Download Tissue deformation imaging in assessment of the right ventricle

Tissue deformation imaging
in the assessment
of the right ventricle:
does load dependency matter?
Ruxandra Jurcut
Department of Cardiology
University of Medicine and Pharmacy “Carol Davila”
Bucharest, Romania
Declaration of conflict of interest: none to declare
Agenda
 Background
 RV – complex anatomy & function
 Load & myocardial deformation in theory
 Demonstration
 RV myocardial deformation parameters in
different loading conditions
 Take home messages
RV remodeling
 The RV and LV differ markedly in their anatomy, mechanics, and
loading conditions:
 Structure: crescent-shaped, thin-walled RV
 Hemodynamics: volume pump, ejecting in a low-resistance pulmonary
arterial circulation.
 Special contraction pattern – peristaltic movement
 87% from the RV stroke volume – RV sinus (apical 4CV)
 80% from the RV stroke volume - longitudinal contraction
RV remodeling/failure and prognosis
 PHT and RV failure - strong predictors of mortality in
LV failure, AMI and COPD
 RV dysfunction is a strong prognostic factor in:
 PulmReg postrepair for Tetralogy of Fallot
 systemic RV in TGA
 RV pressure overload associated with pulmonary valve
stenosis - better prognosis than PAH
 progressive PS induced by PA banding in rats - not associated with
RV failure
Load and contractility
Bijnens et al EJE 2008
Cardiac mechanics –
how is it balanced?
Frank Starling law
SV (ml)
SV (ml)
↓ afterload
↑ inotropy
↑ afterload
↓ inotropy
LVEDP (mmHg)
LVEDP (mmHg)
Load, geometry and contractility
Laplace’s law
RV function assessment
Gold standard: pressure-volume loops
Demonstrate load dependence of dp/dt, stroke work…
Bleeker, Heart 2006
Myocardial deformation imaging –
several techniques, several parameters
IVA=IVV/t
IVV
t
t
Jurcut et al, Eur J Echo 2010
Load and contractility – in theory
La Gerche, Jurcut, Voigt, CurrOppCardiol 2011
Load and contractility – in practice
Rosner et al, EJE 2008
What happens to RV deformation experimental data
Decreased preload
(IVC banding)
Increased afterload
(PA banding)
Maintained SRmax
Maintained ISAmax
Decreased SRmax
Maintained ISAmax
(SRmax ~ global contractility)
Missant et al, Heart 2008
RV and afterload
La Gerche et al, MSSE 2011
Any load insensitive measurements?
Parameter
Equation
ß
p
Srad
33.2-1.5*Ea
-0.58
<0.0001
Scirc
-12.9+1.4*Ea-0.2*LVMV
0.79 (Ea)
<0.0001
-0.52 (LVMV) <0.0001
SRrad
11.5+0.09*PRSW-0.2*LVMV
0.79 (PRSW) <0.001
-0.62 (LVMV) <0.001
SRcirc
-4.5-0.04*PRSW
-0.61
<0.0001
Legend:
Ea = arterial elastance
LVMV = LV myocardial volumes
PRSW = preload recruitable stroke work
Ferferieva et al, AJPHCP 2011
RV deformation - pitfalls
Complex geometry - what region to study?
Henein et al
Heart 2011
RV deformation - pitfalls
Regional function –
what is normal for RV free wall strain?
Paper
Technique
Basal
Mid
Apical
Kowalski et al,
UMB 2001
TDI
-19 ± 6%
-27 ± 6%
-32 ± 6%
Dambrauskaite et al,
JASE 2007
TDI
-42 ± 11%
-
-41 ± 11%
Kittipovanonth et
al, JASE 2008
TDI
-31 ± 6%
-29 ± 6%
-26 ± 7%
Teske et al,
JASE 2008
2DS
-22 ± 7%
-24 ± 7%
-27 ± 9%
Jurcut et al,
JASE 2011
2DS
-29 ± 7%
-30 ± 8%
-28 ± 8%
RV deformation
 Preload alterations
 Atrial septal defect
 Tricuspid regurgitation
 Pulmonary regurgitation
 Afterload alterations
 Pulmonary hypertension
 Pulmonary stenosis
 Transposition of the great arteries
(“systemic RV”)
Atrial septal defect
Marciniak et al, Eur Heart J 2007
Open atrial septal defect
*
Jategaonkar et al, EJE 2009
Atrial septal defect – open vs closed
Van de Breune et al, EJE 2011
Pulmonary Reg in repaired ToF
R=0.45; p<0.05
Kowalik et al, JASE 2011
Pulmonary Hypertension
PASP
LVEI
Puwanant et al, Circulation 2010
Pulmonary Hypertension
PASP
LVEI
Puwanant et al, Circulation 2010
Pulmonary Hypertension
RAP<10 mmHg
RAP>10 mmHg
*#
*
-14±1%
-19±1%
-26±1%
Study group
RV FW LS
ROC curve cutoff
Sn
Sp
Normal PAPs
≤ -27.2%
70%
93.5%
PH compensated vs decompensated
≥ -14.9%
61.5%
85%
Simon et al, Congest Heart Fail 2009
Increased afterload: PHT vs PStenosis
RVP
73±34 mmHg
RVP
88±31 mmHg
RVP
25±4 mmHg
p = 0.37
p<0.001
Jurcut et al, JASE 2011
Arterial PHT
F, 25 years
RVP = 100 mmHg
Pulmonary stenosis
F, 27 years
RVP = 106 mmHg
Increased afterload: PHT vs PStenosis
Jurcut et al, JASE 2011
Pulmonary artery banding ~
PulmSten
PS
Angioproliferative pulmonary
vascular remodeling ~ aPHT
PHT
Bogaard et al, Circulation 2009
TGA – the “systemic right ventricle”
TGA – the “systemic right ventricle”
Pettersen et al, JACC 2007
TGA – the “systemic right ventricle”
Di Salvo et al, Int J Cardiol 2010
TGA – the “systemic right ventricle”
Di Salvo et al, Int J Cardiol 2010
Take home messages
Take home messages
 Interpretation of MDI parameters must always
incorporate loading conditions:
 Influence of volume vs pressure overload
 Influence of geometrical changes (e.g.RV dilation)
 RV function may not be adequately described by
longitudinal function alone.
 Myocardial adaptation to load:
 RV wall transverse fibers hypertrophy with increased afterload
 Different cellular and molecular adaptation mechanisms to
pressure overload (e.g. PS vs PHT)