RIGHT HEART ASSESMENT

Is It Important?Not just a conduitConnected and affectedRisk stratificationTherapy guidanceControversialUnderstudiedExaminers favorite

The Purposes Of GuidelinesDescribe the acoustic windowsDescribe the echocardiographic parameters of RV size and function.Advantages and disadvantages of each measure or technique.Recommend which right-sided measures should be included in the standard echocardiographic report.Provide revised reference values

BASIC VIEWS

BASIC VIEWS

BASIC VIEWS

Segmental Nomenclature

Right Heart DimensionsRight ventricle-focused apical 4 chamber viewMeasured at end-diastole

Which of the following is an abnormal right ventricular (RV) dimension in an adult 30 years old?A. Basal RV diameter of 2.5 cm.B. Mid RV diameter of 3.8 cm.C. Right ventricular outflow tract (RVOT) diameterabove the aortic valve of 2.6 cm.D. Base to apex RV length of 7.5 cm.

Right ventricular dimensions

Basal RV diameterMid cavitary RV diameterRV longitudinal dimension4.2 cm indicates dilatation3.5 cm indicates dilatation8.6 cm indicates RV enlargement

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RV size should be routinely assessed by conventional 2DE using multiple acoustic windowsReport should include both qualitative and quantitative parameters. In laboratories with experience in 3DE, 3D measurement of RV volumes is recommended.RV EDVs of 87 mL/m2 in men and 74 mL/m2 in women RV ESVs of 44 mL/m2 for men and 36 mL/m2 for women

TAPSETAPSE and RV ejection fraction TAPSE 2cm = RVEF 50% TAPSE 1.5cm = RVEF 40% TAPSE 1cm = RVEF 30% TAPSE 0.5cm = RVEF 20%

Event free survival according to TAPSE in patients with CHF

RV Diastolic FunctionFrom the apical 4-chamber view, the Doppler beam should be aligned parallel to RV inflowSample volume is placed at the tips of the tricuspid valve leafletsMeasure at held end-expiration and/or take the average of 5 consecutive beatsMeasurements are essentially the same as those used for the left side

RecommendationMeasurement of RV diastolic function should be considered in patients with suspected RV impairment as a marker of early or subtle RV dysfunction, or in patients with known RV impairment as a marker for poor prognosisTranstricupsid E/A ratio, E/E ratio, and RA size have been most validated are the preferred measuresGrading of RV Diastolic Dysfunction should be done as follows: E/A ratio < 0.8 suggests impaired relaxationE/A ratio 0.8-2.1 with an E/E > 6 or diastolic prominence in the hepatic veins suggest pseudonormal fillingE/A ratio > 2.1 with deceleration time < 120 ms suggests restrictive filling

RecommendationsThe recommended parameter to assess RA size is RA volume, calculated using single-plane area-length or disk summation techniques in a dedicated apical four-chamber view.The normal ranges for 2D echocardiographic RA volume are :Males25 7 ml/m2Females21 6 ml/m2

RA PressureMeasurement of the IVC should be obtained at end-expiration To accurately assess IVC collapse, the change in diameter of the IVC with a sniff and also with quiet respiration

RecommendationsFor simplicity and uniformity of reporting, specific values of RA pressure , rather than ranges, should be used in the determination of SPAPIVC diameterIVC collapsibilityRA pressure 2.1 cm> 50% with a sniff3 mmHg > 2.1 cm < 50 % with a sniff15 mmHgIn indeterminate cases in which IVC diameter and collapse do not fit this paradigm, an intermediate value of 8 mmHg may be used, preferably with use of secondary indices of RA pressures such as: RA dilatation, abnormal bowing of the IAS into the left atrium throughout the cardiac cycle

AdvantagesDisadvantagesIVC dimensions are usually obtainable from the subcostal windowIVC collapse does not accurately reflect RA pressure in ventilator-dependent patientsIt is less reliable for intermediate values of RA pressure

Which of the following is the correct measurement of the IVC diameter in estimating RA pressureA. AB. BC. CD. None of the above

