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Example of SPECT radionuclide angiography. Regional and global evaluation of kinesis as well as quantitative evaluation of right and left ventricular ejection fraction and volumes are feasible and reproducible.
Source publication
Assessment of right ventricular (RV) function is crucial for the evaluation of the dyspnoeic patient and/or with systemic venous congestion and provides powerful prognostic insights. It can be performed using different imaging modalities including standard and advanced echocardiographic techniques, cardiac magnetic resonance imaging, computed tomog...
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Context 1
... these approaches have been extensively validated and, since RVEF is derived from end-systolic and enddiastolic count densities, it is independent of the geometric assumption required for other modalities. 53 SPECT equilibrium radionuclide angiography, due to its 3D view, improves spatial separation and resolution of cardiac chambers and has been shown to provide accurate and reproducible assessment of RV volumes and EF ( Figure 5). 53 Nuclear-imaging techniques are emerging as clinically useful tools to assess RV perfusion and metabolism, to detect isolated RV infarction of RV or LV infarction with RV involvement. ...
Citations
... It enables a comprehensive visualization of the complex anatomical shape of right ventricle, overcoming most of the echocardiography limitations, such as limited acoustic window, variations in body size or deformation (e.g. pectum excavatum), and changes in right ventricle anatomy due to pathology or surgical intervention [32].Scally et al. investigated the potential of CMR to improve the detection rate of right ventricular regional wall motion abnormalities in TS, demonstrating a twofold increase in sensitivity [33]. CMR has the unique ability of tissue characterization, enabling an assessment of myocardial tissue abnormalities that could be linked with long-term outcomes. ...
... The assessment of RV size and systolic function through conventional echocardiography should be conducted in all patients with HHD, considering RV loading conditions. It is crucial to employ a multi-parametric approach and utilize various echocardiographic views to ensure accurate evaluation, especially when there is a discrepancy between different echocardiographic parameters [72]. This comprehensive approach enhances the precision and reliability of the interpretation of findings related to RV size and function. ...
... The 3D evaluation of the RV may considerably contribute to this direction with potential application in patients with HHD [78]. It is crucial to know that accurate 3D echocardiography is strongly dependent on high-quality imaging, invariable heart rates, and specialized and expensive software, and demands substantial time and expertise [72]. ...
It has been well established that arterial hypertension is considered as a predominant risk factor for the development of cardiovascular diseases. Despite the link between arterial hypertension and cardiovascular diseases, arterial hypertension may directly affect cardiac function, leading to heart failure, mostly with preserved ejection fraction (HFpEF). There are echocardiographic findings indicating hypertensive heart disease (HHD), defined as altered cardiac morphology (left ventricular concentric hypertrophy, left atrium dilatation) and function (systolic or diastolic dysfunction) in patients with persistent arterial hypertension irrespective of the cardiac pathologies to which it contributes, such as coronary artery disease and kidney function impairment. In addition to the classical echocardiographic parameters, novel indices, like speckle tracking of the left ventricle and left atrium, 3D volume evaluation, and myocardial work in echocardiography, may provide more accurate and reproducible diagnostic and prognostic data in patients with arterial hypertension. However, their use is still underappreciated. Early detection of and prompt therapy for HHD will greatly improve the prognosis. Hence, in the present review, we shed light on the role of echocardiography in the contemporary diagnostic and prognostic approaches to HHD.
... The evaluation of RV volumes and function by echocardiography is often difficult due to the retrosternal position of the RV and its complex geometry (62). This is particularly true in patients with EA, where the morphological abnormalities of the RV and the altered loading conditions (i.e., volume overload due to tricuspid regurgitation) further challenge this assessment (Figure 2). ...
Advances in pediatric cardiac surgery have resulted in a recent growing epidemic of children and young adults with congenital heart diseases (CHDs). In these patients, congenital defects themselves, surgical operations and remaining lesions may alter cardiac anatomy and impact the mechanical performance of both ventricles. Cardiac function significantly influences outcomes in CHDs, necessitating regular patient follow-up to detect clinical changes and relevant risk factors. Echocardiography remains the primary imaging method for CHDs, but clinicians must understand patients' unique anatomies as different CHDs exhibit distinct anatomical characteristics affecting cardiac mechanics. Additionally, the use of myocardial deformation imaging and 3D echocardiography has gained popularity for enhanced assessment of cardiac function and anatomy. This paper discusses the role of echocardiography in evaluating cardiac mechanics in most significant CHDs, particularly its ability to accommodate and interpret the inherent anatomical substrate in these conditions.
... to other parameters) [16,17]. These observations gain special importance in certain clinical scenarios, when loading conditions are markedly altered. ...
