AND RIGHT VENTRICULAR FUNCTION: AN ADDED VALUE? Denisa Muraru, MD - - PowerPoint PPT Presentation

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AND RIGHT VENTRICULAR FUNCTION: AN ADDED VALUE? Denisa Muraru, MD - - PowerPoint PPT Presentation

Feb 14, 2023 152 likes •461 views

Cardiology Department University of Padua Head of Dpt: Prof. Sabino Iliceto SPECKLE-TRACKING ECHOCARDIOGRAPHY AND RIGHT VENTRICULAR FUNCTION: AN ADDED VALUE? Denisa Muraru, MD RIGHT VENTRICLE Not anymore an innocent bystander of the left

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SLIDE 1

SPECKLE-TRACKING ECHOCARDIOGRAPHY AND RIGHT VENTRICULAR FUNCTION: AN ADDED VALUE?

Denisa Muraru, MD Cardiology Department University of Padua

Head of Dpt: Prof. Sabino Iliceto

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SLIDE 2

RIGHT VENTRICLE

Important prognostic value:

  • after acute myocardial infarction
  • heart failure
  • valvular heart disease
  • congenital heart disease (Fallot)
  • pulmonary hypertension
  • after cardiac transplantation

Hochreiter C. Circulation 1986 Pfisterer M et al. Eur Heart J 1986 Bhatia SJS et al. Circulation 1994 Di Salvo TG et al. JACC 1995 Van Straten A et al. Eur Radiol 2005 Nath J et al. Echocardiography 2005

Not anymore an innocent bystander of the left

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SLIDE 3

ASSESSMENT OF RIGHT VENTRICULAR FUNCTION IN CLINICAL SETTINGS

Shift from qualitative to quantitative RV study

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SLIDE 4

Challenges for conventional echocardiography

  • thin-walled chamber behind the sternum
  • separate inflow and outflow portions
  • asymmetrical, crescentic shape, wrapped around LV
  • variations of shape with loading conditions
  • heavily trabeculated

(several views needed) (non-simultaneously imaged) (difficult to describe by any simple geometric model) (poor reproducibility of endocardial tracing)

RIGHT VENTRICLE

Courtesy of Prof. Cristina Basso, Cardiovascular Pathology, University of Padua PV TV MB RA 1 2 3 Ao IVSm TV RA Ao PV MB IVSm

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SLIDE 5

1D

  • M-mode (RV diameters, RV wall thickness,TAPSE, septal motion

pattern)

2D

  • RV diameters, areas and wall thickness (1D measures)
  • Fractional area change (FAC)
  • RV ejection fraction (RVEF)

Doppler

  • Spectral (RV dp/dt, Tei index, diastolic fx, RV systolic pressure)
  • TDI (Tei index, S velocity, diastolic fx, strain/strain-rate)

STE

  • Strain/strain-rate

3D

  • RV volumes
  • RVEF
  • RV shape and mass

ECHO ASSESSMENT OF RIGHT VENTRICLE

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SLIDE 6

CLINICAL CASE: 56 y/o man

  • Severe porto-pulmonary hypertension (pressure and volume overload)
  • Significant tricuspid regurgitation and increased RA pressure

TAPSE 24 mm RV S wave 12.5 cm/s

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SLIDE 7

Courtesy of Dr Sorin Giusca

RV FUNCTION BEFORE AND AFTER PULMONARY ENDARTERECTOMY

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SLIDE 8

DEFORMATION IMAGING DESCRIBES RV FUNCTION BETTER THAN TAPSE

Courtesy of Dr S. Giusca TAPSE LV apex displacement Midwall RV strain Basal RV strain

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SLIDE 9
  • Angle-independent
  • Sensitive measure of global

and segmental longitudinal RV function

  • Discriminates true myocardial

deformation from displacement and tethering

  • Less load dependent than

velocities and EF

  • Provides both regional

amplitude and timing (RV dyssynchrony)

RV LONGITUDINAL DEFORMATION 2D strain by speckle-tracking

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SLIDE 10

RV LONGITUDINAL STRAIN

Normal subject

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SLIDE 11

Normal subject

RV LONGITUDINAL STRAIN RATE

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SLIDE 12

Parameter N=100 PLSS (%, mean±SD) Range (%) Time to PLSS (ms, mean±SD) Range (ms) Global

