echo assessment RV function by dr amit (1).pptx

RV aseessment and its functions

1. Echo assessment of RV function Presenter: Dr. Amit Pandey DM Cardiology Resident SPMC ,BIKANER

2. Introduction RV function is strongly associated with clinical outcomes although being neglected Limited data regarding the normal dimensions of the right ventricle because of its complex shape. Thin walled pyramidal structures, wraps around LV Composed of 3 distinct portions: Smooth muscular inflow (body) Outflow region Trabecular apical region.

3. Additional unique structures to RV: Crista supraventricularis Prominent trabeculations Moderator band RV volume > LV volume RV mass = 1/6 th of LV mass

4. Segment nomenclature & coronary supply of RV walls

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

7. RV Wall Thickness U seful measurement for RVH (Pressure overload) ↑ RV wall thickness - can be seen in infiltrative and hypertrophic cardiomyopathies M easured at end-diastole by m-mode or 2d echo from the subcostal window, preferably at the level of the tip of the anterior tricuspid leaflet or left parasternal windows when there is significant thickening of the visceral pericardium, measurement of the RV wall may be challenging.

8. C ertain conditions are associated with RV wall thinning - ARVD N o accepted echo criteria to define an abnormally thin RV wall.

9. Normal: less than 0.5 cm Measure at the level of TV chordae & at the peak of R wave of ECG on subcostal view Well correlated with peak RV systolic pressure

10. RV Wall Thickness…. Advantages: Can be measured by M-mode or 2D echocardiography from either the subcostal or left parasternal window. Disadvantages: Lack of established prognostic information

11. RV DIMENSIONS Using 2D echocardiography, RV size can be measured from a 4-chamber view obtained from the apical window at end-diastole Taken at 3 levels: Diameters above the tricuspid valve annulus Mid RV cavity Distance from the TV annulus to RV apex

12. RV DIMENSIONS RV dilation: Basal > 4.2 cm Mid: > 3.5 cm Longitudinal: > 8.6 cm

13. RV DIMENSIONS … Advantages: Easily obtained on an apical 4-chamber view Markers of RV dilatation. Disadvantages: Highly dependent on probe rotation by the user, which can result in an underestimation of RV width.

14. 2D and M-mode: RVOT Size Best viewed from the left parasternal and subcostal windows Size of the RVOT measured at end-diastole on the QRS deflection. In PLAX view, a portion of the proximal RVOT can be measured (RVOT- Prox )

15. In PSAX, RVOT linear dimension measured from Anterior aortic wall to the RV free wall above the aortic valve (RVOT- Prox ) & Just proximal to the pulmonary valve (RVOT-Distal) PLAX view of RVOT - used in evaluation for ARVD

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

17. RV Area and FAC Endocardial border is traced A4C views from the tricuspid annulus along the free wall to the apex, then back to the annulus, along the interventricular septum at end-diastole (ED) and end-systole(ES). Trabeculation, tricuspid leaflets, and chords are included in the chamber.

18. RV Area and FAC Normal FAC >35%. End diastolic area – End systolic area 100 End diastolic area

19. TAPSE or Tricuspid Annular Motion (TAM) TAPSE or TAM is a method to measure the distance of systolic excursion of the RV annular segment along its longitudinal plane, from a standard apical 4-chamber window. Acquired by placing an M-mode cursor through the tricuspid annulus & measuring the amount of longitudinal motion of the annulus at peak systole TAPSE <16mm → RV dysfunction

20. TAPSE… Advantages: Simple, less dependent on optimal image quality, and reproducible Does not require sophisticated equipment or prolonged image analysis. Disadvantages: Assumes that the displacement of a single segment represents the function of a complex 3D structure. It is angle dependent, and there are no large-scale validation studies. Finally, TAPSE may be load dependent.

21. RIMP or Tei index Global estimate of both systolic and diastolic function of the right ventricle. Based on the relationship between ejection and non ejection work of the heart Obtained by two methods: the pulsed Doppler method & the tissue Doppler method.

22. RIMP or Tei index The upper reference limit RIMP is 0.40 using the pulsed Doppler method & 0.55 using the pulsed tissue Doppler method. IVCT + IVRT ET

23. Advantages: Feasible in a large majority of subjects both with and without TR Reproducible Avoids the geometric assumptions and limitations of complex RV geometry. Disadvantages: Unreliable when RV ET and TR time are measured with differing R-R intervals, as in atrial fibrillation. It is load dependent & unreliable when RA pressure is elevated.

24. 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

25. Normal > 10 cm/s

26. TISSUE DOPPLER IMAGING 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 non basal 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

27. 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

28. 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 ) 120 220 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

29. 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: Impaired relaxation E/A ratio < 0.8 Pseudonormal filling E/A ratio 0.8-< 2.0 with an E/E’ ratio > 6 or diastolic prominence in the hepatic veins Restrictive filling E/A ratio > 2.1 with deceleration time < 120 ms

30. RIGHT ATRIAL ASSESSMENT Apical 4-chamber view Estimation of right atrial area by planimetry The maximum long distance of the RA is from the center of the tricuspid annulus to the superior RA wall, parallel to the interatrial septum A mid RA minor distance 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 RA Enlargement: Area > 18 cm2 Length (major dimension) > 53mm, Diameter (minor dimension) > 44mm

31. 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

32. Estimation of RA pressure from IVC diameter Variable Normal (0-5 [3] mm Hg) Normal (0-5 [3] mm Hg) Intermediate (5-10 [8] mm Hg) High (15mm) IVC diameter ≤ 2.1 cm ≤ 2.1 cm >2.1 cm >2.1 cm Collapse with sniff >50% <50% >50% <50% Secondary indices of elevated RA pressure Restrictive filling Tricuspid E/E0 > 6 Diastolic flow predominance in hepatic veins (systolic filling fraction < 55%) Ref: ASE 2010

33. RV PATHOLOGY 1. RV VOLUME OVERLOAD 2. RV PRESSURE OVERLOAD 3. RV INFARCTION 4. ARVD 5. PULMONARY EMBOLISM 6. CARDIAC TEMPONADE

34. 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+RApressure Normal peak RVSP is 35 to 36mmHg assuming RA pressure of 3 to 5mmHg Note : Measure TR jet velocity from various views to get the highest velocity

35. SYSTOLIC PULMONARY ARTERY PRESSURE

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

37. HEMODYNAMIC ASSESSMENT Mean Pulmonary Pressure can be measured : MAP = 1/3 (SPAP ) + 2/3(PADP) MPAP = 4(Peak velocity of PR jet)+RA PRESSURE

38. 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