1
Steven J. Lester MD, FACC, FRCPC, FASESteven J. Lester MD, FACC, FRCPC, FASE
Relevant Financial Relationship(s)
NoneOff Label Usage
None
Relevant Financial Relationship(s)
NoneOff Label Usage
None
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J Am Coll Cardiol 1998;32:948J Am Coll Cardiol 1998;32:948
0.0
0.2
0.4
0.6
0.8
1.0
0 365 730 1,095 1,460 1,825 2,190Survival (days)Survival (days)
2=13.9P=0.00022=13.9P=0.0002
RVEF >39%RVEF >39%
RVEF 39%RVEF 39%
To review and understandthe strengths and limitations of the echocardiographic methods used to evaluate right ventricular size and function.
To review and understandthe strengths and limitations of the echocardiographic methods used to evaluate right ventricular size and function.
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Hurst The Heart 12th edition
Right-handed Helixsubendo
Left-handed Helixsubepi
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RV LV
Image from Circ 2008:117
1. Shape: Geometric Model?2. Heavy Trabeculation:
Definition of endocardial surface3. Load Dependence
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• Gold standard for RV quantification
Image qualityHigh reproducibility
• LimitationNot widely availableTime consuming
• Gold standard for RV quantification
Image qualityHigh reproducibility
• LimitationNot widely availableTime consuming
Its configurability, harmless energy source and unparalleled temporal resolution make it the principle clinical tool used to evaluate RV structure and function
Its configurability, harmless energy source and unparalleled temporal resolution make it the principle clinical tool used to evaluate RV structure and function
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Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
J Am Soc Echocardiogr 2005;18:1440-1463J Am Soc Echocardiogr 2005;18:1440-1463
Over 5000 citations
Adapted from Roberto Lang MD
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Guidelines for the Echocardiographic Assessment ofThe Right Heart in Adults: A Report from the American
Society of EchocardiographyJ Am Soc Echocardiogr 2010;23:685-713
J Am Soc Echocardiogr 2015;28:1-39J Am Soc Echocardiogr 2015;28:1-39
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
A goal was to eliminate discrepanciesbetween previous guidelines
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•StructureBig or Not?
•FunctionNormal or Not?
•StructureBig or Not?
•FunctionNormal or Not?
RVD1>41mm
RVD2>35mm
> 83mm
RVOT Prox
RVOT Prox
RVOT Distal
>35mm
>27mm
Lang et al. J Am Soc Echocardiogr 2015;28:1-39
9
Posterior
Anterior
Posterior
Anterior
Surgeon > 70mm
Echo (4C view)> 40mm or 21mm/m2
10
11
49mm
55mm46mm
12
A B C
49mm
55mm 46mm
Axial Lateral
Detail seen along the Line of the ultrasound beam
The ability to distinguish two points perpendicular to the
direction of the beam
Higher! Lower!
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The GapsLine Density
The Width of the beamPoint Spread Artifact
A B C
49mm
55mm 46mm
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A B C
49mm
55mm 46mm
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J Am Soc Echocardiogr 2015;28:1-39J Am Soc Echocardiogr 2015;28:1-39
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
1.1 Linear Measurements. • It is recommended that linear internal measurements of the LV and its walls be performed in the PLAX view.• Perpendicular to the LV long axis at or immediately below the mitral leaflet tips.• Measures obtained with 2D or 2D guided M-mode, although2D images are preferred to avoid oblique sections of the ventricle.
39mm (>41)
28mm (>35)
31mm
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35mm
Image from Rudski et al. J Am Soc Echocardiogr 2010
No fixed reference
point
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Lang et al. J Am Soc Echocardiogr 2015;28:1-39
“…it is apparent that minor variations in the four-chamber plane position (dashed line) with respect to the right ventricular crescent shape may result in variability of right ventricular size when performed by linear measurements.”
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“Care should be taken to obtain the image withthe LV apex at the center of the scanning sector, while displaying the largest basal RV diameter and thus avoiding foreshortening”.
Lang et al. J Am Soc Echocardiogr 2015;28:1-39
3.7 cm
“In all complete echocardiographic studies, the RV basal measurement should be reported, and the report should state the window from which the measurement was performed (ideally the right ventricle–focused view), to permit interstudy comparisons. The relative size of the right ventricle should be compared with that of the LV to help the study interpreter determine if there is RV dilatation, and the interpreter may report the right ventricle as dilated despite measuring within the normal range, on the basis of a right ventricle appearing significantly larger than the left ventricle”.
