Right Heart Flashcards
RV Anatomy
3 walls of RV?
anterior, inferior, septal
RV Anatomy
Inlet (*route/entrance) contains….
- TV
- chordae tendineae
- papillary muscles
RV Anatomy
apical (inferior surface) section of thr RV has…
- apical endocardium/apical trabecular
- trabeculae carneae
- supraventricular crest (a prominent trabecula) separates the trabeculated inferior ventricle from smooth wall of RVOT
RV Anatomy
There are ____ pap muscles
3
RV Anatomy
anterior pap muscle is _____, and with chordae tendineae, it attaches to _____ & ______ cusps
largest
anterior/posterior
RV Anatomy
posterior pap muscle is _____, and with chordae tendineae, it attaches to _____ & ______ cusps of TV
smallest
posterior
septal
RV Anatomy
smooth RVOT up to the PV called
infundibular or outlet
Abnormal RV Size
RV basal (base/RVD1)
4.2 cm
> 4.0 cm
Abnormal RV Size
RV mid (RVD2)
> 3.5cm
Abnormal RV Size
RV longitudinal (RVD3)
> 8.6 cm
Abnormal RV Size
RVOT PLAX proximal
> 3.3 cm
Abnormal RV Size
RVOT PSAX distal
> 2.7 cm
Abnormal RV Size
RV wall thickness
> 0.5 cm
RV Area
Manual tracing of RV endocardial border from the lateral tricuspid annulus along the free wall to the apex and back to the medial tricuspid annulus, along the interventricular septum at _______ and at ________
end-diastolic
end systole
RV Area
_____, ______, and ______ are included in the cavity of RV, therefore do not trace them when assessing EDA
trabeculations
papillary muscles
moderator band
RV Linear Dimensions: Inflow
maximal transversal dimension in the basal one third of RV inflow at end-diastole in the RV- focused view
Basal RV linear diameter (RVD1)
RV Linear Dimensions: Inflow
transversal RV dimension in the middle third of RF inflow, approximately halfway between the maximal basal diameter and the apex, at the level of papillary muscles at end diastole
Mid-cavity RF linear diameter (RVd2)
RV Linear Dimensions: Outflow
linear dimension measured from the anterior RV wall to the i_nter-ventricular septal-aortic junction_ (in parasternal long-axis view) or to the aortic valve (in parasternal short-axis) at end-diastole
Proximal RV outflow diameter (RVOT Prox)
*>3.3cm indicates enlargement
RV Linear Dimensions: Outflow
linear transversal dimension measured just proximal to the pulmonary valve at end-diastole.
Distal RV outflow diameter (RVOT Distal)
Which wall?
inferior
*Note: facing posterior wall of the heart
Which wall?
lateral free wall
Which wall?
red
green
yellow
- red: anterior
- green: lateral
- yellow: inferior
Which wall?
red
yellow
red: anterior free wall
yellow: inferior free wall
RV Wall Thickness Measurement
Linear measurement of RV free wall thickness (either by M-mode or 2D) performed at ______, below the _______ at a distance approximating the length of anterior tricuspid leaflet when it is fully open and parallel to the RV free wall
end- diastole (EDWT)
tricuspid annulus
*note: subcostal view
RV Wall Thickness Measurement
_______, ________ and _______ should be excluded
Trabeculae
papillary muscles
epicardial fat
RV vs LV Comparison
Structure (wall characteristics)
RV: thin compacta, heavily trabeculated cavity
LV: thicker compacta
RV vs LV Comparison
Shape
RV: Crescentric with triangular
LV: Truncated ellipse
RV vs LV Comparison
EDV
RV: 75 +/- 13 (49 – 101)
LV: 66 +/- 12 (64 – 109)
RV vs LV Comparison
Wall Thickness range
RV: 2-5
LV: 7 - 11
RV vs LV Comparison
Pressure
RV:
- Systolic: 25 ( 15 – 30)
- Diastolic: 4 (1 – 7)
LV:
- Systolic: 130 (90 – 140)
- Diastolic: 8 (5 – 12)
RV vs LV Comparison
EF
RV: > 40 - 45
LV: > 50
RV vs LV Comparison
Major vector of contraction
RV: Longitudinal
LV: Circumferential and Longitudinal
RV Coronary Artery supply
Anterior wall is supplied by:
RCA conus branch & LAD branch
RV Coronary Artery supply
lateral wall is supplied by:
RCA marginal branches
RV Coronary Artery supply
posterior wall &posterior interventricular septum are supplied by:
PDA (posterior descending artery)
