Rv assessment
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The document discusses assessment of right ventricular systolic function. It begins by reviewing the anatomy and physiology of the right ventricle. Assessment techniques are then described, including echocardiography, MRI, and cardiac catheterization. Echocardiography is the main method used, allowing evaluation of dimensions, fractional area change, TAPSE, tissue Doppler imaging, and the myocardial performance index. Global and regional RV function provide important information for evaluating diseases affecting the right ventricle.
Rv assessment
- 1. Right Ventricular Systolic Assessment Dr Joura Vishal 17th August 2016
- 2. Introduction Sir William Harvey , 1616 , first described importance of right ventricular function ̊̊̊̊̊̊̊̊̊̊̊̊̊̊̊̊ Thus the right ventricle may be said to be maid for transmitting blood through the lungs , not for nourishing them ̊̊̊̊̊̊̊̊̊̊̊̊̊̊̊̊ De Motu Cordis Emphasis remained on left ventricle
- 3. Function of right ventricle • Maintain adequate pulmonary perfusion pressure under varying circulatory and loading conditions in order to deliver desaturated venous blood to the gas exchange membranes of the lungs • Maintain a low systemic venous pressure to prevent tissue and organ congestion
- 4. Anatomy of Right Ventricle • Most anteriorly situated cardiac chamber • Lies immediately behind the sternum • Delimited by tricuspid annulus and pulmonary valve
- 5. Anatomy of Right Ventricle: components Three components • Inlet : consists of TV , chordae tendinae, papillary muscles • Trabeculated apex • Infundibulum : the smooth outflow region
- 6. Anatomy of Right Ventricle: components
- 7. Anatomy of Right Ventricle: muscular bands • Parietal band ( along with infundibular septum makes the crista supraventricularis ) • Septomarginal band extends inferiorly to continue as • Moderator band Venriculoinfundibular fold separates TV and PV
- 8. Anatomy of Right Ventricle Shape of RV : triangular in side view and crescent in cross section Septum is concave towards LV and convex towards RV
- 9. RV hemodynamics • Lower impedance , highly distensible pulmonary circulation • RV pressure tracings : early peaking , a rapid declining pressure ( c.f rounded contour of LV ) • RV IVCT is shorter as RVSP rapidly exceeds PADP and flow continues in +nce of negative VA gradient
- 10. RV hemodynamics
- 11. Right ventricular function RV function impaired in • Primary right sided disease • Secondary to left sided cardiomyopathy / valvular heart disease RV function can itself affect LV function • Affecting LV preload • Systolic / diastolic interaction via IVS • Ventricular interdependence
- 12. RV failure : Causes
- 13. RV failure : Causes
- 14. Assessment of right ventricle • Echocardiography including 2D / Tissue doppler imaging / Doppler –pulse wave /colour wave : main stay in RV structure and function 3D echo • MRI : most accurate for RV volume assessment MRI flow studies : calculate flow across AV valves / semilunar ; regurgitant fractions ; shunt fractions; CO
- 15. Assessment of right ventricle • Radionuclide studies • Pressure volume loops • Cardiac catheterization • Pressure volume loops : quantification RV assessment – done with conductance catheter RV elastance ; dP/dT ; ventricular compliance ; stroke work ;
- 16. Assessment of right ventricle Evaluation of RV function is an essential component of clinical management Challenges in RV assessment : • Complex geometry of Right ventricle • Limited definition of RV trabeculated myocardium • Retrosternal position
- 17. Segmental anatomy of RV in echocardiography
- 18. Echocardiographic RV assessment • Done with various views as each view is complimentary to other • Discrepancies in structure and function should be analyzed the echo cardiographer to gather varied information in different views
- 19. Assessment of Right Ventricle
- 26. Right ventricle and Coronary supply
- 27. Right ventricle and Coronary supply • The more proximal occlusion of RCA : more the RV is involved • PDA : affects RV inflow wall only – best seen in RV inflow view • PDA affects the posterior 1/3 rd of the ventricular septum • LAD supplies the RV apex
