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Assessment of right ventricular volumes and ejection fraction by echocardiography: from geometric approximations to realistic shapes

Assessment of right ventricular volumes and ejection fraction by echocardiography: from geometric... Right ventricular volumes and ejection fraction are challenging to assess by echocardio- Key Words graphy, but are well established as functional and prognostic parameters. Three-dimensional " right ventricle (3D) echocardiography has become widespread and relatively easy to use, making " volumes calculation of these parameters feasible in the large majority of patients. We review past " systolic function attempts to estimate right ventricular volumes, current strengths and weaknesses of 3D " echocardiography echocardiography for this task, and compare with corresponding data from magnetic " 3D echocardiography resonance imaging. Why are right ventricular volumes important? or radionuclide angiography, contains substantial functional and prognostic information from LV para- The right ventricle (RV) far from being ‘forgotten’, as has meters as well as from conventional functional RV been suggested, challenged echocardiographic diagnostic parameters independently. efforts from very early on. It is a considerably more complex RV ejection fraction is excellent for the assessment of and more difficult structure to visualize and quantitate functional consequences of chronic and acute pulmonary than the left ventricle (LV). The main reasons for this are hypertension. Kawut et al. (1) found that RV ejection as follows: fraction by radionuclide angiography predicted death or i) RV overall shape, which can be described as a shell lung transplantation in 84 adult patients with pulmonary or a roughly triangular body covering part of the hypertension, while pulmonary arterial pressures did not. circumference of the LV, following the shape of the In a study of pulmonary hypertension of different LV, with a crescent-shaped short-axis cross-section. etiologies in children (nZ100), absolute RV volumes and Different from the LV, it has anatomically distinct RV ejection fraction by MRI were found to predict inflow and outflow tracts, a relatively thin free wall, prognosis more strongly than conventional echocardio- and is heavily trabecularized. graphic parameters or pulmonary pressure estimated by echocardiography or measured by right heart catheteriza- ii) RV location, which is in the near field of parasternal tion (2). Patients with an RV ejection fraction!44% had a echocardiographic windows, and in apical views may 1-, 2-, and 3-year survival of 87, 78, and 65% respectively, be obscured by ribs, sternum, or lung, especially if while those with an RV ejection fraction of 44–55% had a the image is optimized for the LV (Fig. 1). survival rate of 97, 97, and 90% for the same intervals Thus, RV ejection fraction, which until recently could and patients with a normal ejection fraction (O55%) only be determined by magnetic resonance imaging (MRI) had a survival rate of 97% throughout the first 3 years. This work is licensed under a Creative Commons q 2015 The authors www.echorespract.com Attribution-NonCommercial-NoDerivs 4.0 Published by Bioscientifica Ltd International License. E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 Recently, a multi-center study in 94 adult patients with pulmonary hypertension of various etiologies demonstrated Lung that MRI-derived RV ejection fraction and its changes over 1 year paralleled changes in functional class (e.g., 6-min S PA walking distance) and survival under contemporary drug therapy with endothelin receptor antagonists and/or phosphodiesterase inhibitors (3). Size and function of the Ao RV are also critical for the management of many forms of congenital heart disease, for example, atrial septal defect or pulmonary regurgitation in operated patients with RA tetralogy of Fallot (4). Furthermore, it has increasingly become clear in recent years that, in many ‘left-sided’ clinical scenarios, RV such as heart failure due to coronary artery disease, the RV co-determines course and prognosis. Larose et al. (5) showed that MRI-determined RV ejection fraction inde- pendent of LV ejection fraction and infarct size strongly Probe predicted survival in patients after myocardial infarction (adjusted hazard rate of RV ejection fraction, !40% 3.54 (CI, 1.50–8.36)). The outcome of heart failure therapy using continu- Lung ous-flow LV assist devices critically depends on RV function, with RV failure predicting short-term and long- S PA term mortalities (6). It is reasonable to assume that three- dimensional (3D) echocardiographic measurement of volumes and ejection fraction might improve assessment of RV function in this scenario, although such data are Ao lacking. RA How can RV volumes be measured by echocardiography? RV Two-dimensional echocardiography While there is no meaningful way to calculate RV volumes from M-mode, extensive research has been carried out Probe to derive RV volumes from two-dimensional (2D) views. In principle, two approaches can be distinguished: area– length and Simpson’s rule. Area–length methods calculate Figure 1 volume of a body by a formula of the form: volumeZ Schematic illustration of the right ventricle and the difficulties to include the whole volume. The inflow and outflow tracts are in the same plane – an c!A!L, where A is the cross-sectional area in one view, oblique sagittal plane – as the apex. The right ventricle (RV) is depicted with L is the long-axis length in the cross-section, and c is a the adjacent structures of the right atrium (RA), the pulmonary trunk (PA), constant that has to be found empirically. Simpson’s rule the sternum (S), the ascending aorta (Ao), and lung tissue. (A) The sternum, ribs, and lung tissue can shadow the imaging of the RV, in particular the approaches use two perpendicular planes sharing a long anterior part of the right ventricular outflow tract (RVOT). (B) Either the axis to calculate the volume as a stack of elliptical discs. anterior part of the RV or the apex may not be included in the whole Acquiring such two planes of the RV by 2D echocardio- volume when trying to overcome this shadowing, especially if the RV is dilated. Reproduced from Ostenfeld E, Carlsson M, Shahgaldi K, Roijer A & graphy, however, is very difficult and still neglects the RV Holm J 2012 Manual correction of semi-automatic three-dimensional outflow tract; therefore, biplane approaches of Simpson’s echocardiography is needed for right ventricular assessment in adults; rule were abandoned. Researchers using angiographic validation with cardiac magnetic resonance. Cardiovascular Ultrasound 10 1, published as an open access article by Biomed Central. right ventriculography had found that RV volumes could www.echorespract.com R2 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 be relatively accurately determined from paired X-ray ii) the most popular functional parameter due to its ease projections in end-systole and end-diastole, as was already of acquisition became the M-mode registration of a common practice and reasonably validated for the LV the cyclic apico-basal motion of the lateral inser- (7). Thus, a number of echocardiographic approaches tion point of the tricuspid valve leaflet (TAPSE). imitating the angiographic methodology were published, An alternative functional parameter is RV free wall with encouraging validation in vitro (8) and in vivo against systolic velocity measured by tissue Doppler; radionuclide angiography (9). However, these methods iii) as a surrogate of ejection fraction, RV fractional area were cumbersome, required views that were not well change has been used (RV end-diastolic area minus obtainable in many patients, had