Φωτεινή Α. Λαζαρίδου Επιμελήτρια Α Γενικό Νοσοκομείο Αγιος Παύλος, Θεσσαλονίκη

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1 17 ο Πανελλήνιο Καρδιολογικό Συνέδριο ΚΕΒΕ Θεσσαλονίκη, Μαϊου 2018 Στρογγυλό τραπέζι: Κλινικά προβλήματα στην πνευμονική υπέρταση Φωτεινή Α. Λαζαρίδου Επιμελήτρια Α Γενικό Νοσοκομείο Αγιος Παύλος, Θεσσαλονίκη

2 Right heart RV: Triangular shape in frontal plane RV: crescent shape in the transversal plane

3 RV The muscle mass of the RV is about one-sixth that of the LV. The RV pumps the same stroke volume as does the LV, but with about 25% of the stroke work due to the low resistance of the pulmonary vasculature. Longitudinal shortening is a greater and more important contributor to RV stroke volume than is circumferential shortening. The RV is linked to the LV in several ways: by a shared wall (via the septum), by reciprocally encircling epicardial fibers, by sharing the pericardial space, and by the attachment of RV free wall to the anterior and posterior septum. Arch Cardiovasc Imaging November; 3(4):e35717.

4 RV contraction physiology Regarding RV contraction physiology, three individual components lead to normal contraction: I. the inward motion of the free wall; II. III. longitudinal shortening; and the traction of the free wall, secondary to LV contraction. In consequence, RV contraction relies mostly on LV-RV interactionand longitudinal deformation.

5 Difficulties in RV assessment RV does not have a symmetrical, well-defined shape and does not lend itself to simplified formulas. the position of the RV directly behind the sternum can impair adequate visualization of all segments of the RV. visualization of the RV inflow-outflow tract is difficult to perform on echocardiograms. there are no clear landmarks to address standardization of views. Different angulations can result in very different measurements. Clinical Cardiology. 2017;40:

6 RV has three wall segments: anterior wall, inferior wall and lateral wall

7 Standard RV views by echo anterior & inferior RV walls, RV inflow tract two leaflets RV anterior wall prox part of RVOT basal part of RV anterior wall, RVOT, two leaflets, pulmonary valve PA RV crescent shape, eccentricity index, IVS septum motion; RV inferior wall; inflow and apical RV, RV lateral wall, interventricular septum, and s/p leaflets Kardiologia Polska 2016; 74, 6:

8 Qualitative assessment Eccentricity index >1 at end diastole is highly suggestive for RV volume overload, and at end systole or during the whole cardiac cycle for RV pressure overload Visual assessment of the RV size may be performed from the apical 4C view : the area of normal RV should not exceed two-thirds of the LV (aprox). Evaluation of the RV walls structure and motion (aneurysm, hypo/a-kinesia) Surkova, 2016

9 RV focused view Avoid underestimation Rotate the transducer until the maximal plane is obtained Avoid overestimation Ensure that the RV is not foreshortened and that the LVOT is not opened up (avoid the apical 5-chamber view) J. Am. Soc. Echocardiogr. 23 (7) (2010) J. Am. Soc. Echocardiogr. 28 (1) (2015) 1 39.

10 RVOT size The PSAX distal RVOT diameter, just proximal to the pulmonary annulus, is the most reproducible and should be generally used J. Am. Soc. Echocardiogr. 23 (7) (2010) J. Am. Soc. Echocardiogr. 28 (1) (2015) 1 39.

11 RV wall thickness RV wall thickness important in pts with RV pressure overload, biventricular hypertrophic cardiomyopathies, and storage diseases. It is recommended to use the zoomed image of the RV free wall

12 Transoesophageal echo Some segments of the RV, such as the RVOT contributing up to 25 30% of the RV volume, could be overlooked when using standard transthoracic 2DE (TTE) Transesophageal echocardiography (TEE) with the midesophageal inflow outflow view can evaluate RVOT. TEE is essential in the peri- and intraoperative settings and allows continuous monitoring of right heart function during noncardiac surgery In addition to standard TEE views, five additional deep transgastric views have been suggested to provide additional information on the RV inflow tract, free wall, outflow tract and the right-sided valves. International Journal of Cardiology 214 (2016) 54 69