- 28. Assessment of Right Ventricle RV wall thickness : a useful measurement for RVH Seen in • PAH • Infiltrative and hypertrophic cardiomyopathies • LVH even in absence of PH
- 29. Assessment of Right Ventricle RV wall thickness :measured • End diastole • M mode / subcoastal view Abnormal > 0.5 cm from either view
- 30. RV wall thickness : subcostal view
- 33. RV wall thickness : M Mode
- 34. RV linear dimensions • RV dilates in response to chronic volume and /or pressure overload and RV failure • Indexed RV end diastolic diameter : predictor of survival in COPD Burgess MI et al J Am Soc Echocardiogr 2002 • RV / LD end diastolic diameter ratio : predictor of adverse clinical events and /or hospital survival in acute PE Quiroz R et al Circulation 2004
- 35. RV linear dimensions • 4 chamber view at end diastole Qualitatively • RV appears smaller than LV • Not more than 2/3 rd of size of LV • Not an apex forming ventricle Note : avoid 5 chamber view for RV linear dimensions
- 36. RV linear dimensions • Basal diameter : maximal short axis diameter in basal 1/3 rd of RV seen on 4 chamber view ( URL is 4.2 cm ) • Mid cavity diameter : middle third of RV at level of papillary muscles • Longitudinal diameter : from plane of tricuspid annulus to RV apex Basal diameter serves as a standard for interstudy comparisons
- 38. RVOT • Include the sub pulmonary infundibulum , or conus and the pulmonary valve • sub pulmonary infundibulum : extends from crista semilunaris to pulmonary valve Importance • First segment to show diastolic inversion in cardiac temponade • Congenital heart disease and arrhythmias
- 39. RVOT Best view • Left parasternal • Subcostal Measured at end diastole on the QRS deflection In short axis measure : RVOT prox : anterior aortic wall to RV free wall RVOT distal : just proximal to Pulmonary valve
- 40. RVOT proximal
- 41. RVOT distal • Used to calculate stroke volume for calculation of Qp/Qs or regugitant fraction • Most reproducible • Important is case for ARVD • URL : PLAX ( 33mm) ; PSAX ( 27mm)
- 42. Fractional area change • Defined as EDA –ESA / EDA X 100 • Correletes with RV EF measured by MRI Anavekar NS et al Echocardiography 2007 • Quantitatively estimation of RV function • Lower reference value is 35%
- 45. RV dilatation RV cavity dilation can be seen as • Base to apex lengthening • Free wall to septum with RV apex progressively replacing the LV as true apex In PSAX LV assumes a D shaped cavity Predominantly end diastole : volume overload Predominantly end diastole : pressure overload
- 46. RV dilation Eccentricity index : ratio of LV anteroposterior diameter and septolateral diameter Eccentricity Index >1.0 : signifies RV dilatation
- 48. Hemodynamic Assessment • Systolic pulmonary artery pressure • PA diastolic pressure • Mean PA pressure • Pulmonary vascular resistance • Measurement of PA pressure during exercise
- 49. 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+RA pressure • Normal peak RVSP is 35 to 36 mmHg assuming RA pressure of 3 to 5 mmHg Note : Measure TR jet velocity from various views to get the highest velocity
- 50. Systolic Pulmonary artery pressure
- 51. Hemodynamic Assessment Pulmonary artery diastolic pressure ( PADP ) • Estimated from velocity of end diastolic pulmonary regurgitant jet using PADP = 4(V)2+ RA pressure
- 52. Hemodynamic Assessment Mean Pulmonary Pressure Can be measured : • MAP = 1/3 (SPAP ) + 2/3 (PADP) • Using pulsed Doppler of Pulmonary artery using AT MAP = 79-(0.45XAT ) Note : shorter the AT (measured from the onset of Q wave on ECG to onset of peak pulmonary flow velocity ) , the higher the PVR and hence the PAP
- 53. Hemodynamic Assessment Pulmonary vascular resistance • Elevation in SPAP does not imply high PVR • As pressure = flow X resistance • It distinguishes elevated SPAP due to high flow vs due to high vascular resistance. • Measured as ratio of peak TR velocity( in m/s) to RVOT velocity time integral ( in cm ) Note : valid for PVR <8 Wood unit , not a substitute for invasive measurement
