![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](https://image.slidesharecdn.com/assessmentofrvfunction-190811072307/85/Assessment-of-rv-function-16-320.jpg)
![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](https://image.slidesharecdn.com/assessmentofrvfunction-190811072307/85/Assessment-of-rv-function-36-320.jpg)
Assessment of rv 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