Download Evaluation of Right Ventricular Function and Its Prognostic Value

Evaluation of Right
Ventricular Function
and Its Prognostic Value
Sarinya Puwanant, MD, FASE
Scope
Importance of the Right Ventricle
Right Ventricular Anatomy
Evaluation of Right Ventricular Function
Scope
Importance of the Right Ventricle
Right Ventricular Anatomy
Evaluation of Right Ventricular Function
Time to move to the right--the study of right
ventricular systolic performance: too long neglected.
“Time to incorporate RV systolic function into the
mainstream of cardiology practice.”
Hesse & Asher at Cleveland Clinic 2005
Prognostic Value of RV function in
rEF-HF
7
RVEF >39%
Stage IA
RVEF <=39%
Stage IIA
Stage IIB
Stage III
Survival time ( days)
J Am Coll Cardiol 1998;32:948 –54
Am J Respir Crit Care Med Vol 172. pp 523–529, 2005
Prognostic Value of RV function in
pEF-HF
8
<=15 mm
N=562
Circulation. 2014;130:2310-2320
Survival rates of PAH patients
stratified by RVEF by Cardiac MRI
N=140
M.J. Brewis et al. / International Journal of Cardiology 218 (2016) 206–211
Prognostic value of right ventricular
dysfunction for mortality in patients with
pulmonary embolism without shock
European Heart Journal (2008) 29, 1569–1577
Post MI LVEF ≤ 40% without signs of heart
failure (n=416) SAVE Investigator
RV FAC ≥ 32.2%
RV FAC < 32.2%
Each 5% decrease in the RV FAC was associated with a 16% increased odds of
cardiovascular mortality (95% confidence interval 4.3% to 29.2%; p 0.006).
J Am Coll Cardiol 2002;39:1450 –5
LVAD patients
N=69
N=69
Kavarana MN et al. Ann Thorac Surg 2002;73:745–50
Scope
Importance of the Right Ventricle
Right Ventricular Anatomy
Evaluation of Right Ventricular Function
 Two areas of RV
 Inflow
 Outflow
 RV Contraction
 Longitudinal contraction
(4Ch)
 RV Free wall contract
towards the septum
 Torsion/Twist of the LV
17
RVOT
TV
TV
RVOT
Scope
Importance of the Right Ventricle
Right Ventricular Anatomy
Evaluation of Right Ventricular Function
Right Ventricular Function:
Modality
RV Angiogram
Cardiac Catheterization
Cardiac MRI
Nuclear
Cardiac CT Scan
Echocardiography
Right Ventricular Function:
RV Systolic Function
RV Diastolic Function
RV Systolic Function:
 Qualitative
 Quantitative
 Volumetric Assessment:
 RV Fractional Area Change (RV FAC)
 3-D RV Ejection Fraction
 Non-volumetric Assessment:
 Global Assessment:
 RV Index of Myocardial Performance (RIMP)
 RV dp/dt
 Regional Assessment:
 Tricuspid Annular Plane Systolic Excursion (TAPSE)
 Peak systolic velocity of tricuspid annulus by PW DTI (S’)
 Peak systolic strain
RV Systolic Function:
 Qualitative
 Quantitative
 Volumetric Assessment:
 RV Fractional Area Change (RV FAC)
 3-D RV Ejection Fraction
 Non-volumetric Assessment:
 Global Assessment:
 RV Index of Myocardial Performance (RIMP)
 RV dp/dt
 Regional Assessment:
 Tricuspid Annular Plane Systolic Excursion (TAPSE)
 Peak systolic velocity of tricuspid annulus by PW DTI (S’)
 Peak systolic strain
RV Fractional Area Change
RV FAC = ED Area-ES Area
X 100
ED Area
RV Focused View
Echo-MRI lag period =10+34 days
N= 223
European Journal of Echocardiography (2011) 12, 871–880
Lower reference value: 35%
J Am Soc Echocardiogr 2010;23:685-713.
