SHA24/080003

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.