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SCCS SCCS Zabrze Zabrze Quantitation of right Basics of cardiac ventricular dimensions assessment and function Tomasz Kukulski, MD PhD Dept of Cardiology, Congenital Heart Disease and Electrotherapy Silesian Medical University Silesian Center for Heart Disease, Zabrze Adults Echo Laboratory I HAVE NO DISCLOSURE SCCS Zabrze Scope of presentation • RV anatomy & morphology • RV Size and shape measurements • RV Functional measuerements • Echo Imaging methods: which technique ? Strengths and limitations SCCS Zabrze Limitations in the assessment of RV morphology and function • Complex RV geometry • Increased RV endocardial trabeculation endocardial borders are difficult to define • Retrosternal position • Load dependency of the majority of functional parameters SCCS Zabrze RV function – important facts • RV outflow tract generates 81% of RV End- diastolic volume • RV inflow tract generates 87% of RV Stroke volume • Longitudinal fiber shortening of the inflow part is significantly higher than outflow part SCCS Zabrze Distinct RV structure & shape OUTLET INLET APICAL From Rushmer RF, Cardiovascular dynamics, WB Saunders Co. 1970 SCCS Zabrze Mechanisms of blood ejection 1 2 3 From Rushmer RF, Cardiovascular dynamics, WB Saunders Co. 1970 SCCS Zabrze Determinants of RV function RV Preload contractility RV Afterload RV function Synchronicity IAS,IVS shunts TR, PR rhytm SCCS Zabrze Right ventricle-focused view Maximazing RV chamber size * RV-focused view should be indicated in the ECHO report ASE/EAE Guidelines J Am Soc Echocardiogr 2010;23:685-713.) SCCS Zabrze RV Chamber Measurements ASE/EAE Guidelines J Am Soc Echocardiogr 2010;23:685-713.) SCCS Zabrze RVOT measurements RVOT proximal RVOT distal SCCS Zabrze Clinical importance of RA size measurement ASE/EAE Guidelines J Am Soc Echocardiogr 2010;23:685-713.) ASE/EAE Guidelines J Am Soc Echocardiogr 2010;23:685-713.) SCCS Zabrze Fractional Area Change FAC – Fractional Area Change = (RVED area-RVES area)/(RVED area ) x 100% Normal values: 35-59% Kaul. S Am.Heart J. 1984 *Trabeculation,tricuspid valve,chords should be included in the chamber SCCS Zabrze Limitations of RV volume measurements using 2D echocardiography The asymmetrical chamber is divided in slices having the same thickness; the volume of each slice = as area x height . The sum of slices gives the chamber volume. Gentzler et al., Circulation 1974 • This is not feasible with echo: to calculate the volumes of slices, the chamber must be visualized in two ortogonal projection having a common long axis ( do not exist for RV) SCCS Zabrze RA pressure estimation ASE/EAE Guidelines J Am Soc Echocardiogr 2010;23:685-713.) SCCS Zabrze Ventricular interdependence Excentricity index = Long LV diameter Short LV diameter SCCS Zabrze Severe pulmonary hypertension 2 -dimensional Echocardiography EI RA area SCCS Zabrze (MPI) Tei index- how to measure? SCCS Zabrze Assessment of PAH severity Prognostic value of echo measurements based on multivariable analysis • • • • Pericardial effusion RA size (RA area index) Exscentricity index TEI index ESC guidelines 2009 SCCS Zabrze Tricuspid annulus motion TAPSE- Tricuspid Anular Plane Systolic movEment <16 mm RV mechanical dysfunction Mmode SCCS Zabrze Prognostic value of TAPSE SCCS Zabrze Measurement of RVSP RVSP= 4 x TR2 +RA pressure SCCS Zabrze How to estimate pulmonary artery pressure? TR Systolic PA pressure = 4 x TR2+RAP 4x42+20 mmHg=80 mmHg RAP=20 mmHg End diastolic PA pressure = 4x(PR end diastolic velocity)2 +RAP= 4x32+20=56 mmHg PR SCCS Zabrze Tissue Velocity Imaging Colour Doppler 0.1 Curved M-mode Pulsed Doppler apical 0.05 0 -0.05 0.1 medial 0.05 0 -0.05 0.1 0.05 s basal s 0 s -0.05 e a e a e a SCCS Zabrze Age -dependence of RV diastolic velocities Age vs regional RV wall e/a velocities ratio 3,5 e/a 3 y = -0,0408x + 2,8385 R2 = 0,5812 r= -0,76 2,5 2 1,5 age 1 y = -0,0366x + 2,5979 R2 = 0,4316 r= -0,69 y = -0,0304x + 2,3264 R2 = 0,3854 r= -0,65 0,5 0 0 10 20 anulus 30 40 basal 50 60 70 medial T.Kukulski et al J Am Soc Echocardiogr 2000;13:194-204.. SCCS Zabrze Myocardial acceleration during isovolumic contraction In studies ,in patients with conditions affected by RV function, RV IVA may be used, and should be measured at the lateral tricuspid annulus. RV IVA is not recommended as a screening parameter for RV systolic function in the general echocardiography laboratory population. Vogel M et al., Circulation. 2002;105:1693-1699.) SCCS Zabrze Limitations of regional velocity measurements Traction Fibers shortening Tethering Tricuspid ring motion Doppler Velocity vector Pressure overload Volume overload Overall heart motion Frank-Starling mechanism SCCS Zabrze RV deformation Imaging in CHF pts Doppler based RV free wall strain Donal et al. Echocardiographic right ventricular strain analysis in CHF. Eur J Echocardiography 2007 SCCS Zabrze RV free wall strain in pulmonary arterial hypertension Rv free wall –longitudinal strain Basal segment Medial segment Apical segment RV longitudinal strain for RV dyssynchrony measurements in PAH pts SCCS Zabrze normal mild PAH moderate PAH severe PAH Lopez-Candales et al, Cardiovacsular Ultrasound 2009 SCCS Zabrze Relation between strain parameters and global RV function measures Lopez-Candales et al, Cardiovacsular Ultrasound 2009 SCCS Zabrze RV Strain, strain rate aplications limitations • Different results obtained by Speckle tracking and Doppler techniques • Non - homogenous distribution within RV free wall in comparison to LV distribution • In pulmonary hypertension pts- the lowest strain values in outflow part of RV wall • Rapid increase in afterload result in systolic strain rate increase and systolic strain reduction • Reduction in systolic strain reflects decrese in RV stroke volume SCCS Zabrze Summary • A gradual shift to more quantitative approaches for the assessment of RV size and function will help standardize assessment of the right ventricle across laboratories and allow clinicians to better incorporate assessment of the right heart into an echocardiographic evaluation • Improvements in 3D imaging will result in increased use and have the potential to help in the clinical assessment of RV size and function