Module 3 - RV Systolic Dysfunction and Pulmonary Herat Disease

Name the views for imaging and assessment of the RV.

PSLAX

PSSAX

PF RV inflow

Apical 4C

Focused apical 4C

Modified apical 4C

Subcostal views

Compare modified 4C vs focused 4C.

Modified: assess RV wall function and TR Doppler

Focused: measure RV diameter and show true structure of RV

Identify this view.

RV focused apical 4C.

Identify this view.

RV modified apical 4C.

Explain the process of obtaining RV linear measurements.

All measured during diastole.

From RV focused apical 4C, make one longitudinal measurement from annulus to apex and horizontal measurements at the basal and mid walls.

From PSLAX, measure RVOT.

From PSSAX, measure RVOT proximal and RVOT distal.

Explain how to measure RV EDWT.

From SC 4C, zoom on the RV lateral wall and measure.

Explain how to measure TAPSE.

From apical RV focused 4C, place the M-mode cursor through the lateral tricuspid annulus. Measure the slope of the lateral annulus from end-diastole to mid-systole.

Describe how TDI can be used to measure RV function.

Derived tricuspid lateral annular systolic velocity.

RV TDI can assess S’ velocity by moving the cursor through the lateral annulus in RV focused 4C.

Explain how to measure FAC.

From RV focused apical 4C, trace the endocardial border in end-diastole and end-systole. Ignore trabeculations and the moderator band.

Wat does FAC stand for? What does it measure?

Fractional area change.

Measures the overall wall motion of the RV.

Provide some examples of qualitative measurements of the RV.

RV enlargement (RV>LV)

Wall motion abnormalities

Provide some examples of quantitative measurements of the RV.

RV linear dimensions

RV TDI S’`

TAPSE

FAC

Define end-organ consequence.

Organs supplied by the circulatory system suffer damage from hypertension.

Why is aging a risk for hypertension.

Progressive stiffening and loss of compliance in arteries.

What does it mean when a disease is “primary” vs “secondary”?

Primary - unknown etiology

Secondary - identified cause

Explain how renal disease can cause secondary hypertension.

Kidneys regulate blood volume. When kidneys are dysfunctional, blood volume increases → increased BP → damage to the arteries → cardiovascular disease.

List some common echo findings with renal disease.

Hypertension

LVH

Pericardial effusion

Describe the myocardial remodeling progression of the LV due to HTN.

1. LVH → diastolic function impaired, systolic function preserved

2. Ventricular dilation → diastolic function better but still impaired, systolic function impaired

List some common echo findings with systemic HTN.

LVH

Diastolic dysfunction

LA dilation

Systolic dysfunction

Valve disease

What are the 4 parameters required to assess LVH?

1. Septal and posterior wall thickness

2. RWT

3. LVM/BSA

4. LV geometry

How does the LV remodel in response to ↑Pr? How is this beneficial but decompensatory?

Increases wall thickness → ↑concentric force

Reduces wall stress but decreases compliance.

How does the LV remodel in response to ↑volume? How is this beneficial but decompensatory?

Dilates → accommodate larger volumes

Increases compliance but decreases systolic function.

In concentric hypertrophy, sarcomeres are added…

In parallel

In eccentric hypertrophy, sarcomeres are added…

In series

Describe the geometry of LV eccentric hypertrophy.

Dilated LV.

Describe the geometry of LV concentric remodeling.

Increased RWT.

Describe the geometry of LV concentric hypertrophy.

Dilated LV with increased RWT.

Describe the Doppler patterns found in a patient with grade 1 hypertension.

Diastole is impaired but presents with a pseudonormal pattern because of ↑LAP.

MV PW is normal in appearance.

TDI shows ↓E’/A’.

Describe a situation where you might observe hyperkinetic LV walls.

Hypertrophic cardiomyopathies to preserve EF.

List some common valvular diseases associated with systemic HTN.

MR

MAC

AR

Ao root dilation

List some examples of secondary pulmonary heart disease.

Diseases that cause elevated pulmonary venous pressure

Intrinsic lung disease

Acute and chronic pulmonary embolism

Intracardiac shunting.

Describe the initial compensatory mechanism for chronic pulmonary HTN. Describe how this becomes decompensatory and the subsequent effects on the rest of the heart.

Initial - RV hypertrophy to preserve RV systolic function.

Becomes decompensatory as the RV dilates to preserve diastolic function.

Leads to TR, RA enlargement, and elevated PAP.

