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Presented at ISE Webinar on 28 August 2020.This presentation material and its content belong exclusively to the presenter. This material can be used for educational purpose only, as long as the original work is properly cited. Reproducing this material for commercial purpose is prohibited.

EVALUATE RIGHT VENTRICLE FUNCTIONBY ECHOCARDIOGRAPHY

dr. Agnes Lucia Panda, Sp.PD, Sp.JP(K)

THE FORGOTTEN CHAMBER

Dilorenzo MP, et all. How best to assess right ventricular function by echocardiography. Cardiol Young. 2015 ;25(8):1473–81.

The right ventricle plays an important role in the morbidity and mortality of patients presenting with signs and symptoms of cardiopulmonary disease

We often focus on Left Side better than Right Side

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HISTORY OF PULMONARY AND RIGHT HEART

West JB. Ibn al-Nafis, the pulmonary circulation, and the Islamic Golden Age.Vol. 105, Journal of Applied Physiology. American Physiological Society; 2008

Made significant contributions to the early knowledge of the Pulmonary circulation and Right Heart Contribution

Dyspnoe patient have connection between Pulmonary and Right Heart

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THE“UNIQUE”ANATOMY AND FUNCTION

Zaidi A, et al. Echocardiographic assessment of the right heart in adults: A practical guideline from the British Society of Echocardiography. BioScientificaLtd.; 2020. p. G19–41.

Under normal loading conditions:

Right Ventricle Triangular shape when viewed from the side

Crescentic Sagittal plane, wrapping around the conical left ventricle.

RV longitudinal contraction play dominant role like “Bellows”

Differ than LV radial dominant

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Importance of Evaluating The Right Ventricle

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Role in the clinical outcome of cardiopulmonary disease

Size and function adversely affected by :

Left ventricular dysfunction

Primary pulmonary hypertension

Conditions that affect the tricuspid valve leading to significant tricuspid regurgitatio

The Stepwise Approach in RV evaluation

1. Right heart evaluation by multiple acoustic windows

2. Report represent qualitative and quantitative parameters.

3. Measure size of RA, RV and wall thickness

4. RV systolic function (at least one method: FAC, S‘ velocity, TAPSE, RIMP)

5. The correlation with Pulmonary Circulation

1. SPAP

2. Estimation of RA pressure on → IVC size and collapse.

3. additional measures PADP

6. RV diastolic function (if indicated)

American Society of Echocardiography (ASE) Recommendation:

Rudski LG, et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. Vol. 23.J Am Soc: p. 685–713. Echocardiography 2010.

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THE VIEWS

Common view to visualize RV when viewing the LV simultaneously

6Lang RM, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015: 28(1):1-39.e14.

THE VIEWS

Typical view to optimize visualization of RV


HOW TO OBTAIN THE VIEWS

RV INFLOW Importance :Anterior/ inferior RV Tricuspid anterior/ posterior leafletTR jet parameter


RIGHT HEART DIMENSION

RIGHT VENTRICLE


All parameters should be measure at End Diastolic Phase

Diameter RV Base < 42 mm Mid < 35 mm Longitudinal <83 mm

LV: RV ratio < 1.3


RIGHT ATRIAL


Parameters should be measure at End Systolic Phase

RA area < 18 cm2

Better indicator for RV diastolic dysfunction

RA (major) < 53 mmRA (minor) < 44 mm

ADVANTAGES: Easily obtained and a marker ofRV dilatation

LIMITATION : Highly dependent on probe rotationwhich can result in an underestimation of RV width


RVOT prox PLAX diameter ≤ 30 mm

RVOT prox PSAX diameter ≤ 35 mm

RVOT distal PSAX diameter ≤ 27 mm

RV Thickness ≤ 5 mm


ADVANTAGES: Easily obtained from the left PSAX window.

LIMITATION:Limited normative data, window formeasurement not yet standardized, wall isoften suboptimal.

RIGHT VENTRICULAR THICKNESS

Normal RV Thickness > 5 mm

Courtesy of ECHO12312

ADVANTAGE:Easy to perform

LIMITATIONS:• Single site measurement • Overestimated by harmonic imaging and oblique M-Mode • Challenging with thickened visceral pericardium

HOW TO OBTAIN IMAGE OF RV FREE WALL/THICKNESS

Courtesy of ECHO123

4CH View optimization of RV to get the reliable image of RV free wall / thickness


Move a little bit to :

“Lateral” get RV freewall

“Medial” get septal RV

American Society of Echocardiography

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RIGHT VENTRICULAR FUNCTION

GLOBAL• RV dP/dt• RIMP• FAC• 3D EF

REGIONAL• TAPSE• Doppler Tissue Imaging• Myocardial Acceleration during

Isovolumic Contraction• Regional RV Strain/ Strain Rate

• RV diastolic Function• How to measure• Effect of Age, Respiration,

Heart Rate, Loading Condition• Clinical Relevance

ASSESMENT OF SYSTOLIC FUNCTION ASSESMENT OF DIASTOLIC FUNCTION


2D Strain STE

Schneider M, et al. Echocardiographic assessment of right ventricular function: current clinical practice. Int J Cardiovasc Imaging. 2019 Jan 15;35(1):49–56.