RV Fractional Area Change
Advantages
Disadvantages
 Established prognostic value
 RV FAC found to be
independent predictor of heart
failure, sudden death, stroke,
and/or mortality in studies of
patients after pulmonary
embolectomy
 Longitudinal and radial
components of RV contraction
 Correlates with RV EF by CMR
 No RVOT component
 Require good quality image
and geometric dependent
Pyramid
Pyramid
Pyramid
Prism
Pyramid
Rectangular
Parallelepiped
Hemi elliptical
Crescentic
Shell
Ellipsoid
Pyramid
Prism
Vol. = 4/3¶(axbxc) , V = 2/3AxL
Vol. = AH/3
Vol. = h/2(AAxBB)
3-D RV Ejection Fraction
RV EF =
EDV -ESV
EDV
3-D RV Ejection Fraction
RV EF =
EDV -ESV
EDV
TV
PV
RV apex
4D RV-FUNCTION is a module of TOMTEC-ARENA TM
N=31
16 were nl
J Am Coll Cardiol 2007;50:1668–76
N=28
J Am Coll Cardiol Img 2010;3:10–8
Cut-Off: Normal 3-D RVEF > 45%
J Am Soc Echocardiogr 2015 Jan.
3D-RV Ejection Fraction
Advantages
 Unique measures of RV
global size that includes
inflow, outflow and apical
regions
 Independent of geometric
assumptions
 Validated against cardiac
magnetic resonance
Disadvantages
 Dependent on image quality,
Regular rhythm, patient
cooperation
 Needs specific 3D
echocardiographic equipment
and training
 Reference values
established in few
publications
TAPSE: Tricuspid Annular Plane Systolic Excursion
Onset of annular motion in atrial direction
Point of max. excursion towards ventricle
Total annular excursion
Point
of max.
excursion
towards
atrium
Motion
caused
by atrial
contraction
RV
RA
60
RVEF
by
ERNA
50
•N=30,
10 = normal
20= CAD
•25 mCi Tc 99mm
Pertecnitate
• LAO
40
30
Y = 0.31X+0.3
20
R=0.92
10
P<0.001
0
5
10
15
20
TAPSE ( mm)
Kaul S et al. Am H J 1984; 107:526
N=63
Echo –MRI interval 0-38 days
Referred for
MRI
Normal 12
Sickle cell 25
CM 7
PH 10
CAD 3
Congenital 3
Others 3
TOF (n=156)
R =0.65
CHD-PAH (n=49)
R=0.81
P<0.01
Echo on the same day of MRI
P<0.01
Echocardiography 2012;29:19-24
N= 31
NYHA II-III LVEF < 45%
Congenit Heart Dis. 2012;7:250–258
N= 223
Diseases 70% (CM CAD TOF, PH, valve, CHD)
Normal 30%
Echo –MRI Lag period 10 days
RVEF by MRI
P=0.01
Echo on the same day of MRI
J Ultrasound Med 2015; 34:247–255
European Journal of Echocardiography (2011) 12, 871–880
Echo right after MRI
N=60
Echocardiography 2015;32:966–974
Cut-Off: Normal TAPSE < 17 mm
J Am Soc Echocardiogr 2015 Jan.
TAPSE in Heart Failure
J Cardiac Fail 2012;18:216e225
LVEF <=45%
J Cardiac Fail 2012;18:216e225
TAPSE in PAH
N=63
N=47
Am J Respir Crit Care Med Vol 174. pp 1034–1041, 2006
TAPSE
Advantages
Disadvantages
 Established prognostic value
 Non-geometric
 Less depend on acoustic
window
 Angle Dependent
 Partial Represent Global RV
Function
TDI of the lateral TV annulus
•N= 44, CHF
( LVEF24 +/-7%)
•N=30 , Normal
RVEF by FP radionuclide
•FP 2hr prior to echo
740 MBq Tc 99m,
RAO 30º
•ERNA after FP
740 MBq Tc 99m,
RAO 45º-LPO
•TTE study
Sa (cm/s)
Sa velocity < 11.5 can be used as a predictor of
RVEF < 45% by radionuclide ventriculogram
with a sensitivity of 90 % and a specificity of 85%.
