Echocardiographic assument of RV function

1. ECHOCARDIOGRAPHIC
ASSESSMENT OF RIGHT
VENTRICULAR FUNCTION

2. • RV dysfunction is associated with excess morbidity and mortality in patients with
1. chronic left-sided heart failure,
2. acute myocardial infarction (with or without RV involvement),
3. pulmonary embolism,
4. pulmonary arterial hypertension, and
5. congenital heart disease

3. RIGHT VENTRICULAR ANATOMY AND PHYSIOLOGY
• Composed of three portions:
 the inlet,
 the body, and
 the outflow tract.

4. • Contraction is generated by a deep layer of longitudinal fibers that result in longitudinal (base to apex)
shortening, and a superficial layer of circumferential fibers that result in inward thickening
• The RV lacks a third layer of spiral fibers as seen in the left ventricle.
• RV ejection is accomplished with a mass that is approximately one-fifth that of the left ventricle.

5. RA SIZE
1. RA major-axis
dimension indexed to
BSA : ≤3.0 cm/m2 in
men and
≤3.1 cm/m2 in women
2. RA area is measured
by planimetry : RA
area is ≤18.5 cm2

6. RIGHT
VENTRICULAR
1. RV area : RV end-
diastolic area is ≤24
cm2 in men and ≤20
cm2 in women
2. RV linear dimensions :
RV basal dimension
and RV mid-cavity
dimension ≤4.1 and
≤3.5 cm

7. RIGHT
VENTRICULAR
1. RVOT dimension : parasternal
long-axis or parasternal short-axis
view are ≤3.3 and ≤3.5 cm, distal
RVOT diameter is ≤2.7 cm .
2. RV volume : RV end-diastolic
volume indexed to BSA are
≤87 mL/m2 in men and
≤74 mL/m2 in women .
3. Wall thickness : RV free wall in
diastole is approximately 3 to 4
mm thick; if it exceeds 5 mm, it is
considered hypertrophied

8. LIMITATIONS OF ECHOCARDIOGRAPHY IN
THE EVALUATIONS OF RV FUNCTION
• Difficultiesin the estimationof RVvolume
• crescentic shape of RV
• separation between RV inflow andoutflow
• no uniform geometric assumption for measuringvolume
• Difficultiesin thedelineationof endocardial borderowingto
• well developed trabeculation
• Difficultiesin theadequateimageacquisitionowingto the
• location just behind thesternum

9. • Difficult to standardize the evaluation method of RVfunction
• Variations in the direction or location of the RV arecommon
• Easily affected by preload, afterload, or LVfunction
• Different complex contraction-relaxation mechanism among the segments of the RV
• Cannot image the entire RV in a single view

10. PARAMETERS IN ASSESSING RV SYSTOLIC FUNCTION
1. Tricuspid annular plane systolic excursion
2. Tricuspid annular velocity
3. Fractional area change
4. Myocardial performance index
5. RV ejection fraction by 3D
6. Strain imaging by 2D
7. RV Diastolic function

11. TRICUSPID ANNULAR PLANE SYSTOLIC EXCURSION
NORMAL MILD MODERATE SEVERE
17-20 mm 16-13mm 12-10 mm Less than
10 mm

12. Common sources of error with
TAPSE are:
1. Not placing the M-mode cursor
parallel to the plane of
longitudinal motion, which
results in angle-dependent
underestimation of TAPSE.
2. Incorrectly measuring the
magnitude of displacement
from the M-mode image

13. TRICUSPID ANNULAR VELOCITY
• Reflects the longitudinal displacement of the tricuspid annulus during systole, S’ reflects the
longitudinal velocity of the tricuspid annulus during systole
• S’ is measured in the apical four-chamber view by placing a tissue Doppler cursor on the lateral
tricuspid annulus and measuring the peak velocity of this reference point during systole
• normal reference limit being an S’ of ≥9.5 cm/s

15. TISSUEDOPPLER(S´)
Advantages
• A simple,reproducible techniquewith good
discriminatory ability to detect normal
versusabnormalRV function
• PulsedDopplerisavailableon all
modern systems
• Maybeobtainedandanalyzedoff-line
Disadvantages
• Lessreproduciblefor nonbasal segments
• Is angledependent
• Limitednormativedatainal ranges'and in
both sexes
• It assumes that the function of a single
segment represents the function of the entire
rightventricle

16. FRACTIONAL AREA CHANGE
• Percent change in RV area from diastole to systole,
• FAC = [(end-diastolic RV area – end-systolic RV area) / end-diastolic RV area] x 100
• the primary challenge and main limitation of FAC is the accurate identification and tracing of the true
RV endocardial border rather than the prominent trabeculations and muscle bands

17. • SAVE and VALIANT trials
• Four independent predictors of subsequent all-cause mortality were identified:
1. age,
2. Killip classification,
3. LV ejection fraction, and
4. FAC; with FAC <35 percent
• adjusted hazard ratio of 3.56 (95% CI 1.07-11.90).