SYSTOLIC FUNCTION

American Society of EchocardiographyMost ”Favorite” :

TAPSE & Eyeballing

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1. RIGHT VENTRICLE dP/dt


GLOBAL NON VOLUMETRIC ASSESSMENT

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ADVANTAGES: • Less affected by heart rate (both methods) • Single beat recording, no need for R-R

interval matching (Pulse Tissue Doppler Method)

Ascending limb of the TR continuous wave Doppler signal:• Mark 1 and 2 m/sec (4 and 16 mmHg) • dP=12mmHg • dT =time required for the TR jet to increase in velocity

from 1 to 2 m/s.

LIMITATIONS: • Unreliable when RA pressure is elevated (both) >R-R

interval matching of 2 separate recordings (Pulse Doppler Method)

Normal ≥ 400 mmHg/s

2. RIMP (Right ventricle Index of Myocardial Performance)/Tei Index


Estimate of both systolic and diastolic function of the right ventricle:

MPI = (TCO - ET)/ETor

(IVRT + IVCT)/ET

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PULSED TISSUE DOPPLER METHOD

RIMP < 0.43 by pulsed Doppler and < 0.54 by tissue Doppler

Caveat!!Load-dependent and may pseudo normalise in conditions with elevated RAP

3. FAC (Fractional Area Change)


FAC > 35%

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ADVANTAGES• Established prognostic value• Reflects both longitudinal and radial RV contraction• Correlates with RVEF by CMR

LIMITATIONS• Neglects contribution of RV outflow tract to overall systolic function

RV FAC in RV-Focused Apical 4CH

RV FAC(%) = 100 X EDA-ESA)/EDA

4. 3D RV EF

3D EF > 45 %

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GLOBAL VOLUMETRIC ASSESSMENT

Lang RM, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015: 28(1):1-39.e14.

ADVANTAGES• No geometric assumptions • Includes RV outflow tract contribution to overall function • Correlates with RV EF by CMR

LIMITATIONS•Depends on adequate image quality •Requires offline analysis and experience •Prognostic value not established

Fractional RV Volume Change by 3D TTE

RV EF (%) = 100 X (EDV-ESV)/ EDV

1. TAPSE (Tricuspid Annulus Plain Systolic Excursion)


TAPSE > 16 mm

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REGIONAL NON VOLUMETRIC ASSESSMENT

LIMITATIONS:• Angle dependency• Partial representation of RV Global

Function

ADVANTAGES:• Established prognostic value• Validated against radionuclide EF

2. TISSUE DOPPLER S’ WAVE VELOCITY

S’ velocity > 9,5 cm/s

ADVANTAGES: • Easily measured, reliable and reproducible. • Correlates well with other measures of global RV

systolic function. • Validated against radionuclide EF • Established prognostic value


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REGIONAL NON VOLUMETRIC ASSESSMENT

LIMITATIONS:• Angle dependent • Not fully representative of RV global

function after thoracotomy, pulmonarythromboendarterectomy or hearttransplantation

3. 2D RV STRAIN STE

Wu CC, Takeuchi M. Echocardiographic assessment of right ventricular systolic function. Vol. 8, Cardiovascular Diagnosis and Therapy. AME Publishing Company; 2018. p. 70–9. 22

REGIONAL/ GLOBAL NON VOLUMETRIC ASSESSMENT

ADVANTAGES: • Relatively angle independent • Possesses an improved signal-to-noise ratio. • Provide regional function estimates, as well as a more

‘‘global’’ function.

DISADVANTAGES: • Lack of normative data and need additional validation.• Different algorithms in different platforms may result in

different normal ranges.

Normal :−29.0±4.5% in the 2015 ASE/EACVI guidelines

CASE RV STRAIN GLS

Wu CC, Takeuchi M. Echocardiographic assessment of right ventricular systolic function. Vol. 8, Cardiovascular Diagnosis and Therapy. AME Publishing Company; 2018. p. 70–9.

