right v

Denisa Muraru, MD*#

*Department of Cardiac,Vascular and Thoracic Sciences, University of Padua, Padua (Italy)

#Echocardiography Laboratory, Carol Davila University of Medicine, Bucharest (Romania)

EUROECHO CONGRESS - COPENHAGEN - 2010

RIGHT VENTRICLE

Important prognostic value:

• after acute myocardial infarction

• heart failure

• valvular heart disease

• congenital heart disease (Fallot)

• pulmonary hypertension

• after cardiac transplantation

Hochreiter C. Circulation 1986

Pfisterer M et al. Eur Heart J 1986

Bhatia SJS et al. Circulation 1994

Di Salvo TG et al. JACC 1995

Van Straten A et al. Eur Radiol 2005

Nath J et al. Echocardiography 2005

Not anymore an innocent bystander of the left

RIGHT VENTRICLE ASSESSMENT IN CLINICAL

SETTINGS

Shift from qualitative to quantitative RV study

Is there a place for echocardiography?

1D

• M-mode (RV diameters, RV wall thickness,TAPSE, septal motion pattern)

2D

• RV diameters, areas and wall thickness (1D measures)

• Fractional area change (FAC)

• RV ejection fraction (RVEF)

Doppler

• Spectral (RV dp/dt, Tei index, diastolic fx, RV systolic pressure)

• TDI (Tei index, S velocity, diastolic fx, strain/strain-rate)

STE• Strain/strain-rate

3D

• RV volumes

• RVEF

• RV shape and mass

ECHO ASSESSMENT OF RIGHT VENTRICLE

Assessment based on qualitative and quantitative parameters

RV systolic function - at least one of the following:

• fractional area change (FAC)

• S wave (TDI)

• tricuspid annular plane systolic excursion (TAPSE)

•± RV index of myocardial performance (Tei index)

! 2D RVEF is not recommended, because of the heterogeneity

of methods and the numerous geometric assumptions.

Rudsky LG et al. J Am Soc Echocardiogr 2010

Challenges for 2D echocardiography

• thin-walled chamber behind the sternum

• separate inflow and outflow portions

• asymmetrical, crescentic shape, wrapped around LV

• variations of shape with loading conditions

• heavily trabeculated

(several views needed)

(non-simultaneously imaged)

(difficult to describe

by any simple

geometric model)

(poor reproducibility of endocardial tracing)

RIGHT VENTRICLE

2D• RV fractional area change (RVFAC)

• Poor reproducibility

• RV apical foreshortening in 4Ch

• Depends on high image quality and

operator experience to accurately

include endocardial trabeculations

• End-systolic view not the same as

end-diastolic one depending on

extent of heart twisting

End-diastolic Area

End-systolic Area

GLOBAL RV SYSTOLIC FUNCTION

RV FAC < 35% = RV systolic dysfx

Limitations:

Doppler• RV Tei index = (IVCT+IVRT)/Ejection time

• Load dependency - pseudonormalizes

when right atrial pressure is high (e.g.

RV infarction) due to shortened IVRT

• Needs similar RR intervals

Tei C et al. JACC 1996

Yoshifuku S et al. Am J Cardiol 2003

Tei index = (a-b)/b

Tricuspid flow

RVOT flow

GLOBAL RV SYSTOLIC FUNCTION

Limitations:

Tei index >0.40 = RV systolic dysfx

• measured with external reference point

and thus influenced by overall heart

displacement from base to apex

• highly influenced by angle of interrogation

and load (i.e. TR)

• TAPSE possibly depends not only on RV

systolic function, but also on LV systolic

function due to ventricular interdependence

Jiang L et al. Echocardiography 1997

Kaul S. Am Heart J 1984

Lopez-Candales A et al. Am J Cardiol 2006

Tamborini G et al. Eur J Echocardiogr 2009

1D• M-mode: TAPSE

TAPSE <16 mm = RV systolic dysfx

REGIONAL INDICES OF RV SYSTOLIC FUNCTION

Limitations:

Doppler• Tissue Doppler imaging: peak S wave

Limitations:

• One-dimensional and regional

• Tricuspid valve disease

• Non-sinus rhythm (not validated)

• Technical pitfalls (alignment,

tethering, spectral broadening)

S

E’A’

CIV

Peak S <10 mm = RV systolic dysfx

REGIONAL INDICES OF RV SYSTOLIC FUNCTION

Courtesy of Dr S. Giusca

TAPSE

LV apex

displacement

Midwall RV strain

Basal RV strain

DEFORMATION IMAGING DESCRIBES RV

FUNCTION BETTER THAN TAPSE

STE• RV deformation (longitudinal 2D strain)

• Angle-independent method based

on routine 2D images

• Sensitive and rapid measure of

global and segmental longitudinal RV

function

• Discriminates true myocardial

deformation from displacement and

tethering

• Less load dependent than velocities

and EF

• Provides both regional amplitude

and timing (RV dyssynchrony)