We aimed to evaluate clinical and prognostic significance of myocardial work parameters of the systemic right ventricle (SRV). Thirty-eight patients with the SRV underwent echocardiographic assessment of the SRV systolic function including 3D-echocardiography derived ejection fraction, 2D longitudinal strain and myocardial work analysis. The study endpoint was the combination of all-cause mortality and heart transplantation. Global constructive work (GCW) and global work index (GWI) demonstrated moderate correlation with the 3DE-derived SRV ejection fraction (EF) (Rho 0.64, p < 0.0001 and Rho 0.63, p < 0.0001, respectively). GCW showed the strongest correlation with the BNP level (Rho − 0.77, p < 0.0001), closely followed by GWI, 4-chamber longitudinal strain and 3DE EF (all Rho − 0.73, p < 0.0001). GCW and GWI were significantly lower in patients with moderate or severe tricuspid regurgitation compared with less than moderate regurgitation (1226 ± 439 vs 1509 ± 264 mmHg%, p = 0.02, and 984 ± 348 vs 1259 ± 278 mmHg%, p = 0.01, respectively). During a follow-up of 3.5 (2.8–3.9) years, seven patients (18%) died and one received transplantation (3%). They had significantly lower GCW and GWI compared with patients who did not reach the study endpoint (908 ± 255 vs 1433 ± %, p < 0.001 and 721 ± 210 vs 1173 ± 315 mmHg%, p < 0.001, respectively). In Cox regression analysis, GCW, GWI, 3DE SRV volumes and EF were the best-fit models based on the Akaike Information Criterion, outperforming longitudinal strain parameters. GWI and GCW, novel echocardiographic parameters of myocardial work, provided reliable quantification of the SRV systolic function. GWI, GCW and 3DE-derived SRV parameters were closely associated with all-cause mortality and heart transplantation in patients with the SRV.
Graphical abstract
Thirty-eight patients with the SRV underwent complete echocardiographic assessment of the SRV systolic function including 3D-echocardiography derived ejection fraction, 2D longitudinal strain and myocardial work analysis. GCW and GWI were associated with the study endpoint (combination of all-cause mortality and heart transplantation). In Cox regression analysis, GCW, GWI, and 3DE parameters were the best-fit models based on the Akaike Information Criterion, outperforming longitudinal strain parameters. 3DE three-dimensional echocardiography, EF ejection fraction, FAC fractional area change, GCW global constructive work, GWI global work index, LS longitudinal strain, LV left ventricle, SRV systemic right ventricle, TAPSE tricuspid annulus plane systolic excursion.
... Assessment of RV function entails interpretation of multiple measures. A single-view assessment is insufficient to determine RV enlargement or dysfunction [73]. RV function assessment is complex as it utilizes a combination of parameters without a clear cutoff. ...
Purpose of Review
This review discusses the current limitations of assessing the right ventricle (RV) using Point-of-Care Ultrasound, explains the challenges in describing the complexity of the RV, and provides guidance on how to use Point-of-Care Ultrasound data in clinical practice.
Recent Findings
Assessing the RV requires assessments from multiple views and parameters due to its complex shape. Combined use of multiple ultrasound-derived measures along with clinical information from other sources is recommended. Artificial intelligence is increasingly used in Point-of-Care Ultrasound and will help improve validity and consistency of measurements. Future studies are needed to examine the impact of the Point-of-Care Ultrasound exam on clinical outcomes.
Summary
Multiple challenges exist in RV assessment. Future studies and guidance are required to investigate the feasibility of Point-of-Care Ultrasound in specific clinical settings, training and credentialing of examiners, and practice guidance on parameters to be used and reported.
... 9 The assessment of RV size and systolic function through conventional echocardiography should be conducted in all patients with HHD, considering RV loading conditions. It is crucial to employ a multi-parametric approach and utilize various echocardiographic views to ensure accurate evaluation, especially when there is a discrepancy between different echocardiographic parameters [70]. This comprehensive approach enhances the precision and reliability of the interpretation of findings related to RV size and function. ...
It has been well established that hypertension is considered as a predominant risk factor for the development of cardiovascular diseases. Despite the link between hypertension and cardiovascular diseases, hypertension may directly affect the cardiac function leading in heart failure, mostly with preserved ejection fraction (HFpEF). There are echocardiographic findings indicating hypertensive heart disease (HHD) defined as altered cardiac morphology (left ventricular concentric hypertrophy, left atrium dilatation) and function (systolic or diastolic dysfunction) in patients with persistent hypertension irrespective of cardiac pathologies to which it contributes, such as coronary artery disease and kidney function impairment. In addition to classical echocardiographic parameters, novel indices, like speckle tracking of the left ventricle and left atrium, 3D volume evaluation, myocardial work in echocardiography may provide more accurate and reproducible diagnostic and prognostic data in patients with hypertension. However, their use is still underappreciated. An early detection and prompt therapy of HHD will greatly improve the prognosis. Hence, in the present review, we shed light on the role of echocardiography in the contemporary diagnostic and prognostic approach of HHD.
