Echocardiography of the Right Ventricle

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Echocardiography of the Right Ventricle Powered By Docstoc

     Selwyn Wong
  Middlemore Hospital
      Echocardiography Basics
Ultrasound waves sent from chest wall
Echocardiography Basics
Two-dimensional imaging
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
  Echocardiography Basics
One-dimensional imaging (M-mode)
  Echocardiography Basics
One-dimensional imaging (M-mode)
 Echocardiography Basics
    Doppler - Spectral
Pulse             Continuous

Bernoulli equation P = 4V2
Echocardiography Basics
     Doppler - Colour
Echocardiography Basics
  Tissue velocity imaging
Echocardiography Basics
  Tissue velocity imaging
Left ventricle - size

Left ventricle - size

Left ventricle - wall thickness

                  IVS and PW
                   0.6 -1.1cm
Left ventricle - systolic function
    Fractional Shortening (FS)

    FS = EDD-ESD / EDD
Left ventricle - systolic function
    Fractional Shortening (FS)

    FS = EDD-ESD / EDD
Left ventricle - systolic function
  Left ventricle - systolic function

           Ejection fraction (%)
Normal               >55
Mild                 40-50
Moderate             30-40
Moderate-severe      20-30
Severe               <20
                            Part One
A 67-year-old woman with congestive cardiac failure remains breathless
on moderate exertion despite treatment with 40 mg frusemide and 20
mg enalapril daily. On examination she has a pulse rate of 80/minute,
blood pressure of 125/70 mmHg and a jugular venous pressure (JVP) of
+1 cm. She has a soft systolic murmur with no added sounds, her chest
is clear and she has no oedema. An ECG shows sinus rhythm. A chest
X-ray shows cardiomegaly with a cardiothoracic ratio of 15.5/28 but no
pulmonary congestion. Echocardiography demonstrates systolic
dysfunction with fractional shortening of 18% and mild mitral
regurgitation. Her serum creatinine level is normal.

Which of the following is the most appropriate next step in treatment?
A. Increase the frusemide dose.
B. Add digoxin.
C. Add an aldosterone antagonist.
D. Add an angiotensin II receptor antagonist.
E. Add a beta blocker.
     Left ventricle - diastolic function

Mitral inflow     Pulmonary       Mitral TVI
  LV diastolic function - mitral inflow

E/A > 1        E/A < 1        E/A >>1
    LV diastolic function - mitral TVI

E/A > 1         E/A < 1        E/A >>1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size

               Normal 2.0-4.0cm
                Mild 4.0-5.0cm
              Moderate 5.0-6.0cm
                Severe >6.0cm
Left atrium - size

                Normal <20cm2
                 Mild 20-30cm2
              Moderate 30-40cm2
                Severe >40cm2
Left atrium - thrombus
                Cardiac Valves
Valve dysfunction
    serial evaluation
Valve regurgitation - quantification

                       Colour - jet size/width
                       Spectral doppler

            AR - LV Response
• Chronic AR - decompensated LV
• LVEF<55%, LVESD>55mm, LVESV 60ml/m2
                              Part One
A patient with aortic regurgitation has the following haemodynamic
cardiac output (CO) 7.5 L/minute
heart rate (HR) 75/minute
left ventricular end-diastolic volume (LVEDV) 200 mL
left ventricular end-systolic volume (LVESV) 50 mL
The regurgitant fraction is defined as the ratio of the regurgitant volume
to the total volume flowing through the valve with each beat.

The regurgitant fraction in this patient is:
A. 25%.
B. 33%.
C. 50%.
D. 67%.
E. 75%.
                            Part One
A 45-year-old asymptomatic man returns for follow-up. He
was diagnosed 10 years ago with aortic regurgitation due
to a congenital bicuspid aortic valve. He has never had
Which one of the following echocardiographic profiles most
strongly indicates the need for aortic valve replacement?
     LVEDD (mm)[35-55]       FS [0.30-0.40]            LA size (mm) [<40]
A.          70                    0.30                            60
B.          75                    0.40                            40
C.          70                    0.25                            45
D.          65                    0.45                            50
E.          75                    0.35                            55

     Key:    LVEDD Left ventricular end-diastolic diameter
             LVESD Left ventricular end-systolic diameter
             FS Fractional shortening = (LVEDD - LVESD) / LVEDD
             LA Left atrial
    MR- Quantification of LV contractility

 LV systolic function - most important parameter
•Ejection fraction, fractional shortening, velocity of
circumferential fibre shortening - load dependent

•MR allows supranormal values of EF etc.

