Chamber Quantitation Guidelines - Update II
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1 Chamber Quantitation Guidelines - Update II Right Heart Measurements Steven A. Goldstein MD FACC FASE Professor of Medicine Georgetown University Medical Center MedStar Heart Institute Washington Hospital Center Sunday, October 8, 2017 I have no relevant financial relationships to disclose Steven Goldstein 1
2 I. What to Measure; How to measure II. Importance of RV Function GUIDELINES AND STANDARDS Guidelines for the Echocardiographic Assessment of The Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered Branch of the European Society of Cardiology, and the Canadian Society of Echocardiography Lawrence G. Rudski, MD, FASE, Chair, Wyman W. Lai, MD, MPH, FASE, Jonathan Afilo, MD, Msc, Lanqi Hua, RDCS, FASE, Mark D. Handschumacher, BSc, Krishnaswamy Chandrasekaran, MD, FASE, Scott D. Solomon, MD, Eric K. Louie, MD, and Nelson B. Schiller, MD J Am Soc Echocardiogr 2010;23(7): asecho.org 2
3 GUIDELINES AND STANDARDS J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org The RV is Challenging Close to chest wall Nongeometric shape Determining RV-focused view Inflow portion Infundibulum (outflow portion) Body (apex) RV foreshortening Endocardial border definition Interrelationship with the LV Sensitivity to loading conditions 3
4 I. What to Measure How to Measure Imaging the Right Heart: Views, Anatomy, Normal Values 4
5 Imaging the Right Ventricle Use Multiple Acoustic Windows Apical 4-chamber view RV-focused apical 4-chamber view Parasternal long axis view Parasternal short-axis view RV inflow view Right Ventricle Parameters to Perform and Report Measure of RV size Measure of RA size RV systolic function (at least one of following) - Fractional area change (FAC) - TDI S - Tricuspid annular plane systolic excursion (TAPSE) With/without RV index of myocardial performance Systolic pulmonary artery pressure Estimate of RA pressure (based on IVC) 5
6 RV Size Measuring RV Size J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org 6
7 2.8 cm 3.6 cm 2 measurements cm and 3.6 cm Measuring RV Size Challenging/Limitations Endocardial border definition (image quality) Trabeculations Foreshortening May not reflect global size J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org 7
8 * Rudsky et al, J Am Soc Echocardiogr 2010;23:685 2D Echocardiography RV EDD basal: mm now mm RV EDD mid: mm RV EDD long: mm Rudsky et al, J Am Soc Echocardiogr 2010;23:685 8
9 Measurement of RV Dimensions Longitudinal dimension (RV3) (from middle of TV to RV apex) Midcavitary dimension (RV2) (middle third of the RV at the papillary muscle level) RV1 Basal dimension (RV1) (maximal dimension of the RV in the basal 1/3 of RV) Table 8 Normal values for RV chamber size Parameter Mean ± SD Normal range J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org 9
10 Right Ventricle-Focused View Adjust from usual focus on LV Rotate tsdr until max plane obtained Aim to see RV lateral wall RV Basal Diameter Studies n LRV (95% CI) Mean (95% CI) URV (95% CI) (21-27) 33 ± 2 42 (39-45) ± 4 41 (25-41) LRV lower reference value URV upper reference value Rudski J Am Soc Echocardiogr 2010;23: Lang J Am Soc Echocardiogr 2015;28:
11 RV Size - Reference Values (cm) Ref Range Mildly Abnl Mod Abnl Severely Abnl RV dimensions Basal RV diameter Mid-RV diameter Base-to-apex length RVOT diameters Above aortic valve Above pulm valve Foale Br Heart J 56:33(1986) 41 normal adults (age 19 46; 32 yrs) RV-Focused View J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org 11
12 Case 57 RV thickness = 1 cm RV Function 12
