6/22/2013 Outline Echocardiographic Assessment of RV • Conventional Doppler Function and Failure in Children with Pulmonary Hypertensive Vascular Disease • 2-D assessment of RV function • Annular motion • Assessment of myocardial deformation Mark K. Friedberg, MD • Isovolumic acceleration • The duration of systole and diastole • Capacitance Clinical questions to be answered by echo: Assessment of RV function is difficult • Severity of pulmonary hypertension (Pulmonary artery systolic and diastolic pressures) • Underlying lesions / shunting across intra-cardiac • No axis of symmetry: complicates geometric communication modeling. • Associated lesions • Endocardial delineation is difficult (prominent • Right ventricular hypertrophy endocardial trabeculations) • Tricuspid regurgitation • Retrosternal location limits acoustic access. • Right and left ventricular function 1
6/22/2013 RV structure Which is worse? RV Free Wall IVS Anderson, Semin Thorac Cardiovasc Surg Chin, Coronary Artery Disease Pediatr Card Surg Ann 2007 10:76 2005, 16:13–18 ‘ Eyeball’ assessment still most common method RV does not tolerate acute increases in afterload MacNee W. Am J Respir Crit Care Med . 1994;150: 833–852. 2
6/22/2013 RV dimensions Adaptation to increased afterload 15 year old girl with presenting with pulmonary emboli RV dilatation as initial response to increased afterload Courtesy Luc Mertens Lopez, J Am Soc Echocardiogr 2010;23:465-95 Parameters of longitudinal function Tricuspid annular plane systolic excursion (TAPSE) Koestenberger, JASE 2009 3
6/22/2013 TAPSE correlates with RV EF TAPSE correlates with stroke volume Deviation of TAPSE values from mean age- related reference values Deviation of TAPSE values in patients with PAH-CHD and TOF from mean age- related reference values is shown (TAPSE ). D Ability of TAPSE to predict RV indexed stroke volume of 29 ml/ m2. grey diamonds PAH-CHD patients black triangles TOF patients López-Candales, Am J Cardiol 2006;98:973 Koestenberger, Congenit Heart Dis. 2012;7:250 Forfia, Am J Respir Crit Care Med 2006 174:1034–1041 TAPSE correlates with survival Tricuspid tissue Doppler velocities Forfia, Am J Respir Crit Care Med, 2006 174:1034 Eidem, J Am Soc Echocardiogr 2004;17:212-21 4
6/22/2013 TDI severe PAH Tissue Displacement Pre-tricuspid Eisenmenger 13y, iPAH, PAH worsening, pneumonia Normal TAPSE Low FAC% due to apical dysfunction 5
6/22/2013 Assessment of regional RV function by strain Fractional area of change Dambrauskaite, J Am Soc Echocardiogr 2007;20:1172 Mertens, L. L. & Friedberg, M. K. Nat. Rev. Cardiol, 2010 3-D assessment of RV volumes and EF LV function influences TAPSE López-Candales, AJC 2006;98:973 6
6/22/2013 Conventional echo parameters in children with PAH Other important 2-D parameters Right atrial size Pericardial effusion Bustamante-Labarta, JASE 2002;15:1160 Douglas, Circulation 1989;80:353 Kassem E, Am Heart J. 2013;165:1024-31 Conventional echo parameters in children with PAH Assessment of myocardial function iPAH All Kassem E, Am Heart J. 2013;165:1024-31 7
6/22/2013 Strain and strain rate Strain correlates with stroke volume *SV determined at cath Urheim, AJC 2005;96:1173 Isovolumic acceleration is a relatively load RV myocardial function independent measure of RV function Vogel, Circulation . 2002;105:1693-1699 Urheim, AJC 2005;96:1173 8
6/22/2013 RV strain in pediatric iPAH patients IVA is relatively load independent Urheim, AJC 2005;96:1173 Submitted RV strain in pediatric iPAH patients Back to Doppler…. Submitted 9
6/22/2013 Doppler hemodynamics MPI for RV function “ “ “ “ a ” ” is duration of tricuspid valve regurgitation ” ” “ “ b ” ” is RV ejection time “ “ ” ” + Rap … Eidem , Am J Cardiol 2000;86:654 Mertens, L. L. & Friedberg, M. K. Nat. Rev. Cardiol, 2010 The S/D Duration ratio Problems with MPI • Cannot assess RV inflow and outflow simultaneously • HR has to be similar in both measurements • ICT is short in the normal RV -> IRT becomes more important (itself an independent index) • Measurement of small intervals-prone to measurement error Friedberg, JASE, 2006;19:1326 10
6/22/2013 SD ratio in the RV in HLHS SD ratio in PAH Alkon, Am J Cardiol 2010;106:430 Friedberg, J Am Soc Echocardiogr 2007;20:749 Ventricular interactions in PAH The S/D duration ratio in PAH Gan . Am J Physiol 2006; 290:1528 Alkon, Am J Cardiol 2010;106:430 Marcus, J Am Coll Cardiol 2008; 51:750 11
