Right Heart

Question 1

TEE view of the right heart

Answer 1

ME4C** — one of best views
•calculate FAC of RV - correlates with MRI EF
•examine TV and TAPSE
•nonseptal (posterior if pushed in and CS / anterior if pulled out and see LVOT) and septal leaflets of TV

ME RV inflow-outflow view
•assess TV function and TR jet
•evaluated pulmonic valve

TG SAX — probe turned right

TG RV inflow — angle at 90 deg

Deep TG RV inflow**
•TDI of lateral TV annulus — systolic velocity
•IVA measurement

ME Asc Ao SAX
•visualize MPA, RPA, and LPA

UE Ao Arch SAX
•assess flow through PA and doppler pulmonary valve
•innominate vein seen next to aorta

ME Bicaval / modified bicaval**
•coronary sinus and CWD of TR jet for RVSP

Question 2

Right Ventricle Function

Answer 2

•Assessment is more qualitative than LV due to complex shape and architecture
•High compliance and low resistance therefore very sensitive to loading conditions
**IVA does NOT change to loading conditions
•20% post CPB failure d/t RV dysfunction
RCA anterior —> air
Retrograde cardioplegia doesn’t protect as well due to right hear draining via thebesian veins
Topical slush doesn’t cool right heart as much
•severe refractor RV failure 0.1% after cardiology, 2-3% after transplant, 20-30% after LVAD

Question 3

Parameters of RV function

Answer 3

RVFAC ≥ 35%
•ME4C view — good correlation with MRI EF
•FAC = (EDA - ESA) / EDA

RVEF ≥45%
•EF slightly lower than LVEF because EDV and ESV are higher than LV

TAPSE > 15 mm [normal = 20 - 25 mm]
•ME4C lateral TV annulus during systole

TV S’ > 12 cm/s
•Deep TG RV inflow-outflow 100+ deg
•S’ towards probe, E’ and A’ away from probe

IVA = 1.4 - 2.2 ± 0.5 m/s^2
•most load independent measure of RV systolic function
•Deep TG view using TDI: End of A’ to beginning of S’ is isovolumetric contraction
•Peak of spike is peak isovolumetric velocity
•Divide by time it takes to achieve the peak velocity

Question 4

Problems with RV function

Answer 4

Volume Overload
•flattening of septum at END DIASTOLE when volume is highest
•etiology: PI, ASD, TR
•TG Mid papillary SAX view
•Eccentricity Index > 1

Pressure Overload
•septum shifts left at END SYSTOLE when pressure is the highest
•chronic —> RVH (wall > 5mm)

RV should not form the apex — severe

McConnell’s sign = PE
•RV apex moves normally but RV base is hypokinetic

Question 5

RV Systolic Function Evaluation

Answer 5

1. Subjective/Geometric assessment
   •not very reliable
2. TAPSE > 17 mm
   •gold standard RVEF = cardiac MRI doesn’t correlate well with TAPSE
   •any TR greater than trace/mild eliminates usefulness
   •decreases with surgery despite evidence of normal RV function
3. S’ > 9.5 cm/s
   •angle dependent
   •anything inhibiting motion of annulus (i.e. ring) causes inaccuracy
   •any TR > moderate eliminates usefulness
   •decreases with surgery despite evidence of normal RV function —> opening pericardium changes RV motion from longitudinal to radial
4. Strain < - 20
   •no significant correlation with CI
   •very load dependent
5. FAC > 35%
   •doesn’t change over perioperative period
   •better correlation but not ideal
   •obtain largest TV diameter to prevent foreshortening
   •not a good correlation with hemodynamics (SV) — use as a trend
   •Simpson’s method not recommended
   •3D RVEF > 45% ***
   Good correlation with MRI
   Doesn’t change perioperative
   Good correlation with SV

6. RV MPI — PWD < 0.43 , TDI < 0.54
•lower = better
•(IVCT + IVRT)/ET
•PWD TR jet —> IVCT, ET, IVRT
•PWD RVOT —> ET
•(TR jet duration - ET) / ET = RIMP
•good correlation with MRI

7. Sequence of assessment...
•Hemodynamics —  CVP and CI
•Position of IAS — RAP >< LAP
•TR — almost always functional ... worse = RV dysfunction
•RV geometry
•RV free wall motion / FAC
•RIMP with PWD