Chamber Quantitation Guidelines II Right Heart Measurements

Transcription

1 Chamber Quantitation Guidelines II Right Heart Measurements Steven A. Goldstein MD FACC FASE Director, Noninvasive Cardiology MedStar Heart Institute Washington Hospital Center Sunday, October 9, 2016

2 I have no relevant financial relationships to disclose Steven Goldstein

3 I. What to Measure II. Importance of RV Function

4 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

5 GUIDELINES AND STANDARDS J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org

6 J Am Coll Cardiol 2014;63(22):e57-185

7 I. What to Measure

8 Imaging the Right Heart: Views, Anatomy, Normal Values

9 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

10 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)

11 RV Size

12 Measuring RV Size J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org

13 2 measurements cm and 3.6 cm

14 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

15 * Rudsky et al, J Am Soc Echocardiogr 2010;23:685

16 2D Echocardiography RV EDD basal: mm RV EDD mid: mm RV EDD long: mm Rudsky et al, J Am Soc Echocardiogr 2010;23:685

17 Table 8 Normal values for RV chamber size Parameter Mean ± SD Normal range J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org

18 Right Ventricle-Focused View Adjust from usual focus on LV Rotate tsdr until max plane obtained Aim to see RV lateral wall

19 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;28:1-35

20 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)

21 RV-Focused View J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org

22 Case 57 RV thickness = 1 cm

23 RV Function

24 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)

25 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

26 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

27 RV Contraction Predominantly longitudinal shortening RV outflow tract plays minor role Twisting and rotational movements do not contribute significantly

28 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

29 Parameters of RV Function - Feasibility 50 patients with ARDS in ICU with mechanical ventilation % Fichet Echocardiography 2012;29:513-21

30 RV FAC RV Function RV MPI TAPSE TV Annular S

31 Table 7 Recommendations for the echocardiographic assessment of RV size Echocardiographic imaging Recommended methods Advantages Disadvantages J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org continued...

32 Table 7 Recommendations for the echocardiographic assessment of RV size Echocardiographic imaging Recommended methods Advantages Disadvantages J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org continued...

33 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

34 Tricuspid Annular Plane Systolic Excursion (TAPSE)

35 TAPSE - Limitations Angle dependency Atrial fibrillation Patients on ventilators Highly dependent on RV loading conditions (may become pseudo-normailzed0

36 Case 1

37 33 mm

38 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

39 Case 2

40 MW - 75 year-old woman lbs S/P TAVI 1-year follow-up Technically difficult study (obesity)

41

42 S = 13 cm/s

43 Case 3 Transesophageal Echo TEE TAPSE, S, Pulm Accel Time

44 Case 45

45 Case 45

46 Case 45

47 Case 4 TAPSE importance of angle

48 TAPSE reduced... but, look at angle

49

50 Case 5 TAPSE varies with atrial fibrillation

51 8 mm 12 mm 15 mm 6.5 mm

52 Case 6 TAPSE varies with PVCs

53 Case 76 PVC 15 cm 20 cm 15 cm

54 Case 7 TAPSE varies with bigeminy

55 TAPSE - atrial bigeminy

56 FAC

57 Recommended Apical 4-Chamber View (1*) Recommended Sensitivity of RV size to angular change

58 Examples of RV Fractional Area Change 60% 40% 20% Guidelines for Assessment of Right Heart in Adults J Am Soc Echocardiogr 2010;23(7):

59 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

60 TEI RIMP

61 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

62 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

63 Calculation of TEI Index (RIMP) TV C-O PVET RIMP = TV C-O PVET PVET

64 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 0.28 ± 0.04

65 Clinical Implication of RIMP Normal values for RIMP 0.28 ± 0.04 Severe pulm HTN 0.89 ± 0.25 The higher the RIMP, the more abnormal the RV RIMP predicts survival in PHTN

66 Calculation of RV Myocardial Performance Index MPI = TCO - ET ET TCO = tricuspid closure-opening ET = ejection time S ET TCO E A Note that S, E, and A are also measured from the same tracing

67 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

68 IVC

69 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

70 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

71 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

72 RV Function Given the complex geometry of the RV, none of these variables alone is sufficient to describe RV function, and the overall impression of an experienced physician is often more important than single variables Galie Eur Heart J 2016;37(1): ESC/ERS PHTN Guidelines

73 II. Importance of RV Function

74 Importance of RV Impact on hemodynamics Impact on prognosis Impact on functional capacity

75 RV Function Clinical Relevance Prognostic Importance Heart failure Post myocardial infarction Cardiomyopathies and myocarditis Pulmonary thrombo-embolic disease COPD, ARDS, primary pulmonary HTN Valvular heart disease Repaired congenital heart disease

76 Indices of Adverse Outcome in HF RV size RV ejection fraction and FAC TAPSE RV S RV myocardial performance index Strain/strain rate

