Download Gustavo A. Restrepo Molina

Incorporating the New Echo
Guidelines Into Everyday Practice
Clinical Case
RIGHT VENTRICULAR FAILURE
Gustavo Restrepo MD
President Elect Interamerican Society of Cardiology
Director Fellowship Training in Echocardiography. CES University/Clínica Medellín
ACC – Colombia Chapter Governor
Medellín, Colombia
Disclosure Information
• I will not discuss off label use or
investigational use in my presentation
• I have no financial relationships to disclose
Clinical Case
• 65 years old male, farmer
• 2 years history of progressive dyspnea, fatigue,
severe exercise intolerance
• PMH: severe COPD
• PE: BP 120/70 HR 90, RR 20, Sa02 90%
• Neck veins distended, bilateral hypoventilation,
systolic murmur (tricuspid area), bilateral leg oedema
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J Am Soc Echocardiogr 2015;28:1-39
Apical 4-chamber
Focused
Apical 4-chamber
RV Modified
Apical 4-chamber
27±4mm
33±4mm
25±2mm
28±3.5mm
22±2.5mm
RV systolic function evaluation
•
FRACTIONAL AREA CHANGE (FAC)
•
S WAVE OF THE TRICUSPID ANNULUS (S’)
•
TRICUSPID ANNULAR SYSTOLIC EXCURSION (TAPSE)
•
RV INDEX OF MYOCARDIAL PERFORMANCE (RVIMP, TEI INDEX)
•
RV EJECTION FRACTION 3D EVALUATION
•
LONGITUDINAL STRAIN AND STRAIN RATE
Global Assessment of RV function
• MYOCARDIAL PERFORMANCE INDEX (MPI)
• RV dP/dt
• RV EJECTION FRACTION
• FRACTIONAL AREA CHANGE (FAC)
RIGHT VENTRICULAR INDEX OF MYOCARDIAL PERFORMANCE (RIMP)
Ratio of isovolumic time divided by et
(IVRT + IVCT) / ET
Tissue Doppler of the tricuspid annulus
ABNORMAL FINDING > 0.55
(Tissue Doppler)
MPI = 0.86
RIGHT VENTRICULAR INDEX OF MYOCARDIAL PERFORMANCE (RIMP)
LIMITATIONS
ATRIAL FIBRILATION
MPI has been demonstrated to be unreliable when RA pressure is elevated, shortening the
IVRT and resulting in an inappropriately small MPI.
It should not be used with irregular heart rates.
RV dP/ dt
numerator is 15 mmHg
dt = 35 ms
+
50
+
dP/dt :15/35 = 428 mmHg/s
Recommendations: Because of the lack of data in normal subjects, RV dP/dt cannot be recommended for
routine uses. It can be considered in subjects with suspected RV dysfunction.
RV FRACTIONAL AREA CHANGE (%)
100 X (END DIASTOLIC AREA – END SYSTOLIC AREA)/ END DIASTOLIC AREA
Abnormal RV Systolic function FAC < 35%
ES Area 22.5
ED Area 25.6
RV FAC 12%
Relationship between MRI- derived RVEF and echo derived
RVFAC,Fractional Shortening, and Tricuspid Annular Motion
Anavekar NS. Echocardiography 2007:24:452-456
2 Dimensional Volume and RV EF
RV Ejection Fraction= ( end diastolic volume – end systolic volume) / end diastolic volume
RV Ejection Fraction > 44% (normal value)
Area lenght methods
Disk summation mehods
RV volumes are understimated because of the exclusion of the RVOT
Both methods are inferior in comparison with 3D echocardiographic methods
Two dimensionally derived estimation of RV EF is not
recommended, because of the heterogeneity of methods and the
numerous geometric assumptions.
3D RVEF ≧ 45%
Freed B, Lang RM et al. J Am Soc Echocardiogr 2012;25(6):116
REGIONAL ASSESSMENT OF RV FUNCTION
• TISSUE DOPPLER-DERIVED SYSTOLIC VELOCITIES OF
THE ANNULUS (S’)
• TRICUSPID PLANE SYSTOLIC EXCURSION (TAPSE)
• TISSUE DOPPLER DERIVED AND 2D LONGITUDINAL
STRAIN AND STRAIN RATE
24±3.5, mm
<17, mm
14.1±2.3, cm/s
<9.5, cm/s
-29±4.5, %
>-20, %
TISSUE DOPPLER TRICUSPID ANNULUS VELOCITY
Systolic excursion velocity (s´)
ABNORMAL FINDING: S’ < 9,5
Advantages:
1. A simple reproducible technique with good discriminatory ability to detect
normal versus abnormal RV function.
2. Pulsed Doppler is available on all modern ultrasound equipment
Disadvantages
1. This technique is less reproducible for non basal segments
2. It is angle dependent
3. It assumes that the function of a single segment represents the function
of the entire RV
4. There are insufficent data in the elderly
TRICUSPID ANNULAR PLANE SYSTOLIC EXCURSION (TAPSE)
ABNORMAL FINDING
TAPSE < 17 MM
Disadvantages:
1. Assumes that the displacement of a single segment represents the function
of a complex 3D structure.
2. It is angle dependent.
3. There are no large-scale validation studies
4. Load dependent
Recommendations:
TAPSE should be used routinely as a simple method of estimating RV function,
with a lower reference value for impaired RV systolic function of 17 mm.
Global RV
Longitudinal
Strain
Free wall RV
Longitudinal
Strain
Free Wall RV Longitudinal Strain: Sensitivity 96%, Specificity 93% to predict
RVEF <45% (MRI) using a cut-off value of less than -17.0%
European Heart Journal Cardiovascular Imaging 2015;16:47-52
RV SPECKLE TRACKING
Normal RV
Global RV Longitudinal Strain - 25%
Severe RV Dysfunction
Global RV Longitudinal Strain – 8,8%
J Am Soc Echocardiogr 2013;26:721-6
J Am Soc Echocardiogr 2013;26:721-6
Traditional measures of right ventricular systolic function
•
Fractional area shortening (FAC)
•
Tricuspid annular plane systolic excursion (TAPSE)
•
Pulsed tissue Doppler of the tricuspid lateral annular systolic velocity (S’)
•
Myocardial performance index (MPI)
•
RV Global Longitudinal Strain / RV Free Wall Longitudinal Strain
•
3D RV EF
Combining more than one measure of RV function, may more reliable distinguish normal from abnormal function