Chamber Quantitation Guidelines...

Chamber Quantitation

Guidelines II

Steven A. Goldstein MD FACC FASE

Director, Noninvasive Cardiology

MedStar Heart Institute

Washington Hospital Center

Sunday, October 9, 2016

Right Heart Measurements

I have no relevant financial

relationships to disclose

Steven Goldstein

I. What to Measure

II. Importance of RV Function

GUIDELINES AND STANDARDS

Guidelines for the Echocardiographic Assessment of

The Right Heart in Adults: A Report from the American

Society of Echocardiography

J Am Soc Echocardiogr 2010;23(7):685-713

Lawrence G. Rudski, MD, FASE, Chair, Wyman W. Lai, MD, MPH, FASE, Jonathan Afilo, MD, Msc,

Lanqi Hua, RDCS, FASE, Mark D. Handschumacher, BSc, Krishnaswamy Chandrasekaran, MD, FASE,

Scott D. Solomon, MD, Eric K. Louie, MD, and Nelson B. Schiller, MD

Endorsed by the European Association of Echocardiography, a registered

Branch of the European Society of Cardiology, and the Canadian Society of

Echocardiography

asecho.org

GUIDELINES AND STANDARDS


asecho.org

J Am Coll Cardiol 2014;63(22):e57-185

I. What to Measure

Imaging the Right Heart:

Views, Anatomy, Normal Values

Imaging the Right Ventricle

Use Multiple Acoustic Windows

• Apical 4-chamber view

• RV-focused apical 4-chamber view

• Parasternal long axis view

• Parasternal short-axis view

• RV inflow view

Right Ventricle

Parameters to Perform and Report

• Measure of RV size

• Measure of RA size

• RV systolic function (at least one of following)

• With/without RV index of myocardial performance

• Systolic pulmonary artery pressure

• Estimate of RA pressure (based on IVC)

- Fractional area change (FAC)

- TDI S’

- Tricuspid annular plane systolic excursion (TAPSE)

RV Size

J Am Soc Echocardiogr 2015;28(1):1-39 asecho.org

Measuring RV Size

2 measurements - 2.8 cm and 3.6 cm

Endocardial border

definition (image quality)

Trabeculations

Foreshortening

May not reflect global

size


Measuring RV Size

Challenging/Limitations

Rudsky et al, J Am Soc Echocardiogr 2010;23:685

*

2D Echocardiography

RV EDD basal: 24-42 mm RV EDD mid: 20-35 mm

RV EDD long: 56-86 mm

Rudsky et al, J Am Soc Echocardiogr 2010;23:685

Mean ± SD Normal range

Table 8 Normal values for RV chamber size

J Am Soc Echocardiogr

2015;28(1):1-39

asecho.org

Parameter

Right Ventricle-Focused View

• Adjust from usual focus on LV

• Rotate tsdr until max plane obtained

• Aim to see RV lateral wall

RV Basal Diameter

2010

2015

24 (21-27)

33 ± 2

33 ± 4

42 (39-45)

41 (25-41)

LRV (95% CI) Mean (95% CI) URV (95% CI)

Rudski J Am Soc Echocardiogr 2010;23:685-713

Lang J Am Soc Echocardiogr 2015;28:1-35

Studies n

10

12

376

695

LRV – lower reference value

URV – upper reference value

RV Size - Reference Values (cm)

RV dimensions

RVOT diameters

Basal RV diameter

Mid-RV diameter

Base-to-apex length

Above aortic valve

Above pulm valve

Ref Range

Mildly Abnl

Mod Abnl

Severely Abnl

2.5–2.9

1.7–2.3

2.0–2.8

2.7–3.3

7.1–7.9

3.0–3.2

2.4–2.7

2.9–3.3

3.4–3.7

8.0–8.5

3.3–3.5

2.8–3.1

3.4–3.8

3.8–4.1

8.6–9.1

≥3.6

≥3.2

≥3.9

≥4.2

≥9.2

Foale Br Heart J 56:33(1986) 41 “normal” adults (age 19–46; 32 yrs)

RV-Focused View


Case 57

RV thickness = 1 cm

RV Function

RV Physiology

(PVR 1/10 SVR)

• Thin free wall and crescentic shape

impart high degree of compliance

• Ability to accommodate large volumes

• Low vascular impedance of pulm circul’n

LV RV

Right Ventricular Physiology

• RV suited to eject across low resistance of the pulmonary circuit

• Performs at a lower dP/dt than the LV

• RV wall motion not like LV:

