ECHOCARDIOGRAPHIC ASSESSMENT OF RIGHT VENTRICULAR SIZE AND FUNCTION

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ECHOCARDIOGRAPHIC ASSESSMENT OF RIGHT
VENTRICULAR SIZE AND FUNCTION
AZIENDA OSPEDALIERO-UNIVERSITARIA S. MARIA DELLA
MISERICORDIA DI RILIEVO NAZIONALE E DI ALTA
SPECIALIZZAZIONE UDINE DIPARTIMENTO DI SCIENZE
CARDIOPOLMONARI S.O.C. Cardiologia Direttore
Paolo M. Fioretti
DENISA MURARU, MD
Prof. Dr. C.C. Iliescu Institute of
Cardiovascular Diseases, Bucharest, Romania
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RIGHT VENTRICLE the neglected neighbour of the
left
Not anymore!
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RIGHT VENTRICLEAnatomy

• 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)
(difficult edge detection)
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ECHO ASSESSMENT OF RIGHT VENTRICLE
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ECHO ASSESSMENT OF RIGHT VENTRICLE
D
M-mode
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ECHO ASSESSMENT OF RIGHT VENTRICLE
- 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 et
al. Am Heart J 1984 Lopez-Candales A et al. Am J
Cardiol 2006
TAPSE lt18 mm RV systolic dysfunction
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ECHO ASSESSMENT OF RIGHT VENTRICLE

• RV diameters are influenced by RV shape, RV
  rotation in the chest, patient position

- relative comparison RV vs LV from 4C is
useless when LV is enlarged too
- in RV volume overload, RV is frequently
foreshortened in apical 4C view
Jiang L et al. Echocardiography 1997
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ECHO ASSESSMENT OF RIGHT VENTRICLE
Diastole

• tedious
• poor reproducibility
• - depends on high image quality for accurate
  border detection

Systole
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ECHO ASSESSMENT OF RIGHT VENTRICLE

• Area-Length method
• underestimates RV volume by 60-65 with respect
  to angiography
• Simpsons rule
• assumes 2 (non-verifiable) orthogonal views and
  elliptic symmetry of RV
• the selected views often do not include
  infundibulum, lack in internal landmarks or
  adequate free wall definition

Jiang L et al. Echocardiography 1997
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ECHO ASSESSMENT OF RIGHT VENTRICLE

• Doppler index of global RV function
• Incorporates elements of both systolic and
  diastolic phases
• Normal values 0.28 0.04
• (increased Tei index RV dysfx)
• Limitation ? RA pressure ?Tei index due to
  shortened IVRT

Tricuspid inflow
Tei C et al. JACC 1996 Yoshifuku S et al. Am J
Cardiol 2003
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ECHO ASSESSMENT OF RIGHT VENTRICLE

• Smaller evidence
• Advantage simpler, more rapid assessment of RV
  fx based on same cycle measurements

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ECHO ASSESSMENT OF RIGHT VENTRICLE

• Simple TDI parameter for RV systolic fx
• Normal values
• Sm 14 2 cm/sec for spectral TD
• Sm 10 2 cm/sec for color TD

Sm
Gondi S. Echocardiography 2007
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ECHO ASSESSMENT OF RIGHT VENTRICLE

• Evidence-based importance in various conditions
• (e.g. RV involvement in acute inferior MI,
  independent predictor of outcome in LVHF etc)
• Limitations
• One-dimensional evaluation of only RV basal
  segment
• Tricuspid valve disease (TS, significant TR,
  annuloplasty etc)
• Nonsinus rhythm (TDI not validated)
• Technical pitfalls (alignment, tethering,
  spectral broadening)

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ECHO ASSESSMENT OF RIGHT VENTRICLE
State-of-the-Art

• RV fx assessment - still elusive in clinical
  practice
• Integrated approach based on multiple parameters
• Need for additional simple and reproducible
  parameters
• - to allow accurate quantitative comparisons
  between pts or serially within a given
  patient
• - to outline the subtle changes in response to
  treatment and to guide specific therapy
• - to improve communication with clinicians.

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ECHO ASSESSMENT OF RIGHT VENTRICLE

• Angle-independent method based on routine 2D
  images
• Rapid and sensitive measure of global and
  segmental longitudinal RV deformation
• Provides both amplitude and timing (RV
  dyssynchrony)

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ECHO ASSESSMENT OF RIGHT VENTRICLE

• Actual 3D acquisition
• Easily repeatable
• No geometric assumptions
• Validated against CMR
• Handheld transducer, portable equipments
  also available
• Dynamic reconstructed 3D images of beating
  heart
• Rapid spatial appreciation from multiple
  perspectives
• Provides RV volumes, stroke volume and ejection
  fraction

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ECHO ASSESSMENT OF RIGHT VENTRICLE