•Early systolic dysfunction if;

   •EF < 60% (severe MR)

   •ES diameter < 45mm (26mm/m2)
       Mitral stenosis - quantification
Severity      MVA (cm2)   LAP (mm Hg)   CO
Mild            >2.0        <10-12      NL
Moderate       1.1-2.0      ~10-17      NL
Severe          <1.0          >18         
Very Severe     <0.8        >20-25      
                            Part One
A 35-year-old woman has increasing breathlessness on exertion. Her
cardiac silhouette is slightly enlarged on a chest X-ray and an ECG
demonstrates sinus rhythm.
The continuous wave Doppler flow signal through the mitral inflow tract
(shown above) is most consistent with which one of the following?
A. Severe pulmonary hypertension (cor pulmonale).
B. Aortic stenosis.
C. Mitral regurgitation.
D. Mitral stenosis.
E. Aortic regurgitation.
                           Part One
A 28-year-old woman, who emigrated from Cambodia 10 years ago,
presents to the emergency department with a three-week history of
increasing shortness of breath, orthopnoea, nocturnal dyspnoea and
ankle oedema. She is 25 weeks pregnant and has no significant past
medical history.
The presence of pulmonary oedema is confirmed clinically and
radiologically. She responds well to intravenous frusemide but remains
tachypnoeic with a heart rate of 120/minute in sinus rhythm. Her blood
pressure is 125/85 mmHg.
Echocardiography demonstrates mitral stenosis with an estimated valve
area of 1.3 cm2 and a left atrial diameter of 50 mm [<40 mm]. There are
no other abnormalities.
What is the most appropriate next step in management?
A. Balloon valvotomy.
B. Surgical valvotomy.
C. Digoxin therapy.
D. Beta-blocker therapy.
E. Angiotensin converting enzyme (ACE) inhibitor therapy.
                             Part One
A 55-year-old man presents with acute pulmonary oedema. Five years
earlier, he has undergone a mitral valve replacement with a bileaflet tilting
disk valve (St. Jude) for mixed mitral valve disease. He has been well with
normal exercise tolerance prior to the day of admission.
Examination on admission reveals tachypnoea, sinus tachycardia of
110/minute, blood pressure of 105/60 mmHg, elevated jugular venous
pressure (+ 5 cm) and bilateral crepitations throughout the lung fields. His
prothrombin time−international normalised ratio (PT-INR) is 1.9 [desired
therapeutic range 2.0-3.5]. Serum urea, creatinine and electrolytes are
normal. The cardiothoracic ratio on chest X-ray is normal but the
presence of pulmonary oedema is confirmed. Echocardiography reveals
that one of the prosthetic valve leaflets is not moving and there is an
increased flow rate in diastole across the valve orifice (2 metres/second).
What is the most appropriate course of action?
A. Administration of intravenous streptokinase.
B. Administration of intravenous heparin.
C. Administration of intravenous antibiotics.
D. Addition of an antiplatelet agent.
E. Immediate mitral valve replacement. .
Aortic stenosis - quantification
   Aortic stenosis - quantification
           Mean gradient   Peak Ao     AVA
             (mmHg)        velocity   (cm2)
Normal                     1.0-2.0     >2.5
Mild           <20         2.5-2.9     >1.7
Moderate      20-40        3.0-4.0    1.0-1.7
Severe         >40          >4.0       <1.0
Right ventricle - size & function
   Estimation of Pulmonary Pressure
         PA systolic pressure
• Tricuspid regurgitation jet velocity
  Estimation of Pulmonary Pressure
            RA pressure

• IVC size
                            Part One
The severity of pulmonary hypertension can be determined using
continuous wave Doppler measurements of the velocity of tricuspid
regurgitation. This method uses the Bernoulli equation which states that
���� P = 4v2 (where ���� P = instantaneous pressure gradient and v =
velocity across the valve). There is tricuspid regurgitation with a peak
velocity of 4 metres/second and a mean velocity of 3.5 metres/second.
Assuming right atrial pressure is 5 mmHg, the best estimate of the peak
right ventricular systolic pressure (± 2 mmHg) is:

        A. 50 mmHg.
        B. 55 mmHg.
        C. 60 mmHg.
        D. 65 mmHg.
        E. 70 mmHg.
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
                            Part One
A 65-year-old woman presents with a one-week history of progressive
dyspnoea. On admission, there are signs of shock, a systolic murmur
and an elevated jugular venous pressure. The ECG shows sinus
tachycardia but no other abnormality. An antero-posterior chest X-ray
shows cardiomegaly. The serum troponin I level is 0.5 mg/L [<0.1]. A
computed tomography (CT) scan is shown below.

What is the most likely diagnosis?
A. Pulmonary embolism.
B. Right ventricular infarction.
C. Pericardial tamponade.
D. Myocarditis.
E. Acute mitral regurgitation.

                  Positive echocardiogram for IE
  Discrete, echogenic, oscillating intracardiac mass located at a site of
endocardial injury (e.g., on a valve or supporting structure, in pathway of
regurgitant jet, or site of implanted material), or Periannular abscess, or
                   New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation

           •Severe heart failure
           treatment to restore co-
           ordination to LV contraction

           •NYHA 3-4
           •EF < 35%
           •QRS duration > 120 msec

•Useful non-invasive tool
•Reports objective and subjective

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