• RV ejection is a complex mechanism

LV all walls and base move more or less

equally toward the center

RV base-to-apex shortening more pronounced

RV Ejection is Complex

Several Components

1. Contraction along long-axis (TV toward apex)

2. Inward movement of RV free wall

3. Bulging of septum into RV chamber

4. Circumferential contraction of RV outflow tract

1

2 3

4

++++

++

+

+

RV Contraction

• Predominantly longitudinal shortening

• RV outflow tract plays minor role

• Twisting and rotational movements do

not contribute significantly

RV Systolic Function

Echo Methods of Assessing

• Visual assessment (“gestalt”)

• Fractional area shortening

• TAPSE

• Tissue Doppler imaging of RV free wall (S’)

• Tei index

• RV dP/dt from TR signal

• RV strain and strain rate

• RV acceleration time

Parameters of RV Function - Feasibility

50 patients with ARDS in ICU with mechanical ventilation

Fichet Echocardiography 2012;29:513-21

72

62

96 96

%

RV FAC RV MPI

TAPSE TV Annular S’

RV Function

Table 7 Recommendations for the echocardiographic assessment of RV size

Echocardiographic imaging Recommended methods Advantages Disadvantages

continued . . .


2015;28(1):1-39 asecho.org

Table 7 Recommendations for the echocardiographic assessment of RV size

Echocardiographic imaging Recommended methods Advantages Disadvantages

continued . . .


2015;28(1):1-39 asecho.org

RV Function

Tricuspid Annular Plane Systolic Excursion

• Descent of RV base toward relatively fixed apex

• Represents function of longitudinal muscles

• Apical 4-chamber view

• 2D-echo and TEE

Tricuspid Annular Plane Systolic Excursion

(TAPSE)

TAPSE - Limitations

• Angle dependency

• Atrial fibrillation

• Patients on ventilators

• Highly dependent on RV loading conditions

(may become pseudo-normailzed0

Case 1

33 mm

Recommended Measures of RV Function

Summary of Reference Limits (2015)

TAPSE

Pulsed Doppler peak velocity (S’)

Pulsed Doppler MPI

Tissue Doppler MPI

FAC

<1.7 cm

<9.5 cm/s

>0.43

>0.54

<35 %

Variable Abnormal

(at the annulus)

MPI = myocardial performance index

Case 2

MW - 75 year-old woman

5’4” 298 lbs

S/P TAVI 1-year follow-up

Technically difficult study (obesity)

S’ = 13 cm/s

Case 3

TEE TAPSE, S’, Pulm Accel Time

Transesophageal Echo

Case 45

Case 45

Case 45

Case 4

TAPSE – importance of angle

TAPSE reduced . . . but, look at angle

Case 5

TAPSE varies with atrial fibrillation

8 mm 12 mm 15 mm 6.5 mm

Case 6

TAPSE varies with PVCs

Case 76

PVC

15 cm 20 cm 15 cm

Case 7

TAPSE varies with bigeminy

TAPSE - atrial bigeminy

FAC

Recommended Apical 4-Chamber View (1*)

Sensitivity of RV size to angular change

Recommended

Examples of RV Fractional Area Change

60% 40% 20%

Guidelines for Assessment of Right Heart in Adults


Recommended Measures of RV Function

Summary of Reference Limits (2015)

TAPSE

Pulsed Doppler peak velocity

Pulsed Doppler MPI

Tissue Doppler MPI

FAC

<1.7 cm

<9.5 cm/s

>0.43

>0.54

<35 %

Variable Abnormal

(at the annulus)

MPI = myocardial performance index

TEI RIMP

TEI Index of Myocardial Performance

Right Ventricle (RIMP)

• Doppler-derived index of myocardial performance of RV (RIMP)

• Represents global RV function independent of ventricular geometry

• Indicated for patients with increased TR velocity ≥ 3.0 m/sec

Calculation of TEI Index

(RIMP)

• Optimize right heart Doppler signals

• Measure pulm valve ejection time (PVET)

• Measure atrioventricular closure-opening

• Calculate RIMP

(TV C-O)

RIMP = TV C-O PVET

PVET

Calculation of TEI Index (RIMP)

RIMP = TV C-O PVET

PVET

TV C-O

PVET

Example of RIMP Calculation

RIMP = TVC-TVO PVET

PVET

Measurements

TVC – TVO

PVET

440 msec

280 msec

RIMP = 440 msec 280 msec

280 msec = 0.57

Normal values for RIMP 0.28 ± 0.04

Clinical Implication of RIMP

Normal values for RIMP 0.28 ± 0.04

Severe pulm HTN 0.89 ± 0.25

The higher the RIMP, the

more abnormal the RV

RIMP predicts survival in PHTN

Calculation of RV Myocardial Performance Index

MPI = TCO - ET

ET

TCO = tricuspid closure-opening ET = ejection time

Note that S’, E’, and A’ are also measured from the same tracing

S’