13 Functions of LV and RV ARE Different RV LV Low pressure system < 1/10 resistance to flow of systemic bed RV Physiology RV LV Thin free wall and crescentic shape impart high degree of compliance Ability to accommodate large volumes Low vascular impedance of pulm circul n (PVR 1/10 SVR) 13
14 Right Ventricular Physiology RV suited to eject across low resistance of the pulmonary circuit Performs at a lower dp/dt than the LV RV wall motion not like LV: LV all walls and base move more or less equally toward the center RV base-to-apex shortening more pronounced RV ejection is a complex mechanism RV Ejection is Complex Several Components Contraction along long-axis (TV toward apex) 2. Inward movement of RV free wall 3. Bulging of septum into RV chamber 4. Circumferential contraction of RV outflow tract
15 Visual assessment of RV function is inadequate RV Systolic Function Echo Methods of Assessing Visual assessment ( gestalt ) Fractional area shortening TAPSE Tissue Doppler imaging of RV free wall (S ) Tei index RV dp/dt from TR signal RV strain and strain rate RV acceleration time 15
16 TAPSE RV Contraction Predominantly longitudinal shortening RV outflow tract plays minor role Twisting and rotational movements do not contribute significantly 16
17 Parameters of RV Function - Feasibility 50 patients with ARDS in ICU with mechanical ventilation % Fichet Echocardiography 2012;29: RV FAC RV Function RV MPI TAPSE TV Annular S 17
18 RV Function Tricuspid Annular Plane Systolic Excursion Descent of RV base toward relatively fixed apex Represents function of longitudinal muscles Apical 4-chamber view 2D-echo and TEE Tricuspid Annular Plane Systolic Excursion (TAPSE) 18
19 Advantages of TAPSE Highly feasible and easy Highly reproducible Numerical Not affected by dropout or trabeculations Reflects longitudinal RV shortening TAPSE - Limitations Angle dependency Atrial fibrillation TAPSE; NSR TAPSE Patients on ventilators Highly dependent on RV loading conditions (may become pseudo-normailzed) Ventricular interdependence 19
20 Strong Correlation between FAC and TAPSE TAPSE (cm) y = x R = 0.73 P < TAPSE good FAC bad RV-FAC (%) Lopez-Candeles Am J Cardiol 2006;98: Strong Correlation between FAC and TAPSE y = x R = 0.73 P < TAPSE (cm) TAPSE bad FAC good RV-FAC (%) Lopez-Candeles Am J Cardiol 2006;98:
21 Correlation between RV EF (CMR) and TAPSE (Echo) RV ejection fraction by MRI (%) r 2 =0.113, p< Tricuspid annular peak systolic excursion, TAPSE (mm) Pavlicek Eur J Echocardiogr 2011;12: RVF Is Not the Sole Determinant of TAPSE TAPSE (cm) TAPSE NL RVEF NL LVEF TAPSE NL RVEF Low LVEF TAPSE Low RVEF NL LVEF TAPSE Low RVEF Low LVEF Lopez-Candeles Am J Cardiol 2006;98:
22 Recommended Measures of RV Function Summary of Reference Limits (2015) Variable TAPSE Pulsed Doppler peak velocity (S ) (at the annulus) Pulsed Doppler MPI Tissue Doppler MPI FAC Abnormal <1.7 cm <9.5 cm/s >0.43 >0.54 <35 % MPI = myocardial performance index Prognostic Value of TAPSE in CHF 1.00 (Idiopathic or Ischemic Cardiomyopathy) Event-free survival* tapse > 14 tapse months Ghio Am J Cardiol 2000;85: * death or emergency transplantation 22
23 TAPSE Predicts Survival in Pulmonary Hypertension 1.00 Survival TAPSE 1.8 cm TAPSE 1.8 cm P = Months Forfia Am J Respir Crit Care 2006;174(9): Relation between Mortality and TV Annulus Motion in RV Infarction Mortality % 45% 4% 9% (n=118) (n=56) (n=20) Samad Am J Cardiol 2002;90:778 23
24 FAC Recommended Apical 4-Chamber View (1*) Recommended Sensitivity of RV size to angular change 24
