2015 Ase Guideline - Right Heart Assessment + Reference Ranges

Front 1

RV DIMENSIONS:

1)What basal and mid RV diameter measurements classify the RV as dilated?

2) What longitudinal dimension classifies the RV as enlarged?

Back 1

1) basal > 42mm

mid > 35mm

2) longitudinal > 86mm

Front 2

RA DIMENSIONS:

What 1) area 2) length 3) diameter classify the RA as enlarged?

Back 2

1) > 18 cm^2

2) > 53 mm

3) >44 mm

Front 3

RVOT DIMENSIONS:

1) What are the upper cut-offs for RVOT measured from PSAX (distal RVOT) and PLAX (prox RVOT)?

2) What is the most accurate sight to use and why?

Back 3

1) PSAX - distal >2.7cm

PLAX - prox >3.3 cm

2) Distal - just before the PV - more reproducible

Front 4

RV WALL THICKNESS:

1) What is the upper cut off for RV wall thickness?

2) What can cause RVH or wall thickening?

3) Sight of measurement and why?

Back 4

1) > 0.5 cm

2) PHTN - RVH

thickening - infiltrative disorders like amalyoid

3) subcostal

- better beam alignment - ax res > lat res

Front 5

RV SYSTOLIC FUNCTION:

1) Name 5 ways to assess RV systolic function and there cut off values.

Back 5

1) TAPSE - m-mode - <1.6 cm

2) DTI lat annulus - < 10 cm/s

3) PW MPI - > 0.4

4) DTI MPI - >0.55

5) FAC - < 35 %

Front 6

RV DIASTOLIC FUNCTION:

1) How is this performed?

2) What 3 values are used as indicators of RV diastolic dysfunction.

Back 6

1) PW at TV leaflet tips for tricuspid inflow

2) a; E/A <0.8 or >2.1

b; E/E' >6

c: DT <120 ms

Front 7

1) Name 5 views that the RV can be assessed from.

2) Why is it important to use so many views?

Back 7

1) PLAX, RV PLAX (inflow), PSAX, Ap 4C, RV focused 4C, subcostal

2) Complex morphology, cant see all structures from one view

Front 8

R. HEART CORONARY SUPPLY:

1) What is the main coronary artery that supplies the RV?

2) what branch is this via?

3) What branch supplies the posterior 1/3 of the ventricular septal wall? Via what?

Back 8

1) RCA

2) acute marginal branch

3) Posterior descending artery via posterior septal perforators.

Front 9

R. HEART CORONARY SUPPLY:

4) What branch supplies the moderator band?

5) In 30% of patients the ______ _______ arises for a separate coronary ostium and supplies the ______.

Back 9

4) first septal perforating branch o f the LAD CA

5) conus artery, infundibulum

Front 10

6) 10% of hearts, the____________ branch of the _______ ____________ supplies a portion of the RV free wall.

7) What may supply the RV apex?

Back 10

6) posterolateral, circumflex artery

7) LAD

Front 11

CONVENTIONAL 2D ASSESMENT OF R. HEART:

RA

1) what are 3 ways the RA assists in RV filling?

Back 11

1) a- acting as a reservoir for systemic venous re turn when TV closed

b- acting as a passive conduit in early diastole when TV ope

c- acting as a passive conduit in late diastole during atrial contraction

Front 12

2) What are the 3 linear measurements used to assess the RA? What are there cut offs?

Back 12

2) area (18cm^2),

length/major axis (53mm),

width/minor axis (44mm)

Front 13

PSP/ RVSP

1) a TR velocity > ___ to ___ corresponds to an SPAP of ~ ____mmHg, assuming and RAP of 3-5mmHg.

2) What does this indicate?

Back 13

1) 2.8 - 2.9 m/s, 36

2) elevated RVSP and PAP

Front 14

R. HEART CORONARY SUPPLY:

7) What CA supplies which part of the RV/ RVOT... Anterior, inferior, RVOT, lateral, moderator band and septum.

Back 14

7) Anterior RV - RCA acute marginal branch

*Inferior - RCA posterior decending artery

*RVOT - RCA conus branch

*Lateral - RCA acute marginal branch

*Mod band - LDA

*Septum - LAD (apex end) RCA post desc artery (crux end)

Front 15

CONVENTIONAL 2D ASSESMENT OF R. HEART:

RAP

1) RAP is most commonly estimated by what 2 things?

2) As RAP increases where is the pressure transmitted to and what does this result in?