RV Structure
_______ surface?
sternocostal
RV Structure
_______ surface?
Diaphragmatic
RV Structure
RVSP – Right Ventricular Systolic Pressure Equation
4V2 + RAP
*RAP decided by 3/8/15 method
*V = peak TR velocity jet
RAP 3/8/15 Method
The IVC size is relatively small (< 2.1 cm) with normal respiratory response (collapse > 50%)
What is the RAP?
3 mmHg (5 mmHg)
normal
RAP 3/8/15 Method
The IVC size is relative small (< 2.1 cm) with no IVC respiratory response (collapse < 50%)
What is the RAP?
8 mmHg (6/10 mmHg)
intermediate
RAP 3/8/15 Method
The IVC size is > 2 cm with respiratory response (collapse > 50%)
What is the RAP?
8 mmHg (10-15 mmHg)
intermediate
RAP 3/8/15 Method
The IVC size is > 2 cm with no respiratory response (collapse < 50%)
What is the RAP?
15 mmHg (15-20 mmHg)
Increased
What is Cor Pulmonale?
Cor Pulmonale is an increase in bulk of the right ventricle of the heart, generally caused by chronic diseases or malfunction of the lungs. This condition can lead to heart failure
Cor Pulmonale, or pulmonary heart disease, occurs in _____of patients with chronic obstructive pulmonary disease (COPD)
25%
About _____of patients diagnosed with cor Pulmonale have COPD
85%
________ and _______ are types of COPD
Chronic bronchitis
emphysema
_________ causes the enlargement of the right ventricle
High blood pressure in the blood vessels of the lungs (pulmonary hypertension)
Cor pulmonale may also be caused by lung diseases, such as ______, __________, _________and _________.
- cystic fibrosis: a genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestine. Long-term issues include difficulty breathing and coughing up mucus as a result of frequent lung infections
- pulmonary embolism
- pneumoconiosis: a disease of the lungs due to inhalation of dust, characterized by inflammation, coughing, and fibrosis
- muscular dystrophy: Muscular dystrophy is a group of diseases that cause progressive weakness and loss of muscle mass. In muscular dystrophy, abnormal genes (mutations) interfere with the production of proteins needed to form healthy muscle. There are many kinds of muscular dystrophy
*Loss of lung tissue after lung surgery or certain chest-wall disturbances can produce cor pulmonale as well
What is TAPSE ?
Tricuspid Annular Peak Systolic Excursion
TAPSE is measured as the displacement of the lateral tricuspid annulus toward the apex during systole = RV Longitudinal Systolic Function
*By using M-mode, it measures between end-diastole and peak systole. In presence of severe TR and normal contractility TAPSE is increased. In presence of mildly reduced contractility (and severe TR) TAPSE is within the normal range. If TAPSE is reduced this means that RV longitudinal function is severely impaired.
RV Function Assessment by TDI
RV Pulsed tissue Doppler S wave
The right ventricular myocardial performance index and tricuspid annulus motion are used in the assessment of global right ventricular function
In pulmonary hypertension, S’ wave assessment may be used for therapeutic efficacy evaluation. Longitudinal strain reduction indicates an increased risk of vascular events, while an increased value of myocardial performance index is a predictor for a survival in pulmonary hypertension. A decreased S’ wave velocity is associated with limited pulmonary vascular flow in patients with pulmonary embolism
“Systolic wave prime” or “S Prime” (Abbreviated to S’ when writing), refers to….
the maximum velocity achieved by the lateral tricuspid annulus during systole = systolic excursion velocity. It is a useful index to assess right ventricular function.