... (1) According to guidelines [12], TAPSE was measured using M-mode with a cursor positioned at the junction of the lateral tricuspid leaflet and the RV-free wall. (2) A published report described the methodology for RV-LSF analysis [13]. ...
... The 6-month cumulative risk of MACE was 59% (95%CI at [38-74]) with RV-LSF/PASP < 0.30%.mmHg −1 and 17% (95%CI at [12][13][14][15][16][17][18][19][20][21][22][23]) with RV-LSF/PASP ≥ 0.30%.mmHg −1 (p < 0.0001, Figure 3). ...
Introduction: Right-ventricular-to-pulmonary artery (RV-PA) coupling, measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP), has emerged as a predictor factor in patients undergoing transcatheter aortic valvular replacement (TAVR). Right ventricular longitudinal shortening fraction (RV-LSF) outperformed TAPSE as a prognostic parameter in several diseases. We aimed to compare the prognostic ability of two RV-PA coupling parameters (TAPSE/PASP and the RV-LSF/PASP ratio) in identifying MACE occurrences. Method: A prospective and single-center study involving 197 patients who underwent TAVR was conducted. MACE (heart failure, myocardial infarction, stroke, and death within six months) constituted the primary outcome. ROC curve analysis determined cutoff values for RV-PA ratios. Multivariable Cox regression analysis explored the association between RV-PA ratios and MACE. Results: Forty-six patients (23%) experienced the primary outcome. No significant difference in ROC curve analysis was found (RV-LSF/PASP with AUC = 0.67, 95%CI = [0.58–0.77] vs. TAPSE/PASP with AUC = 0.62, 95%CI = [0.49–0.69]; p = 0.16). RV-LSF/PASP < 0.30%.mmHg−1 was independently associated with the primary outcome. The 6-month cumulative risk of MACE was 59% (95%CI = [38–74]) for patients with RV-LSF/PASP < 0.30%.mmHg−1 and 17% (95%CI = [12–23]) for those with RV-LSF/PASP ≥ 0.30%.mmHg−1; (p < 0.0001). Conclusions: In a contemporary cohort of patients undergoing TAVR, RV-PA uncoupling defined by an RV-LSF/PASP < 0.30%.mmHg−1 was associated with MACE at 6 months.
... It is a non-invasive, relatively cost-effective and easy-to-use modality that can support clinical decision making by meaningful structural and functional parameters. Moreover, the application of emerging techniques, such as deformation imaging and three-dimensional (3D) echocardiography, may offer even more granular quantification during resting conditions and also enable a more 2 detailed characterization of the right ventricle (RV) [9,10]. Deformation along the long axis (by longitudinal strain) is a primetime measure of RV function in clinical adult cardiology; however, the non-longitudinal mechanical directions are also physiologically important components of RV systolic performance [11]. ...
The aim of this study was to characterize the right ventricular (RV) contraction pattern and its associations with exercise capacity in a large cohort of adolescent athletes using resting three-dimensional echocardiography (3DE). We enrolled 215 adolescent athletes (16±1 years, 169 males, 12±6 hours of training/week) and compared them to 38 age- and sex-matched healthy, sedentary adolescents. We measured the 3DE-derived biventricular ejection fractions (EF). We also determined the relative contributions of longitudinal EF (LEF/RVEF) and radial EF (REF/RVEF) to the RVEF. Same-day cardiopulmonary exercise testing was performed to calculate VO2/kg. Both LV and RVEFs were significantly lower (athletes vs controls; LVEF: 57±4 vs 61±3, RVEF: 55±5 vs 60±5%, p<0.001). Interestingly, while the relative contribution of radial shortening to the global RV EF was also reduced (REF/RVEF: 0.40±0.10 vs 0.49±0.06, p<0.001), the contribution of the longitudinal contraction was significantly higher in athletes (LEF/RVEF: 0.45±0.08 vs 0.40±0.07, p<0.01). The supernormal longitudinal shortening correlated weakly with a higher VO2/kg (r= 0.138, P = 0.044). Similarly to the adult athlete’s heart, the cardiac adaptation of adolescent athletes comprises higher biventricular volumes and lower resting functional measures with supernormal RV longitudinal shortening. Characteristic exercise-induced structural and functional cardiac changes are already present in adolescence.