Back 15

1) IVC diameter and insp collapse

2) transmitted to the IVC = reduced collapse with insp and dilation

Front 16

CONVENTIONAL 2D ASSESMENT OF R. HEART:

RAP

3) where do you measure the IVC?

Back 16

3) 0.5-3cm proximal to the ostium of the RA

Front 17

CONVENTIONAL 2D ASSESMENT OF R. HEART:

RAP

4) What con provide a complimentary insight into RAP and what flow patterns are seen?

Back 17

4) Hepatic venous flow

low or normal RAP = systolic dominance - S wave greater then the d wave

high RAP = systolic dominance is lost - S wave significantly decreases S/D wave ratio <1

Front 18

CONVENTIONAL 2D ASSESMENT OF R. HEART:

RAP

5) What are 2 other qualitative signs for assessing RAP?

Back 18

5) dilated RA, IAS that bludges into LA though out cardiac cycle

Front 19

CONVENTIONAL 2D ASSESMENT OF R. HEART:

RAP

6) What IVC diameters and collapsibility % make us assume and RAP of 3mmHg(0-5mmHg), 8mmHg (5-10mmHg) and 15mmHg (10-20mmHg).

7) What are to indices to use if the IVC parameters are not definite?

Back 19

6)

* = 21mm, > 50%

* intermediate values

* > 21mm , < 50%

7) R diastolic filling pattern E/E' >6 and D wave dominance in hepatic vein

- present - upgrade to 15mmHg

- absent - downgrade to 3 mmHg

Front 20

CONVENTIONAL 2D ASSESMENT OF R. HEART:

RV

1) What 3 things can cause the RV to dilate?

2) What is one quick visual way you can tell if the RV is dilated?

Back 20

1) Pressure, volume, RVF

2) It must be no bigger then 2/3 the size of the LV ( in Ap 4C view) and the cardiac apex should be make of the LV (PSAX view)

Front 21

3) What makes the RV hard to assess and what is the consequence of this?

Back 21

3) Complex geometry, no fixed reference points, view from many different windows to assess, hard to really classify size and function - use RV focused view

Front 22

4) where should RV linear measurements for basal, mid and longitudinal measure be taken from?

Back 22

4) all in RV focused view

Basal - TV leaflet insertions (lateral and septal)

Mid - at the leave of the LV pap muscles

Long - plane of the tricuspid annulus to RV apex

Front 23

CONVENTIONAL 2D ASSESMENT OF R. HEART:

RVOT

1) What does the regional delay in contraction of the RVOT contribute to?

2) What are the best views to view it from?

3) At what point in the ECG should it be measured?

Back 23

1) peristalsis like contraction of the RV

2) PLAX and subcostal

3) QRS complex

Front 24

VOLUMETRIC ASSESSMENT OF RV

1) What is % RV FAC?

2) How is it obtained?

3) what is the lower reference value for normal RV sys func?

Back 24

1) [(E Dia area - E sys area)/ (E Dia area)] x 100

a measure of RV systolic function

2) By tracing the endocardium of the RV at end systole and end diastole

3) 35%

Front 25

4) What view is the area length method of RV sys func (RVEF) assessment done in? What is the limitation?

5) What is the lower reference limit for RVEF?

Back 25

4) Ap 4C

Limitation is that this view does not include RVOT and imaging of free wall is difficult

5) 44% (same for 3D but not enough data yet)

Front 26

RV + IVS MORPHOLOGY

1) What causes D shaped flattening of the IVS in SAX view? What is this generally due to?

Back 26

1) Caused by the change in ralitive pressure gradients between the LV and RV at each stage int he cardiac cycle. Generally secondary to increased LVFP or caused by TR (which leads to RV/ RA dilation)

Front 27

2) When does D flattening occur for RV volume overload?

3) When does D flattening occur for pressure overload?

Back 27

2) End of diastole only (marked shift)

3) Though out the cycle (increased at end systole)

Note - assess though out study - not diagnostic but good hint

Front 28

HAEMODYN ASSESSMENT OF RV + PULM CIRC

1) How can you estimate mPAP?

Back 28

1) mPAP = 1/3 (SPAP) + 2/3 (PDAP)

or

mPAP = 79- (0.45 x PA accel time (AT))

if AT <120ms mPAP = 90 - (0.62 xAT)

Note: shorter the AT = higher the PVR and therefore PAP

Front 29

2) In the absence of a gradient across the PV or RVOT (no shunting...) the RVSP = ____?

3) Who doe you calculate the RVSP?

Back 29

2) SPAP

3) RVSP or SPAP = 4V^2 + RAP

Note - if SPAP . 35-40mmHg - investigate for PHTN

Front 30

4) how do you estimate PADP? and Why would you?

