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Posts Tagged ‘rv ejection fraction’

Right ventricular function assessment has always been difficult in view of it complex shape and limited imaging planes in echocardiography .

Recently , we learnt tricuspid annular motion can give  a quick assessment of  RV function . This was accomplished by M-mode echo of tricuspid annulus. (TAPSE)  tricuspid annular plane systolic excursion . This simple parameter has  brought the  maligned M mode echocardiography into limelight again.

tapsee rca motion by coroanry angiogram rv systolic function tricuspid annulus motion right av groove atrio ventricular grrove mapsee m mode echo

Currently coronary angiogram is done just like a non invasive echocardiogram across the nooks and corners  of any country

Modern day  cardiologist is expected to  look  beyond the coronary artery  narrowing  when reading coronary angiogram.  If only we give little importance to how the coronary artery moves with  reference to  cardiac cycle we can  get  excellent information about  mechanical properties of heart.

Every cath-lab  work station has a DSA mode . With this one can measure the coronary artery swing and document   it  objectively  .Right coronary artery swing  faithfully reflect  RV longitudinal function . This motion is more accurate than the TAPSE by echo . We have found the normal excursion to be 15-20mm (Slightly  lower than TAPSE) . Similarly LCX motion give us an estimate of longitudinal LV function and LAD motion can tell us how IVS moves .

Final message

Coronary artery swing*  is a   new  method (  rapid  and accurate) to assess  cardiac  function  in cath lab !   We should utilise this more often .I feel it may throw more valuable  than the sophisticated but complex 3D reconstructed and post proceed  imaging modalities  to assess individual  chamber function .

* There is no published reference available for  modality  .It is so simple  concept  i think ,  it does not require any major experiments for a  proof !

Reference

RV  function assessment ASE  guidelines

http://www.echobasics.de/rv-en.html

Normal RV function Indices .

TAPSE (tricuspid annular plane systolic excursion) < 2 cm

TASV (tricuspid annular systolic velocity)< 15 cm/s

Tei-Index (myocardial performance index)> 0,50

TAPSE  can be correlated with coronary swing

Further research potential 

Now we   require  comparing  the  TAPSE   with the quantum of RCA swing by angiography.  I have asked my fellows to look into this  aspect . I guess TAPSE by  Echo over-estimates the true  motion ( normal 2 cm )   seems on higher side. It includes translational motion of echo which is eliminated in angiographic annular movement .

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Here is a patient with class 3  dyspnea  who was referred  for echocardiography

X ray chest showing cardiomegaly

         Moderate TR due to dilatation of tricuspid annulus.This patient had dilatation of all 4 chambers of the heart.LV EF was 24 %

Right ventricular dysfunction is major determinant of  clinical outcome in patients with dilated cardiomyopathy. The  myocardium of the  entire heart is now known to be a single sheet of muscle rolled into different chambers . So any primary disease of myocardium will involve the entire musculature . This is the reason  , all the  4 chambers of heart goes for dilatation in  primary cardiomyopathy . Of course there can be minor variations  due to differential hemodynamic impact.

But it is certain ,  RV  function will definitely be compromised  In  most patients  with  Idiopathic DCM (Less common in Ischemic DCM ) Rapid assessment of RV function is difficult  . Of course We have some clues .

2 d Features

  • Simple dilatation  of RV is suffice to say it is struggling with the  loading conditions
  • Septal bowing
  • Tricuspid annular dilatation
  • RV ejection fraction (Continues to be complex for routine usage )

TR jet

  • Dp/Dt
  • Morphology may be useful (Mainly for TR severity )

Tissue doppler

  • TAPSE
  • RV strain rate Imaging etc.

And  now  , we have observed a new echocardiographic  sign   ie  TR jet alternans  in patient with  DCM .

Note the changing TR velocity implying severe RV contractile dysfunction.

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