25 RV Fractional Area Change RV end-diastolic area 32 cm 2 RV end-systolic area 16 cm FAC = = 50% 32 Recommended Measures of RV Function Summary of Reference Limits (2015) Variable TAPSE Pulsed Doppler peak velocity (at the annulus) Pulsed Doppler MPI Tissue Doppler MPI FAC Abnormal <1.7 cm <9.5 cm/s >0.43 >0.54 <35 % MPI = myocardial performance index 25
26 S (TDI) Pulsed Tissue Doppler Imaging Tricuspid Annular Velocity Profile 26
27 TDI of Tricuspid Annulus (normal RV systolic function) Evaluation of RV Systolic Function TDI of Tricuspid Annulus Simple rapid method Feasibility high (>95%) Primarily reflects function of longitudinal myocardial fibers Peak systolic annular velocity correlates with RV ejection fraction (MUGA) Normal peak systolic velocity > 9.5 cm/s 27
28 Evaluation of RV Systolic Function Limitations of TDI of Tricuspid Annulus Primarily reflects function of longitudinal myocardial fibers Influenced not only by myocardial function, but also by translational and rotational motion of the whole heart (but, LV translational motion and rotation in the long-axis is not important) Peak systolic TV annular velocity is load dependent Kaplan-Meier Curves for Subgroups Stratified by Pulsed Wave Systolic Tissue Doppler Imaging (PSV tdi ) Event-free Survival PSV tdi 9.5 cm s -1 PSV tdi < 9.5 cm s Time (days) Damy Eur J Heart Failure 2009;11: S 28
29 RV Systolic Function TAPSE S RIMP (PW Doppler) RIMP (DTI) FAC < 16 mm <10 cm/s >0.40 >0.55 <35% < 17 mm < 9.5 cm/s >0.43 >0.54 <35% Rudski J Am Soc Echocardiogr 2010;23: Lang J Am Soc Echocardiogr 2015;28:1-35 RIMP 29
30 TEI Index of Myocardial Performance Right Ventricle (RIMP) Doppler-derived index of myocardial performance of RV (RIMP) Represents global RV function independent of ventricular geometry Indicated for patients with increased TR velocity 3.0 m/sec Calculation of TEI Index (RIMP) Optimize right heart Doppler signals Measure pulm valve ejection time (PVET) Measure atrioventricular closure-opening (TV C-O) Calculate RIMP RIMP = TV C-O PVET PVET 30
31 Calculation of TEI Index (RIMP) TV C-O PVET RIMP = TV C-O PVET PVET Example of RIMP Calculation Measurements TVC TVO PVET 440 msec 280 msec RIMP = TVC-TVO PVET PVET RIMP = 440 msec 280 msec 280 msec = 0.57 Normal values for RIMP >0.43 (PW Doppler) >0.55 (TDI) 31
32 Clinical Implication of RIMP The higher the RIMP, the more abnormal the RV RIMP predicts survival in PHTN IVC 32
33 Estimation of RV Pressure Normal (0-5 [3] mm Hg) Intermediate (5-10 [8] mm Hg) High (10-20 [15] mm Hg) IVC diameter 21 cm 21 cm >21 cm >21 cm Collapse with sniff >50% < 50% >50% < 50% Rudski J Am Soc Echocardiogr 2010;23: Lang J Am Soc Echocardiogr 2015;28:1-35 Estimation of RA Pressure Limitation of IVC Assessment Caveats Dilatation of the IVC with normal RAP has been observed in athletes and in patients on mechanical ventilation 33
34 Secondary Indices of Elevated RA Pressure (Use to downgrade or upgrade RV pressure) Restrictive filling Tricuspid E/e > 6 Hepatic vein diastolic predominance Caution: Athletes Patients on ventilators Strain 34
35 3D RV Function 3D-Echo Possible to visualize entire RV and re-slice it in short-axis cuts Eliminates need for simple geometric model Resolution and wall delineation marginal, but improving 35
36 3D-Echo for RV Volumes Avoid RV trabeculae and moderator band 3DE tends to underestimate RV volumes compared to cardiac MRI 3D-Echo RV Volume Interobserver Variability Interobserver variability = 1.86 ml or 4.0% of mean 80 OBSERVER 2 OBSERVER 1 Volume (cc) n = 10 dogs RV Intraobserver variability = 1.23 ml or 2.0% of mean Jiang, Siu, Handschumaker, et al Circulation 89:2342(1994) 36
37 Case 7 RV infarct McConnell s sign 37
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