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The Right Ventricle: Clinicaland Imaging Strategies for
The Right Ventricle: Clinicaland Imaging Strategies for
AssessmentAssessmentS iddharthS inghM BBS ,M S
N on-invasiveCardiacL aboratory andCardiacCriticalCare
CedarsS inai
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• No disclosures• No disclosures
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RV ANATOMY
• N orm althickness2-3 m m• N orm althickness2-3 m m
• Distinctinflow andoutflow regionsseparatedby cristasupraventricularisseparatedby cristasupraventricularis
• T rabeculated
• Com plex geom etricshape• Com plex geom etricshape
Sheehan F. Heart20 0 8
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RV FIBER ARRANGEMENT• S uperficialcircum ferentialm usclefibersresponsibleform usclefibersresponsibleforitsinw ardbellow sm ovem ent
• Deeperlongitudinalfibers• Deeperlongitudinalfibersthatresultinthebase-to-apex contractionapex contraction
• Base-to-apex shorteningm ayplay greaterroleinR Vplay greaterroleinR Vem ptying
• S eptum haslongitudinalR VCourtesy GrantT. Gullberg, Law rence Berkley Lab
• S eptum haslongitudinalR Vfibers
Sanchez-Guintana Heart1 996;76:280 –6
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RV PHYSIOLOGY• Ill-definedisovolum icrelaxationand• Ill-definedisovolum icrelaxationand
contractionphase• Continuedejectionduring• Continuedejectionduring
pressuredecline
• M inorchangesinafterloadm aycauselargedecreaseinS VcauselargedecreaseinS V
• R CA perfusion
• Heart-L unginteractions• Heart-L unginteractions• Coupledtolow im pedancepulm onary
circuit• Changesinpreloadw ithrespiration• Changesinpreloadw ithrespiration
Hadad F. Circulation; 1 1 7: 1 436-1 448Sheehan F. Heart20 0 8 Nov;94( 1 1 ) :1 51 0 -5
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VENTRICULO-VENTRICULAR INTERACTIONS
*N orm alR V contractileperform anceisnotably dependentonthatoftheLV
Konstam M Circulation.20 1 8;1 37:e578–e622Hadad F. Circulation; 1 1 7: 1 436-1 448Dam iano RLJrAm JPhysio 1 991 ; 261 :H1 51 4-24
notably dependentonthatoftheLV*30% ofcontractileenergy ofR V generated byLV
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CLINICAL ASSESSMENT• ElevatedJVP w ithprom inentV w ave• ElevatedJVP w ithprom inentV w ave
• Peripheraledem a
• Bloating/early satiety/abdom inaldiscom fort
• P rom inentS 2 (P 2)(P H)
• Right-sided S3 gallop
• Holosystolic m urm urLLSB ( TR)• Holosystolic m urm urLLSB ( TR)
• RV parasternalheave
• Cardiorenalsyndrom e• Cardiorenalsyndrom e
• Cardiohepaticsyndrom e
• P roteinL osingEnteropathy
N arrow pulsepressure• N arrow pulsepressure
• Coolextrem ities
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CMR: REFERENCE STANDARD
Kaw el-Boehm N. JCMR 20 1 51 7:29
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RV ASSESSMENT BY ECHO
R V ContractilityR V Contractility
• R V FractionalA reaChange-(FAC)• MyocardialPerform ance Index ( Tei)
• R V P R EL O A D
• MyocardialPerform ance Index ( Tei)• RV dP/ dt• RV outflow tractvelocity tim e integral
( VTI)• R V P R EL O A D
• Cham bersizeandseptalposition• IVC sizeandcollapsibility• T ricupsidR egurgitation• T ricuspidinflow
• RV outflow tractvelocity tim e integral( VTI)
• T ricuspidA nnularP laneS ystolicExcursion(T A P S E)
• M m ode• T ricupsidR egurgitation• T ricuspidinflow
• R V A FT ER L O A D
Excursion(T A P S E)• M m ode• T issueDoppler
• Tissue Doppler–derived and 2D strain• R V A FT ER L O A D
• P A S P andP A DP• T A P S E/P A S P ratio• R VO T notching
Tissue Doppler–derived and 2D strain• 3 D EjectionFraction
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T A P S E FR ACT IO N A L A R EA CHA N GE R V CO