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J Am Soc Echocardiogr 2015;28:1-39J Am Soc Echocardiogr 2015;28:1-39
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
7. RV Measurements (Recommendations). “RV size should be routinely assessed by conventional 2DE usingmultiple acoustic windows, and the report should include bothQualitative and Quantitative parameters.”
1. Spatial resolution: axial versus lateral resolution
2. RV endocardial borders are coarsely trabeculated
3. Measuring medial – lateral dimension. Annulus dilates more in the anterior – posterior dimension
4. No fixed reference points to ensure reproducibleimages.
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RVD1 (>41mm)Basal Dimension
RVD2 (>35mm)Mid Cavity
- End-diastole, below the tricuspidannulus at a distance approximating the length of the anterior tricuspid leaflet, when it is fully open and parallel to the RV free wall
- Trabeculae, papillary musclesand epicardial fat to be excluded
>5mm
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• Overall RV wall thickness is a poor index of RV mass.
• Consider use in individual patients as a parameter to follow.
• Congenital heart disease, pulmonary HTN and HCM
•StructureBig or Not?
•FunctionNormal or Not?
•StructureBig or Not?
•FunctionNormal or Not?
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•Complex contraction pattern
•Complex geometric shape
•Complex contraction pattern
•Complex geometric shape
Pulmonary valve
Tricuspid valve
Interventricularseptum
FAC = 1 -19.3
= 32%28.5
28.5 cm2 19.3 cm2
Abnormal Threshold < 35%
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StrengthsStrengths• FAC has established
prognostic valve• Reflects both radial
and longitudinal components of RV contraction
• Correlates with RVEF by MRI
• FAC has established prognostic valve
• Reflects both radial and longitudinal components of RV contraction
• Correlates with RVEF by MRI
LimitationsLimitations• Neglects
contribution of the RV outflow tract
• Only fair interobservervariability
• Neglects contribution of the RV outflow tract
• Only fair interobservervariability
Image from Rudski et al. J Am Soc Echocardiogr 2010
No fixed reference
point
2D derived measures of RV area can vary widely in the same patient with
relatively minor rotations in the transducer position.
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“Two dimensionally derived estimation of RVEF is not recommended, because of the heterogeneity of methods and the numerous geometric assumptions.”
J Am Soc Echocardiogr 2010;23:685-713
Lang et al. J Am Soc Echocardiogr 2015;28:1-39
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J Am Soc Echocardiogr 2015;28:1-39J Am Soc Echocardiogr 2015;28:1-39
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al
“In laboratories with appropriate 3D platforms and experience, 3DE-derived RV EF should be considered as
a method of quantifying RV systolic function, with the limitations mentioned above. Roughly, an RV EF of <45% usually reflects abnormal RV systolic function, though laboratories may choose to refer to age- and gender-
specific values.”
1. TAPSE2. Annular
Velocity (s’)3. Strain4. RIMP
1. TAPSE2. Annular
Velocity (s’)3. Strain4. RIMP
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Normal Abnormal
• Green circle = Lateral TV annular position at ED
end-systole end-diastole
LVRV
LV RV
• Pink circle = Lateral TV annular position at ES
Systolic TAM = distance of yellow arrow
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19mm
1
RV
RA
Kjaergaard J et al: Eur J Echocardiogr, 2005Kjaergaard J et al: Eur J Echocardiogr, 2005
0
20
40
60
80
100
0 1 2 3 4
RVEFby MRI
(%)
RVEFby MRI
(%)
2D Echo M mode TAM (cm)2D Echo M mode TAM (cm)
IHDPulm hypNormal subjects