18. MYOCARDIAL PERFORMANCE INDEX
• RV index of myocardial performance (RIMP) or RV Tei index
• systolic and diastolic function of the RV
• MPI is based on time intervals and is independent of chamber geometry and contraction pattern
• MPI = (isovolumetric relaxation time + isovolumetric contraction time) / ejection time = (tricuspid
closure-to-opening time – ejection time) / ejection time

21. ADVANTAGES
• Thisapproachis feasibleinalarge
majorityofsubjects
• The MPI is reproducible
• It avoids geometric assumptionsand
limitations ofthe complex RV geometry
• The pulsedTDI method allows for measurement of
MPI aswel asS´,E´,and A´al from a single image
DISADVANTAGES
• TheMPI isunreliablewhenRVETandTR time
are measuredwith differing R-R intervals,as in
atrial fibrillation
• It is load dependent andunreliable when RA
pressures are elevated

22. RV EJECTION FRACTION BY 3D
• normal reference limit for 3D-
derived RVEF is ≥45 percent

23. STRAIN IMAGING BY 2D
• Strain is defined as the percent change in
myocardial deformation
• Strain is currently measured principally by
the speckle-tracking approach
• The normal reference limit for speckle-
tracking strain of the RV free wall is -23
percent

24. RV DIASTOLIC FUNCTION
• Fromtheapical4-chamberview,theDoppler beamshould be alignedparallel to RVinflow
• Samplevolumeisplacedatthetipsof thetricuspidvalveleaflets
• Measureatheldend-expirationand/or taketheaverageof≥5consecutivebeats
• Measurementsareessentiallythesameasthoseusedfor theleftside

25. • MeasurementofRVdiastolicfunctionshouldbeconsideredinpatientswithsuspectedRV
impairment asamarkerofearlyor subtleRVdysfunction,or inpatientswithknownRV impairment
asamarkerfor poor prognosis
• TranstricupsidE/Aratio,E/E’ratio,andRAsizehavebeenmostvalidatedarethepreferred
measures

26. • Grading of RV Diastolic Dysfunction should be done as follows:
• E/A ratio <0.8 suggests impaired relaxation
• E/A ratio 0.8-< 2.0 with an E/E’ ratio >6 or diastolic prominence in the hepatic veins suggest Pseudo-
normal filling
• E/A ratio >2.with deceleration time <120ms suggests restrictive filling

27. RIGHT VENTRICULAR WALL MOTION ASSESSMENT
• Apical four chamber view for lateral wall
• Parasternal RV inflow view for anterior and inferior wall
• Parasternal short axis view for infundibulum
• McConnell sign

29. INTERVENTRICULAR SEPTAL SHAPE
• A D-shaped left ventricular cavity (also referred to as a flattened interventricular septum) in systole
(particularly end-systole) suggests right ventricular (RV) pressure overload,
• a D-shaped left ventricular cavity in diastole suggests RV volume overload

30. RIGHT VENTRICULAR ECCENTRICITY INDEX

32. HEMODYNAMICS
• RA pressure :
 Indicator of volume status and responsiveness to fluid challenge in critically ill patients
 sensitive diagnostic sign in patients with suspected cardiac tamponade or other pericardial syndromes
 part of the echocardiographic estimation of pulmonary artery pressure

33. • RAP is most commonly estimated based on the diameter and degree of collapse of the inferior vena
cava (IVC) imaged from the subcostal view during quiet inspiration and during rapid inspiration ("sniff")

34. • Normal RAP (3 mmHg): IVC diameter ≤2.1 cm and collapse during sniff >50 percent.
• Intermediate RAP (8 mmHg): IVC diameter ≤2.1 cm and collapse during sniff <50 percent or IVC
diameter >2.1 cm and collapse during sniff >50 percent.
• Elevated RAP (15 mmHg): IVC diameter >2.1 cm and collapse during sniff <50 percent.

35. PULMONARY ARTERY PRESSURE
• PASP ≈ RVSP = 4(peak TRV2) + RAP

36. OTHER MEASURES OF PULMONARY ARTERY PRESSURE
• Mean PAP = 4V2
early PR velocity + RAP
• Mean PAP = 79 – [(0.45) (Acceleration time)]
• Mean PAP = VTI of the TR jet + RAP
• Mean PAP = 0.61 x PASP + 2
• Systolic PAP = 10[(-0.004)(Acceleration time) + 2.1]
• Diastolic PAP = 4V2
end PR velocity + RA