... A detailed description of the assessment of RV and right atrial function and TR by imaging is given in other reviews and position statements and goes beyond the aims of the present document. 1,6,33,[47][48][49][50][51] We only provide in the following paragraph a brief overview of the main imaging tools that can be adopted for the assessment of right heart chambers and TV in patients with HF. ...
... 57 Cardiac magnetic resonance (CMR), although considered the reference imaging modality for RV dimension and function assessment, is often limited by time, costs, availability, and presence of CIED but should be performed particularly when echocardiographic image quality is poor and the findings are not conclusive, when detailed anatomical information (such as in congenital heart disease) is necessary, and when tissue characterization is required. 48 Assessment of the RV function by cardiac computed tomography (CCT) has been validated in multiple studies using CMR as the reference standard showing that volumes are slightly overestimated and, consequently, LVEF and stroke volume are underestimated. Limitations for CCT include need for contrast and radiation exposure and low temporal resolution for functional assessments. ...
Right‐sided heart failure and tricuspid regurgitation are common and strongly associated with poor quality of life and an increased risk of heart failure hospitalizations and death. While medical therapy for right‐sided heart failure is limited, treatment options for tricuspid regurgitation include surgery and, based on recent developments, several transcatheter interventions. However, the patients who might benefit from tricuspid valve interventions are yet unknown, as is the ideal time for these treatments given the paucity of clinical evidence. In this context, it is crucial to elucidate etiology and pathophysiological mechanisms leading to right‐sided heart failure and tricuspid regurgitation in order to recognize when tricuspid regurgitation is a mere bystander and when it can cause or contribute to heart failure progression. Notably, early identification of right heart failure and tricuspid regurgitation may be crucial and optimal management requires knowledge about the different mechanisms and causes, clinical course and presentation, as well as possible treatment options.
The aim of this clinical consensus statement is to summarize current knowledge about epidemiology, pathophysiology and treatment of tricuspid regurgitation in right‐sided heart failure providing practical suggestions for patient identification and management.
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... Emerging literature suggests that echocardiographyderived 2D RV free-wall longitudinal strain may be an early measure of RVD, outperforming 3D RVEF, FAC, and other markers of longitudinal RV function (Souza et al. 2007;Subramani et al. 2022;Surkova et al. 2022;Tadic et al. 2021;Tadic 2017;Tamborini et al. 2008). Technically easier to perform than 3D RVEF, RV strain analysis does not require 3D acquisition and is considered the preferred method for early identification of perioperative RVD (Dalla et al. 2019;Guazzi et al. 2013;Surkova et al. 2022;Tadic et al. 2021;Tadic 2017;Tello et al. 2019;Tokodi et al. 2021;Vizzardi et al. 2015). ...
... Emerging literature suggests that echocardiographyderived 2D RV free-wall longitudinal strain may be an early measure of RVD, outperforming 3D RVEF, FAC, and other markers of longitudinal RV function (Souza et al. 2007;Subramani et al. 2022;Surkova et al. 2022;Tadic et al. 2021;Tadic 2017;Tamborini et al. 2008). Technically easier to perform than 3D RVEF, RV strain analysis does not require 3D acquisition and is considered the preferred method for early identification of perioperative RVD (Dalla et al. 2019;Guazzi et al. 2013;Surkova et al. 2022;Tadic et al. 2021;Tadic 2017;Tello et al. 2019;Tokodi et al. 2021;Vizzardi et al. 2015). Venous excess ultrasound (VExUS) uses Doppler technology in the hepatic, portal, and intrarenal veins to identify patterns of flow abnormality reflective of increased right heart pressures but only has limited clinical outcome data in cardiac surgery, heart failure, and general ICU populations (Wiese 2000;Zaidi et al. 2020). ...
Background
The right ventricle (RV) plays a central role in the maintenance of effective cardiac pump function. Despite overwhelming evidence that perioperative RV dysfunction (RVD) and failure (RVF) are associated with poor clinical outcomes, there are very few published recommendations or guidelines for comprehensive, evidence-based RV assessment on the risk of developing either during the perioperative period.
Main text
To address this gap, the Perioperative Quality Initiative-IX (POQI-IX) investigators group, comprised of clinical experts in anesthesiology, cardiovascular surgery, internal medicine, critical care medicine, and advanced practice nursing, has developed a consensus statement based on current literature, published society recommendations, and the clinical expertise of the group. Herein, the group provides recommendations and evidence-based tools related to perioperative RV assessment, functional screening, staging, and the clinical implications of each. These assessment tools are based on comprehensive patient evaluation consisting of physical examination, biomarker data, imaging, and hemodynamic assessment.
Conclusion
This review presents a comprehensive tool for assessing perioperative RV function. We hope that this simple, intuitive tool can be applied to all phases of perioperative care and thereby improve patient outcomes.