Back 30

4) From the mean gradient of the TR jet or from the end diastolic velocity of the PR jet.

In patients with PAHTN or HF

Front 31

5) When will there be an early TR signal cut off? Why and what will this cause?

Back 31

5) When there is severe "free TR" because the RVP and RAP with rapidly equalise = underestimation of TR severity

Front 32

6) What is a normal PVR reading and what is an abnormal one suggesting significant PHTN?

7) What can = an increase in PVR?

Back 32

6) 1.5 woods units (120 dynes/cm/s^2)

3 woods units (240 dynes/cm/s^2)

7) limited capability of the pulmonary vasculature bed to cope with CO due to COPD or congenital heart disease)

Front 33

8) What happens to SV and PVR in exercise?

Back 33

8) increase in SV, decrease in PVR

Front 34

NONVOLUMETRIC ASSESS OF RV FUNC

1) what are the 2 types of myocardial fibers in the RV and what do they do?

Back 34

1) superficial - squeezes / bellows mmt

longitudinal - apex to base contraction

Front 35

2) RVEF does not = ____ ________ when there is significant _____?

3) what is the issue with TAPSE when used to assess RV function?

Back 35

2) RV, contractility, TR

3) Does not look at the whole RV - only a regional measure of function

Front 36

4) What is RV dP/dT? How is it measured in echo? What is it dependent on?

5) < what RV sP/sT is abnormal?

Back 36

4) Rate of pressure rise

* From the ascending limb of the TR CW signal between 0.5-2m/s = 15mmHg

* Less accurate for severe TR and load dependent

5) <~ 400mmHg/sec

(dP/dt = mmHg / time in sec = mmHg/sec)

Front 37

6) What is RMPI (ie: Tei index)?

7) How is RMPI calculated?

8) What are the 2 methods of calculating it and there cut offs?

Back 37

6) Global estimate of RV syst and diastolic function, based on the relationship between ejection and non ejection work of the heart

7) RMPI = [(IVRT + IVRC) / ET)]

8) PW doppler - 0.4

DTI - 0.55

Front 38

9) Name are some advantages and disadvantages of RMPI?

Back 38

9) Advs; avoids geometric assumptions, can be used on most people, DTI measures all variables on one trace, + or - TR jet, good for a range of HR's

disadvs; PW dop need multiple signals = up error, load dependent (unreliable when increased RAP), sensitive to preload

Front 39

10) What is TAPSE? What is it a measure of? What does it presume?

Back 39

10) TAPSE = mmt of the RV free wall - measurement of the distance of syst excursion of the lat RV annulus in the longitudinal plane in Ap 4C view.

* Measure of regional RV syst function (longitudinal motion)

* Presumes regional function reflects global function

Front 40

11) What is the cut off for TAPSE? and what method is used to measure it?

Back 40

11) < 16mm = abnormal / impaired function

*M-mode of the RV free wall annulus (zoom this)

Front 41

12) DTI of the lateral RV annulus is another form of what? What does it assume?

13) Where is it measured and how? What is the cut off value? What is measured?

Back 41

12) Regional assessment of RV syst function. Assumes regional function reflects global function.

13) Using DTI at lat basal TR annulus.

* S' <10 cm/s = abnormal

* The S' wave (not the IVCT peak)

Front 42

14) How is myocardial acceleration during isovolumetric contraction (MADIVCT) measured? What does it correlate well with?

15) Name 1 advantage and 1 disadvantage of MADIVCT.

Back 42

14) DTI at lat RV annulus

MADIVCT = (peak isovol myocard velocity/ time to peak velocity)

8 correlates well with severity of illness affecting R. heart function eg MS, obst sleep apnoea

15) adv - load independent.

disadv - no ref values therefore used for screening only

Front 43

16) What is the difference between strain and strain rate?

17) How is 1D strain measured? name 2 adv's and 2 disadvantages.

Back 43

16) strain = % change in myocardial deformation

Strain rate = rate of deformation over time (closely correlated with contractility)

17) DTI at basal, mid and apex of RV free wall = longitudinal strain

*adv - less load dep, ? applicable for wide range of pathologies

*disadv - angle dependent, needs high FR, poor signal to noise ratio

Front 44

18) How is 2D strain measured? Name 2 adv's and 2 disadv's.

