Scribd Logo
Upload

Welcome to Scribd!

  • 105 views

    RV Dysfunction - Assessment by Echocardiography

    Uploaded by

    Nag Mallesh Rao
    The document discusses various echocardiography techniques for assessing right ventricular (RV) function, which is important for conditions affecting the RV. Standard 2D echo has limitations for the RV due to its complex shape. Tissue Doppler imaging (TDI) of the RV can provide systolic, diastolic, and myocardial performance index (MPI) measurements. Newer deformation imaging such as strain and strain rate may allow more load-independent assessment of RV function compared to other echo techniques, but normal values have not been established. While MRI is considered the gold standard, echo provides a cheaper, more accessible option for evaluating the challenging RV.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    RV Dysfunction - Assessment by Echocardiography

    Uploaded by

    Nag Mallesh Rao
    105 views52 pages
    The document discusses various echocardiography techniques for assessing right ventricular (RV) function, which is important for conditions affecting the RV. Standard 2D echo has limitations for the RV due to its complex shape. Tissue Doppler imaging (TDI) of the RV can provide systolic, diastolic, and myocardial performance index (MPI) measurements. Newer deformation imaging such as strain and strain rate may allow more load-independent assessment of RV function compared to other echo techniques, but normal values have not been established. While MRI is considered the gold standard, echo provides a cheaper, more accessible option for evaluating the challenging RV.

    Original Description:

    RT.VENYTICLE

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document discusses various echocardiography techniques for assessing right ventricular (RV) function, which is important for conditions affecting the RV. Standard 2D echo has limitations for the RV due to its complex shape. Tissue Doppler imaging (TDI) of the RV can provide systolic, diastolic, and myocardial performance index (MPI) measurements. Newer deformation imaging such as strain and strain rate may allow more load-independent assessment of RV function compared to other echo techniques, but normal values have not been established. While MRI is considered the gold standard, echo provides a cheaper, more accessible option for evaluating the challenging RV.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    105 views52 pages

    RV Dysfunction - Assessment by Echocardiography

    Uploaded by

    Nag Mallesh Rao
    The document discusses various echocardiography techniques for assessing right ventricular (RV) function, which is important for conditions affecting the RV. Standard 2D echo has limitations for the RV due to its complex shape. Tissue Doppler imaging (TDI) of the RV can provide systolic, diastolic, and myocardial performance index (MPI) measurements. Newer deformation imaging such as strain and strain rate may allow more load-independent assessment of RV function compared to other echo techniques, but normal values have not been established. While MRI is considered the gold standard, echo provides a cheaper, more accessible option for evaluating the challenging RV.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 52

    RV (Dys)function assessment

    by echocardiography
    Trevor Richens
    Glasgow Sick Kids

    The Forgotten Ventricle

    Importance of RV Function
    Congenital Heart Disease
    Single RV morphology ventricles
    Systemic RVs Senning/Mustard/cTGA
    Post Op ToF

    Acquired Heart Disease


    Ischaemic Heart Disease
    Ventricular Failure
    Pulmonary Hypertension
    Post Heart Transplant

    RV dysfunction
    now known to
    correlate with poor
    outcome

    Single Ventricle

    Senning

    Tetralogy

    RV Structure
    RV wraps
    around LV

    LPA
    RPA

    MPA
    Pulmonary Valve
    RVOT

    SVC
    Infundibulum

    RA

    IVC

    RV

    RV Echo Lx

    RV Sx

    RV echo Standard Views II

    And in infants

    Problems with RV Echo


    Poor windows unless youre <5Kg
    Particularly difficult to see anterior wall

    Difficult to delineate RV cavity


    Coarse trabeculations complicate edge
    detection

    Complex shape prevents simple


    mathematical models
    Pattern of contraction
    Wringing rather than contracting

    Where and What to Measure

    That said
    MRI seen as gold standard limited by:
    Accessibility
    Cost
    Time (anaesthetic)

    Gated radionuclide techniques


    Accessibility
    Cost
    Radiation exposure

    Invasive techniques Contrast ventriculography,


    conductance catheters
    Accessibility
    Cost
    Radiation exposure

    Echo

    Cheap
    Quick (at bed-side)
    Accessible
    Non-invasive
    No radiation exposure

    Right Ventricular Function


    2D
    Tissue Doppler
    Spectral (systolic)
    Colour coded (mean)

    Deformation
    Strain
    Strain rate

    Eyeball Assessment
    Using MRI as gold standard
    22 patients 16.6 +/- 7.1 years
    Eyeball vs. MRI

    Poor ability to assess either RV size or function


    by eyeballing
    Fine
    But: Any method assessing changes in volume is
    dependent on pre/after load so MRI flawed as well

    Still, lots of information there

    M Mode

    Flat or Paradoxical Septum

    Paradoxical Septal Motion


    RV volume Overload

    ASD
    Severe TR
    Severe PR (e.g. post op Tetralogy)
    Partial anomalous pulmonary venous drainage
    (PAPVD)

    Post cardiac surgery to ventricular septum


    Pericardial effusion
    ?RBBB

    Compare to LV

    Severe Branch Pulmonary Stenosis

    Compare to LV

    2D Assessment
    Gross changes can be appreciated
    Quantitative, comparative measurements
    are not possible
    Abnormal septal motion can indicate
    potential pathology

