Steven J. Lester MD, FACC, FRCPC, FASE · 15 J Am SocEchocardiogr2015;28:1-39 Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al 1.1 Linear

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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

2

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


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




A goal was to eliminate discrepanciesbetween previous guidelines

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•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

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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

14

A B C

49mm

55mm 46mm

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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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“…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”.


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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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





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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


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“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

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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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Documents

Steven J. Lester MD, FACC, FRCPC, FASE · 15 J Am SocEchocardiogr2015;28:1-39 Members of the Chamber Quantification Writing Group are: Roberto M. Lang, MD, FASE, et al 1.1 Linear