Echo assesment of rv function

Echo assesment of rv function

1. ECHO ASSESMENT OF RV FUNCTION DR . AZIZUL HAQUE REGISTRAR CARDIOLOGY DHAKA MEDICAL COLLEGE HOSPITAL

2. RIGHT VENTRICULAR ANATOMY

3. Limitations of Echocardiography in The Evaluations of RV Function ▶ Difficulties in the estimation of RV volume : crescentic shape of RV : separation between RV inflow and outflow : no uniform geometric assumption for measuring volume ▶ Difficulties in the delineation of endocardial border owing to well developed trabeculation ▶ Difficulties in the adequate image acquisition owing to the location just behind the sternum

4. Limitations of Echocardiography in The Evaluations of RV Function ▶ Difficult to standardize the evaluation method of RV function : Variations in the direction or location of the RV are common : Easily affected by preload, afterload, or LV function ▶ Different complex contraction-relaxation mechanism among the segments of the RV ▶ Cannot image the entire RV in a single view

5. Function of the Right Ventricle Why should we measure RV function? ▶ RV is not just a conduit of blood flow : has its unique function ▶ Prognostic significance in various clinical settings ▶ Risk stratification or guide to optimal therapy

6. Function of the Right Ventricle ▶ Maintain adequate pulmonary artery perfusion pressure to improve gas exchange ▶ Maintain low systemic venous pressure to prevent congestion of tissues or organs ▶ Affect LV function : limit LV preload in RV dysfunction : Ventricular interdependence ▶ Prognostic significance in various clinical settings

7. 2D and M-mode: RV Area and FAC in A4C ▶ Well correlated with RV function measured by radionuclide ventriculography or MRI ▶ Good predictor of prognosis ▶ Limitations: fail to measure FAC due to inadequate RV tracing Reference range Mild abnormal Moderate abnormal Severe abnormal RV diastolic area (cm 2 ) 11-28 29-32 33-37 ≥ 38 RV systolic area (cm 2 ) 7.5-16 17-19 20-22 ≥ 23 RV FAC (%) 32-60 25-31 18-24 ≤17

8. RV WALL THICKNESS AND CHAMBER SIZE RV INFERIOR WA LL SU B COS T A L VIEW N=<0.5cm Measured at peak r wave

9. 2D and M-mode: Thickness of RV Free Wall ▶ Normal: less than 0.5 cm ▶ Measure at the level of TV chordae and at the peak of R wave of ECG on subcostal view ▶ Well correlated with peak RV systolic pressure

10. RV DIMENTIONS DIAMETERS ABOVE THE TRICUSPID VALVE ANNULUS MID RV CAVITY DISTANCE FROM THE TV ANNULUS TO RV APEX

11. RV DIMENTIONS

12. 2D and M-mode: RV Dimension Reference range Mild abnormal Moderate abnormal Severe abnormal Basal RV diameter (RVD1) 2.0-2.8 2.9-3.3 3 .4-3.8 ≥ 3.9 Mid-RV diameter (RVD2) 2.7-3.3 3.4-3.7 3.8-4.1 ≥ 4.2 Base–to-apex (RVD3) 7.1-7.9 8.0-8.5 8.6-9.1 ≥ 9.2

13. 2D and M-mode: RVOT and PA Size

14. 2D and M-mode: RVOT and PA Size Reference range Mild abnormal Moderate abnormal Severe abnormal RVOT diameters, cm Above aortic v a l ve ( R V O T 1 ) 2.5-2.9 3.0-3.2 3.3-3.5 ≥ 3. 6 Above pulmonic valve(RVOT1) 1.7-2.3 2.4-2.7 2.8-3.1 ≥ 3. 2 PA Diameters, cm Below pulmonic valve (PA1) 1.5-2.1 2.2-2.5 2.6-2.9 ≥ 3.

15. 2D and M-mode: RV Size ▶ Normal RV is approximately 2/3 of the size of the LV ▶ RV Dilatation : appears similar or larger than LV size : shares the apex

16. Right ventricular function assessed by five methods – TAPSE FAC TEI INDEX S’ (Tissue doppler systolic signal velocity of TV lateral annulus) Visual estimation of RV free wall and TV annular motion

17. 2D and M-mode: Fractional Area Change (FAC) (End-diastolic area) – (end-systolic area) x 100 (end-systolic area)

18. Tricuspid Annular Plane Systolic Excursion ▶ Degree of systolic excursion of TV lateral annulus on A4C : 1 .7-2.6 cm in normal : Value less than 1. 7 cm is considered as abnormal ▶ Well correlated with RVEF measured by RVG ▶ Reproducible ▶ Strong predictor of prognosis in patients with CHF

19. R E G IO N A L A SS E SS M E N T O F R I G HT V E N T RICLE : TAPSE

20. Tricuspid Annular Plane Systolic Excursion ※ TAPSE and RV ejection fraction : TAPSE 2cm = RVEF 50% : TAPSE 1. 7 cm = RVEF 4 5 % : TAPSE 1cm = RVEF 30% : TAPSE 0.5cm = RVEF 20% Event free survival according to TAPSE in patients with CHF

21. TISSUE DOPPLER IMAGING An apical four chamber view is used The pulsed Doppler sample volume is placed in either the tricuspid annulus or the middle of the basal segment of the RV free wall The S´ velocity is read as the highest systolic velocity without over-gaining the Doppler envelope Normal > 10 cm/s