only a modest accuracy, end-systolic area divided by end-diastolic area, with and were never validated in a substantial number of areas measured in the apical four-chamber or ‘RV- patients with different diseases. Therefore, RV volume optimized’ four-chamber view; Fig. 2). Alternatively, a determination by 2D echocardiography remained a monoplane Simpson’s rule analog of LV ejection research method, and echocardiographically derived RV fraction is sometimes used, which is derived from the ejection fraction remained impractical to assess RV same view. This of course underestimates true RV function. For routine clinical purposes, the most widely volumes as the RV outflow tract is not included, but used morphology-based parameters of RV size and func- relatively good correlations of RV ejection fraction tion are given as follows (10): with an angiographic standard were obtained in a i) linear parameters such as the antero-posterior small study in children (11). diameter in parasternal long- and short-axis views, as well as short-axis diameters in the apical four-chamber Finally, an approach has been used successfully, in view at different levels of the long axis of the RV; which RV 3D data are reconstructed from 2D images that Figure 2 Examples of fractional area change (FAC) (A and C) in a healthy person (FACZ44%) and (B and D) in a patient with pulmonary arterial hypertension (FACZ13%). A and B are at end-diastole. C and D are at end-systole. www.echorespract.com R3 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 are registered during acquisition in a magnetic field and modality on the brink of clinical routine usage, with then mathematically fitted to ‘knowledge-based’ RV highly improved spatial and temporal resolution as well as shapes (12, 13). a relatively small transducer footprint. 2D parameters have the advantage of relying on routinely acquired standard views. However, as they only Image acquisition consider a section of the RV and imply geometric assumptions, they are fundamentally problematic, and Current transthoracic 3D transducers, the so-called ‘fully particularly so in pathologically remodeled ventricles. sampled matrix transducers’, while still slightly heavier Thus, the limited accuracy and reliability of 2D measures of RV volume has been a major limitation of echocardio- graphic imaging, in particular with regard to the manage- ment of congenital heart disease (e.g., the follow-up of patients with pulmonary regurgitation after surgical correction of tetralogy of Fallot), with MRI now being the recommended modality to assess the RV size and function (4). Another vexing problem in the practical application of echocardiographic RV volume assessment has been the diagnosis of arrhythmogenic RV cardiomyopathy (ARVC), a genetically transmitted disease for which familial screening is recommended. The currently ‘proposed modification’ of the international task force guidelines for the diagnosis of ARVC (14) uses only linear measure- ments of RV volume by echocardiography, and they only constitute criteria for the diagnosis of ARVC if co-existing with a regional akinesia or dyskinesia/aneurysm of the RV. Nevertheless, only 50% of patients with imaging-positive ARVC by CMR fulfilled echocardiographic ARVC 2010 criteria (15). The overlap between RV dimensions sugges- tive of ARVC and those of healthy individuals, in particular endurance athletes, is also considerable; Oxborough et al. (16) found that fully 83% of elite endurance runners or cyclists met the RV outflow tract diameter cut-off incor- porated in the ‘minor’ ARVC criteria and still 28% met the size requirements for ‘major’ ARVC criteria. In an ironical twist, this has led to the proposal of hypothesis that high levels of exercise may enhance phenotypical penetrance of ARVC genotype carriers that actually lead to a ARVC-like disease (17), or even that there is an ‘exercise-induced ARVC’ (18, 19), without necessitating a desmosomal abnormality. Both 3D echocardiography and MRI seem to offer better discrimination, in particular using RV ejection fraction impairment in addition to absolute volume cut-offs (20, 21). Figure 3 Full-volume three-dimensional datasets cropped to display the cavity of (A) 3D echocardiography a normal person acquired with the lateral approach and (B) a patient with 3D echocardiography has over the last 20 years evolved pulmonary arterial hypertension (PAH) acquired with the medial approach. The right ventricle (RV) and atrium (RA) are enlarged and the septum (*) is from a challenging experimental technique requiring bulging into the small left ventricle (LV) in the PAH patient and, at the apex, outstanding image quality, the use of large 3D trans- the right ventricle is larger than the maximum sector angle illustrating the challenge of acquisition of the whole volume. ducers, and time-consuming post-processing steps, into a www.echorespract.com R4 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 and larger than 2D transducers, have a similar footprint to volume is included in the dataset, as the axis can be standard 2D transducers and are capable of imaging the corrected in the post-processing step. In our experience, the entire RV with frame rates of 20–30 frames/s. feasibility isw85% in a non-selected adult population (24, Apical acquisition of volumes is recommended in the 25). As with 2D echocardiography, focus, depth, and sector adult population. An effort should be made to include should be adjusted to the area of interest to maximize the the tricuspid valve, the apex, and the outflow tract with the image quality. Nevertheless, if there is poor 2D image pulmonary valve in the full volume. As it is often difficult to quality, this will also be the case with 3D include the whole RV volume in the acquisition sector, a echocardiography. modified apical view can be advantageous. The modified The 3D dataset for volumetric assessment is acquired view is off-axis compared with the standard 2D apical by recording the whole heart in automatically created four-chamber view. One way (the medial approach) is to small subvolumes over two to seven heart beats, obtaining move the transducer medially to the RV modified apical one subvolume during each heartbeat. The subvolumes four-chamber view and then tilt the transducer cranially are then electronically merged into one dataset and image. and anteriorly – and even rotate – to include the pulmonary Ideally, this requires equally long heart cycles and no valve in the guidance images (Fig. 3). Near-field resolution, breathing motion during acquisition, otherwise the heart ribs, and the sternum are often limiting factors in acquiring is not in the same position at equivalent time points of adequate images from this view. Another way (the lateral each heart beat and ‘stitching artifacts’ can arise. Atrial approach) is to displace the transducer laterally with an fibrillation or other irregular rhythms are therefore anterior tilt. To include both the pulmonary and tricuspid detrimental. Recently, single-beat acquisition of large valves, it can sometimes be of use to move the transducer pyramidal volumes has become technically feasible, further laterally than the RV-focused apical four-chamber although at the cost of lower spatial and temporal view and even to a more cranial intercostal space, as well resolution. While, in sinus rhythm, intra- and inter- as rotating the transducer (Fig. 3). The lateral approach is personal variabilities for measuring LV volumes and EF challenged by far-field resolution, ribs, and interpositioned were the same for single-beat and four-beat acquisition, lung tissue (Fig. 1)(22, 23, 24, 25). Foreshortening is not single-beat acquisition had lower variability than four- an issue in 3D echocardiography (3DE), as long as the