A’ E’

ET

TCO

RV Systolic Function

TAPSE S’ RIMP (PW Doppler)

RIMP (DTI)

FAC

< 16 mm

<10 cm/s

>0.40 >0.55

<35%

2010 2015



< 17 mm

< 9.5 cm/s

>0.43 >0.54

<35%

IVC

Estimation of RV Pressure

IVC diameter

Collapse with

sniff

≤ 21 cm

>50%

≤ 21 cm

< 50%

>21 cm

>50%

>21 cm

< 50%

Normal (0-5 [3] mm Hg)

Intermediate (5-10 [8] mm Hg)

High (10-20 [15] mm Hg)



Estimation of RA Pressure

Limitation of IVC Assessment

Dilatation of the IVC with normal RAP

has been observed in athletes and in

patients on mechanical ventilation

Caveats

Secondary Indices of Elevated RA Pressure

(Use to downgrade or upgrade RV pressure)

• Restrictive filling

• Tricuspid E/e’ > 6

• Hepatic vein diastolic predominance

Caution: • Athletes

• Patients on ventilators

Given the complex geometry of the RV,

none of these variables alone is sufficient

to describe RV function, and the overall

impression of an experienced physician is

often more important than single variables”

“

Galie Eur Heart J 2016;37(1):67-119 - ESC/ERS PHTN Guidelines

RV Function

II. Importance of RV

Function

Importance of RV

• Impact on hemodynamics

• Impact on prognosis

• Impact on functional capacity

RV Function

Clinical Relevance

• Heart failure

• Post myocardial infarction

• Cardiomyopathies and myocarditis

• Pulmonary thrombo-embolic disease

• COPD, ARDS, primary pulmonary HTN

• Valvular heart disease

• Repaired congenital heart disease

Prognostic Importance

Indices of Adverse Outcome in HF

RV size RV ejection fraction and FAC TAPSE RV S’ RV myocardial performance index Strain/strain rate

Sun (Cleve Clinic) Am J Cardiol 80:1583(1997)

RV Enlargement Increases Mortality

In Idiopathic Dilated Cardiomyopathy

0 24 48 72 96 0.0

0.2

0.4

0.6

0.8

1.0

Months

Surv

ival P

rob

ab

ility

No RV enlargement

RV enlargement p = 0.001

RV area/LV area >0.5

Size

Discordance in Degree of LV and RV Dilation in DCM

Clinical Implications

Lewis J Am Coll Cardiol 21:649(1993)

LV>RV (n=29)

LV=RV (n=38)

0 10 20 30 40 50 60

20

40

60

80

100

70

0

Duration of Follow-Up (Months)

% S

urv

ival

p=0.03

Size

tapse > 14

tapse ≤ 14

months 0 20 40 60

0.00

0.25

0.50

0.75

1.00

Event-

free s

urv

ival*

Ghio Am J Cardiol 2000;85:837-42 * death or emergency transplantation

Prognostic Value of TAPSE

tapse ≤ 14

CHF 2º Idiopathic or Ischemic DCM

n = 140

LVEF <35%

Kjaergaard Eur J Heart Failure 2007;9:610-16; ECHOS Trial

0 1 2 3 4 0.0

0.2

0.4

0.6

0.8

1.0

Years

Su

rviv

al

TAPSE ≥ 14 mm

TAPSE < 14 mm

RV Dysfunction: Independent Predictor

of Mortality in Patients with HF

n = 817

LVEF ≤ 35%

NYHA III-IV

TAPSE

Survival in Myocarditis

Normal vs Abnormal RV Function

Mendes, Dec, Picard, Davidoff, et al Am Heart J 128:3019(1994)

0 400 800 1,200 1,600 2,000

0

20

40

60

80

100

Follow-up (days)

Even

t-fr

ee s

urv

ival

(%

)

Normal RV TAPSE >17 mm)

Abnormal RV (TAPSE <17mm) p = 0.03

TAPSE

(Biopsy proven acute myocarditis; n=23)

Forfia Am J Respir Crit Care 2006;174(9):1034-41

TAPSE Predicts Survival in Pulmonary Hypertension

0 6 12 18 24 0.00

0.25

0.50

0.75

1.00

Months

Su

rviv

al

TAPSE ≥1.8 cm

TAPSE<1.8 cm

P = 0.009

TAPSE

PAH: m PAP ≥25 mm Hg; PCWP ≤ 15 mm Hg

Although the initial insult involves the

pulmonary vasculature, survival of

patients with PAH is closely related

to RV function.