*L ongitudinalm otionoflateral T V annulus (≥1.6 cm )
*R eflectslongitudinalandradialcom ponentsofR V
* R VO T VT IX HEA R T R AT E*S houldbeatleast1000*DifficultiesinR VO T
lateral T V annulus (≥1.6 cm )*Dependentonangleandloadingconditions*N otaccurateafterthoracotom y ortransplant
radialcom ponentsofR Vcontraction ( ≥35% )*Correlatesw ellw ithR VEFby CM R*N eglectscontributionof
*DifficultiesinR VO Tdiam eterm easurem ent*Canbeserially trackedU sefulinLVA D patientsthoracotom y ortransplant
*M oderatecorrelationw ith3D R VEF
*N eglectscontributionofR V outflow tracttooverallfunction
U sefulinLVA D patients* L argevalidationstudieslacking
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GLOBAL LONGITUDINAL STRAIN
• P eakvalueof2D longitudinalspeckletrackingderivedstrainaveragedover3 segm entsoffreeaveragedover3 segm entsoffreew all
• A ngleindependent
• Vendordependent• Vendordependent
• P rognosticrole
• Dependsonloadingconditionsand• DependsonloadingconditionsandR V size
• GL S > -20% islikely abnorm al
A.Janjic
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3D ECHO
• ValidatedagainstcardiacM R
• Volum etricsem i-autom ated
• Im agequality m ay beaconcern• Im agequality m ay beaconcern
• L oad-dependent
• 45% goodthresholdforL L N• 45% goodthresholdforL L N
Increasingly linkedtooutcom esNagata Y. Circ Im aging. 20 1 7;1 0 :e0 0 5384Murata M O ncotarget. 20 1 6Dec 27; 7( 52) : 86781 –86790
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CARDIAC CT
• Retrospective gating used• Retrospective gating used• Spiralw ith Dose m odulation
• Contrastm ay be given atslow errate orinjection tim e extended toopacify RVopacify RV
• Look forcontrastrefluxin IVC
Courtesy BalajiT am arappooM D
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HEMODYNAMIC ASSESSMENT
Variable Calculation T hresholdsA ssociatedW ithClinicalEvents
R ight-to-leftdiscordanceof R A P :P CW P >0.63 R HFafterLVA DR ight-to-leftdiscordanceoffillingpressures
R A P :P CW P >0.63 R HFafterLVA D>0.86R HFinacuteM I
P A pulsatility index (P A S P -P A DP )/R A P <1 R HFinacuteM I<1.85R HFafterLVA D<1.85R HFafterLVA D
R V strokew orkindex (M P A P -CVP )x S VI <0.25m m Hg.l/m 2 R HFafterLVA D
P VR (M P A P – P CW P )/ CO >3.6W U R HFafterLVA DP VR (M P A P – P CW P )/ CO >3.6W U R HFafterLVA D
P A com pliance S V/ (P A S P -P A DP ) <2.5m l/m m HgR HFinchronicHFandR V-P AcouplinginP A HcouplinginP A H
Hem odynam iccorrelatesinconsistentacrossstudiesCanthesebenoninvasively assessed?
KapurNK Circulation. 20 1 7;1 36:31 4–326
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Predicting RHF AfterLVAD ImplantationLVAD Implantation
Variable O R S core
RA/ PCW P >0 .54 2.2 1RA/ PCW P >0 .54 2.2 1
Hb ≤1 0 g/ dl 2.6 1 .5
Multiple inotropes 3.0 2Multiple inotropes 3.0 2
INTERMACS Class 1 -3 3.4 2
Severe RV 2.1 1Severe RVDysfunction
2.1 1
CPB tim e >1 0 0 m in 2.0 1
Solim an O II. Circulation 20 1 8; 1 37:891 -90 6
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SUMMARYSUMMARY
• W hilew idely used2D echocardiography haslim itationsinassessingR V function-m ultiparam etricapproach
• W hilew idely used2D echocardiography haslim itationsinassessingR V function-m ultiparam etricapproachrecom m ended
• CardiacM R Irem ainsreferencestandardforassessingR V• CardiacM R Irem ainsreferencestandardforassessingR Vsystolicfunction
• Clinicalassessm entw ithechocardiography andrightheart• Clinicalassessm entw ithechocardiography andrightheartcatheterizationatbedsidem ay beoptim alinICU setting
• Im portanttoconsiderR V afterloadandpreloadw hileevaluatingR V function
• Im portanttoconsiderR V afterloadandpreloadw hileevaluatingR V function