whole beat acquisition in patients with atrial fibrillation (26). Figure 4 Example of delineation of a normal right ventricle (RV) in end-diastole the boxes with the corresponding color. (B) Example of a three-dimensional showing the endocardial contour detection in green. (A) The three left echocardiographic reconstruction of the delineation of the right ventricle images (magenta, blue, and green boxes) are the short-axis views at seen from the septal side (end-diastolic volume 153 ml, end-systolic volume different levels with the left ventricle (LV) to the right of the 64 ml, and ejection fraction 58%). The mesh is the right ventricle at end- interventricular septum (*). The upper left image (magenta box) is closer to diastole, in green at end-systole. Pulmonary valve (PV) is shown in white in the base and right ventricular outflow tract (RVOT) and the lower image the upper left side, tricuspid valve (TV) is shown in the upper right side, and (green box) closer to the apex. The upper right image (yellow box) is a four- right ventricular (RV) apex toward the bottom. *shows the interventricular chamber view and the lower right image (purple box) is a right ventricular septum bulging into RV. Data were processed using a dedicated software three-chamber view with tricuspid valve (TV), apex, and pulmonary valve (4D RV-Function, TomTec Imaging Systems). See also Video 1. (PV) in the same projection. The dashed colored lines represent the plane of www.echorespract.com R5 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 Figure 5 Example of delineation of a patient with pulmonary hypertension in end- 137 ml, ejection fraction 31%) shows an enlarged right ventricle with a diastole. Box, line, and color descriptions are the same as in Fig. 4. (A) The flattened septum in diastole (mesh) and even more so in systole (green). right ventricle is enlarged and the trabeculation is hypertrophied. Both the longitudinal and lateral functions appear to be altered. Data were Trabeculations are included in the volume. The septum is flattened, even in processed using a dedicated software (4D RV-Function, TomTec Imaging diastole, in the short-axis images. (B) The three-dimensional echocardio- Systems). See also Video 2. graphic representation (end-diastolic volume 200 ml, end-systolic volume The acquisition time for obtaining all four heart chambers, 14% for end-systolic volumes, and 8% for ejection fraction including the RV, by 3D echocardiography is on average when different observers repeated a study on the same !5 min (22, 23). subject, using semi-automated border delineating software. Image analyses There are several software packages available for endocar- Video 1 dial delineation of cardiac chambers, with some being 3D echocardiography reconstruction of a right ventricle dedicated to the RV (Figs 4 and 5, Videos 1 and 2). (green) with normal systolic function (end-diastolic Pronounced trabeculations, prominent moderator band, volume 153 ml, end-systolic volume 64 ml, ejection or anterior papillary muscle are difficult to differentiate fraction 58 %). The mesh is the right ventricle at end- from the anterior RV wall using the semi-automatic diastole. The white areas are the pulmonary valve in the upper left side and the tricuspid valve in the upper right delineation software, especially with limited image quality side. The right ventricular apex is towards the bottom. (27). Owing to the fact that as much as 25% of the RV Data was processed with dedicated software (4D RV- volumes may originate from the RV outflow tract (28), Function, TomTec Imaging Systems). Download Video 1 via semi-automated border tracing can miss out considerable http://dx.doi.org/10.1530/ERP-14-0077-v1 parts of the volume if manual correction is not performed (Fig. 6 and Video 3). The underestimation of volumes in comparison to cardiac MRI decreases when manual Video 2 correction is performed, yet at the cost of substantially Example of a 3D echocardiographic reconstruction of a increased time requirements for analysis. Manual correc- patient with pulmonary hypertension (end-diastolic tion of semi-automated border delineation can take three volume 200 ml, end-systolic volume 137 ml, ejection to four times longer than the uncorrected delineation, fraction 31 %) showing an enlarged right ventricle which on average takes !4 min; it is even longer than the (green) with a flattened septum in diastole (mesh) and time that manual delineation of a transversal stack of even more so in systole. Both the longitudinal and lateral magnetic resonance images would take (25). function appear altered. Data was processed with Importantly, encouraging test–retest reliability for dedicated software (4D RV-Function, TomTec Imaging RV 3D echocardiographic volumes has been reported Systems). Download Video 2 via http://dx.doi.org/10. (29, 30), with variabilities of 7% for end-diastolic volumes, 1530/ERP-14-0077-v2 www.echorespract.com R6 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 3D echocardiography (31). Systematic underestimation of all cardiac chamber volumes by 3D echocardiogra- phy compared with MRI and also cardiac computed tomography is well established, with less effect on ejection fraction as the absolute volume differences cancel out. Accordingly, an extensive meta-analysis of many small studies directly comparing 3D echocardiography and MRI for RV volumes revealed systematic underestimation of end-systolic RV volume by 5.5 ml, of end-diastolic RV volume by 13.9 ml, and of RV ejection fraction by 0.9% (29, 31). What is normal? Several recent publications have sought to establish normal values for RV volumes and ejection fraction (32, 33, 34, 35, 36). While all studies showed dependency of volumes on body surface area and sex, most also showed an age dependency, with a decrease in volumes and a very small increase in ejection fraction with age. This is in accordance with large-scale studies of RV morphology by MRI (37), which furthermore showed an influence of race. Remarkably, normal volumes, whether indexed or not, have been quite different from study to study by 3D echocardiography, at least in part probably due to evolution in transducer technology and software. For Figure 6 Example of semi-automated delineation of the right ventricle (A) without example, absolute RV volumes of normals were w50% manual correction and (B) with manual correction. The endocardial higher in the study by van der Zwaan et al. (34) than in the contour detection (green) is enhanced in a basal short-axis view (magenta study by Maffessanti et al. (36). Although the underlying box, yellow, and purple lines as in Fig. 4A) from a three-dimensional dataset. The semi-automated delineation crosses, and hence includes, ‘normal’ cohorts were somewhat different in height and parts of the septum (*) in the right ventricular volume. On the other hand, body surface area, this seems to be insufficient to explain the delineation does not follow the anterior part of the right ventricular the discrepancy. Beyond hardware- and software-related outflow tract (RVOT) and that volume is excluded from calculation. See also Video 3. factors, differing levels of manual correction of the automated tracking algorithm most probably play a role in this. In our experience, which is supported by Video 3 observations in the literature (31), manual contour Example of semi-automated delineation of the right tracking corrections lead to higher calculated volumes by ventricle without manual correction. The semi-automated avoiding ‘streamlined’ RV contours. Thus, in the absence delineation crosses, and hence includes, parts of the of a real standard technique, no definitive normal values septum in the right ventricular volume. On the other can be given at this time (Table 1). hand, the delineation