SHA24/080002

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