• Dedicated training and learning curve
• Off-line measurements
• Cumbersome to apply in daily routine practice
• Patient cooperation for dataset acquisition
  during breathhold
• Depends on image quality
• (Limited acoustic access in small pts)
• (Arrhythmias)
• (Cost)

Tricuspid valve
Pulmonary valve
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RV 3D dynamic reconstruction (beutel) and
quantitation
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RIGHT VENTRICULAR ASSESSMENT
GOLD STANDARD Cardiac MR PROs - High image
quality - Highly reproducible -
Noninvasive - No geometric assumptions CONs
- Expensive, not widely available technique -
Lack of portability - Time consuming -
Impossible in patients with metallic devices
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RV assessment RT3DE vs CMR validation studies
- Study group 13 children with operated CHD
Close correlation with CMR results

• Older generation internally rotating omniplane
  transducer
• Manually tracing of endocardial border,
  summation of volumetric slices

Papavassiliou DP et al. J Am Soc Echocardiogr 1998
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RV assessment RT3DE vs CMR validation studies

• RT3DE versus 2DE (AL, Simpson, 2DS) and CMR (50
  pts with AMI and suspected RV involvment)
• Modified apical window, semi-automated border
  detection

• EF estimations were similar using each
  technique volumes were slightly underestimated
  by RT3DE and greatly by any other 2DE
• RT3DE showed less of a difference from MRI than
  any of the 2DE techniques
• RT3DE had less test-retest variation of RV
  volumes and EFs than any 2DE measurements
  (Simpson the least reproducible!)

Jenkins C et al. Chest 2007
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RV assessment RT3DE vs CMR validation studies
- 3D semi-automated RV analysis software for
anatomically oriented assessment of RV volumes
(16 pts with congenital HD, 14 normals)
Good intra- and interobs variability lt 3 and 10
Niemann PS et al . J Am Coll Cardiol 2007
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RIGHT VENTRICULAR ASSESSMENT Comparison of Echo
Techniques

• Methods
• Subjects
• 1. Study group
• Patients (46) with various heart diseases
• Normal subjects (12)
• 2. Validation group (13 pts) underwent 3DE and
  CMR 1hour apart
• All subjects were studied during the same visit
  with 2DE and 3DE

Badano LP et al. G Ital Cardiol 2009 (abstr)
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RIGHT VENTRICULAR ASSESSMENT Comparison of Echo
Techniques

• Methods
• 2D measurements of RV size and function were
  performed according to EAE/ASE guidelines
• Right ventricular volumes and ejection fraction
  were measured using the 4D RV function analysis
  software (TomTec, Unterschleissheim, Germany)

Badano LP et al. G Ital Cardiol 2009 (abstr)
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RIGHT VENTRICULAR ASSESSMENT Comparison of Echo
Techniques Results
Badano LP et al. G Ital Cardiol 2009 (abstr)
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RIGHT VENTRICULAR ASSESSMENT Comparison of Echo
Techniques

• Results Validation Group

Badano LP et al. G Ital Cardiol 2009 (abstr)
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RIGHT VENTRICULAR ASSESSMENT Comparison of Echo
Techniques

• Results 3D RVEF vs FAC and TAPSE

r 0.32
r 0.30
Badano LP et al. G Ital Cardiol 2009 (abstr)
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RIGHT VENTRICULAR ASSESSMENT Comparison of Echo
Techniques

• Results RV size

r 0,59
r 0,65
Badano LP et al. G Ital Cardiol 2009 (abstr)
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RIGHT VENTRICULAR ASSESSMENT Comparison of Echo
Techniques

• Results RV size

r 0,53
r 0,48
EDDbas
EDDmed
Badano LP et al. G Ital Cardiol 2009 (abstr)
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RIGHT VENTRICULAR ASSESSMENT Comparison of Echo
Techniques

• CONCLUSIONS
• 3DE provides an accurate measurement of RV
  volumes in comparison to CMR
• Conversely, due to the complex structural
  geometry of the RV, M-mode and 2D parameters
  provide only a rough estimate of actual RV size
  and function
• Performance of M-mode and 2D parameters prevents
  their use for clinical decision making in the
  single patient.

Badano LP et al. G Ital Cardiol 2009 (abstr)
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Case 1
Case 2
Case 3
TAPSE 18 mm
TAPSE 24 mm
TAPSE 18 mm
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Case 1
Case 2
Case 3
EDV 77ml ESV 28ml RVEF 64
EDV 140ml ESV 68ml RVEF 52
EDV 113ml ESV 78ml RVEF 31
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Case 1
Case 2
Case 3
dyssynchronous
synchronous
synchronous
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To summarize

• RT3DE may complement routine 2D assessment
  of RV providing more accurate volumetric
  information
• Newer semi-automated contour detection program
  designed specifically for the RV works fairly
  rapid, accurate and with reassuring
  reproducibility
• As with any other new method, future will
  ultimately certify its clinical benefits