  • 24.2 ± 2.9
  • 30.0 to -17.7

387 ± 39 302 to 474 Free wall

  • 28.7 ± 4.1%
  • 37.7 to -19.8

388 ± 43 287 to 482 Septum

  • 19.8 ± 3.4%
  • 27.0 to -12.8

385 ± 42 288 to 480 Basal free wall

  • 43.2 to -14.9

284 to 511 Mid free wall

  • 40.9 to -20.1

284 to 505 Apical free wall

  • 39.01 to -13.1

285 to 468 Basal septum

  • 26.8 to -12.5

283 to 494 Mid septum

  • 27.3 to -12.7

291 to 484 Apical septum

  • 33.6 to -9.7

294 to 467

RV LONGITUDINAL STRAIN

Reference ranges

Adapted after Meris A et al. J Am Soc Echocardiogr 2010

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SLIDE 13

RV LONGITUDINAL STRAIN

Discrimination between normal and abnormal function

Sv 95% Sp 85%

Meris A et al. J Am Soc Echocardiogr 2010

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SLIDE 14

TAPSE 18 mm TAPSE 24 mm TAPSE 18 mm Control Tricuspid Reg. PAH

Volume vs pressure RV overload

ECHO ASSESSMENT OF RV FUNCTION

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SLIDE 15

Pressure overload Normal Volume overload

84 ms Control Tricuspid Reg. PAH

Global L Strain = -22% Global L Strain = -22.7% Global L Strain = -13.8%

ECHO ASSESSMENT OF RV FUNCTION

Volume vs pressure RV overload

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SLIDE 16

EDV= 77 ml ESV= 28 ml RVEF= 64% EDV =140 ml ESV= 68 ml RVEF= 52% EDV= 113 ml ESV= 78 ml RVEF= 31%

ECHO ASSESSMENT OF RV FUNCTION

Control Tricuspid Reg. PAH

Volume vs pressure RV overload

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SLIDE 17

RV FUNCTION IN PULMONARY HYPERTENSION

Case #1 (NYHA III-IV) Case #2 (NYHA II)

PAPm = 58 mmHg PAPm = 56 mmHg

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SLIDE 18

RV FUNCTION IN PULMONARY HYPERTENSION

Case #1 Case #2

GLS = -10.7% GLS = -18.8%

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SLIDE 19

RV FUNCTION IN PULMONARY HYPERTENSION

Case #2

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SLIDE 20

RV DYSFUNCTION IN PULMONARY HYPERTENSION

  • the main cause of death of PAH patients (70% of all deaths)
  • associated with very poor prognosis
  • conventional echo indices reflect RV dysfx only in advanced

stages, when disease-targeted therapy has a limited efficacy

  • STE could aid in understanding the highly variable adaptation
  • f RV to pressure overload and explain discrepancies in

functional capacity and outcome (Eisenmenger vs PAH)

D'Alonzo GE et al. Ann Intern Med 1991

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SLIDE 21

Severe secondary PH in DCM Severe PAH

GS -11% GS -10%

REGIONAL DEFORMATION DIFFERENCES

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SLIDE 22

RV DEFORMATION IN PULMONARY EMBOLISM

McConnell sign GS -6.1% “60/60” sign

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SLIDE 23

ECHO ASSESSMENT OF RIGHT VENTRICLE

  • RV function impairment is only about a

reduced pump function?

  • RV diastolic function
  • RV dyssynchrony
  • Could echo identify subtle RV impairment before

the RV systolic dysfunction becomes apparent?

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SLIDE 24

RV DIASTOLIC FUNCTION

Much more than RV wall thickness

  • marker of early or subtle RV dysfunction
  • marker of poor prognosis in patients with known RV impairment

E A S E’ A’ rIVRT EDT

Rudsky LG et al. J Am Soc Echocardiogr 2010

Assessing and grading RV diastolic function should be considered in patients with suspected RV impairment as:

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SLIDE 25

E’ A’

TAPSE 23 mm

Ԑ SRs SRe SRa

Global RV strain -23% Global RV strain rate

A E

EARLY DIASTOLIC DYSFUNCTION IN PAH

=12 cm/s

S

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SLIDE 26

RIGHT VENTRICULAR DYSSYNCHRONY

Timing is also important

  • In pulmonary hypertension, RV dyssynchrony correlated with

RV dysfunction (Tei index, FAC, GLS), disease severity and functional capacity

  • RV dyssynchrony becomes evident even in mild PH when

standard echo indices of RV size and function (TAPSE, FAC) are still normal

  • Both acute and chronic RV pressure overload have been

associated with discoordinated RV longitudinal contraction

Sugiura E et al. J Am Soc Echocardiogr 2009 Kalogeropoulos AP et al. J Am Soc Echocardiogr 2008 Lopez-Candales A et al. Echocardiography 2007

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SLIDE 27

RIGHT VENTRICULAR DYSSYNCHRONY

Dyssynchronized longitudinal contraction could further impair RV function in addition to the actual decrease in contractility and may contribute to the observed discrepancy between regional and global parameters of RV function Normal subject Pulmonary arterial hypertension

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SLIDE 28
  • Current echo techniques allow a tailored quantitative approach

for the assessment of RV size and function

  • A multi-parameter approach and the advanced technologies

(STE, 3DE) can compensate for the flaws of single conventional indices of RV function

  • RV diastolic function and dyssynchrony could provide novel

insights in RV function impairment early in disease course

  • Further outcome studies are needed to certify the clinical value
  • f novel echo methods over the conventional RV indices

CONCLUSIONS

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SLIDE 29