does not follow the anterior part of the right ventricular outflow tract and that part is therefore by default not included in automated volume How do RV volumes and ejection fraction calculation. Data was processed with dedicated software compare with other functional parameters? (4D RV-Function, TomTec Imaging Systems). Download As they are difficult to measure, quantitatively estimated Video 3 via http://dx.doi.org/10.1530/ERP-14-0077-v3 RV volumes have played a relatively minor role in clinical practice. This stands in stark contrast to the central Comparison with MRI importance of LV volumes and ejection fraction in clinical Overall, there is a good to reasonable correlation between cardiology, from heart failure to valvular heart disease RV volumes and ejection fraction measured by MRI and management. Instead, mostly non-volumetric parameters www.echorespract.com R7 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 Table 1 Published RV absolute and indexed volume values by Speckle tracking-based assessment of global LV func- 3D echocardiography from healthy adults. tion has received much recent attention. It was found more sensitive in detecting early functional impairment (33) (46) (34) (35) than volume-based functional indices such as ejection fraction in several clinical scenarios such as cardiotoxicity RVEDV (ml) 77G23 86G21 RVEDVI (ml/m)70G14 40G11 75G12 49G10 of cancer chemotherapy, early cardiomyopathy, and RVESV (ml) 30G12 29G11 2 others. Naturally, this paradigm also seems to be attractive RVESVI (ml/m)33G10 16G633G716G6 RVEF (%) 53G10 61G10 57G467G8 for the RV. However, the complexity of RV shape and n 71 166 31 245 absence of an established RV segment model, together Remarks RVOT was not with the absence of dedicated software, have so far included restricted the application of speckle-tracking analysis to the apical four-chamber view, where a portion of the RV RVOT, right ventricular outflow tract; RVEDV, right ventricular end-diastolic volume; RVEDVI, right ventricular end-diastolic volume index; RVESV, right free wall (and the septum) can be analyzed (38, 41). ventricular systolic volume; RVESVI, right ventricular end-systolic index; RVEF, right ventricular ejection fraction. Furthermore, real-time 3D strain assessment, allowing for a more comprehensive assessment of the RV, has become are used for RV function (10), of which all are based on the technically possible. Recently, in 97 patients with mostly apical four-chamber view and therefore neglect the RV primary pulmonary hypertension, RV ejection fraction outflow tract. TAPSE and tissue Doppler measure the correlated highly with 3D RV strain data and both longitudinal function of the RV free wall, which is an even predicted prognosis independently (42), thus confirming more selective way of looking at RV function. Importantly, earlier data on 3D echocardiography-derived RV ejection TAPSE and free wall tissue velocity measure displacement fraction and prognosis in patients with pulmonary and velocity relative to the stationary transducer, which hypertension (43). may produce misleading results. For example, it has been Clinical experience with RV volumes and ejection demonstrated that contraction of the LV lateral wall may fraction from 3D echocardiography, beyond validation induce passive motion of the RV free wall because of studies with MRI and comparison with other functional tethering (tissue continuity) between left and RV free walls echocardiographic parameters, is still limited. In patients (38). Such mechanisms may also be at work to produce the with dilated cardiomyopathy, a modest, but independent, well-known, but poorly explained, postoperative deterio- correlation of RV ejection fraction with oxygen uptake ration of TAPSE after heart surgery, which occurs in spite during a cardiopulmonary exercise test was noted (44). of preserved RV ejection fraction by 3D echocardiography Another study used 3D echocardiography data to divide (38, 39). Remarkably, reduction in longitudinal tissue the RV in patients with secondary pulmonary hyperten- velocity has been noted intraoperatively to coincide with sion and healthy controls into three compartments pericardial opening, thereby largely excluding material (inflow and outflow tract, and apex) and calculated the damage to the myocardium as a cause (40). partial ejection fractions as well as the timing of Compounding these problems is the variability of the contraction of each of these compartments, finding ‘standard’ apical four-chamber view, on which most differences among normals, patients with ischemic heart measurements are based. In the routine examination, failure without pulmonary hypertension, and such the apical four-chamber view is typically fine-tuned to patients with pulmonary hypertension (45). optimize depiction of the LV, avoiding LV foreshortening and excluding the LV outflow tract. There is, however, Conclusion considerable potential of misrepresenting the RV by a tangential cut, which will result in a falsely too small RV Given the increasing use of 3D echocardiography and MRI, cavity. Therefore, guidelines of the American and it is likely that RV ejection fraction will become a more European echocardiographic societies (10) have proposed broadly used functional measure than in the past, where it a modification of the standard four-chamber view, the was impossible to obtain by echocardiography. Potentially ‘RV-focused view’, which implies rotating the apically useful interventional applications of echocardiographic positioned transducer to achieve a maximal RV cross- RV 3D imaging include fusion with fluoroscopic images section (especially in the minor axis), while keeping the or electrical activation maps. It is unlikely to replace the cardiac apex at the top of the sector and not foreshorten- quickly and easily obtained parameters: TAPSE, basal RV ing or otherwise distorting the LV. free wall tissue velocity, and fractional area change. But www.echorespract.com R8 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 6 Hayek S, Sims DB, Markham DW, Butler J & Kalogeropoulos AP 2014 whenever detailed assessment of the RV is required, in Assessment of right ventricular function in left ventricular assist device particular in serial examinations of known pathology, 3D candidates. Circulation. Cardiovascular Imaging 7 379–389. (doi:10.1161/ echocardiographic determination of RV volumes and CIRCIMAGING.113.001127) 7 Arcilla RA, Tsai P, Thilenius O & Ranniger K 1971 Angiographic method ejection fraction will probably become standard. For the for volume estimation of right and left ventricles. 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(doi:10.1016/j.echo.2010.06.029) Cuomo S, Del Viscovo L, Ferrara I, De Rimini ML et al. 2011 Right www.echorespract.com R10 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 ventricular ejection fraction and left ventricular dyssynchrony by 3D pulmonary hypertension: three-dimensional echostudy. Heart 97 echo correlate with functional impairment in patients with dilated 1004–1011. (doi:10.1136/hrt.2010.208900) cardiomyopathy. Journal of Cardiac Failure 17 309–317. (doi:10.1016/j. 46 Aune E, Baekkevar M, Rodevand O & Otterstad JE 2009 The limited cardfail.2010.11.005) usefulness of real-time 3-dimensional echocardiography in obtaining 45 Calcutteea A, Chung R, Lindqvist P, Hodson M & Henein MY 2011 normal reference ranges for right ventricular volumes. Cardiovascular Differential right ventricular regional function and the effect of Ultrasound 7 35. (doi:10.1186/1476-7120-7-35) Received in final form 16 December 2014 Accepted 7 January 2015 www.echorespract.com R11 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Echo Research & Practice Springer Journals