6/22/2013 13y, iPAH, pneumonia, PAH worsening S/D ratio=2.3 S/D ratio=1.3 Echo predictors of mortality in Eisenmenger ’ s Ventricular-vascular interactions Moceri, Circulation. 2012;126:1461-1468 J Am Soc Echocardio gr 2006; 19:1045 12
6/22/2013 Pulmonary arterial capacitance by echo Pulmonary arterial capacitance PAC = RV stroke volume/pulmonary artery pulse pressure Friedberg, J AmSoc Echocardiogr 2006;19: 559 Sajan, Am Heart J 2011;162:562 Friedberg, J Am Soc Echocardiogr 2007;20:186 Summary RV stroke work • Assessment of RV function is important in PAH. • Echo is the mainstay of imaging in PAH, but has important limitations. • Newer methods can be combined with conventional assessment to provide more comprehensive evaluation. • Further validation of the newer methods in clinical practice is needed. • Left ventricular function and ventricular-vascular interactions should be accounted for DiMaria, ASE 2013 13
6/22/2013 Thank you Transesophageal echocardiography The Evolution of Echocardiography………… • Can be performed relatively safely and is usually well tolerated (even when baseline oxygen saturation levels are < 80%. • May be useful for detecting atrial septal defects / patent ductus arteriosus and for imaging pulmonary veins. • Should be performed in lung transplant candidates (detect unsuspected intracardiac defects/ shunts, proximal pulmonary artery thrombus). A-Mode……M-mode……2D…Doppler…Color- flow Doppler……COMPUTERS!!!!!!!! Gorcsan. Transesophageal echocardiography to evaluate patients with severe pulmonary hypertension for lung transplantation. Ann Thorac Surg. 1995; 59:717-22. 14
6/22/2013 Acoustic Quantification Assessing Myocardial Deformation Echocardiography Geva, Circulation . 1998;98:339 Courtesy of Piet Claus RV strain by speckle tracking The S/D ratio: Dilated Cardiomyopathy Friedberg, Am J Cardiol 2006;97:101–105 15
6/22/2013 SD ratio in PHTN 3D assessment of RV function A higher S/D ratio is associated with: - higher systolic, diastolic and mean PAP - higher RVSP, RV/BP ratio - higher PVR after exposure to 40ppm NO - lower RV FAC%, lower RVEF (MRI) - higher RVED - lower systemic blood pressure - shorter 6 minute walk distance - younger age at diagnosis - non-repaired CHD Marcus, J Am Soc Echocardiogr 2002;15: 1145 RV VVI What are we trying to capture? Kutty Echocardiography, Vol 25, 2008 16
6/22/2013 A smaller TAPSE may originate from RV Nelson Schiller and Annular excursion mechanical delay Isaaz K, Munoz del Romeral L, Lee E, Schiller NB. Quantitation of the motion of the cardiac base in normal subjects by Doppler “ Because the motion of the base of the heart plays a central role echocardiography. J Am Soc Echocardiogr. 1993 Mar-Apr;6(2):166-76. in its filling and emptying, we developed an original method to characterize the base motion dynamics throughout each cycle by use of pulsed Doppler echocardiography. A 100 Hz wall filter and low gain settings were used to record the low-frequency, high- energy Doppler signals generated by the motion of the base. From the apical four-chamber view, the sample volume was the tricuspid and mitral annuli. ” placed at the lateral margin and at the common septal margin of “ The method reported in the present study allows a more informative noninvasive quantitation of the cardiac base motion acceleration. ” derived from measurements of its velocity, excursion, and Lopez-Candales Am J Cardiol 2005;96:602 What should we measure? M-mode Celermajer and Marwick, Int J Card (2008) 125 :294–303 17
6/22/2013 Normal RV TDI/ strain values in children RV strain is influenced by afterload Weidemann, Ped Cardiol, 2002;23:292 Mertens and Friedberg Nature Reviews Cardiology. (2010): p551. TGA after ASO with PHT TAPSE correlates with RV EF TAPSE NORMAL FOR AGE Tissue Doppler López-Candales, Am J Cardiol 2006;98:973 Lissin, Am J Cardiol 2004;93:654–657 18
6/22/2013 Improved LV filling after relief of RV outflow TGA after ASO with PHT obstruction REDUCED APICAL FUNCTION Lurz, EHJ 2009 30, 2266–2274 Improved LV filling after relief of RV outflow obstruction Lurz, EHJ 2009 30, 2266–2274 19
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