13 Kardiologia Polska 2016; 74, 6: ; J Am Soc Echocardiogr, 2015; 28:1 39.e14. 3D echo 3D echo limitation: poor lateral resolution in right ventricular cavity dilatation 3DE tends to underestimate RV volumes compared CMR Overall, women have smaller 3D echocardiographic RV volumes, despite indexing to BSA, and higher EFs. Also, older age is associated with smaller volumes (expected decrements of 5 ml/decade for EDV and 3 ml/decade for ESV) and higher EF (an expected increment of 1% per decade)

14 RV shape- 3DE RV regional curvature The curvature of the RV inflow tract was a more robust predictor of death than RVEF, RV volumes, or other regional curvature indices Surkova et al; Kardiologia Polska 2016 Addetia et al ; JASE 2017 Surkova et al; International Journal of Cardiology 214 (2016)

15 RV systolic function RV systolic function is a reflection of contractility, afterload, and preload. RV performance is also influenced by heart rhythm, synchrony of ventricular contraction, RV force interval relationship, and ventricular interdependence. J Cardiovasc Ultrasound 2016;24(3): Circulation 2008;117:

16 RV systolic function assessment RV systolic function should be assessed by at least one or combination of the following: FAC, S Wave, TAPSE or RIMP. ASE JASE 2015

17 RV function The assessment of RVEF using 2DE is no longer recommended due to its inaccuracy a number of surrogate echocardiographic parameters :RV fractional area change, tricuspid annular plane systolic excursion, peak S wave velocity of the lateral tricuspid annulus by tissue Doppler imaging [TDI], and RV myocardial performance index) have been proposed for clinical use. Dp/dt J Am Soc Echocardiogr, 2015; 28:1 39.e14

18 Fractional area change

19 FAC Advantages of FAC for RV Systolic Function Established prognostic value RV FAC is found to be an independent predictor of: Heart Failure Sudden Death Stroke Mortality in patients after pulmonary embolectomy Longitudinal and radial components of RV contraction Correlates with CMR Limitations of FAC Neglects contribution of RVOT to overall RV function Limited inter-observer reproducibility

20 TAPSE and S Wave limitations The 3 main limitations are: Angle dependency Load dependency Do not fully represent RV global function and therefore may over or underestimate global RV function

21 This study shows that the TAPSE(longitudinal RV fiber shortening) vs PASP (force generated by the RV ) relationship is shifted downward in nonsurvivors with a similar distribution in HFrEF and HFpEF, and their ratio improves prognostic resolution.

22 RV mechanics RV longitudinal strain Being extremely load dependent, RVEF is a partial indicator of the RV systolic function RV longitudinal strain : either TDI or 2DSTE techniques. The correlation between Doppler-derived and 2DSTE-derived RV longitudinal strain appears to be moderate abnormality threshold for the RV free-wall longitudinal strain : 20% The term global RV longitudinal strain is commonly used for average values calculated from three segments of the RV free wall and three segments of the IVS from apical fourchamber view, even though the contribution of other walls and RVOT is neglected relatively low repeatability of regional RV strain represents a relative weakness of both echocardiographic techniques limiting their routine use for an individual patient follow-up of segmental function Kardiologia Polska 2016; 74, 6:

23 RV tissue characterisation RV freewall strain may be an accurate echocardiographic marker of the extent of RV myocardial fibrosis correlating with patients functional capacity (end stage HF pts) JACC Cardiovasc. Imaging 8 (5) (2015)

24 J Am Coll Cardiol Cardiovasc Imaging, 2015; 8: Kardiologia Polska 2016; 74, 6: RV dyssynchrony a cutoff value of 18 ms was introduced as a criterion for RV dyssynchrony

25 RV evaluation TAPSE, RVFAC, and RVEF can change with a change in load without any true change in myocardial contractility and therefore do not reflect innate myocardial function. RIMP can be falsely low in conditions associated with elevated RA pressures, which will shorten the IVRT. Clinical Cardiology. 2017;40: J Am Soc Echocardiogr 2015;28:1-39.

