The Right Ventricle: Clinicaland Imaging Strategies for

The Right Ventricle: Clinicaland Imaging Strategies for

AssessmentAssessmentS iddharthS inghM BBS ,M S

N on-invasiveCardiacL aboratory andCardiacCriticalCare

CedarsS inai

• No disclosures• No disclosures

RV ANATOMY

• N orm althickness2-3 m m• N orm althickness2-3 m m

• Distinctinflow andoutflow regionsseparatedby cristasupraventricularisseparatedby cristasupraventricularis

• T rabeculated

• Com plex geom etricshape• Com plex geom etricshape

Sheehan F. Heart20 0 8

RV FIBER ARRANGEMENT• S uperficialcircum ferentialm usclefibersresponsibleform usclefibersresponsibleforitsinw ardbellow sm ovem ent

• Deeperlongitudinalfibers• Deeperlongitudinalfibersthatresultinthebase-to-apex contractionapex contraction

• Base-to-apex shorteningm ayplay greaterroleinR Vplay greaterroleinR Vem ptying

• S eptum haslongitudinalR VCourtesy GrantT. Gullberg, Law rence Berkley Lab

• S eptum haslongitudinalR Vfibers

Sanchez-Guintana Heart1 996;76:280 –6

RV PHYSIOLOGY• Ill-definedisovolum icrelaxationand• Ill-definedisovolum icrelaxationand

contractionphase• Continuedejectionduring• Continuedejectionduring

pressuredecline

• M inorchangesinafterloadm aycauselargedecreaseinS VcauselargedecreaseinS V

• R CA perfusion

• Heart-L unginteractions• Heart-L unginteractions• Coupledtolow im pedancepulm onary

circuit• Changesinpreloadw ithrespiration• Changesinpreloadw ithrespiration

Hadad F. Circulation; 1 1 7: 1 436-1 448Sheehan F. Heart20 0 8 Nov;94( 1 1 ) :1 51 0 -5

VENTRICULO-VENTRICULAR INTERACTIONS

*N orm alR V contractileperform anceisnotably dependentonthatoftheLV

Konstam M Circulation.20 1 8;1 37:e578–e622Hadad F. Circulation; 1 1 7: 1 436-1 448Dam iano RLJrAm JPhysio 1 991 ; 261 :H1 51 4-24

notably dependentonthatoftheLV*30% ofcontractileenergy ofR V generated byLV

CLINICAL ASSESSMENT• ElevatedJVP w ithprom inentV w ave• ElevatedJVP w ithprom inentV w ave

• Peripheraledem a

• Bloating/early satiety/abdom inaldiscom fort

• P rom inentS 2 (P 2)(P H)

• Right-sided S3 gallop

• Holosystolic m urm urLLSB ( TR)• Holosystolic m urm urLLSB ( TR)

• RV parasternalheave

• Cardiorenalsyndrom e• Cardiorenalsyndrom e

• Cardiohepaticsyndrom e

• P roteinL osingEnteropathy

N arrow pulsepressure• N arrow pulsepressure

• Coolextrem ities

CMR: REFERENCE STANDARD

Kaw el-Boehm N. JCMR 20 1 51 7:29

RV ASSESSMENT BY ECHO

R V ContractilityR V Contractility

• R V FractionalA reaChange-(FAC)• MyocardialPerform ance Index ( Tei)

• R V P R EL O A D

• MyocardialPerform ance Index ( Tei)• RV dP/ dt• RV outflow tractvelocity tim e integral

( VTI)• R V P R EL O A D

• Cham bersizeandseptalposition• IVC sizeandcollapsibility• T ricupsidR egurgitation• T ricuspidinflow

• RV outflow tractvelocity tim e integral( VTI)

• T ricuspidA nnularP laneS ystolicExcursion(T A P S E)

• M m ode• T ricupsidR egurgitation• T ricuspidinflow

• R V A FT ER L O A D

Excursion(T A P S E)• M m ode• T issueDoppler

• Tissue Doppler–derived and 2D strain• R V A FT ER L O A D

• P A S P andP A DP• T A P S E/P A S P ratio• R VO T notching

Tissue Doppler–derived and 2D strain• 3 D EjectionFraction

T A P S E FR ACT IO N A L A R EA CHA N GE R V CO

*L ongitudinalm otionoflateral T V annulus (≥1.6 cm )