Meluzin J. et al. Eur Heart J 2001;22:348
Echo –MRI interval 0-38 days
Ebstein’s, Echo-MRI within 24 hrs
N=32 CTEPH
R=0.689
P<0.01
Echo on the same day of MRI
Y. Li et al. / Thrombosis Research 135 (2015) 602–606
N= 31
NYHA II-III LVEF < 45%
N= 223
Diseases 70% (CM CAD TOF, PH, valve, CHD)
Normal 30%
Echo –MRI Lag period 10 days
RVEF by MRI
P=0.01
Echo on the same day of MRI
J Ultrasound Med 2015; 34:247–255
European Journal of Echocardiography (2011) 12, 871–880
Cut-Off: Normal TV S’ > 9.5 cm/s
J Am Soc Echocardiogr 2015 Jan.
Tricuspid S’
Advantage
Disadvantage
 Established prognostic value
in HF, PH, CHD
 Non-geometric
 Less depend on acoustic
window
 Reproducible
 Angle dependent
 Partial represent global RV
function
 Limited use in Ebstein’s ,
post OHTx, Post pulm.
thromboembolectomy
RV Peak Systolic Strain
Echo right after MRI
N=60
Echocardiography 2015;32:966–974
N=60
Echocardiography 2015;32:966–974
Cut-Off: Normal = Deeper than -20
J Am Soc Echocardiogr 2015 Jan.
Peak value of 2D longitudinal speckle
tracking derived strain
Advantage
 Angle independent
 More Prognostic Value
 Reproducible
Disadvantage
 Need practice
332 Chronic HF with LVEF < 45%
Echocardiography 2016;33:992–1000
RV Index of Myocardial
Performance (RIMP) or Tei Index
RIMP
RIMP = TCO-ET
ET
RIMP (TDI)
n-= 40 ( 1Mo-22yo)
Normal
RIMP ( Pulse Doppler)
Harada K et al. Am J Cardiol 2002;90:566
Cut-Off: Normal RIMP <0.54
J Am Soc Echocardiogr 2015 Jan.
Survival rate in patients with primary PH
(n=26)
J Am Soc Echocardiogr 1996;9:838-47
N=32 CTEPH
R=0.689
P<0.01
TOF, n=57
Echo-MRI within 6 months
Echo on the same day of MRI
Y. Li et al. / Thrombosis Research 135 (2015) 602–606
Am J Cardiol 2007; 99:1593–1597
RIMP
Advantages
Disadvantages
 Global ventricular function
 Reproducible
 Geometry independent
 Not significantly affected by
HR or BP
 Prognostic values in PH, RV
infarction, hypertrophic
cardiomyopathy, and
congenital heart disease,
among others
 Afib –limited
 Elevated RAP-uncertained
RV dp/dt = 15 / Δt
0.5 cm/s  4(0.5)(0.5)= 1 mmHg
(16-1)
=15 mmHg
2 cm/s  4(2)(2)= 16mmHg
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 71 JUNE 15,1993
RV dp/dt
Advantage
 Simple
 Geometry independent
 Physiologic
Disadvantage
 Load dependent
 Less accurate in TR
Conclusions
 The right ventricle plays an important role in the
morbidity and mortality of patients with
cardiopulmonary diseases.
 Right ventricular function is difficult to assess due to
complex RV anatomy
 A gradual shift to more quantitative approaches for the
assessment of RV size and function will help
standardize assessment of the right ventricle
 Always use both Qualitative and Quantitative
measures to assess RV function
 No single echo parameter to obligatorily determine RV
function
Thank you