Why does S’ index matter?
S’ is an index that has been shown to correlate with RV ejection fraction, and with outcomes in people with RV dysfunction- pulmonary hypertension, pulmonary embolus, and cardiogenic shock.
What is normal S’?
RV S’ of more than 10cm/s is considered normal
Identify 1 & 2
- IVCT
- IVRT
*Note: you can identify by following ECG
To obtain S’, it is important to differentiate _____ from the S’ velocity
IVCT
*increasing sweep speed can help with this
What is Global longitudinal strain (GLS)?
a newly emerging topic which has a significant role in predicting cardiovascular outcomes, compared to Left ventricular ejection fraction (LVEF). LVEF is the most extensively used and investigated cardiac pumping function for many decades
*note: Because GLS normally varies with age, sex, and LV loading conditions, defining abnormal GLS is not straightforward. However, in adults, GLS <16% (sic) is abnormal, GLS >18% (sic) is normal, and GLS 16% to 18% is borderline. (Editor’s note: GLS is expressed as a negative number
What is RIMP ?
Right ventricular Index of Myocardial Performance aka: Tei index
is an index of global RV performance.
RIMP Equation
RIMP = (IVCT + IVRT) / ET
IVCT = isovolumic contraction time
IVRT = isovolumic relaxation time
ET = ejection time
For RIMP, measure in 2 separate heart beats with similar R-R intervals. Important to note that IVCT and IVRT do not exist in the case of ______
TR
RIMP (Right ventricular index of myocardial performance/ Tei index) Equation 2
RIMP = ( TCO - ET) / ET
*note: TCO – Tricuspid Closure-Open Time. This is the time between the tricuspid valve opening and closing
RV Function
Abnormal Threshold
TAPSE
< 17 mm
*mean +/- SD = 24 +/- 3.5
RV Function
Abnormal Threshold
Pulsed TDI S wave (cm/s)
< 9.5 cm/s
*mean SD = 14.1 + 2.3
RV Function
Abnormal Threshold
RV fractional Area change (%)
< 35 %
*mean SD = 49 +/- 7 %
Fractional area change (FAC) is a measurement that provides an estimate of the global RV systolic function. Remember this is a formula to calculate the % of area change within the RV between diastole and systole. The value provided is a percentage but please do not confuse this with the ejection fraction %
RV Function
Abnormal Threshold
RV Function
Abnormal Threshold
RV Function
Abnormal Threshold
mean +/- SD = 1.4 +/- 0.3
RV Function
Abnormal Threshold
mean +/- SD = 4/0 +/- 1.0
Hepatic Vein Waveform Assessment
What can hepatic waveform represent in regard to right heart?
The hepatic vein waveform can be reflective on the severity of TR present. The more severe the regurgitation, the more pulsatile the waveform becomes.
When RA pressure rises, HV flow pattern is _______ - systolic wave velocity is _____ diastolic wave velocity
opposite
less than
*use PW in HV to confirm elevated RAP
RA Anatomy
- SA node
- Eustachian valve: (EV) is located in the superior portion of the inferior vena cava (IVC) and protrudes into the right atrial cavity. It is considered to be a functional valve in the fetus that helps direct oxygenated blood from the IVC toward the foramen ovale, thereby bypassing the pulmonary circulation. An embryological remnant of the inferior vena cava (IVC) valve. It is usually absent or inconspicuous and has no known function in the normal adult
- Thebesian valve: also known as the valve of the coronary sinus, is a fold in the right atrium at the opening of the coronary sinus
- Pectinate muscle
- Crista Terminalis
RA Anatomy
Chiari network
What is Chiari network?
The Chiari network is a congenital remnant of the right valve of the sinus venosus, which is reabsorbed to varying degrees in utero (in the uterus).