*R eflectslongitudinalandradialcom ponentsofR V

* R VO T VT IX HEA R T R AT E*S houldbeatleast1000*DifficultiesinR VO T

lateral T V annulus (≥1.6 cm )*Dependentonangleandloadingconditions*N otaccurateafterthoracotom y ortransplant

radialcom ponentsofR Vcontraction ( ≥35% )*Correlatesw ellw ithR VEFby CM R*N eglectscontributionof

*DifficultiesinR VO Tdiam eterm easurem ent*Canbeserially trackedU sefulinLVA D patientsthoracotom y ortransplant

*M oderatecorrelationw ith3D R VEF

*N eglectscontributionofR V outflow tracttooverallfunction

U sefulinLVA D patients* L argevalidationstudieslacking

GLOBAL LONGITUDINAL STRAIN

• P eakvalueof2D longitudinalspeckletrackingderivedstrainaveragedover3 segm entsoffreeaveragedover3 segm entsoffreew all

• A ngleindependent

• Vendordependent• Vendordependent

• P rognosticrole

• Dependsonloadingconditionsand• DependsonloadingconditionsandR V size

• GL S > -20% islikely abnorm al

A.Janjic

3D ECHO

• ValidatedagainstcardiacM R

• Volum etricsem i-autom ated

• Im agequality m ay beaconcern• Im agequality m ay beaconcern

• L oad-dependent

• 45% goodthresholdforL L N• 45% goodthresholdforL L N

Increasingly linkedtooutcom esNagata Y. Circ Im aging. 20 1 7;1 0 :e0 0 5384Murata M O ncotarget. 20 1 6Dec 27; 7( 52) : 86781 –86790

CARDIAC CT

• Retrospective gating used• Retrospective gating used• Spiralw ith Dose m odulation

• Contrastm ay be given atslow errate orinjection tim e extended toopacify RVopacify RV

• Look forcontrastrefluxin IVC

Courtesy BalajiT am arappooM D

HEMODYNAMIC ASSESSMENT

Variable Calculation T hresholdsA ssociatedW ithClinicalEvents

R ight-to-leftdiscordanceof R A P :P CW P >0.63 R HFafterLVA DR ight-to-leftdiscordanceoffillingpressures

R A P :P CW P >0.63 R HFafterLVA D>0.86R HFinacuteM I

P A pulsatility index (P A S P -P A DP )/R A P <1 R HFinacuteM I<1.85R HFafterLVA D<1.85R HFafterLVA D

R V strokew orkindex (M P A P -CVP )x S VI <0.25m m Hg.l/m 2 R HFafterLVA D

P VR (M P A P – P CW P )/ CO >3.6W U R HFafterLVA DP VR (M P A P – P CW P )/ CO >3.6W U R HFafterLVA D

P A com pliance S V/ (P A S P -P A DP ) <2.5m l/m m HgR HFinchronicHFandR V-P AcouplinginP A HcouplinginP A H

Hem odynam iccorrelatesinconsistentacrossstudiesCanthesebenoninvasively assessed?

KapurNK Circulation. 20 1 7;1 36:31 4–326

Predicting RHF AfterLVAD ImplantationLVAD Implantation

Variable O R S core

RA/ PCW P >0 .54 2.2 1RA/ PCW P >0 .54 2.2 1

Hb ≤1 0 g/ dl 2.6 1 .5

Multiple inotropes 3.0 2Multiple inotropes 3.0 2

INTERMACS Class 1 -3 3.4 2

Severe RV 2.1 1Severe RVDysfunction

2.1 1

CPB tim e >1 0 0 m in 2.0 1

Solim an O II. Circulation 20 1 8; 1 37:891 -90 6

SUMMARYSUMMARY

• W hilew idely used2D echocardiography haslim itationsinassessingR V function-m ultiparam etricapproach

• W hilew idely used2D echocardiography haslim itationsinassessingR V function-m ultiparam etricapproachrecom m ended

• CardiacM R Irem ainsreferencestandardforassessingR V• CardiacM R Irem ainsreferencestandardforassessingR Vsystolicfunction

• Clinicalassessm entw ithechocardiography andrightheart• Clinicalassessm entw ithechocardiography andrightheartcatheterizationatbedsidem ay beoptim alinICU setting

• Im portanttoconsiderR V afterloadandpreloadw hileevaluatingR V function

• Im portanttoconsiderR V afterloadandpreloadw hileevaluatingR V function