ABC

The end-systolic and end-diastolic parasternal short-axis views of a 75-year-old patient are shown. Which of the following statements is more likely to be true?A. This patient likely has carcinoid heart disease.B. This patient likely has Eisenmenger physiology.C. There is evidence of a restrictive VSD.D. Pulmonic stenosis is suspected.E. These images are classic for Ebstein anomaly

Other RecommendationsVisual assessment of ventricular septal curvature looking for a D-shaped pattern in systole and diastole should be used to help in the diagnosis of RV volume an/or pressure overload

RV pressure overload-septal shift throughout cardiac cycle with most marked distortion of LV at end systoleRV volume overload-septal shift occurs predominately in mid to late diastole

Pulmonary Artery PressuresPASP should be estimated and reported in all subjects with reliable tricuspid regurgitant jets

Which of the following parameters are used to calculate Pulmonary artery systolic pressure?A. TR onlyB. TR and PR onlyC. TR and VSD onlyD. TR, PR, and VSD onlyE. TR, AR, PR, and VSD

What is the PA systolic pressure of the patient with pulmonary stenosis, where peak TR velocity is 4 m/sec, peak velocity across pulmonic valve 3 m/sec, and RA pressure 10 mm Hg?A. PA systolic pressure 46 mm Hg.B. PA systolic pressure 74 mm Hg.C. PA systolic pressure 38 mm Hg.D. PA systolic pressure 50 mm Hg.

What is the PA systolic pressure of the patient with pulmonary stenosis, where peak TR velocity is 4 m/sec, peak velocity across pulmonic valve 3 m/sec, and RA pressure 10 mm Hg?A. PA systolic pressure 46 mm Hg.B. PA systolic pressure 74 mm Hg.C. PA systolic pressure 38 mm Hg.D. PA systolic pressure 50 mm Hg.RVSP4 (4)2 + 1064 + 107474 PSPG74 4 (3)274 - 3638PASP = RVSP - PSPG

28-year-old man with liver disease presents with jugular venous distensions

A. Right ventricular systolic function is markedly diminished.B. Peak velocity of 2.2 m/sec excludes the diagnosis of pulmonary HTNC. Tricuspid regurgitation is likely mild.There is right ventricular midcavitary gradient during systole. Right ventricular systolic function can not be accurately assessed.

A patient with holosystolic murmur at the left sternal border. What is RVSP?Blood Pressure150/80 mmHgRA Pressure15 mmHg35 mmHg65 mmHg50 mmHgCan not be calculated

Other Recommendations

1/3 (SPAP) + 2/3 (PADP)1. Mean PA pressure =2. Mean PA pressure = 79 (0.45 x AT)3. Mean PA pressure = 90 (0.62 x AT)4. Mean PA pressure = 4 x (early PR vel) + est. RAP

What is the PA diastolic pressure in this patient with dyspnea on exertion? The IVC is dilated and does not collapse with sniffing.A. PA diastolic pressure 14 mm Hg.B. PA diastolic pressure 17 mm Hg.C. PA diastolic pressure 28 mm Hg.D. PA diastolic pressure 19 mm Hg.

Pulmonary Vascular Resistance

PVR = TRV max / RVOT TVI x 10 + 0.16 Significant PHTN exists when PVR is > 3 Wood units

RV dP/dtThe rate of pressure rise in the right ventricleEstimated from the ascending limb of the tricuspid regurgitant CW Doppler signal

RV dP/dt < 400 mmHg/s is likely abnormal

Hepatic Vein DopplerThe normal HV waveform has three antegrade wavesA larger systolic S wave A smaller diastolic D waveA small retrograde flow reversal from atrial contraction A wave

The following statement is TRUE regarding below given Hepatic vein Doppler:A. Abnormal interventricular septal motion is due to right ventricular volume overload.B. Inspiratory increase in forward hepatic vein flow velocities is abnormal.C. Above M-mode recordings are diagnostic of a large pericardial effusion and tamponadeD. Patient has ventricular interdependence.

Which of the following is most compatible with the hepatic venous flow in Figure below:A. 56-year-old man with systemic hypertension under control with medical therapy.B. 39-year-old woman with hypotension in the setting of acute inferior wall MI.C. 25-year-old man with recurrent septic pulmonary embolism.D. 63-year-old man in atrial fibrillation

Thanks for your patience

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