IHDPulm hypNormal subjects
y=12.4x + 29SEE=11%r2=0.23P<0.01
y=12.4x + 29SEE=11%r2=0.23P<0.01
LRV: 17mm
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Longitudinal shortening – easy way to assess and follow RV function
Sensitive indicator of impaired function
Can be reduced while radial function is still normal or even increased (compensatory)
Always reduced after cardiac surgery
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S’
E’A’
Normal ValuesS’ > 9.5cm/se’ > 7.8 cm/sa’ > 8 cm/s
Meluzin J et al: Eur Heart J 22:348, 2001Meluzin J et al: Eur Heart J 22:348, 2001
y=5.693 + 2.959xr=0.648P<0.001
y=5.693 + 2.959xr=0.648P<0.001
10
20
30
40
50
60
70
4 6 8 10 12 14 16
Sa (cm•s-1)Sa (cm•s-1)
RV
EF
by
FP
rad
ion
ucl
ide
RV
EF
by
FP
rad
ion
ucl
ide
LRV: 9.5 cm/sec
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Peak value of 2D longitudinalSpeckle tracking strain, average Over 3 segments of RV free wall In RV focused A4C view (%)
Normal (>)-20%
Prognostic Value of Right Ventricular LongitudinalPeak Systolic Strain in Patients With Pulmonary
Hypertension
Circ Cardiovasc Imaging 2012;5:628-6360 1 2 3 4
0
25
50
75
100
RV LPSS > -19%
RV LPSS < -19%
Logrank p=0.001
Follow-up (years)
Su
rviv
al (
%)
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Tricuspid flowTricuspid flow
RIMP = (a - b) / b= (ICT + IRT) / ET
IRT = c - d
ICT = (a - b) - (c - d)
RIMP = (a - b) / b= (ICT + IRT) / ET
IRT = c - d
ICT = (a - b) - (c - d)
Pulmonary flowPulmonary flow
aa
bb
ccdd
ICTICT ETET IRTIRT
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Xms
Yms
RIMP= ( )
X
-Y
Y
= …
2
Harada K et al. Am J Cardiol 2002;90:566
Harada K et al: Am J Cardiol 90:566, 2002Harada K et al: Am J Cardiol 90:566, 2002
0.0
0.2
0.4
0.6
0.8
0.0 0.2 0.4 0.6 0.8
RIMP (pulse Doppler)RIMP (pulse Doppler)
RIM
P (
TD
I)R
IMP
(T
DI)
y=0.069 + 0.84xr=0.81P<0.0001n=40
y=0.069 + 0.84xr=0.81P<0.0001n=40
-0.4
-0.2
0.0
0.2
0.4
0.0 0.2 0.4 0.6 0.8
Mean Tei indexMean Tei index
Dif
fere
nce
Tei
in
dex
Dif
fere
nce
Tei
in
dex
+2 SD+2 SD
MeanMean
–2 SD–2 SD
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>0.54
>0.43
0 0.2 0.4 0.6
Pulsed Doppler Tissue Doppler
MPI ValueLang et al. J Am Soc Echocardiogr 2015;28:1-39
0 41 32 50
0.2
0.4
0.6
0.8
1.0 RIMP < 0.83
RIMP> 0.83
Years
Su
rviv
al
Yeo et al, Am J Cardiol, 1998;81:1157-61
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arterial
ventricular
atrial
arterial
ventricular
atrial
35
Tricuspid Flow Velocity
- 0.5 m/s
RVOT Flow Velocity
Lasix 80 mg
Effect of decrease in PA pressure
IMP = = 0.68170250
IMP = = 0.2360260
Courtesy Dr. Hatle
arterial
ventricular
atrial
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Courtesy Dr. Hatle
Lasix 80 mg
Ao
Ac Mo
Tei index = = 0.96215
225Tei index = = 1.22
275
225
Effect of decrease in LA pressure
• Mixes systolic and diastolic function
- these should be assessed separately
• Varies with pressure and volume status
- RV - pulm. hypertension or RV dysfunction?
• Measurement may include presystolic time
- diastolic MR or TR – elevated pressure or long PR?
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0
10
20
30
40
50
60
70
80
90
100
MPI>0.4
SensSpecPPVNPVAUC
Miller et al J Am Soc Echo 2004;17:443-7
1. Big or Not: Remains largely qualitative with some measures used to follow individual patients
2. Function:• Limited volumetric methods• Non volumetric methods
• TAPSE (how much does it move)• TDI (how fast does it move)• Free Wall Strain• RIMP (Limitations)
1. Big or Not: Remains largely qualitative with some measures used to follow individual patients
2. Function:• Limited volumetric methods• Non volumetric methods
• TAPSE (how much does it move)• TDI (how fast does it move)• Free Wall Strain• RIMP (Limitations)
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