It has been found in 1.3% to 4% of autopsy studies
When Chiari network is seen, there is a greater prevalence of both ______ and _______ with agitated saline contrast.
a patent foramen ovale (PFO)
a greater degree of shunting across the PFO
RA Anatomy
Normal Variants
- Eustachian valve
- Chiari network
- Eustachian ridge
- Crista terminalis
- Lipomatous hypertrophy of the atrial septum - characterized by an infiltration of adipocytes into myocytes of the interatrial septum, sparing the fossa ovalis, which gives a characteristic hourglass-shaped image
- Fatty infiltration of tricuspid annulus
What is ECMO ?
Extracorporeal (situated outside body) membrane oxygenation catheters
a treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream of a very ill baby. This system provides heart- lung bypass support outside of the baby’s body. It may help support a child who is awaiting a heart or lung transplant.
Right Atrial Dimensions and Volume 2D
Longest plane from Tricuspid valve to superior RA wall (parallel to the IAS)
RA major
Right Atrial Dimensions and Volume 2D
A mid distance from the middle of RA free wall to the IAS (perpendicular to long axis)
RA minor
Coronary Artery
anterior wall & inferior wall are supplied by:
anterior: RCA - acute marginal branch
inferior: RCA - PDA
Coronary Artery
anterior wall is supplied by:
RCA - conus branch
Coronary Artery
anterior wall & RVOT are supplied by:
anterior: RCA - acute marginal branch
RVOT: RCA - conus branch
Coronary Artery
lateral wall & IVS/moderator band are supplied by:
lateral wall: RCA - acute marginal branch
IVS/moderator band: LAD
assessment of the veins of the heart , right sided chambers and vessels.
Right Heart Catherization
*assessment of the venous
catheter is accessed from the left subclavian vein
Assessment of the Arteries of the heart (left sided chambers and vessels)
Left heart Cath
*assessment of the arterial
maneuvered into position just above the outlet valve on the left ventricle is called…
angiogram catheter
Indications for right heart cath?
- Heart failure
- Acute MI
- Acute of chronic pulmonary disease
- Congenital heart disease
- Complications of transplanted heart
- Screening for unspecified respiratory disease
- Hypotension
- Valvular heart disease
- Mechanical complications
- Endomyocardial fibrosis
ハークシュ！ベラボーめ
Pulmonary embolism (PE) is common and often fatal
US -250,000 annually
Undiagnosed: _____ mortality
30%
Symptoms of PE (pulmonary embolism)
dyspnea: difficult breathing
chest pain,
tachypnea: abnormally rapid breathing
hypotension
Chronic bronchitis and emphysema are types of …
COPD (chronic obstructive pulmonary disease)
_____ is the longest plane from TV to superior RA
RA major
4 types of foreign bodies that may be possible for patients
- Pacemaker / defibrillator wires
- Central venous catheters including dialysis catheters
- Extracorporneal membrane oxygenation catheters (ECMO)
- Atrial septal defect occluder devices
4 indications for RH cath
- Heart failure
- Acute MI
- Acute of chronic pulmonary disease
- Screening for unspecified respiratory disease
- Hypotension
- Valvular heart disease
- Mechanical complications
- Endomyocardial fibrosis
- Congenital heart disease
- Complicationsof
- transplanted heart
What is RVSP ?
Right Ventricular Systolic Pressure
*RVSP can be calculated using the simplified Bernoulli equation: 4V2 + RAP, where V = peak TR velocity jet.
When measuring RV wall thickness, avoid……
Trabeculations
papillary muscles
moderator band
TAPSE value
What are the 2 surfaces of RV?
1. Sternocostal surface
2. Diaphragmatic surface
A large pulmonary embolism may lead to chronic Cor pulmonade
T or F ?
F
A large pulmonary thromboembolism (blood clot) may lead to acute cor pulmonale.
Major vector of contraction RV
longitudinal
Pulmonary Emboli echo findings?
