC
TVO
PHTN PVO
A
PVC
E
*
AT ET PVO
TVC
TVO
RVOT IVRT
PVC
• Pre-ejection period • Ejection time • RVOT acceleration time • IVRT
TVO
RV time intervals:
TR
4.5 m/sec
Blood pool IVRT Normal PA pressure RVOT
PHTN TVO
PVC R – PVC = 380 msec
R – TVO = 390 msec
IVRT ~ 10 msec
Normal PA pressure PR
TDI IVRT
PVC
TVO
R – PVC = 370 msec
R – TVO = 430 msec
IVRT ~ 60 msec
PHTN
Brechot. Eur J Echocardiogr; 2008
Coronary supply to RV