Clinica Cardiologica UniversitĂ degli Studi di Padova Direttore: Prof. Sabino Iliceto
3D ASSESSMENT OF RIGHT VENTRICULAR SIZE AND FUNCTION Prof. Patrizio Lancellotti on behalf of Prof. Luigi P. Badano**, MD, FESC, FACC **Dr. Badano has received honoraries and research grants from GE Healthcare, Sorin cardio S.p.A., Actelion, Edwards Lifesciences *No off-label use of device
RIGHT VENTRICLE – the neglected neighbour of the left Not anymore! Important prognostic value: • after acute myocardial infarction • heart failure • valvular heart disease • congenital heart disease (Fallot) • pulmonary hypertension • after cardiac transplantation
Pfisterer M et al. Eur Heart J 1986 Van Straten A et al. Eur Radiol 2005 Nath J et al. Echocardiography 2005 Di Salvo TG et al. JACC 1995 Hochreiter C. Circulation 1986 Bhatia SJS et al. Circulation 1994
RIGHT VENTRICLE Anatomy Complex shape of the right ventricle: Crescent and truncated ventricle; Separate inflow and outflow portions; Chamber poorly approximates to any convenient geometric model; Incompletely visualized in any single 2D echocardiographic view.
RIGHT VENTRICULAR ASSESSMENT GOLD STANDARD: Cardiac MR PROs: - High image quality - Highly reproducible - Noninvasive - No geometric assumptions CONs: - Expensive, not widely available technique - Lack of portability - Time consuming - Impossible in patients with metallic devices
ECHO ASSESSMENT OF RIGHT VENTRICLE
ECHO ASSESSMENT OF RIGHT VENTRICLE Full volume 3D Echocardiography A
VP
Ao
SIVm
VT
AD
BM
Courtesy of Prof. Cristina Basso, MD, PhD Cardiovascular Pathology University of Padua, Italy
ECHO ASSESSMENT OF RIGHT VENTRICLE
- Actual 3D acquisition; - Easily repeatable; - No geometric assumptions; - Validated against CMR; - Dynamic reconstructed 3D images of beating heart; - Rapid spatial appreciation from multiple perspectives; - Provides RV volumes, stroke volume and ejection fraction
ECHO ASSESSMENT OF RIGHT VENTRICLE 4D Echocardiography: How to do it? Step 6: Surface rendered reconstruction
ECHO ASSESSMENT OF RIGHT VENTRICLE
- Dedicated training and learning curve; - Off-line measurements; - Cumbersome to apply in daily routine practice; - Patient cooperation for dataset acquisition during breathhold; - Depends on image quality; - (Limited acoustic access in small patients); - (Arrhythmias); - (Cost)
ECHO ASSESSMENT OF RIGHT VENTRICLE 3DE vs CMR: validation studies - Study group: 13 children with operated CHD Close correlation with CMR results
• Older generation internally rotating omniplane transducer • Manually tracing of endocardial border, summation of volumetric slices Papavassiliou DP et al. J Am Soc Echocardiogr 1998
ECHO ASSESSMENT OF RIGHT VENTRICLE 3DE vs CMR validation studies - 3DE versus 2DE (AL, Simpson, 2DS) and CMR (50 pts with AMI and suspected RV involvment) - Modified apical window, semiautomated border detection • EF estimations were similar using each technique; volumes were slightly underestimated by 3DE and greatly by any other 2DE • 3DE showed less of a difference from MRI than any of the 2DE techniques • 3DE had less test-retest variation of RV volumes and EFs than any 2DE measurements (Simpson – the least reproducible!)
Jenkins C et al. Chest 2007
ECHO ASSESSMENT OF RIGHT VENTRICLE 3DE vs CMR validation studies - 3D semiautomated RV analysis software for anatomically oriented assessment of RV volumes (16 pts with congenital HD, 14 normals)
Excellent correlation between the two techniques
Good intra- and interobs variability: < 3% and 10% Niemann PS et al . J Am Coll Cardiol 2007
ECHO ASSESSMENT OF RIGHT VENTRICLE 3DE vs CMR validation studies Population
RV EDV
RV ESV
RV EF
characteristics
mL (95%CI)
mL (95%CI)
mL (95%CI)
Shimada et al. (2010)
Meta-analysis (n=807)
-13.9 (-17.7, -10.1)
Grapsa et al. (2010)
Normal subjects (n=20)
-1.5 (-4.57, 1.57)
0.80 (-1.35, 2.95)
-1.3 (-3.1, 0.5)
Grapsa et al. (2010)
PAH (n=60)
-3.7 (-10.96, 3.56)
-0.02 (-6.19, 6.15)
-1.3 (-3.07, 0.47)
Sugeng et al. (2010)
Patients (n=28)
-14 (-27.8, -0.2)
-9 (-19.2, 1.2)
-2 (-4.27, 0.27)
van der Zwaan et al. (2010)
CHD (n=50)
-34 (-43.26, -24.74)
-11 (-18.71, -3.29)
-4 (-5.91, -2.09)
Patients (n=88)
-10.2 (-14.63, -5.77)
-4.5 (-7.53, -1.47)
-0.4 (-1.97, 1.17)
Leibundgut et al. (2010)
-5.5 (-7.6, -3.4)
-0.9 (-1.8, -0.1)
Shimada YJ et al . J Am Soc Echocardiogr 2010
ECHO ASSESSMENT OF RIGHT VENTRICLE Reference Values from 245 Normal Subjects EDV
ESV
86 ± 21 mL
29 ± 11 mL
(49 ± 10 mL/m2)
(16 ± 6 mL/m2)
Men
99 ± 14 mL
35 ± 7 mL
64 ± 8%
Women
74 ± 14 mL
23 ± 7 mL
69 ± 8%
All
RV EF
67 ± 8%
Tamborini G. et al . J Am Soc Echocardiogr 2010
RIGHT VENTRICULAR ASSESSMENT Comparison of Echo Techniques: Clinical Cases Control
TAPSE 24 mm
Tricuspid Reg.
TAPSE 18 mm
PAH
TAPSE 18 mm
RIGHT VENTRICULAR ASSESSMENT Comparison of Echo Techniques: Clinical Cases Control
EDV= 77 ml ESV= 28 ml RVEF= 64%
Tricuspid Reg.
EDV =140 ml ESV= 68 ml RVEF= 52%
PAH
EDV= 113 ml ESV= 78 ml RVEF= 31%
3D ECHO TO ASSESS RV VENTRICULAR CAVITY SIZE AND FUNCTION Conclusions • 3DE
opens a completely new way to RV size and function quantitattion; •Accurate assessment of RV size and function are increasingly recognized as being of paramount importance in many heart diseases; •Another step toward the assessment of the function of the “heart as an organ” opposed to consider LV, RV, LA and RA as “independent” components.