Assessment of right ventricular volumes and ejection fraction by echocardiography: from geometric approximations to realistic shapes

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Abstract

Right ventricular volumes and ejection fraction are challenging to assess by echocardio- Key Words graphy, but are well established as functional and prognostic parameters. Three-dimensional " right ventricle (3D) echocardiography has become widespread and relatively easy to use, making " volumes calculation of these parameters feasible in the large majority of patients. We review past " systolic function attempts to estimate right ventricular volumes, current strengths and weaknesses of 3D " echocardiography echocardiography for this task, and compare with corresponding data from magnetic " 3D echocardiography resonance imaging. Why are right ventricular volumes important? or radionuclide angiography, contains substantial functional and prognostic information from LV para- The right ventricle (RV) far from being ‘forgotten’, as has meters as well as from conventional functional RV been suggested, challenged echocardiographic diagnostic parameters independently. efforts from very early on. It is a considerably more complex RV ejection fraction is excellent for the assessment of and more difficult structure to visualize and quantitate functional consequences of chronic and acute pulmonary than the left ventricle (LV). The main reasons for this are hypertension. Kawut et al. (1) found that RV ejection as follows: fraction by radionuclide angiography predicted death or i) RV overall shape, which can be described as a shell lung transplantation in 84 adult patients with pulmonary or a roughly triangular body covering part of the hypertension, while pulmonary arterial pressures did not. circumference of the LV, following the shape of the In a study of pulmonary hypertension of different LV, with a crescent-shaped short-axis cross-section. etiologies in children (nZ100), absolute RV volumes and Different from the LV, it has anatomically distinct RV ejection fraction by MRI were found to predict inflow and outflow tracts, a relatively thin free wall, prognosis more strongly than conventional echocardio- and is heavily trabecularized. graphic parameters or pulmonary pressure estimated by echocardiography or measured by right heart catheteriza- ii) RV location, which is in the near field of parasternal tion (2). Patients with an RV ejection fraction!44% had a echocardiographic windows, and in apical views may 1-, 2-, and 3-year survival of 87, 78, and 65% respectively, be obscured by ribs, sternum, or lung, especially if while those with an RV ejection fraction of 44–55% had a the image is optimized for the LV (Fig. 1). survival rate of 97, 97, and 90% for the same intervals Thus, RV ejection fraction, which until recently could and patients with a normal ejection fraction (O55%) only be determined by magnetic resonance imaging (MRI) had a survival rate of 97% throughout the first 3 years. This work is licensed under a Creative Commons q 2015 The authors www.echorespract.com Attribution-NonCommercial-NoDerivs 4.0 Published by Bioscientifica Ltd International License. E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 Recently, a multi-center study in 94 adult patients with pulmonary hypertension of various etiologies demonstrated Lung that MRI-derived RV ejection fraction and its changes over 1 year paralleled changes in functional class (e.g., 6-min S PA walking distance) and survival under contemporary drug therapy with endothelin receptor antagonists and/or phosphodiesterase inhibitors (3). Size and function of the Ao RV are also critical for the management of many forms of congenital heart disease, for example, atrial septal defect or pulmonary regurgitation in operated patients with RA tetralogy of Fallot (4). Furthermore, it has increasingly become clear in recent years that, in many ‘left-sided’ clinical scenarios, RV such as heart failure due to coronary artery disease, the RV co-determines course and prognosis. Larose et al. (5) showed that MRI-determined RV ejection fraction inde- pendent of LV ejection fraction and infarct size strongly Probe predicted survival in patients after myocardial infarction (adjusted hazard rate of RV ejection fraction, !40% 3.54 (CI, 1.50–8.36)). The outcome of heart failure therapy using continu- Lung ous-flow LV assist devices critically depends on RV function, with RV failure predicting short-term and long- S PA term mortalities (6). It is reasonable to assume that three- dimensional (3D) echocardiographic measurement of volumes and ejection fraction might improve assessment of RV function in this scenario, although such data are Ao lacking. RA How can RV volumes be measured by echocardiography? RV Two-dimensional echocardiography While there is no meaningful way to calculate RV volumes from M-mode, extensive research has been carried out Probe to derive RV volumes from two-dimensional (2D) views. In principle, two approaches can be distinguished: area– length and Simpson’s rule. Area–length methods calculate Figure 1 volume of a body by a formula of the form: volumeZ Schematic illustration of the right ventricle and the difficulties to include the whole volume. The inflow and outflow tracts are in the same plane – an c!A!L, where A is the cross-sectional area in one view, oblique sagittal plane – as the apex. The right ventricle (RV) is depicted with L is the long-axis length in the cross-section, and c is a the adjacent structures of the right atrium (RA), the pulmonary trunk (PA), constant that has to be found empirically. Simpson’s rule the sternum (S), the ascending aorta (Ao), and lung tissue. (A) The sternum, ribs, and lung tissue can shadow the imaging of the RV, in particular the approaches use two perpendicular planes sharing a long anterior part of the right ventricular outflow tract (RVOT). (B) Either the axis to calculate the volume as a stack of elliptical discs. anterior part of the RV or the apex may not be included in the whole Acquiring such two planes of the RV by 2D echocardio- volume when trying to overcome this shadowing, especially if the RV is dilated. Reproduced from Ostenfeld E, Carlsson M, Shahgaldi K, Roijer A & graphy, however, is very difficult and still neglects the RV Holm J 2012 Manual correction of semi-automatic three-dimensional outflow tract; therefore, biplane approaches of Simpson’s echocardiography is needed for right ventricular assessment in adults; rule were abandoned. Researchers using angiographic validation with cardiac magnetic resonance. Cardiovascular Ultrasound 10 1, published as an open access article by Biomed Central. right ventriculography had found that RV volumes could www.echorespract.com R2 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 be relatively accurately determined from paired X-ray ii) the most popular functional parameter due to its ease projections in end-systole and end-diastole, as was already of acquisition became the M-mode registration of a common practice and reasonably validated for the LV the cyclic apico-basal motion of the lateral inser- (7). Thus, a number of echocardiographic approaches tion point of the tricuspid valve leaflet (TAPSE). imitating the angiographic methodology were published, An alternative functional parameter is RV free wall with encouraging validation in vitro (8) and in vivo against systolic velocity measured by tissue Doppler; radionuclide angiography (9). However, these methods iii) as a surrogate of ejection fraction, RV fractional area were cumbersome, required views that were not well change has been used (RV end-diastolic area minus obtainable in many patients, had only a modest accuracy, end-systolic area divided by end-diastolic area, with and were never validated in a substantial number of