Back 44

18) New measure of global contractility using frame by frame tracking of the speckles on sequential images - generates strain curve for entire RV

*adv's - angle indep, regional and global assess, better signal to noise ratio

* disadvs - lack of normative data, image quality dep, only assess func from a single plane

(use for research at the moment only)

Front 45

RV DIASTOLIC FUNCTION

1) Names 5 causes of RV diast. dysfunc

Back 45

1) * Acute RV damage (eg: MI) = diast. dysfunc with increased filling pressures and increased JVP

* Press and vol overload

* Cardiomyopathies

* Primary lung dieases

* Ageing

+ systemic diseases, LV dysfunc, IHD, CHD

Front 46

2) How do you measure RV diast. fun? What parameter is included in RV diast. fun assessment?

Back 46

2) *PW dop at tips of TV = tricusp. inflow vel

* RAP

Front 47

3) What parameters are used to discribe RV diast. func?

4) What does late diast anterograde flow in the PA indicate?

Back 47

3) E, A, E/A, DT

+ DTI parameters - E', A', E'/A, IVRT

+ RA area/ vol

4) Restrictive diast filling

Front 48

5) Name 4 conditions that affect RV diast func assessment.

6) Is there an increase or decrease in the E/A ratio with age?

7) Inspiration increases or decreases E and therefore increases or decreases E/A?

Back 48

5) age, respiration, heart rate and loading conditions

6) decrease ~ 0.1 per decade

7) increases, increases

Front 49

8) Tachy increases or decreases E and increases of decreases A, therefore increases of decrease E/A.

9) The RV is small and thin walled therefore is sensitive to preload. What is preload and what does an increase in it mean?

Back 49

8) increases, increases++, decreases

9) wall stress, decreased preload --> decr E + decr A = decreased E/A (visa versa)

Front 50

10) What happens to DTI parameters when preload changes?

11) What are the basic changes seen in patients with ischaemia affecting the RV?

Back 50

10) DTI = less load dependent = a decrease in both E' and A' ----> = no change in E'/A'

11) decreased E

increased ++ A

increased ++ RAP

Front 51

12) What does RV diastolic dysfunc indicate in people with HF and PHTN?

13) Name 2 advantages of assessing RV diast func.

Back 51

12) Poor prognosis

13) * Can serial screen to monitor improvement with treatment

* generally present before syst dysfunc, RV dilation and RVH = good easy screening tool

Front 52

14) What are the reference and cut off values for RV diast parameter values?

Back 52

14) *E/A = < 0.8 = impaired relaxation

*E/A 0.8-2.1 + E/E' >6 or D dominance in HV = pseudo normal filling

*E/A >2.1, DT < 120 (+ late diast anterograde flow in PA) = restrictive filling

Front 53

CLINICAL + PROGNOSTIC SIGNIFICANTS OF RV ASSESSMENT

1) What is assessment of RV size and function important for?

2) What is the first marker of increased PVR?

Back 53

1) Pulmonary and cardiac disease

2) RV dilation -- normal RV used to low PVR = thin compliant walls. If up PVR = increased++ RV size prior to augmentation of pulmonary pressure ---> RVH

Front 54

3) What does RVH develop due to and why?

4) What does a PE cause?

Back 54

3) To overcome increased PVR = decreased RV size, increased RV free wall thickness = increased RVSP

4) increased RV vol and diameteres, McConells sign (mid RV wall disconnetic) - reversible with improved haemodynamics

Front 55

5) What is the progression of right heart changes in people with long standing pulm vasc disease or other forms of secondary PHTN (eg COPD)?

6) The more the LV becomes dysfunctional the better or worse the RV function?

Back 55

5) RVH with normal values -----> dilation

6) worse = increased risk of RV dilation and dysfunction

Front 56

7) RV dysfunction is a powerful predictor of outcomes post what?

8) Give an example of diseases that can affect the TV and therefore cause TR which affect size and func of RV.

Back 56

7) MI

8) Carcinoid, rheumatic TV disease, myxomatous degeneration

Note - vol overload that comes with TR --> RV dilation --> more TR

Front 57

9) What is the most common congenital defect affecting the right heart? and how does it do this?

10) Name 2 other CHD's that can affect the right heart

Back 57

9) ASD = increased flow from shunt ---> increased pulmonary pressure + RV dilation

10) *TOF (repaired) = severe PR + severe RV dilation => decreased RV func

*Ebstiens anomaly

Front 58

11) Name 5 conditions associated with RV diast dysfunction.

Back 58

PE, PAHTN, TOF repair, COPD, RCA MI, CHF, cardiac transplant, arrhythmogenic RVAM, HCM, essential HTN, AS, AR, MR, LAD MI, Diabeties, amyloidosis, Ageing (+ more)