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Imaging of the Right Ventricle

Case presentation

Echo views to assess RV

Review of ASE guidelines on the

right heart

Practical approach to assess RV

Lessons from the case

46 year old woman has a long historyof tiredness and exertional dyspnea.

She has LV dysfunction and

1. Dilated RV (mild, moderate, severe).

2. RV systolic dysfunction (mild,

moderate, severe).

3. TR (mild, moderate, severe).4. Intrinsic RV dysfunction versus

secondary to LV dysfunction.

5. The underlying etiology.


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46 y old woman with tiredness and dyspnea

RV diastolic and systolic areasand FAC


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Right Ventricle

Neglected

compared to LV.

Primary diseases of

RV are uncommon.

RV dysfunction is

present in many

conditions.

RV dysfunction can

have incremental

prognostic value.


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Intrinsic myocardial disease

RV ischemia or infarction

CardiomyopathiesARVC,

dilated, hypertrophic, infiltrative

RV dysplasia

Causes of Right Ventricular Failure

Limitation to RV filling

Tricuspid stenosis

Tamponade

Pericardial constriction

Pressure overload

LV failure

Mitral valve disease

Pulmonary veno-occlusive

disease

Pulmonary artery hypertension

Pulmonary hypertension due to

pulmonary diseases

Pulmonary stenosis

Pulmonary arterial stenosis

Volume overload

Atrial septal defect

Anomalous pulmonary venous

return

Pulmonary regurgitationTricuspid regurgitation

RV Assessment by Echo

Guidelines for the echocardiographic

assessment of the right heart in

adults: a report of the American

Society of Echocardiography.

JASE, 2010.

The echocardiographic assessment

of the right ventricle: what to do in

2010? Eur J Echo, 2010


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RV Assessment by Echo

Complex geometrywith distinct inlet and

outlet portions.

Thin wall with heavy

trabeculations.

Not suited for simple

geometric models.

Any single linearmeasurement may be

misleading.

Graphic Representation of the EchocardiographicViews Used for Evaluating the Right Ventricle

Jurcut R et al. Eur J Echocardiogr 2010;11:81-96


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Imaging Views Specific Measurements

Parasternal long-axis End-diastolic RVOT diameter

RV inflow view Anatomy and function of tricuspid valve

RV outflow view Anatomy and function of pulmonary valve

Parasternal RV short-axis views End-diastolic and end-systolic diameters of RVOT

RVOT shortening fraction

RV size and function

RV volume by off-line reconstruction

Parasternal LV short-axis views LV eccentricity index

Apical four-chamber view RV size and function

RV long- and short-axis diameters

RV fractional area change

RV annular TDI

RV strain and strain rate

RV myocardial performance index

Anatomy and function of tricuspid valve

3D RV volume and ejection fraction

Subcostal view RVOT size and obstruction

RV free wall thicknessModified from Jurcut , 2010

Apical 4-chamber viewwith focus on RV


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RV dimensions and FAC

FAC=55%RV basaldiameter 2.9cm

Parasternal RV focused views


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TV annular systolic excursion and

velocities

TAPSE=TAPSE=TAPSE=33mm S=16.9cm/s

RV index of myocardialperformance


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RV longitudinal stain

3D RV volumes and EF


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1

Pulmonary Vascular Resistance

pressure = flow x resistance.

High systolic PA pressure increase

in pulmonary vascular resistance.

PVR (wood units) = 10 x TRv + 0.16

RVOTTVI

Provides insight into etiology of RVdysfunction.

Reference Limits for Measures ofRV Structure and Function

Abnormal

Chamber Dimension

RV basal diameter, cm

RV end-diastolic area, cm2

RV subcostal wall thickness, cm

RVOT PSAX diameter, cm

RVOT PLAX diameter, cm

> 4.2

> 25

> 0.5

> 2.7

> 3.3

Systolic function

TAPSE, cm

Annular S cm/s

Pulsed Doppler RIMP

Tissue Doppler RIMP

FAC, %

< 16

< 10

> 0.40

>0.55

< 35

Modified from Rudski, JASE 2010


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Assessment of RV Size and Function

Retrospective study of 12 patients (age 5219years, 6 women) who had echo and CMR within

24 hours

5 patients had 3-4+ TR, and 2 had 3-4+ PR

15 readers graded RV size and function by visualassessment based on RV views

Followed by brief presentation and distributionof the RV guidelines

Second reading 2 weeks later by same readers onsame views, but now included additional imageswith measurements of RV dimension, RVOT, FAC,S, TAPSE and RIMP

Ling et al, JASE 2012

Accuracy of Echo Assessment of

RV size and function

Sensitivity Specificity K

RV size

Visual

Visual + measurements

87%

98%

38%

78%

0.40

0.77

RV function

Visual

Visual + measurements

80%

92%

52%

84%

0.43

0.66

Ling JASE 2012


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Practical approach to assess

RV size

Kurtz, 2012

Practical approach to assessRV systolic function

Kurtz, 2012


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46 year old woman has a long history

of tiredness and exertional dyspnea.




moderate, severe).

3. TR (mild, moderate, severe).

4. Intrinsic RV dysfunction versus

secondary to LV dysfunction.5. The underlying etiology.



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1


IVC=3.2cm

RV focused apical 4-chamber view


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Quantitative RV MeasurementsRef Value

RV Dimension

RVED area (cm2)

Basal diameter (cm)

Wall thickness (cm)

39.7

5.2

0.36


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46 year old woman has a long history

of tiredness and exertional dyspnea.




moderate, severe).

3. TR (mild, moderate, severe).

4. Intrinsic RV dysfunction versus

secondary to LV dysfunction.5. The underlying etiology.

Echo Assessment of RV

Beware of RV dysfunction.

Exploit RV focused views.

Incorporate RV quantitative measures.

Ease of use measures include TAPSE, S,

RVEDD and FAC.

SPAP does not equate PVR.

3D RV volumes and EF appear promising.

lt. ventricle

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