Incorporating the New Echo Guidelines Into Everyday Practice

Clinical Case

RIGHT VENTRICULAR FAILUREGustavo Restrepo MDPresident Elect Interamerican Society of Cardiology

Director Fellowship Training in Echocardiography. CES University/Clínica Medellín

ACC – Colombia Chapter Governor

Medellín, Colombia

Disclosure Information

• I will not discuss off label use or investigational use in my presentation

• I have no financial relationships to disclose

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, Sa02 90%

• Neck veins distended, bilateral hypoventilation, systolic murmur (tricuspid area), bilateral leg oedema

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J Am Soc Echocardiogr 2015;28:1-39

Apical 4-chamber FocusedApical 4-chamber

RV ModifiedApical 4-chamber

33±4mm

27±4mm

25±2mm

28±3.5mm

22±2.5mm

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

Global Assessment of RV function

• MYOCARDIAL PERFORMANCE INDEX (MPI)

• RV dP/dt

• RV EJECTION FRACTION

• FRACTIONAL AREA CHANGE (FAC)

RIGHT VENTRICULAR INDEX OF MYOCARDIAL PERFORMANCE (RIMP) Ratio of isovolumic time divided by et

(IVRT + IVCT) / ET

MPI = 0.86

ABNORMAL FINDING > 0.55

(Tissue Doppler)

Tissue Doppler of the tricuspid annulus

RIGHT VENTRICULAR INDEX OF MYOCARDIAL PERFORMANCE (RIMP)

LIMITATIONS

It should not be used with irregular heart rates.

ATRIAL FIBRILATION

MPI has been demonstrated to be unreliable when RA pressure is elevated, shortening the

IVRT and resulting in an inappropriately small MPI.

RV dP/ dt

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.

50

+

+

numerator is 15 mmHg

dP/dt :15/35 = 428 mmHg/s

dt = 35 ms

RV FRACTIONAL AREA CHANGE (%)100 X (END DIASTOLIC AREA – END SYSTOLIC AREA)/ END DIASTOLIC AREA

Abnormal RV Systolic function FAC < 35%

RV FAC 12%

ED Area 25.6 ES Area 22.5

Relationship between MRI- derived RVEF and echo derivedRVFAC,Fractional Shortening, and Tricuspid Annular Motion

Anavekar NS. Echocardiography 2007:24:452-456

2 Dimensional Volume and RV EF

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

RV Ejection Fraction= ( end diastolic volume – end systolic volume) / end diastolic volume

RV Ejection Fraction > 44% (normal value)

Two dimensionally derived estimation of RV EF is not

recommended, because of the heterogeneity of methods and the

numerous geometric assumptions.

3D RVEF ≧ 45%

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

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

24±3.5, mm

14.1±2.3, cm/s

-29±4.5, %

<17, mm

>-20, %

<9.5, cm/s

TISSUE DOPPLER TRICUSPID ANNULUS VELOCITYSystolic 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

Disadvantages1. This technique is less reproducible for non basal segments2. It is angle dependent3. It assumes that the function of a single segment represents the function

of the entire RV4. There are insufficent data in the elderly

TRICUSPID ANNULAR PLANE SYSTOLIC EXCURSION (TAPSE)ABNORMAL FINDING

TAPSE < 17 MM

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.

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 studies4. Load dependent

Global RVLongitudinalStrain

Free wall RVLongitudinalStrain

Free Wall RV Longitudinal Strain: Sensitivity 96%, Specificity 93% to predictRVEF <45% (MRI) using a cut-off value of less than -17.0%

European Heart Journal Cardiovascular Imaging 2015;16:47-52

RV SPECKLE TRACKING

Normal RV Severe RV Dysfunction

Global RV Longitudinal Strain - 25% Global RV Longitudinal Strain – 8,8%

J Am Soc Echocardiogr 2013;26:721-6

J Am Soc Echocardiogr 2013;26:721-6

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