77 Survival Probability RV Enlargement Increases Mortality In Idiopathic Dilated Cardiomyopathy 1.0 No RV enlargement p = RV enlargement Months RV area/lv area >0.5 Sun (Cleve Clinic) Am J Cardiol 80:1583(1997) Size

78 % Survival Discordance in Degree of LV and RV Dilation in DCM Clinical Implications LV>RV (n=29) p= LV=RV (n=38) Duration of Follow-Up (Months) 70 Lewis J Am Coll Cardiol 21:649(1993) Size

79 Event-free survival* Prognostic Value of TAPSE CHF 2º Idiopathic or Ischemic DCM tapse > 14 n = 140 LVEF <35% tapse months Ghio Am J Cardiol 2000;85: * death or emergency transplantation

80 Survival RV Dysfunction: Independent Predictor of Mortality in Patients with HF n = 817 LVEF 35% NYHA III-IV TAPSE 14 mm TAPSE < 14 mm Years Kjaergaard Eur J Heart Failure 2007;9:610-16; ECHOS Trial TAPSE

81 Survival in Myocarditis (Biopsy proven acute myocarditis; n=23) Normal vs Abnormal RV Function Event-free survival (%) p = ,200 1,600 2,000 Follow-up (days) Normal RV TAPSE >17 mm) Abnormal RV (TAPSE <17mm) Mendes, Dec, Picard, Davidoff, et al Am Heart J 128:3019(1994) TAPSE

82 Survival TAPSE Predicts Survival in Pulmonary Hypertension PAH: m PAP 25 mm Hg; PCWP 15 mm Hg TAPSE 1.8 cm 0.50 TAPSE<1.8 cm P = Months Forfia Am J Respir Crit Care 2006;174(9): TAPSE

83 Pulmonary Hypertension Although the initial insult involves the pulmonary vasculature, survival of patients with PAH is closely related to RV function.

84 Event-free Survival Stable Heart Failure Patients (EF<35%) Pulsed Wave Systolic Tissue Doppler Imaging (PSV tdi ) PSV tdi 9.5 cm s -1 n= PSV tdi < 9.5 cm s Time (days) Damy Eur J Heart Failure 2009;11: S

85 Survival Survival in HFpEF According to RV Function (FAC) HFpEF, normal RV HFpEF, RV dysfunction (FAC 35%) P = No RV Dys RV Dys Days Melenovsky Eur Heart J 2014;35(48): FAC

86 Survival (%) RV Function after Myocardial Infarction Independent predictor of death 100 No RV Dysfunction n = RV Dysfunction n = FAC<32.2% or >32.2% Time (days) Zornoff J Am Coll Cardiol 2002;39(9): FAC

87 Strain

88

89 RV Strain Usually only measured in longitudinal dimension Reproducible Normal < -20% - < -25% No reference values currently recommended May be earlier marker of RV dysfunction than EF, TAPSE, S, FAC

90 All-cause mortality, % RV Strain and Survival 575 subjects evaluated for pulmonary hypertension RV longitudinal systolic strain P<0.001 Fine (Mayo Clinic) Circ Cardiovasc Imaging 2013;6:711-21

91 Event-Free Survival (%) Survival According to RV Strain 171 patients with chronic systolic heart failure P = RV strain < -14.8% RV strain -14.8% Number at risk Days Motoki J Am Soc Echocardiogr 2014;27:726-32

92 Chi-squared Statistic Incremental Value of RV Strain vs Conventional Parameters 171 patients with chronic systolic heart failure P=0.02 P=0.01 Motoki J Am Soc Echocardiogr 2014;27: RV strain -14.8

93 All-Cause Mortality Chi-square Incremental Prognostic Value of Echo Parameters When Added to Clinical Data Before and After Lung Transplantation p = p = p = Kusunose JACC: CV Img 2014;7(11): Strain

94 Cumulative Death and Acute HF Events Chronic Heart Failure Patients Prognostic Significance of RV Strain N = 104 CHF patients RV 2D-strain > -21% N = 60 RV 2D-strain -21% N = Time (days) Guendouz Circulation J 2012;76: Strain

95 3D

96 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

97 3D-Echo for RV Volumes Avoid RV trabeculae and moderator band 3DE tends to underestimate RV volumes compared to cardiac MRI

98

99 Volume (cc) 3D-Echo RV Volume Interobserver Variability Interobserver variability = 1.86 ml or 4.0% of mean OBSERVER 2 OBSERVER 1 n = 10 dogs RV Intraobserver variability = 1.23 ml or 2.0% of mean Jiang, Siu, Handschumaker, et al Circulation 89:2342(1994)

100 Case 8 RV infarct McConnell s sign

101 Infero-lateral (posterior) wall hypokinetic

102 Basal infero-lateral (posterior) wall hypokinetic

103 McConnell s sign relative preservation of RV apex

104