    2D Quantitative Assessment
    Complex shape prevents simple
    mathematical mode
    No easy and reproducible way to measure
    RV function

    TAPSE

    >18mm

    Tricuspid Annular Systolic Excursion


    Measure of RV function
    Correlates with other echo markers of RV
    function
    Predicts survival in PAH

    3D
    Theoretically solves the mathematical
    modelling problem
    As yet unproven
    Echo windows still an issue anterior RV
    wall
    Demarcation of RV cavity still problematic

    Correlation of 3D RV volume echo


    Measurements
    New Phillips 3D software
    system
    Correlated with MRI
    Good results for
    RV ejection fraction
    RV volumes

    Journal of the American College of Cardiology


    Volume 50, Issue 17, 23 October 2007, Pages 1668-1676

    3D plus Contrast
    Eliminates:
    RV modelling issue
    Edge detection

    Still has problem of echo windows


    Remains a volumetric method therefore
    dependent on preload and afterload.

    Diastolic Function
    More difficult to assess than LV
    Preloading varies widely
    E/A ratio not a particularly good indicator
    of RV diastolic function

    Restrictive RV Physiology
    Post Op
    Tetralogy of
    Fallot
    Restrictive
    Cardiomyopathy

    Anterograde diastolic flow with atrial systole (A wave)

    Right Ventricular Echo


    2D

    Tissue Doppler
    Spectral (systolic)
    Colour coded (mean)
    Deformation
    Strain
    Strain rate

    Tissue Doppler Imaging


    Well established for LV function
    Now sufficient data to justify use in
    assessment of RV function
    Good review of the state of play
    Gondi and Dokainish; Echocardiography 2007 24 522-532

    RV Spectral TDi - How


    Apical 4 chamber view
    3 5mm Doppler sample volume
    Position 10mm or so away from the TV
    annulus
    Avoids sampling from cavity or RA due to
    normal movement in cardiac cycle.

    Check Sampling plane is parallel to RV


    free wall

    Spectral TDi

    Sa

    Ea

    Aa
    ET

    IVRT

    IVCT

    Colour Derived TDi


    IVC
    Sa

    Aa
    Ea

    Movement artefact associated with respiration

    RV TDi
    Profile is similar to
    that seen in LV
    Normal values differ
    RV peak Spectral
    velocitys

    Adult

    Child

    Sa

    15.2

    10

    Ea

    15.7

    13

    Aa

    15.2

    8.7

    RV Sa in Adult
    Practice

    Decreased Sa
    velocity (<10cm/sec)
    In LVF
    Reduction correlates
    with high PAp / Lap
    Independent predictor
    of poor outcome in
    CHF

    In Inferior MI
    Predicts RV infarction
    by angiographic/ECG
    criteria
    Predicts cardiac death
    or rehospitalisation

    In pulmonary
    hypertension
    Sa Reduced but not
    shown to be predictive

    Ea and Aa
    Less known
    Aa/Ea ratio correlates with RV end
    diastolic pressure in some pathologies
    Ea reduced in RV pressure loading
    pulmonary hypertension

    Myocardial Performance index


    Marker of Ventricular Dysfunction
    Covers systolic and diastolic dysfunction
    Adds components of systolic and diastolic function
    Isovolemic contraction time (time taken for RV pressure
    to rise and open pulmonary valve)
    Isovolemic relaxation time (time taken for RV pressure
    to fall and allow tricuspid valve to open)

    Expressed as a fraction of ejection time

    Calculation of MPI
    Use CW Doppler (two different cardiac cycles)

    TR

    PA

    MPI = TR - PA
    PA
    (Tei index)

    Calculation of MPI
    Use TDi (Same cardiac cycle)
    By TDi appears to correlate better with clinical
    parameters

    Sa

    Ea

    Aa

    ET
    IVRT

    IVCT

    MPI = IVRT + IVCT


    ET

    RV MPI

    Other Indices
    Acceleration during
    isovolumic contraction
    Reduction correlates
    with poor RV function
    (<2.5m/sec2)
    Relatively unaffected
    by preload and
    afterload

    Can be hard to image


    Looked good in
    animals but not so
    sure in humans

    Assessment of timing

    Off Line TDi

    Effect of biventricular pacing

    Right Ventricular Echo


    2D
    Tissue Doppler
    Spectral (systolic)
    Colour coded (mean)

    Deformation
    Strain
    Strain rate

    Strain and Strain Rate


    All previous measures of RV function are
    preload and afterload dependent
    Filling state
    LV function
    Hypertension

    Strain measures local ventricular wall


    deformation
    Largely independent of loading

    Calculation of SR
    Measures the
    deformation of
    a small area of
    myocardium
    Use TDi to
    determine the
    velocities at
    two different
    points
    Divide the
    difference by
    the distance
    between them

    Problems
    In LV fibre orientation is longitudinal or radial
    In RV fibres are oblique and contraction wringing
    Unclear as yet how this effects the measurements

    Normal values for RV have not yet been validated

    Conclusion
    Useful information can be gleaned from eyeball
    assessment
    Quantitative, comparative data needs careful
    assessment by:
    TAPSE
    MPI
    TDi Sa

    Load independent assessment may be possible


    with strain rate technology
    MRI might be better at the moment

    You might also like