Pulmonary Hypertension

Damy Eur J Heart Failure 2009;11:818-24

0 800 200 400 600

Time (days)

0

0.2

0.4

0.6

0.8

1.0

Even

t-fr

ee S

urv

ival PSV tdi≥ 9.5 cm s-1

PSV tdi< 9.5 cm s-1

Stable Heart Failure Patients (EF<35%)

Pulsed Wave Systolic Tissue Doppler Imaging (PSV tdi)

S’

n=136

Survival in HFpEF

According to RV Function (FAC)

Melenovsky Eur Heart J 2014;35(48):3452-62

0 500 1000 1500 2000 Days 0.0

0.2

0.4

0.6

0.8

1.0

HFpEF, RV dysfunction

(FAC ≤ 35%)

HFpEF, normal RV

P = 0.0001

64 32 21 8 2

32 17 5 2 0

No RV Dys

RV Dys

Su

rviv

al

FAC

0 500 1000 1500

Time (days)

0

25

50

75

100

Su

rviv

al

(%

)

No RV Dysfunction n = 337

RV Dysfunction n = 79

Zornoff J Am Coll Cardiol 2002;39(9):1450-5

RV Function after Myocardial Infarction

Independent predictor of death

FAC<32.2% or >32.2%

FAC

Strain

RV Strain

• Usually only measured in longitudinal

• Reproducible

• Normal < -20% - < -25%

• No reference values currently recommended

• May be earlier marker of RV dysfunction

dimension

than EF, TAPSE, S’, FAC

Fine (Mayo Clinic) Circ Cardiovasc Imaging 2013;6:711-21

RV Strain and Survival

575 subjects evaluated for pulmonary hypertension A

ll-cause m

ort

alit

y, %

P<0.001 RV longitudinal systolic strain

Motoki J Am Soc Echocardiogr 2014;27:726-32

Survival According to RV Strain 171 patients with chronic systolic heart failure

RV strain < -14.8%

RV strain ≥ -14.8%

Days

Eve

nt-

Fre

e S

urv

iva

l (%

) P = 0.004

Number at risk

Motoki J Am Soc Echocardiogr 2014;27:726-32

Incremental Value of RV Strain

vs Conventional Parameters 171 patients with chronic systolic heart failure

+ RV strain ≥ -14.8

P=0.01

P=0.02

Ch

i-sq

ua

red

Sta

tisti

c

Incremental Prognostic Value of Echo

Parameters When Added to Clinical Data

1.6 8.4 16.8 24.0

p = 0.011

p = 0.010

p = 0.011

All

-Cau

se M

ort

ali

ty

Chi-

squa

re

Kusunose JACC: CV Img 2014;7(11):1084-94

Before and After Lung Transplantation

Strain

Chronic Heart Failure Patients

Prognostic Significance of RV Strain

0 500 1000 1500

0

0.2

0.4

0.6

0.8

1.0

Time (days) Cu

mu

lati

ve

Dea

th a

nd

Acu

te H

F E

ven

ts

RV 2D-strain > -21%

N = 60

RV 2D-strain ≤ -21%

N = 44

N = 104 CHF patients

Guendouz Circulation J 2012;76:127-36 Strain

3D

RV Function

3D-Echo

• Possible to visualize entire RV and re-slice it in short-axis cuts

• Eliminates need for simple geometric model

• Resolution and wall delineation marginal, but improving

3D-Echo for RV Volumes

• Avoid RV trabeculae and moderator band

• 3DE tends to underestimate RV volumes compared to cardiac MRI

3D-Echo RV Volume

Interobserver Variability

Intraobserver variability = 1.23 mL or 2.0% of mean

Jiang, Siu, Handschumaker, et al Circulation 89:2342(1994)

Interobserver variability = 1.86 mL or 4.0% of mean

OBSERVER 2

OBSERVER 1

Volu

me (c

c)

1 2 3 4 5 6 7 8 9 10 0

20

40

60

80

RV

n = 10 dogs

Case 8

RV infarct McConnell’s sign

Infero-lateral (posterior) wall hypokinetic

Basal infero-lateral (posterior) wall hypokinetic

McConnell’s sign relative preservation of RV apex

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