- 54. Hemodynamic Assessment Measurement of PAP during exercise • Exercise increase the stroke volume and decrease PVR • Normal <43mmHg • aged >55yrs and athletes 55 to 60mmHg • IN COPD and CHD patients this decrease in PVR may be limited
- 55. Hemodynamic Assessment • In patients with dyspnea of unknown origin and with normal CAG and normal resting Echocardiography this exercise induced changes in PAP can be a useful measure • Stress echocardiography is performed to estimate the stress induced PH • An upper limit of 43 mmHg is used
- 56. Non volumetric assessment of Right Ventricle • Global assessment of RV • Regional assessment of RV inward bellow movement due to superficial circumferential muscle fibres base to apex contraction inner longitudinal fibers ( play a major role in RV c.f LV )
- 57. Global Assessment of Right Ventricle – Myocardial performance index – RV dp/dT – Right ventricular ejection fraction ( RVEF ) – Fractional area change ( FAC )
- 58. Global Assessment of Right Ventricle RV dP/dT Developed by Gleason and Braunwalds in 1962 • Rate of pressure rise in ventricles ( dP) versus time • Calculated as time required for the TR jet to increase in velocity from 1 to 2 m/s • Equals to 12mmHg divided by time Values <400mmHg/s is abnormal Note : load dependent ; cannot be used in severe TR
- 59. Global Assessment of Right Ventricle Myocardial performance index ( also called Tei index ) • Ratio of isovolumic time to ejection time i.e RIMP = IVCT +IVRT / ET Measured by • Pulsed doppler • Tissue doppler
- 60. Global assessment of RV : Tei Index Pulsed Doppler • RV outflow time ET : Time from onset to cessation of flow across RVOT • Tricuspid closure opening time ( TCO ) time from end of transtricuspid A wave to beginning of transtricuspid E wave Ejection time doesnot include IVCT and IVRT
- 61. Tei Index : TDI • Calculation of all times are done across a single beat
- 62. Tei index : TDI
- 63. IVCT /IVRT
- 64. Tei index
- 65. Tei Index : Tissue Doppler
- 66. Tei Index • Prognostic value • Changes across time has relation with clinical status Seebag I et al Am j Cardio 2001 • URL 0.40 by pulsed doppler and 0.55 by TDI • Note : Unreliable when RA pressures are elevated as there is more equilibration of pressures between RV and RA , shortening of IVRT hence inappropriately low Tei index
- 67. Regional Assessment Of Right Ventricle – TAPSE or tricuspid annular motion – Doppler tissue imaging – Myocardial acceleration during isovolumicv contraction – Regional RV strain
- 68. Regional Assessment Of Right Ventricle : TAPSE • Measure the systolic excursion of RV annular segment along its longitudinal plane • Assunption: displacement of basal and adjacent segment in representative of entire RV function • Measured across TV annulus in M mode
- 69. Regional Assessment Of Right Ventricle : TAPSE Correlates with radinuclide angiography Kaul et al Am Heart J
- 70. Regional Assessment Of Right Ventricle : TDI • Most reliable and reproducible region of RV are tricuspid annulus and basal free wall segment • measures the longitudinal velocity of excursion termed a S’ • S’ by pulsed TDI < 10cm/s is abnormal • Simple reproducible technique but less reliable for non basal segments and it is angle dependent
- 72. Regional Assessment Of Right Ventricle : TDI
- 73. RV strain / strain rate • Defined as percentage change in myocardial deformation • Strain rate is rate of deformation of myocartdium over time • Mainly for basal , mid and to a lesser degree apical segments of RV free wall • Less load dependent and applicable across broad range of pathologies
- 76. Clinical and prognostic significance • Conditions such as Acute PE cause increase in RV size prior to augmentation of pulmonary pressures • Quantitative assessment can guide us more towards quality of life and adds information for functional outcome
- 77. Conclusion • Visual assessment provides qualitative evaluation of RV • Quantitative assessment measures : FAC , TAPSE , Pulsed tissue Doppler S’ and Tei index are reliable , reproducible methods • Combining more than one measure can reliably distinguish normal from abnormal • Strain / strain rate , IVA are not routinely recommended