areas measured in the apical four-chamber or ‘RV- patients with different diseases. Therefore, RV volume optimized’ four-chamber view; Fig. 2). Alternatively, a determination by 2D echocardiography remained a monoplane Simpson’s rule analog of LV ejection research method, and echocardiographically derived RV fraction is sometimes used, which is derived from the ejection fraction remained impractical to assess RV same view. This of course underestimates true RV function. For routine clinical purposes, the most widely volumes as the RV outflow tract is not included, but used morphology-based parameters of RV size and func- relatively good correlations of RV ejection fraction tion are given as follows (10): with an angiographic standard were obtained in a i) linear parameters such as the antero-posterior small study in children (11). diameter in parasternal long- and short-axis views, as well as short-axis diameters in the apical four-chamber Finally, an approach has been used successfully, in view at different levels of the long axis of the RV; which RV 3D data are reconstructed from 2D images that Figure 2 Examples of fractional area change (FAC) (A and C) in a healthy person (FACZ44%) and (B and D) in a patient with pulmonary arterial hypertension (FACZ13%). A and B are at end-diastole. C and D are at end-systole. www.echorespract.com R3 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 are registered during acquisition in a magnetic field and modality on the brink of clinical routine usage, with then mathematically fitted to ‘knowledge-based’ RV highly improved spatial and temporal resolution as well as shapes (12, 13). a relatively small transducer footprint. 2D parameters have the advantage of relying on routinely acquired standard views. However, as they only Image acquisition consider a section of the RV and imply geometric assumptions, they are fundamentally problematic, and Current transthoracic 3D transducers, the so-called ‘fully particularly so in pathologically remodeled ventricles. sampled matrix transducers’, while still slightly heavier Thus, the limited accuracy and reliability of 2D measures of RV volume has been a major limitation of echocardio- graphic imaging, in particular with regard to the manage- ment of congenital heart disease (e.g., the follow-up of patients with pulmonary regurgitation after surgical correction of tetralogy of Fallot), with MRI now being the recommended modality to assess the RV size and function (4). Another vexing problem in the practical application of echocardiographic RV volume assessment has been the diagnosis of arrhythmogenic RV cardiomyopathy (ARVC), a genetically transmitted disease for which familial screening is recommended. The currently ‘proposed modification’ of the international task force guidelines for the diagnosis of ARVC (14) uses only linear measure- ments of RV volume by echocardiography, and they only constitute criteria for the diagnosis of ARVC if co-existing with a regional akinesia or dyskinesia/aneurysm of the RV. Nevertheless, only 50% of patients with imaging-positive ARVC by CMR fulfilled echocardiographic ARVC 2010 criteria (15). The overlap between RV dimensions sugges- tive of ARVC and those of healthy individuals, in particular endurance athletes, is also considerable; Oxborough et al. (16) found that fully 83% of elite endurance runners or cyclists met the RV outflow tract diameter cut-off incor- porated in the ‘minor’ ARVC criteria and still 28% met the size requirements for ‘major’ ARVC criteria. In an ironical twist, this has led to the proposal of hypothesis that high levels of exercise may enhance phenotypical penetrance of ARVC genotype carriers that actually lead to a ARVC-like disease (17), or even that there is an ‘exercise-induced ARVC’ (18, 19), without necessitating a desmosomal abnormality. Both 3D echocardiography and MRI seem to offer better discrimination, in particular using RV ejection fraction impairment in addition to absolute volume cut-offs (20, 21). Figure 3 Full-volume three-dimensional datasets cropped to display the cavity of (A) 3D echocardiography a normal person acquired with the lateral approach and (B) a patient with 3D echocardiography has over the last 20 years evolved pulmonary arterial hypertension (PAH) acquired with the medial approach. The right ventricle (RV) and atrium (RA) are enlarged and the septum (*) is from a challenging experimental technique requiring bulging into the small left ventricle (LV) in the PAH patient and, at the apex, outstanding image quality, the use of large 3D trans- the right ventricle is larger than the maximum sector angle illustrating the challenge of acquisition of the whole volume. ducers, and time-consuming post-processing steps, into a www.echorespract.com R4 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 and larger than 2D transducers, have a similar footprint to volume is included in the dataset, as the axis can be standard 2D transducers and are capable of imaging the corrected in the post-processing step. In our experience, the entire RV with frame rates of 20–30 frames/s. feasibility isw85% in a non-selected adult population (24, Apical acquisition of volumes is recommended in the 25). As with 2D echocardiography, focus, depth, and sector adult population. An effort should be made to include should be adjusted to the area of interest to maximize the the tricuspid valve, the apex, and the outflow tract with the image quality. Nevertheless, if there is poor 2D image pulmonary valve in the full volume. As it is often difficult to quality, this will also be the case with 3D include the whole RV volume in the acquisition sector, a echocardiography. modified apical view can be advantageous. The modified The 3D dataset for volumetric assessment is acquired view is off-axis compared with the standard 2D apical by recording the whole heart in automatically created four-chamber view. One way (the medial approach) is to small subvolumes over two to seven heart beats, obtaining move the transducer medially to the RV modified apical one subvolume during each heartbeat. The subvolumes four-chamber view and then tilt the transducer cranially are then electronically merged into one dataset and image. and anteriorly – and even rotate – to include the pulmonary Ideally, this requires equally long heart cycles and no valve in the guidance images (Fig. 3). Near-field resolution, breathing motion during acquisition, otherwise the heart ribs, and the sternum are often limiting factors in acquiring is not in the same position at equivalent time points of adequate images from this view. Another way (the lateral each heart beat and ‘stitching artifacts’ can arise. Atrial approach) is to displace the transducer laterally with an fibrillation or other irregular rhythms are therefore anterior tilt. To include both the pulmonary and tricuspid detrimental. Recently, single-beat acquisition of large valves, it can sometimes be of use to move the transducer pyramidal volumes has become technically feasible, further laterally than the RV-focused apical four-chamber although at the cost of lower spatial and temporal view and even to a more cranial intercostal space, as well resolution. While, in sinus rhythm, intra- and inter- as rotating the transducer (Fig. 3). The lateral approach is personal variabilities for measuring LV volumes and EF challenged by far-field resolution, ribs, and interpositioned were the same for single-beat and four-beat acquisition, lung tissue (Fig. 1)(22, 23, 24, 25). Foreshortening is not single-beat acquisition had lower variability than four- an issue in 3D echocardiography (3DE), as long as the whole beat acquisition in patients with atrial fibrillation (26). Figure 4 Example of delineation of a normal right ventricle (RV) in