- Visualization of thromboemboli on right side of heart or pulmonary artery
- RV dilation
- RV dysfunction (global or regional)
- Normal or Hyperdynamic LVFX
- Ventricular septal flattening and paradoxical septal motion
- PA dilatation
- Increased TR or PR
- Increased PS pressure
What is McConnell sign?
McConnell’s sign is a distinct echocardiographic feature of acute massive pulmonary embolism. It is defined as a regional pattern of right ventricular dysfunction, with akinesia of the mid free wall and hyper contractility of the apical wall.
The McConnell’s sign is defined as relative hyperkinesis of the apex of the right ventricle (RV) relative to the RV free wall in the setting of RV strain. (aka enlargement
McConnell’s sign is considered as a specific sign of APE
What is 60/60 sign?
acceleration time is significantly decreased (< 60 msec) + TR gradient < 60 mmHg
The 60/60 sign in echocardiography refers to the coexistence of a truncated (shortened in duration or extent) RVOT acceleration time (AT <60 ms) with a pulmonary arterial systolic pressure (PASP) of less than 60 mmHg (but more than 30 mmHg). In the presence of right ventricular failure, it is consistent with an acute elevation in afterload, commonly due to an acute pulmonary embolism.
*note: The PASP is equivalent to RVSP in the absence of pulmonary outflow obstruction
WIGGER’S DIAGRAM
Where does the LV volume drop most?
during ventricular systole
WIGGER’S DIAGRAM
Where does the LV pressure drop the fastest?
end of ventricular systole
WIGGER’S DIAGRAM
Where does LA pressure increase the most?
end of ventricular systole
WIGGER’S DIAGRAM
Where does LV pressure increase the fastest?
during the IVCT
WIGGER’S DIAGRAM
When does MV close?
1
creates S1 sound
at the IVCT
WIGGER’S DIAGRAM
When does AV open?
2
at the beginning of systole (end of IVCT)
WIGGER’S DIAGRAM
When does AV close?
3
creates S2 sound
at the beginning of IVRT
dicrotic notch
The dicrotic notch is universally associated with the closure of the aortic valve and taken as a marker of the end of systole and the start of diastole in the arteries
the result of a short period of backward flow of blood immediately before the aortic valve closes
WIGGER’S DIAGRAM
When does MV open?
4
the end of IVRT
early ventricular diastole
What doe the diagram represent?
MS
*note: scale: 100
higher = MV
What doe the diagram represent?
TS
*note: scale: 20
In atrioventricular stenosis, __________ increases causing a pressure gradient to persist throughout ventricular diastole. (shaded area)
the atrial pressure
What does the diagram represent?
AS
*note: shaded area = PG
What doe the diagram represent?
PS
In semilunar valve stenosis, the _________ increases creating a systolic pressure gradient between the ventricle and great artery. (see shaded area in diagram)
ventricular systolic pressure
What doe the diagram represent?
AR
What doe the diagram represent?
PR
In semilunar valve regurgitation, __________ pressure decreases throughout diastole, thus decreasing the diastolic pressure gradient between the artery and ventricle
the arterial diastolic
What doe the diagram represent?
MR
What doe the diagram represent?
TR
In atrioventricular regurgitation, the atrial pressure tracing will reflect an increase during ventricular systole of the atrial v wave
T or F ?
T
*V wave represents the passive filling before the opening of the mitral valve. This will occur directly with T-wave
assessment of the venous
catheter is accessed from the _________
left subclavian vein
What are the 3 structures unique to RV?
- supraventricular crest (crista supraventricularis)
- moderator band
- prominent trabeculamtions
In an adult, the volume of RV is larger than the volume of LV, whereas RV mass is about one sixth that of the LV.
T or F ?
T
The main driving force of the LV comes from a layer of circumferential constrictor fibers that act to reduce ventricular diameter.
The RV lacks these fibers and thus must rely more heavily on ______ shortening than the LV
longitudinal