26 RV diastolic function During acute RV pressure overload, RV diastolic function is not affected The assessment of RV diastolic function includes: evaluation of the RV inflow by pulsed wave Doppler sampling at the tips of the TV leaflets; measuring the TDI velocities of the Tr annulus at RV free wall; evaluation of right atrial, IVC, and hepatic vein size and function Grades of RV diastolic function Impaired relaxation E/A<0.8 Pseudonormal filling 0.8< E/A <2.1 and E/E >6 Restrictive filling E/A >2.1 and DcT<120ms E/e values > 6 have a sensitivity of 79% and a specificity of 73% for the detection of right atrial pressure > 10 mm Hg. Rudski et al JASE 2010 Kardiologia Polska 2016; 74, 6: ;

27 Right Atrium Smooth walled myocardium, except for appendage Three inlets: SVC, IVC, and coronary sinus Visible fetal remnants: Eustachian valve / Chiari network Normal pressure ranges from 0-5 mmhg The right atrium not only acts as a conduit to fill the RV passively but also optimizes RV filling actively during late diastole. Anatomical deformities of the spine and chest can alter the right atrium and project larger dimensions. Echo : 4C apical views are used to evaluate the RA and the subcostal views to evaluate the IVC J Cardiovasc Ultrasound 2016;24(3):

28 RA dimensions Maximal long axis distance Abnormal >5.3cm Mid-RA minor distance: Abnormal >4.4cm RA area* Abnormal >18cm2 RA volume index Abnormal :Women >33ml/m2 Abnormal: Men >39ml/m2 *In patients with primary pulmonary hypertension right atrial area is a predictor of transplantation or mortality. J Am Soc Echocardiogr 2010;23: ;

29 RV pressures Rudski et al JASE 2010

30 PA pressures

31 Right atrial pressure

32 Elevated right atrial pressure On the left, a normal waveform pattern is demonstrated showing S/D >1 One the right, an abnormal waveform pattern is demonstrated showing S/D <1 : Indication of elevated RAP

33 Hepatic vein systolic filling fracture

34 Elevated PASP RVOT AccT IJC Heart & Vasculature 12 (2016) 45 51

35 Elevated PASP : Sm, SmVTI Sm velocity < 12 cm/s and SmVTI < 2.5 are highly suggestive of elevated PASP

36 Elevated PASP rivrt rivrt of >75 ms reliably predicts pulmonary hypertension while an rivrt of <40 ms has a high negative predictive value for pulmonary hypertension

37 Pulmonary pressure : echo assessment

38 S/D ratio Calculation of the systolic to diastolic duration ratio (S/D ratio) is another means of assessing RV adaptation. An increase in the S/D ratio reflects a certain degree of RV dysfunction, with longer systole and abnormal cardiac performance; it is one of the strongest independent predictors of death in a population with Eisenmenger s syndrome and independently predicts lung transplantation and death in paediatric PAH (cut-off1.4)

39 Screening for pulmonary hypertension Although not diagnostic of pulmonary hypertension, a number >35 mm Hg warranted further studies. An incorrect estimation of RA pressure caused half of the overestimation of pulmonary pressures in one study comparing echocardiographic estimates of pulmonary artery systolic pressure to right-heart catheterization measurements. Among patients with chronic thromboembolic pulmonary hypertension RV basal free wall strain appeared to show the best correlation with mean pulmonary artery pressure on right-heart catheterization. Int Heart J. 2015;56: DUTTA AND ARONOW, Clinical Cardiology. 2017;40:

40 Pre- vs Postcapillary PH J Am Soc Echocardiogr 2015;28:108-15

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42 60/60 sign for acute pulmonary embolism PASP <60 mmhg PAT (pulmonary acceleration time)<60ms

43 McConnell s Sign or Acute regional RV Dysfunction (PE) akinesia of the mid free wall

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45 Echocardiographic parameters of RV failure

46 Paul Cézanne: Il faut réfléchir, l'oeil ne suffit pas, il faut la réflexion Το μάτι δεν είναι αρκετό. Είναι απαραίτητη και η σκέψη Montagne Sainte-Victoire - Paul Cézanne

47 ευχαριστώ Montagne Sainte-Victoire - Paul Cézanne