end-diastole the boxes with the corresponding color. (B) Example of a three-dimensional showing the endocardial contour detection in green. (A) The three left echocardiographic reconstruction of the delineation of the right ventricle images (magenta, blue, and green boxes) are the short-axis views at seen from the septal side (end-diastolic volume 153 ml, end-systolic volume different levels with the left ventricle (LV) to the right of the 64 ml, and ejection fraction 58%). The mesh is the right ventricle at end- interventricular septum (*). The upper left image (magenta box) is closer to diastole, in green at end-systole. Pulmonary valve (PV) is shown in white in the base and right ventricular outflow tract (RVOT) and the lower image the upper left side, tricuspid valve (TV) is shown in the upper right side, and (green box) closer to the apex. The upper right image (yellow box) is a four- right ventricular (RV) apex toward the bottom. *shows the interventricular chamber view and the lower right image (purple box) is a right ventricular septum bulging into RV. Data were processed using a dedicated software three-chamber view with tricuspid valve (TV), apex, and pulmonary valve (4D RV-Function, TomTec Imaging Systems). See also Video 1. (PV) in the same projection. The dashed colored lines represent the plane of www.echorespract.com R5 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 Figure 5 Example of delineation of a patient with pulmonary hypertension in end- 137 ml, ejection fraction 31%) shows an enlarged right ventricle with a diastole. Box, line, and color descriptions are the same as in Fig. 4. (A) The flattened septum in diastole (mesh) and even more so in systole (green). right ventricle is enlarged and the trabeculation is hypertrophied. Both the longitudinal and lateral functions appear to be altered. Data were Trabeculations are included in the volume. The septum is flattened, even in processed using a dedicated software (4D RV-Function, TomTec Imaging diastole, in the short-axis images. (B) The three-dimensional echocardio- Systems). See also Video 2. graphic representation (end-diastolic volume 200 ml, end-systolic volume The acquisition time for obtaining all four heart chambers, 14% for end-systolic volumes, and 8% for ejection fraction including the RV, by 3D echocardiography is on average when different observers repeated a study on the same !5 min (22, 23). subject, using semi-automated border delineating software. Image analyses There are several software packages available for endocar- Video 1 dial delineation of cardiac chambers, with some being 3D echocardiography reconstruction of a right ventricle dedicated to the RV (Figs 4 and 5, Videos 1 and 2). (green) with normal systolic function (end-diastolic Pronounced trabeculations, prominent moderator band, volume 153 ml, end-systolic volume 64 ml, ejection or anterior papillary muscle are difficult to differentiate fraction 58 %). The mesh is the right ventricle at end- from the anterior RV wall using the semi-automatic diastole. The white areas are the pulmonary valve in the upper left side and the tricuspid valve in the upper right delineation software, especially with limited image quality side. The right ventricular apex is towards the bottom. (27). Owing to the fact that as much as 25% of the RV Data was processed with dedicated software (4D RV- volumes may originate from the RV outflow tract (28), Function, TomTec Imaging Systems). Download Video 1 via semi-automated border tracing can miss out considerable http://dx.doi.org/10.1530/ERP-14-0077-v1 parts of the volume if manual correction is not performed (Fig. 6 and Video 3). The underestimation of volumes in comparison to cardiac MRI decreases when manual Video 2 correction is performed, yet at the cost of substantially Example of a 3D echocardiographic reconstruction of a increased time requirements for analysis. Manual correc- patient with pulmonary hypertension (end-diastolic tion of semi-automated border delineation can take three volume 200 ml, end-systolic volume 137 ml, ejection to four times longer than the uncorrected delineation, fraction 31 %) showing an enlarged right ventricle which on average takes !4 min; it is even longer than the (green) with a flattened septum in diastole (mesh) and time that manual delineation of a transversal stack of even more so in systole. Both the longitudinal and lateral magnetic resonance images would take (25). function appear altered. Data was processed with Importantly, encouraging test–retest reliability for dedicated software (4D RV-Function, TomTec Imaging RV 3D echocardiographic volumes has been reported Systems). Download Video 2 via http://dx.doi.org/10. (29, 30), with variabilities of 7% for end-diastolic volumes, 1530/ERP-14-0077-v2 www.echorespract.com R6 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 3D echocardiography (31). Systematic underestimation of all cardiac chamber volumes by 3D echocardiogra- phy compared with MRI and also cardiac computed tomography is well established, with less effect on ejection fraction as the absolute volume differences cancel out. Accordingly, an extensive meta-analysis of many small studies directly comparing 3D echocardiography and MRI for RV volumes revealed systematic underestimation of end-systolic RV volume by 5.5 ml, of end-diastolic RV volume by 13.9 ml, and of RV ejection fraction by 0.9% (29, 31). What is normal? Several recent publications have sought to establish normal values for RV volumes and ejection fraction (32, 33, 34, 35, 36). While all studies showed dependency of volumes on body surface area and sex, most also showed an age dependency, with a decrease in volumes and a very small increase in ejection fraction with age. This is in accordance with large-scale studies of RV morphology by MRI (37), which furthermore showed an influence of race. Remarkably, normal volumes, whether indexed or not, have been quite different from study to study by 3D echocardiography, at least in part probably due to evolution in transducer technology and software. For Figure 6 Example of semi-automated delineation of the right ventricle (A) without example, absolute RV volumes of normals were w50% manual correction and (B) with manual correction. The endocardial higher in the study by van der Zwaan et al. (34) than in the contour detection (green) is enhanced in a basal short-axis view (magenta study by Maffessanti et al. (36). Although the underlying box, yellow, and purple lines as in Fig. 4A) from a three-dimensional dataset. The semi-automated delineation crosses, and hence includes, ‘normal’ cohorts were somewhat different in height and parts of the septum (*) in the right ventricular volume. On the other hand, body surface area, this seems to be insufficient to explain the delineation does not follow the anterior part of the right ventricular the discrepancy. Beyond hardware- and software-related outflow tract (RVOT) and that volume is excluded from calculation. See also Video 3. factors, differing levels of manual correction of the automated tracking algorithm most probably play a role in this. In our experience, which is supported by Video 3 observations in the literature (31), manual contour Example of semi-automated delineation of the right tracking corrections lead to higher calculated volumes by ventricle without manual correction. The semi-automated avoiding ‘streamlined’ RV contours. Thus, in the absence delineation crosses, and hence includes, parts of the of a real standard technique, no definitive normal values septum in the right ventricular volume. On the other can be given at this time (Table 1). hand, the delineation does not follow the anterior part of the right ventricular outflow tract and that part is therefore by default not included in automated