22. TISSUE DOPPLER (S´) Advantages A simple, reproducible technique with good discriminatory ability to detect normal versus abnormal RV function Pulsed Doppler is available on all modern systems Maybe obtained and analyzed off-line Disadvantages Less reproducible for nonbasal segments Is angle dependent Limited normative data in all ranges' and in both sexes It assumes that the function of a single segment represents the function of the entire right ventricle

23. RV MPI (TEI INDEX) Ratio between isovolumic time and ejection time RV index of Myocardial Performance Global index of both systolic and diastolic function of the right ventricle IVRT + IVCT ET Normal < 0.40 Normal < 0.55

24. If Heart rate > 100

25. Advantages This approach is feasible in a large majority of subjects The MPI is reproducible It avoids geometric assumptions and limitations of the complex RV geometry The pulsed TDI method allows for measurement of MPI as well as S´, E´, and A´ all from a single image Disadvantages The MPI is unreliable when RV ET and TR time are measured with differing R-R intervals, as in atrial fibrillation It is load dependent and unreliable when RA pressures are elevated

26. RV DIASTOLIC FUNCTION From the apical 4-chamber view, the Doppler beam should be aligned parallel to RV inflow Sample volume is placed at the tips of the tricuspid valve leaflets Measure at held end-expiration and/or take the average of ≥ 5 consecutive beats Measurements are essentially the same as those used for the left side

27. RV DIASTOLIC FUNCTION Variable Lower reference value Upper reference value E (cm/s) 35 73 A (cm/s) 21 58 E/A ratio 0.8 < 2. Deceleration time (ms) 1 2 22 IVRT (ms) 23 73 E’ (cm/s) 8 20 A’ (cm/s) 7 20 E’/A’ ratio 0.5 1.9 E/E’ 2 6

28. RECOMMENDATION Measurement of RV diastolic function should be considered in patients with suspected RV impairment as a marker of early or subtle RV dysfunction, or in patients with known RV impairment as a marker for poor prognosis Transtricupsid E/A ratio, E/E’ ratio, and RA size have been most validated are the preferred measures Grading of RV Diastolic Dysfunction should be done as follows: E/A ratio < 0.8 suggests impaired relaxation E/A ratio 0.8- < 2. with an E/E’ ratio > 6 or diastolic prominence in the hepatic veins suggest pseudonormal filling E/A ratio > 2 . with deceleration time < 120 ms suggests restrictive filling

29. RIGHT ATRIAL ASSESSMENT Apical 4-chamber view Estimation of right atrial area by planimetry The maximum long distance of the RAis from the center of the tricuspid annulus to the superior RA wall, parallel to the interatrial septum A mid RA minor distancve is defined from the mid level of the RA free wall to the interatrial septum perpendicular to the long axis RA area is traced at the end of ventricular systole, excluding the IVC, SVC, and RAA Normal area < 18 cm ²

30. RA PRESSURE DETERMINATION Measurement of the IVC should be obtained at end-expiration and just proximal to the junction of the hepatic veins that lie approximately 0.5 to 3.0 cm proximal to the ostium of the right atrium To accurately assess IVC collapse, the change in diameter of the IVC with a sniff and also with quiet respiration should be measured, ensuring that the change in diameter does not reflect a translation of the IVC into another plane

31. Estimation of RA pressure from IVC diameter IVC SIZE BSA NORMAL 17 mm <1.55 m2 20 mm 1.55-<1.71 m2 21 mm >1.71 m2 IVC COLLAPSE RAP size Normal IVC >50% 05 mm hg Normal IVC <50% 10 mmhg Dilated IVC >50% 15 mmhg Dilated IVC <50% 20 mmhg

32. R V PATHOLOGY RV VOLUME OVERLOAD RV PRESSURE OVERLOAD RV INFARCTION ARVD PULMONARY EMBOLISM CARDIAC TEMPONADE

33. HEMODYNAMIC ASSESSMENT Systolic pulmonary artery pressure Estimated with TR jet velocity using simplified Bernoulli equation ( provided there is no RVOT obstruction ) RVSP = 4(V) 2 +RA pressure Normal peak RVSP is 35 to 36 mmHg assuming RA pressure of 3 to 5 mmHg Note : Measure TR jet velocity from various views to get the highest velocity

34. SYSTOLIC PULMONARY ARTERY PRESSURE

35. HEMODYNAMIC ASSESSMENT Pulmonary artery diastolic pressure ( PADP ) Estimated from velocity of end diastolic pulmonary regurgitant jet using PADP = 4(V) 2 + RA pressure

36. HEMODYNAMIC ASSESSMENT Mean Pulmonary Pressure Can be measured : MAP = 1/3 (SPAP ) + 2/3 ( PADP ) = 0.6.PASP+2.1 =79-0.45.AT = 4(EARLY PR VELOCITY)2+RA PRESSURE

37. EXCEPTION If the transducer is not parallel to the flow to the TR jet ,peak velocity of the jet will be reduced and underestimation of PASP Incorrectly estimating mean RA pressure from the IVC can lead to under or overestimation of pulmonary pressure

38. SUMMARY OF RECOMMENDATIONS FOR THE ASSESSMENT OF RIGHT VENTRICULAR SYSTOLIC FUNCTION Visual assessment provides qualitative evaluation of RV function. Quantitative assessment measures : FAC , TAPSE , Pulsed tissue Doppler S’ and Tei index are reliable , reproducible methods. Combining more than one measure can reliably distinguish normal from abnormal. Strain and strain rate are not routinely recommended.

39. THANK YOU