Incorporating the New Echo Guidelines Into Everyday Practice

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2 Incorporating the New Echo Guidelines Into Everyday Practice Clinical Case RIGHT VENTRICULAR FAILURE Gustavo Restrepo MD President Elect Interamerican Society of Cardiology Director Fellowship Training in Echocardiography. CES University/Clínica Medellín ACC Colombia Chapter Governor Medellín, Colombia

3 Disclosure Information I will not discuss off label use or investigational use in my presentation I have no financial relationships to disclose

4 Clinical Case 65 years old male, farmer 2 years history of progressive dyspnea, fatigue, severe exercise intolerance PMH: severe COPD PE: BP 120/70 HR 90, RR 20, Sa0 2 90% Neck veins distended, bilateral hypoventilation, systolic murmur (tricuspid area), bilateral leg oedema

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13 J Am Soc Echocardiogr 2015;28:1-39

14 Apical 4-chamber Focused Apical 4-chamber RV Modified Apical 4-chamber

15 27±4mm 33±4mm 25±2mm 28±3.5mm 22±2.5mm

17 RV systolic function evaluation FRACTIONAL AREA CHANGE (FAC) S WAVE OF THE TRICUSPID ANNULUS (S ) TRICUSPID ANNULAR SYSTOLIC EXCURSION (TAPSE) RV INDEX OF MYOCARDIAL PERFORMANCE (RVIMP, TEI INDEX) RV EJECTION FRACTION 3D EVALUATION LONGITUDINAL STRAIN AND STRAIN RATE

18 Global Assessment of RV function MYOCARDIAL PERFORMANCE INDEX (MPI) RV dp/dt RV EJECTION FRACTION FRACTIONAL AREA CHANGE (FAC)

19 RIGHT VENTRICULAR INDEX OF MYOCARDIAL PERFORMANCE (RIMP) Ratio of isovolumic time divided by et (IVRT + IVCT) / ET Tissue Doppler of the tricuspid annulus ABNORMAL FINDING > 0.55 (Tissue Doppler) MPI = 0.86

20 RIGHT VENTRICULAR INDEX OF MYOCARDIAL PERFORMANCE (RIMP) LIMITATIONS ATRIAL FIBRILATION MPI has been demonstrated to be unreliable when RA pressure is elevated, shortening the IVRT and resulting in an inappropriately small MPI. It should not be used with irregular heart rates.

RV dp/ dt numerator is 15 mmhg dt = 35 ms + 50 + dp/dt :15/35 = 428 mmhg/s Recommendations: Because of the lack of data in

21 RV dp/ dt numerator is 15 mmhg dt = 35 ms dp/dt :15/35 = 428 mmhg/s Recommendations: Because of the lack of data in normal subjects, RV dp/dt cannot be recommended for routine uses. It can be considered in subjects with suspected RV dysfunction.

22 RV FRACTIONAL AREA CHANGE (%) 100 X (END DIASTOLIC AREA END SYSTOLIC AREA)/ END DIASTOLIC AREA Abnormal RV Systolic function FAC < 35% ED Area 25.6 ES Area 22.5 RV FAC 12%

23 Relationship between MRI- derived RVEF and echo derived RVFAC,Fractional Shortening, and Tricuspid Annular Motion Anavekar NS. Echocardiography 2007:24:

24 2 Dimensional Volume and RV EF RV Ejection Fraction= ( end diastolic volume end systolic volume) / end diastolic volume RV Ejection Fraction > 44% (normal value) Area lenght methods Disk summation mehods RV volumes are understimated because of the exclusion of the RVOT Both methods are inferior in comparison with 3D echocardiographic methods Two dimensionally derived estimation of RV EF is not recommended, because of the heterogeneity of methods and the numerous geometric assumptions.

25 3D RVEF 45%

26 Freed B, Lang RM et al. J Am Soc Echocardiogr 2012;25(6):116

27 REGIONAL ASSESSMENT OF RV FUNCTION TISSUE DOPPLER-DERIVED SYSTOLIC VELOCITIES OF THE ANNULUS (S ) TRICUSPID PLANE SYSTOLIC EXCURSION (TAPSE) TISSUE DOPPLER DERIVED AND 2D LONGITUDINAL STRAIN AND STRAIN RATE

28 24±3.5, mm <17, mm 14.1±2.3, cm/s <9.5, cm/s -29±4.5, % >-20, %

29 TISSUE DOPPLER TRICUSPID ANNULUS VELOCITY Systolic excursion velocity (s ) ABNORMAL FINDING: S < 9,5 Advantages: 1. A simple reproducible technique with good discriminatory ability to detect normal versus abnormal RV function. 2. Pulsed Doppler is available on all modern ultrasound equipment Disadvantages 1. This technique is less reproducible for non basal segments 2. It is angle dependent 3. It assumes that the function of a single segment represents the function of the entire RV 4. There are insufficent data in the elderly

30 TRICUSPID ANNULAR PLANE SYSTOLIC EXCURSION (TAPSE) ABNORMAL FINDING TAPSE < 17 MM Disadvantages: 1. Assumes that the displacement of a single segment represents the function of a complex 3D structure. 2. It is angle dependent. 3. There are no large-scale validation studies 4. Load dependent Recommendations: TAPSE should be used routinely as a simple method of estimating RV function, with a lower reference value for impaired RV systolic function of 17 mm.

32 Global RV Longitudinal Strain

33 Free wall RV Longitudinal Strain

34 Free Wall RV Longitudinal Strain: Sensitivity 96%, Specificity 93% to predict RVEF <45% (MRI) using a cut-off value of less than -17.0% European Heart Journal Cardiovascular Imaging 2015;16:47-52

35 RV SPECKLE TRACKING Normal RV Severe RV Dysfunction Global RV Longitudinal Strain - 25% Global RV Longitudinal Strain 8,8%

36 J Am Soc Echocardiogr 2013;26:721-6

37 J Am Soc Echocardiogr 2013;26:721-6

38 Traditional measures of right ventricular systolic function Fractional area shortening (FAC) Tricuspid annular plane systolic excursion (TAPSE) Pulsed tissue Doppler of the tricuspid lateral annular systolic velocity (S ) Myocardial performance index (MPI) RV Global Longitudinal Strain / RV Free Wall Longitudinal Strain 3D RV EF Combining more than one measure of RV function, may more reliable distinguish normal from abnormal function

RIGHT VENTRICULAR SIZE AND FUNCTION

RIGHT VENTRICULAR SIZE AND FUNCTION Edwin S. Tucay, MD, FPCC, FPCC, FPSE Philippine Society of Echocardiography Quezon City, Philippines Echo Mission, BRTTH, Legaspi City, July 1-2, 2016 NO DISCLOSURE