RV (Dys)function assessment

by echocardiography
Trevor Richens
Glasgow Sick Kids

The Forgotten Ventricle

Importance of RV Function
Congenital Heart Disease
Single RV morphology ventricles
Systemic RVs Senning/Mustard/cTGA
Post Op ToF

Acquired Heart Disease

Ischaemic Heart Disease
Ventricular Failure
Pulmonary Hypertension
Post Heart Transplant

RV dysfunction
now known to
correlate with poor
outcome

Single Ventricle

Senning

Tetralogy

RV Structure
RV wraps
around LV

LPA
RPA

MPA
Pulmonary Valve
RVOT

SVC
Infundibulum

RA

IVC

RV

RV Echo Lx

RV Sx

RV echo Standard Views II

And in infants

Problems with RV Echo

Poor windows unless youre <5Kg
Particularly difficult to see anterior wall

Difficult to delineate RV cavity

Coarse trabeculations complicate edge
detection

Complex shape prevents simple

mathematical models
Pattern of contraction
Wringing rather than contracting

Where and What to Measure

That said
MRI seen as gold standard limited by:
Accessibility
Cost
Time (anaesthetic)

Gated radionuclide techniques

Accessibility
Cost
Radiation exposure

Invasive techniques Contrast ventriculography,

conductance catheters
Accessibility
Cost
Radiation exposure

Echo

Cheap
Quick (at bed-side)
Accessible
Non-invasive
No radiation exposure

Right Ventricular Function

2D
Tissue Doppler
Spectral (systolic)
Colour coded (mean)

Deformation
Strain
Strain rate

Eyeball Assessment
Using MRI as gold standard
22 patients 16.6 +/- 7.1 years
Eyeball vs. MRI

Poor ability to assess either RV size or function

by eyeballing
Fine
But: Any method assessing changes in volume is
dependent on pre/after load so MRI flawed as well

Still, lots of information there

M Mode

Flat or Paradoxical Septum

Paradoxical Septal Motion

RV volume Overload

ASD
Severe TR
Severe PR (e.g. post op Tetralogy)
Partial anomalous pulmonary venous drainage
(PAPVD)

Post cardiac surgery to ventricular septum

Pericardial effusion
?RBBB

Compare to LV

Severe Branch Pulmonary Stenosis

Compare to LV

2D Assessment
Gross changes can be appreciated
Quantitative, comparative measurements
are not possible
Abnormal septal motion can indicate
potential pathology

2D Quantitative Assessment
Complex shape prevents simple
mathematical mode
No easy and reproducible way to measure
RV function

TAPSE

>18mm

Tricuspid Annular Systolic Excursion

Measure of RV function
Correlates with other echo markers of RV
function
Predicts survival in PAH

3D
Theoretically solves the mathematical
modelling problem
As yet unproven
Echo windows still an issue anterior RV
wall
Demarcation of RV cavity still problematic

Correlation of 3D RV volume echo

Measurements
New Phillips 3D software
system
Correlated with MRI
Good results for
RV ejection fraction
RV volumes

Journal of the American College of Cardiology

Volume 50, Issue 17, 23 October 2007, Pages 1668-1676

3D plus Contrast
Eliminates:
RV modelling issue
Edge detection

Still has problem of echo windows

Remains a volumetric method therefore
dependent on preload and afterload.

Diastolic Function
More difficult to assess than LV
Preloading varies widely
E/A ratio not a particularly good indicator
of RV diastolic function

Restrictive RV Physiology
Post Op
Tetralogy of
Fallot
Restrictive
Cardiomyopathy

Anterograde diastolic flow with atrial systole (A wave)

Right Ventricular Echo

2D

Tissue Doppler
Spectral (systolic)
Colour coded (mean)
Deformation
Strain
Strain rate

Tissue Doppler Imaging

Well established for LV function
Now sufficient data to justify use in
assessment of RV function
Good review of the state of play
Gondi and Dokainish; Echocardiography 2007 24 522-532

RV Spectral TDi - How

Apical 4 chamber view
3 5mm Doppler sample volume
Position 10mm or so away from the TV
annulus
Avoids sampling from cavity or RA due to
normal movement in cardiac cycle.

Check Sampling plane is parallel to RV

free wall

Spectral TDi

Sa

Ea

Aa
ET

IVRT

IVCT

Colour Derived TDi

IVC
Sa

Aa
Ea

Movement artefact associated with respiration

RV TDi
Profile is similar to
that seen in LV
Normal values differ
RV peak Spectral
velocitys

Adult

Child

Sa

15.2

10

Ea

15.7

13

Aa

15.2

8.7

RV Sa in Adult
Practice

Decreased Sa
velocity (<10cm/sec)
In LVF
Reduction correlates
with high PAp / Lap
Independent predictor
of poor outcome in
CHF

In Inferior MI
Predicts RV infarction
by angiographic/ECG
criteria
Predicts cardiac death
or rehospitalisation

In pulmonary
hypertension
Sa Reduced but not
shown to be predictive

Ea and Aa
Less known
Aa/Ea ratio correlates with RV end
diastolic pressure in some pathologies
Ea reduced in RV pressure loading
pulmonary hypertension

Myocardial Performance index

Marker of Ventricular Dysfunction
Covers systolic and diastolic dysfunction
Adds components of systolic and diastolic function
Isovolemic contraction time (time taken for RV pressure
to rise and open pulmonary valve)
Isovolemic relaxation time (time taken for RV pressure
to fall and allow tricuspid valve to open)

Expressed as a fraction of ejection time

Calculation of MPI
Use CW Doppler (two different cardiac cycles)

TR

PA

MPI = TR - PA
PA
(Tei index)

Calculation of MPI
Use TDi (Same cardiac cycle)
By TDi appears to correlate better with clinical
parameters

Sa

Ea

Aa

ET
IVRT

IVCT

MPI = IVRT + IVCT

ET

RV MPI

Other Indices
Acceleration during
isovolumic contraction
Reduction correlates
with poor RV function
(<2.5m/sec2)
Relatively unaffected
by preload and
afterload

Can be hard to image

Looked good in
animals but not so
sure in humans

Assessment of timing

Off Line TDi

Effect of biventricular pacing

Right Ventricular Echo

2D
Tissue Doppler
Spectral (systolic)
Colour coded (mean)

Deformation
Strain
Strain rate

Strain and Strain Rate

All previous measures of RV function are
preload and afterload dependent
Filling state
LV function
Hypertension

Strain measures local ventricular wall

deformation
Largely independent of loading

Calculation of SR
Measures the
deformation of
a small area of
myocardium
Use TDi to
determine the
velocities at
two different
points
Divide the
difference by
the distance
between them

Problems
In LV fibre orientation is longitudinal or radial
In RV fibres are oblique and contraction wringing
Unclear as yet how this effects the measurements

Normal values for RV have not yet been validated

Conclusion
Useful information can be gleaned from eyeball
assessment
Quantitative, comparative data needs careful
assessment by:
TAPSE
MPI
TDi Sa

Load independent assessment may be possible

with strain rate technology
MRI might be better at the moment