volume How do RV volumes and ejection fraction calculation. Data was processed with dedicated software compare with other functional parameters? (4D RV-Function, TomTec Imaging Systems). Download As they are difficult to measure, quantitatively estimated Video 3 via http://dx.doi.org/10.1530/ERP-14-0077-v3 RV volumes have played a relatively minor role in clinical practice. This stands in stark contrast to the central Comparison with MRI importance of LV volumes and ejection fraction in clinical Overall, there is a good to reasonable correlation between cardiology, from heart failure to valvular heart disease RV volumes and ejection fraction measured by MRI and management. Instead, mostly non-volumetric parameters www.echorespract.com R7 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 Table 1 Published RV absolute and indexed volume values by Speckle tracking-based assessment of global LV func- 3D echocardiography from healthy adults. tion has received much recent attention. It was found more sensitive in detecting early functional impairment (33) (46) (34) (35) than volume-based functional indices such as ejection fraction in several clinical scenarios such as cardiotoxicity RVEDV (ml) 77G23 86G21 RVEDVI (ml/m)70G14 40G11 75G12 49G10 of cancer chemotherapy, early cardiomyopathy, and RVESV (ml) 30G12 29G11 2 others. Naturally, this paradigm also seems to be attractive RVESVI (ml/m)33G10 16G633G716G6 RVEF (%) 53G10 61G10 57G467G8 for the RV. However, the complexity of RV shape and n 71 166 31 245 absence of an established RV segment model, together Remarks RVOT was not with the absence of dedicated software, have so far included restricted the application of speckle-tracking analysis to the apical four-chamber view, where a portion of the RV RVOT, right ventricular outflow tract; RVEDV, right ventricular end-diastolic volume; RVEDVI, right ventricular end-diastolic volume index; RVESV, right free wall (and the septum) can be analyzed (38, 41). ventricular systolic volume; RVESVI, right ventricular end-systolic index; RVEF, right ventricular ejection fraction. Furthermore, real-time 3D strain assessment, allowing for a more comprehensive assessment of the RV, has become are used for RV function (10), of which all are based on the technically possible. Recently, in 97 patients with mostly apical four-chamber view and therefore neglect the RV primary pulmonary hypertension, RV ejection fraction outflow tract. TAPSE and tissue Doppler measure the correlated highly with 3D RV strain data and both longitudinal function of the RV free wall, which is an even predicted prognosis independently (42), thus confirming more selective way of looking at RV function. Importantly, earlier data on 3D echocardiography-derived RV ejection TAPSE and free wall tissue velocity measure displacement fraction and prognosis in patients with pulmonary and velocity relative to the stationary transducer, which hypertension (43). may produce misleading results. For example, it has been Clinical experience with RV volumes and ejection demonstrated that contraction of the LV lateral wall may fraction from 3D echocardiography, beyond validation induce passive motion of the RV free wall because of studies with MRI and comparison with other functional tethering (tissue continuity) between left and RV free walls echocardiographic parameters, is still limited. In patients (38). Such mechanisms may also be at work to produce the with dilated cardiomyopathy, a modest, but independent, well-known, but poorly explained, postoperative deterio- correlation of RV ejection fraction with oxygen uptake ration of TAPSE after heart surgery, which occurs in spite during a cardiopulmonary exercise test was noted (44). of preserved RV ejection fraction by 3D echocardiography Another study used 3D echocardiography data to divide (38, 39). Remarkably, reduction in longitudinal tissue the RV in patients with secondary pulmonary hyperten- velocity has been noted intraoperatively to coincide with sion and healthy controls into three compartments pericardial opening, thereby largely excluding material (inflow and outflow tract, and apex) and calculated the damage to the myocardium as a cause (40). partial ejection fractions as well as the timing of Compounding these problems is the variability of the contraction of each of these compartments, finding ‘standard’ apical four-chamber view, on which most differences among normals, patients with ischemic heart measurements are based. In the routine examination, failure without pulmonary hypertension, and such the apical four-chamber view is typically fine-tuned to patients with pulmonary hypertension (45). optimize depiction of the LV, avoiding LV foreshortening and excluding the LV outflow tract. There is, however, Conclusion considerable potential of misrepresenting the RV by a tangential cut, which will result in a falsely too small RV Given the increasing use of 3D echocardiography and MRI, cavity. Therefore, guidelines of the American and it is likely that RV ejection fraction will become a more European echocardiographic societies (10) have proposed broadly used functional measure than in the past, where it a modification of the standard four-chamber view, the was impossible to obtain by echocardiography. Potentially ‘RV-focused view’, which implies rotating the apically useful interventional applications of echocardiographic positioned transducer to achieve a maximal RV cross- RV 3D imaging include fusion with fluoroscopic images section (especially in the minor axis), while keeping the or electrical activation maps. It is unlikely to replace the cardiac apex at the top of the sector and not foreshorten- quickly and easily obtained parameters: TAPSE, basal RV ing or otherwise distorting the LV. free wall tissue velocity, and fractional area change. But www.echorespract.com R8 E Ostenfeld and Right ventricular volumes ID: 14-0077; March 2015 F A Flachskampf DOI: 10.1530/ERP-14-0077 6 Hayek S, Sims DB, Markham DW, Butler J & Kalogeropoulos AP 2014 whenever detailed assessment of the RV is required, in Assessment of right ventricular function in left ventricular assist device particular in serial examinations of known pathology, 3D candidates. Circulation. Cardiovascular Imaging 7 379–389. (doi:10.1161/ echocardiographic determination of RV volumes and CIRCIMAGING.113.001127) 7 Arcilla RA, Tsai P, Thilenius O & Ranniger K 1971 Angiographic method ejection fraction will probably become standard. For the for volume estimation of right and left ventricles. Chest 60 446–454. assessment of LV systolic function, size (volumes), and (doi:10.1378/chest.60.5.446) ejection fraction are the traditional standard, with 8 Levine RA, Gibson TC, Aretz T, Gillam LD, Guyer DE, King ME & Weyman AE 1984 Echocardiographic measurement of right longitudinal function assessment by way of tissue Doppler ventricular volume. Circulation 69 497–505. (doi:10.1161/01.CIR.69. or strain analysis having been added recently. The reverse 3.497) is true for the RV. Simple measures of longitudinal 9 Starling MR, Crawford MH, Sorensen SG & O’Rourke RA 1982 A new two-dimensional echocardiographic technique for evaluating right function such as TAPSE and free wall velocity, as well as ventricular size and performance in patients with obstructive lung fractional area change, as an odd substitute for ejection disease. Circulation 66 612–620. 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(doi:10.1186/1476-7120-7-35) Received in final form 16 December 2014 Accepted 7 January 2015 www.echorespract.com R11

Journal

Echo Research & Practice – Springer Journals

Published: Mar 1, 2015

Keywords: right ventricle; volumes; systolic function; echocardiography; 3D echocardiography

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