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REGIONAL/ GLOBAL NON VOLUMETRIC ASSESSMENT

Summary Recommendation for Assessment of RV Function

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Visual initial qualitative RV systolic function insufficient in this era of standarization


At least one of the above quantitative measures be incorporated into the routine echocardiographic examination

Important when RV dysfunction is suspected

Iso-volumetric acceleration, strain, and strain rate are not currently recommended best reserved for research

RV DIASTOLIC FUNCTION

Zaidi A,, et al. Echocardiographic assessment of the right heart in adults: A practical guideline from the British Society of Echocardiography. Vol. 7, Echo Research and Practice. BioScientifica Ltd.; 2020. p. G19–41

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CLINICAL RELEVANCE

Rudski LG, et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography. Vol. 23.J Am Soc: p. 685–713. Echocardiography 2010. 26

In patient with CHF and PH, RV diastolic dysfunction was associated with worse functional class and was an independent predictor of mortality

Diastolic filling patterns reflect response to therapy, improving with treatment of cardiac condition

Marker of subclinical RV dysfunction

• Impaired Relaxation < 0.8 • Pseudonormal filling → 0.8 - 2.1 with an E/E’ ratio > 6 or diastolic flow

predominance in the hepatic veins • Restrictive filling > 2.1 with a DT < 120 ms (as does late diastolic antegrade

flow in the pulmonary artery).

Grading of RV diastolic dysfunction should be done as follows:

TRICUSPID E/A RATIO:

ESTIMATION OF RIGHT ATRIAL PRESSURE (RAP)

IVC collapse does not accurately reflect RA pressure in ventilator dependent patients

Less reliable for intermediate values of RA pressure.


When to Suspect RV Dysfunction


Bigger “Right and Outflow” than “Left”Always Means

“SOMETHING WRONG”

RV PRESSURE AND VOLUME OVERLOAD

Zaidi A, et al. Echocardiographic assessment of the right heart in adults: A practical guideline from the British Society of Echocardiography. BioScientifica Ltd.; 2020. p. G19–41.

Normal LV-D shaped

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Volume overload only in diastolic

Pressure overload systolic and diastolic

Rotate the transducer to obtain the maximum RV basal diameter

The Connection Theory Between Pulmonary and Right Heart Pressure

Bernoulli Equation

Wu CC, Takeuchi M. Echocardiographic assessment of right ventricular systolic function. Vol. 8, Cardiovascular Diagnosis and Therapy. AME Publishing Company; 2018. p. 70–9.

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The Cascade of Flow to Determine the Other Chamber

TRICUSPID REGURGITATION &

PULMONARY ARTERY SYSTOLIC PRESSURE

Simplified Bernoulli equation:

RVSP = 4(TR Velocity)2+ RA pressure

In the absence of a gradient of across the pulmonic valve or RVOT, SPAP is equal to RVSP

Dilorenzo MP, et all. How best to assess right ventricular function by echocardiography. Cardiol Young. 2015 ;25(8):1473–81. 31

TRICUSPID REGURGITATION GRADIENT

Occasionally underestimate the RV-RA gradient because of its neglect of the inertial component of the complete Bernoulli equation

Normal velocity < 2.8 to 2.9 m/s

Peak systolic Pressure < 35 mm Hg assuming an RA pressure of 3 to 5

Zaidi A,, et al. Echocardiographic assessment of the right heart in adults: A practical guideline from the British Society of Echocardiography. Vol. 7, Echo Research and Practice. BioScientifica Ltd.; 2020. p. G19–41 32

ACC & AHA:Dyspnoe with estimated RVSP > 40 mm Hg or SPAP > 35 mmHg need

further investigation

PULMONARY ACCELERATION TIME

Mean PA pressure = 79 - (0.45 x AT)

Patients with AT < 120 msMean PA pressure is 90 - (0.62 x AT)

Better in normal range of 60 - 100 beats/mins

Dilorenzo MP, et all. How best to assess right ventricular function by echocardiography. Cardiol Young. 2015 ;25(8):1473–81. 33

Mean PA pressure = 1/3(SPAP) + 2/3(PADP)

Mean Pulmonary Artery Pressure &

Pulmonary Artery Diastolic Pressure

“Mid Systolic Notching”

PULMONARY VASCULAR RESISTANCE

Zaidi A, et al. Echocardiographic assessment of the right heart in adults: the British Society of Echocardiography. BioScientifica Ltd.; 2020. p. G19–41. 34

PVR = TRVmax/RVOT TVI) X 10 +0.16

CONCLUSION

RV plays an important role in the morbidity and mortality of patients presenting with signs and symptoms of cardiopulmonary disease

Echocardiographic assessment of RV, largely qualitative because of difficulty to asses RV volume, due to it’s unusual shape

There is no single reliable independent predictor of RV function At least use one quantitative parameter in addition to visual/ eyeballing gradation

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THANK YOU

presented at ise webinar on 28 august 2020. · presented at ise webinar on 28 august 2020. this...

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