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Right Ventricle Echocardiography

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Right Ventricle Echocardiography

  2. 2. Is It Important? • Not just a conduit • Connected and affected • Risk stratification • Therapy guidance • Controversial • Understudied • Examiners favorite
  3. 3. The Purposes Of Guidelines ▪ Describe the acoustic windows ▪ Describe 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
  7. 7. Segmental Nomenclature
  8. 8. Right Heart Dimensions ▪ Right ventricle-focused apical 4 chamber view – Measured at end-diastole
  9. 9. 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.
  10. 10. Right ventricular dimensions 1. Basal RV diameter 2. Mid cavitary RV diameter 3. RV longitudinal dimension  4.2 cm indicates dilatation  3.5 cm indicates dilatation  8.6 cm indicates RV enlargement
  11. 11. ▪ RV size should be routinely assessed by conventional 2DE using multiple acoustic windows ▪ Report 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
  12. 12. TAPSE TAPSE 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 toTAPSE in patients with CHF
  13. 13. RV Diastolic Function ▪ From the apical 4-chamber view, the Doppler beam should be aligned parallel to RV inflow ▪ Sample volume is placed at the tips of the tricuspid valve leaflets ▪ Measure at held end-expiration and/or take the average of ≥ 5 consecutive beats ▪ Measurements are essentially the same as those used for the left side
  14. 14. Recommendation ▪ Measurement 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 prognosis ▪ Transtricupsid E/A ratio, E/E’ ratio, and RA size have been most validated are the preferred measures Grading of RV Diastolic Dysfunction should be done as follows: E/A ratio < 0.8 suggests impaired relaxation E/A ratio 0.8-2.1 with an E/E’ > 6 or diastolic prominence in the hepatic veins suggest pseudonormal filling E/A ratio > 2.1 with deceleration time < 120 ms suggests restrictive filling
  15. 15. Recommendations ▪ The 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 : ▪ Males 25 ± 7 ml/m2 ▪ Females 21 ± 6 ml/m2
  16. 16. RA Pressure ▪ Measurement 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
  17. 17. Recommendations For simplicity and uniformity of reporting, specific values of RA pressure , rather than ranges, should be used in the determination of SPAP IVC diameter IVC collapsibility RA pressure ≤ 2.1 cm > 50% with a sniff 3 mmHg > 2.1 cm < 50 % with a sniff 15 mmHg In 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 Advantages Disadvantages IVC dimensions are usually obtainable from the subcostal window IVC collapse does not accurately reflect RA pressure in ventilator- dependent patients It is less reliable for intermediate values of RA pressure
  18. 18. Which of the following is the correct measurement of the IVC diameter in estimating RA pressure A. A B. B C. C D. None of the above ABC
  19. 19. 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 restrictiveVSD. D. Pulmonic stenosis is suspected. E.These images are classic for Ebstein anomaly
  20. 20. Other Recommendations ▪ Visual 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 systole RV volume overload-septal shift occurs predominately in mid to late diastole
  21. 21. Pulmonary Artery Pressures ▪ PASP should be estimated and reported in all subjects with reliable tricuspid regurgitant jets
  22. 22. Which of the following parameters are used to calculate Pulmonary artery systolic pressure? A. TR only B. TR and PR only C. TR andVSD only D. TR, PR, andVSD only E. TR, AR, PR, andVSD
  23. 23. 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.
  24. 24. 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. RVSP 4 (4)2 + 10 64 + 10 74 74 – PSPG 74 – 4 (3)2 74 - 36 38 PASP = RVSP - PSPG
  25. 25. 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 HTN C. Tricuspid regurgitation is likely mild. D. There is right ventricular midcavitary gradient during systole. E. Right ventricular systolic function can not be accurately assessed.
  26. 26. A patient with holosystolic murmur at the left sternal border. What is RVSP? Blood Pressure 150/80 mmHg RA Pressure 15 mmHg A. 35 mmHg B. 65 mmHg C. 50 mmHg D. Can not be calculated
  27. 27. 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 vel²) + est. RAP
  28. 28. 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.
  29. 29. Pulmonary Vascular Resistance PVR =TRV max / RVOTTVI x 10 + 0.16 Significant PHTN exists when PVR is > 3 Wood units
  30. 30. RV dP/dt ▪ The rate of pressure rise in the right ventricle ▪ Estimated from the ascending limb of the tricuspid regurgitant CW Doppler signal RV dP/dt < 400 mmHg/s is likely abnormal
  31. 31. Hepatic Vein Doppler The normal HV waveform has three antegrade waves ▪ A larger systolic “S wave” ▪ A smaller diastolic “D wave” ▪ A small retrograde flow reversal from atrial contraction “A wave”
  32. 32. 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 tamponade D. Patient has ventricular interdependence.
  33. 33. 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
  34. 34. Thanks for your patience