Describe how pulmonary HTN causes RA enlargement.

RV dilates → ↑TV annulus size

TR → ↑volume in RA

Define cor pulmonale.

Right sided heart failure.

Name the 2 components of cor pulmonale and the symptoms associated.

Chronic pressure overload (RVPO)

Increased RV afterload

Symptoms:

Dyspnea

Syncope

Peripheral edema

Jugular vein dilation

List some echo findings that could indicate pulmonary HTN.

Elevated RVSP

Signs of RVPO (↑RVFWT, paradoxical septal motion)

TR

RA enlargement

Pulmonary flow mid-systolic notch

Name the most reliable method to estimate PAP.

RVSP

What variables are needed during an echo to calculate RVSP?

Peak TR jet

IVC diameter

Collapsibility index

Estimate RVSP when:

Peak TR jet = 5.0m/s

IVC diameter = 1.9cm

IVC collapse <50%

RAP = 8mmHg

RVSP = 4V² + RAP

RVSP = 4(5.0m/s)2 + 8mmHg

RVSP = 4(25) +8mmHg

RVSP = 100 + 8mmHg = 108mmHg

List signs of RVPO on echo.

RV dilation

↑RVFWT

Paradoxical septal motion

Describe and explain septal motion in a patient with RVVO.

The LV has a D shape in diastole.

Increased volume in the RV pushes the septum flat but LV roundness is restored during systole.

Describe and explain septal motion in a patient wit RVPO.

Paradoxical septal motion: the LV has a D shape in diastole and systole.

Increased pressure in the RV pushes the septum flat in diastole and systole.

Describe how mild, moderate, and severe RV enlargement is qualifiable.

Mild RVE: RV < LV but dilated

Moderate RVE: RV = LV

Severe RVE: RV > LV

How is RV hypertrophy measured?

RVFWT

List some causes of RVH.

Pulmonary HTN

Pulmonary stenosis

Cardiomyopathy

TR is secondary to…

Pulmonary HTN

RV dilation

RV systolic dysfuction

List some expected consequences of severe TR and how they are assessed in echo.

Systolic flow reversal in IVC and HV - large a-wave reversal in HV PW

RA dilation - compare to LA size and RV size

Name a imitation to assessing a large TR jet on echo.

Because of the larger area for blood to travel through, regurgitant volume is dispersed, not well visualized, and the peak velocity will be underestimated (underestimate RVSP).

Compare these two tracings of the same valve on different patients. What valve is being measured? Which is normal and which is abnormal? What does the abnormal tracing indicate?

PV PW.

Left is normal with normal acceleration time, peak in the middle of the waveform, and appropriate deceleration time.

Right is abnormal with shortened acceleration time, an early peak, and a mid-systolic notch. These are indications of pulmonary HTN.

Explain why a PV mid-systolic notch may occur in the spectral tracing.

The PV starts closing because the RV pressure and PAP equalize but the RV is still contracting - generates enough pressure to push the leaflets open again.

What condition causes acute pulmonary HTN?

Pulmonary embolism.

List some indirect signs of pulmonary embolism on echo.

Elevated PAP

Acute RVPO

RV dilation and dysfunction

TR

Explain McConnell’s sign. What does it indicate?

Regional RV dysfunction:

Mid RV free wall is akinetic - ↑wall stress → ↓perfusion

RV apex is hypercontractile - proximity to RV apex offloads some wall stress to the LV

Indicates pulmonary embolism.

What happens to a patients clinical status if pulmonary embolism is left untreated.

Pulmonary embolism → ↑PAP → ↑RV afterload → RV dilation → RV dysfunction → ↓RV CO → ↓LV preload → ↓LV CO → hypotension

Echo is an effective way to monitor thrombolytic therapy. Within several hours, after thrombolytic therapy or suction embolectomy, echo demonstrates:

Reversal of RV size to normal

Reversal of RV dysfunction to normal

A patients requestion includes suspicion of pulmonary HTN. What are some observations/measurements you want to make during an echo to investigate?

RV size and function

• FAC

• TAPSE

• S’

RVFWT < 5mm

RA size and volume

Paradoxical IVS

RVSP

• IVC dilation

• TR

Given this HV PW trace, what would you expect to find when imaging the heart?

Elevated A-wave reversal

Expect to see:

↑RAP

RA enlargement

TR

RV dysfunction

RVVO or RVPO

Define thromboectomy.

Surgery to remove a blood clot from an artery.