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Update on Perioperative Right Heart Assessment Using Transesophageal Echocardiography Karsten Bartels, Jörn Karhausen, Breandan L. Sullivan and G. Burkhard Mackensen SEMIN CARDIOTHORAC VASC ANESTH published online 13 February 2014 DOI: 10.1177/1089253214522326 The online version of this article can be found at: http://scv.sagepub.com/content/early/2014/02/12/1089253214522326
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522326 research-article2014
SCVXXX10.1177/1089253214522326Seminars in Cardiothoracic and Vascular AnesthesiaBartels et al
Review
Update on Perioperative Right Heart Assessment Using Transesophageal Echocardiography
Seminars in Cardiothoracic and Vascular Anesthesia 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1089253214522326 scv.sagepub.com
Karsten Bartels, MD1,2, Jörn Karhausen, MD2, Breandan L. Sullivan, MD1, and G. Burkhard Mackensen, MD, PhD, FASE3
Abstract Purpose of the review. This review aims to summarize recent findings relevant for perioperative 2- and 3-dimensional imaging of the right heart with transesophageal echocardiography. Special attention is given to developments that are likely to affect future approaches for prevention and therapy of perioperative right heart failure. Recent findings. Threedimensional transesophageal echocardiography techniques are becoming more common for the evaluation of anatomy, volumes, and functional indices. Summary. Right heart failure continues to contribute to morbidity and mortality in the context of cardiothoracic surgery. The advent and widespread clinical use of innovative tools permitting more accurate echocardiographic assessment of the right heart will open the door to renewed interest in novel therapeutic strategies. Keywords transesophageal echocardiography, 3-dimensional echocardiography, right ventricle, perioperative, cardiothoracic anesthesia, ultrasound imaging Those therefore which I hear denying that blood, yea the whole mass of blood, may pass through the substance of the lungs, as well as the nutritive juyce through the liver, as if it were impossible and no ways to be believed—it is thought that those kind of men [ . . . ], they are afraid.1 —Dr William Harvey (1628), in the section of his epic piece De Motu Cordis that describes the flow of blood from the right heart to the left heart.
Introduction Assessment of right ventricular function is of particular interest to the perioperative clinician. Acute or chronic right heart failure from myocardial ischemia, pulmonary embolism, pulmonary hypertension, congenital heart disease, or cardiomyopathy continues to be a significant source of morbidity and mortality.2-5 In fact, postoperative cardiac patients who suffer from low cardiac output syndrome, have concomitant right ventricular (RV) systolic dysfunction in up to 42% of cases, and affected patients have an in-hospital mortality rate of 44%.6 Acute RV failure leading to difficult separation from cardiopulmonary bypass has been recently shown to be an independent predictor of mortality in high-risk cardiac surgery patients.7 The clinical challenge to accurately diagnose RV failure is immense: For example, a patient may present with exaggerated pulse pressure variation/systolic pressure
variation on his or her arterial line tracing, which would usually indicate fluid responsiveness. However, a failing dilated RV may lead to underfilling of the left ventricle and subsequently to exaggerated stroke volume variation. In this case, an intravascular fluid bolus would be the wrong treatment—echocardiography is a powerful tool to guide therapy in such a clinical scenario. Indeed, echocardiography is a cornerstone of contemporary perioperative cardiac surgical care.8-11 Accordingly, the recent consensus statement of the Society of Cardiovascular Anesthesiologists and the American Society of Echocardiography recommends monitoring of RV function as part of even basic perioperative transesophageal echocardiography (TEE) examinations in at-risk patients.12 Acquisition and interpretation of echocardiographic images of the right heart have traditionally been challenging because of the complex anatomic structure of the RV. With TEE, 1
Department of Anesthesiology, University of Colorado Denver, Aurora, CO, USA 2 Department of Anesthesiology, Duke University, Durham, NC, USA 3 Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA Corresponding Author: G. Burkhard Mackensen, MD, PhD, FASE, Department of Anesthesiology & Pain Medicine, University of Washington, Box 356540, Seattle, WA 98195-6540, USA. Email: [email protected]
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the ultrasound probe is at a strategically disadvantageous position in the posterior thorax. Therefore, in contrast to transthoracic13 and epicardial14 echocardiography, image quality of right heart structures located in the anterior chest is often limited. Three-dimensional (3D) TEE imaging offers additional views of the right heart and advanced applications of 3D TEE permit improved perioperative imaging of the RV. Since comprehensive guidelines for the transthoracic echocardiographic assessment of the right heart have been published by the American Society of Echocardiography,15 this review will highlight recent developments, mostly as they pertain to the utilization of perioperative TEE.