TAPSE 18 mmTAPSE 24 mm TAPSE 18 mm

Control Tricuspid Reg. PAH


Volume vs pressure RV overload

Pressure overloadNormal Volume overload

84 ms

STE• RV deformation (longitudinal 2D strain)



Global L Strain = -22% Global L Strain = -22.7% Global L Strain = -13.8%

GS -19% Severe PH in Eisenmenger sd

GS -24% Severe pulmonary valve stenosis GS -11% Severe PAH

Grad VD-AD 21 mmHg

GS -10% Severe PH in post-myocarditis DCM

RV-RA gradient 65 mmHg RV-RA gradient 75 mmHg

RV-RA gradient 75 mmHg RV-RA gradient 99 mmHg

HIGHLY VARIABLE RV ADAPTATION TO

SEVERE PRESSURE OVERLOAD

Severe secondary PH in DCM

Severe PAH GS -11%

GS -10%

REGIONAL DEFORMATION DIFFERENCES

CLINICAL CASE

Operated Fallot tetralogy:

• Hypertrophied dilated RV with distorted geometry

• Abnormal septal motion

• Recent surgery

• Tricuspid annuloplasty

• Signs of increased RA pressures

• Atrial fibrillation

RV foreshortening

ES and ED difficult to identify for FAC calculation

TAPSE not reliable

TAPSE, TDI S wave not reliable

Tei index may “pseudonormalize’’

TDI S wave not validated, Tei index and RV strain not

applicable

Doppler• Tissue Doppler derived RV Tei index

• Simpler and more rapid, based on single

cycle measurements

• Independent of heart rate

• Feasible in pts with irregular R-R

• Smaller evidence

• Different reference values

(TDI Tei index >0.55 = RV dysfunction)


a

b

b

3D Echocardiography

VOLUMETRIC RV FUNCTION ASSESSMENT

Clinical case:

- EDV = 119 ml

- ESV = 96 ml

- RVEF = 20%

• Full-volume 3D echocardiography: Pros3D


• Actual 3D acquisition and measurements

• Unlimited repeatability

• No geometric assumptions about RV shape

• Rapid spatial appreciation from multiple

perspectives

• Extensively validated against CMR

• Provides RV volumes, stroke volume and

ejection fraction

• Reference values are now available

Niemann PS et al. J Am Coll Cardiol 2007

Shimada YJ et al. J Am Soc Echocardiogr 2010

Tamborini G et al. J Am Soc Echocardiogr 2010

Unprecedented in vivo anatomy in beating heart


Courtesy of Dr. Cristina Basso, Cardiovascular Pathology, University of Padua, Italy

PV

TV

MBRA

1

2

3

Ao

IVSm

TV

RA

Ao PV

MB

IVSm

EDV= 77 ml ESV= 28 ml RVEF= 64%

EDV =140 ml ESV= 68 ml RVEF= 52%

EDV= 113 ml ESV= 78 ml RVEF= 31%



Volume vs pressure RV overload

RV FUNCTION AFTER SURGERY

TAPSE3D RVEF TDI S wave

• After surgery, TAPSE and TDI S amplitude decreased, despite no

sign or symptom of RV failure was present before or after surgery

• Conversely, 3D EF remained unchanged

• RV longitudinal function as assessed by TAPSE/TDI may not reflect

true RV global performance after uncomplicated cardiac surgery

(presumably due to geometrical changes of RV chamber)

Tamborini G et al. Eur J Echocardiogr 2009


Limitations of current 3D echocardiography

• Systematic bias versus CMR (especially in large RVs and in elderly)

• Endocardial blurring affecting semi-automated tracking algorithm

• Limited temporal resolution

• RV anterior wall and RVOT inadequately imaged (especially in

enlarged RVs)

• To date, only qualitative assessment of regional function possible

• Patient cooperation needed

• Dedicated training for both acquisition and offline analysis

• (Arrhythmias)

• (Cost)

Shimada YJ et al. J Am Soc Echocardiogr 2010

RV DIASTOLIC FUNCTION

Much more than RV wall thickness

• marker of early or subtle RV dysfunction

• marker of poor prognosis in patients with known RV impairment

E

AS

E’A’

rIVRT

EDT

Rudsky LG et al. J Am Soc Echocardiogr 2010

Assessing and grading RV diastolic function should be considered

in patients with suspected RV impairment as:

E’A’

TAPSE 23 mm

Ԑ

SRs

SRe

SRa

Global RV strain -23%

Global RV strain rate

AE

EARLY DIASTOLIC DYSFUNCTION IN PAH

=12 cm/sS

• Current echo techniques allow a tailored quantitative approach

for the assessment of RV size and function

• 3DE has no rival for measuring the complex-shaped RV and is

the only volumetric echo method to assess global RV function

• A multi-parameter approach and the advanced technologies

(STE, 3DE) can compensate for the flaws of single conventional

indices of RV function

• RV diastolic function could provide novel insights in RV function

impairment early in disease course

• Further outcome studies are needed to certify the clinical value

of novel echo methods over the conventional RV indices

CONCLUSIONS

I hear and I forget,

I see and I remember,

I do and I understand!

Confucius

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