atrial chamber quantification obtained through computer tomography imaging.20 Nonetheless, accurate representations of specific right atrial structures such as the crista terminalis or the cavotricuspid isthmus are of special interest to the invasive cardiologist performing ablation procedures and can be more reliably obtained using real-time 3D TEE.21 The superior accuracy of 3D TEE compared with conventional 2D TEE originated descriptions of patent foramen ovale morphology has also been established.22 In addition, 3D TEE facilitates real-time guidance of various interventional procedures, such as placement of a coronary sinus catheter and the percutaneous closure of interatrial septal defects.23-25
Right Atrium
Tricuspid Valve
Accurate representation of right atrial anatomy is receiving increased attention. Many current invasive procedures, such as trans-septal approaches to left-sided catheterization, or coronary sinus catheter placement via the right internal jugular vein, use the right atrium as a conduit to other structures of the heart. Successful and timely conclusion of such procedures depends on precise guidance by a skilled echocardiographer. Recommended standard 2D TEE views for imaging of the right atrium are the midesophageal 4-chamber view and the mid-esophageal bicaval view.16,17 Specific attention is given to the size of the right atrium and adjacent structures, such as the interatrial septum, the superior and inferior vena cava, the coronary sinus, the crista terminalis, and the right atrial appendage. Right atrial size as estimated by 2D transthoracic echocardiography (TTE) planimetry is considered enlarged if it exceeds 18 cm2 or is greater than 4.4 × 5.3 cm in the shortand long-axis dimensions, respectively.15 Volumetric assessment is more accurate if more than only 2 planes of the right atrium are interrogated.18 The interatrial septum is examined for atrial septal defects, such as a patent foramen ovale, other secundum type defects, primum type defects, or sinus venosus defects. Left atrial pressure is usually slightly higher than right atrial pressure, leading to a bulge of the septum toward the right atrium. Although dynamic indices such as arterial pulse pressure variation are usually more accurate to guide perioperative fluid therapy, right atrial pressure remains an important clinical measurement in heart failure patients. Since central venous catheterization is not always available, noninvasive estimation of right atrial pressure often forms the basis of clinical decision making. Measurement of right atrial size using 3D TTE in conjunction with 2D echocardiographic evaluation of the diameter and respirophasic collapse of the inferior vena cava is more accurate in predicting right atrial pressure than conventional 2D evaluation alone.19 Although it seems that 3D measurements are more accurate than 2D measurements, 3D TTE–derived assessments still slightly underestimates atrial size compared with right
In light of the increasing interest in tricuspid valve (TV) repair techniques, there is an enhanced desire to better understand the changes that occur in the TV apparatus anatomy and the correlation of these changes with the severity of tricuspid regurgitation.26,27 The perioperative significance of TV dysfunction has been highlighted in recent years by data supporting improved outcomes following TV annuloplasty27,28 and the expanding role of its repair as a concomitant part of other cardiac surgical procedures, such as left ventricular assist device implantation.29,30 The 3 leaflets of the TV are anterior, septal, and posterior. Together with the TV annulus, chordae tendineae, and papillary muscles they form the TV. With 2D TEE, imaging from multiple windows is required to obtain a more comprehensive assessment of TV anatomy and function. The 3 leaflets of the TV are best assessed in the midesophageal 4-chamber view, the mid-esophageal RV inflow–outflow view, the mid-esophageal modified bicaval view, and the transgastric RV inflow view.16,17,31 The mid-esophageal inflow–outflow view and the mid-esophageal modified bicaval TV view are commonly chosen for Doppler interrogation of transvalvular flow.17 For 3D examinations, a 0° to 30° mid-esophageal 4-chamber view and a 40° transgastric view with anteflexion is recommended.32 Annulus area normally ranges from 8 to 12 cm2 in 2D examinations,32 which is consistent with reported annular areas averaging 10 cm2 in normal individuals using 3D echocardiography.33 Examination of the TV with 3D TTE is performed reliably and reproducibly yielding realistic images in real time.33,34 However, visualization of the TV apparatus with 3D TEE is much less reliable, mainly because of its thin leaflets and anterior position.35 A novel application of 3D echocardiographic imaging involves automated tracking of specific cardiac structures over time.36 Quantitative descriptions of these temporospatial relationships have been termed 4D echocardiography. Although the clinical application of this technology is not yet widespread, its ability to more precisely define
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Bartels et al tricuspid annular morphology seems highly promising.37 Three-dimensional TEE also permits the precise description of the elliptical shape of the TV annulus and its dimensions in a clinically feasible fashion.37 Conventional assessment of tricuspid regurgitation (TR) severity includes integration of several echocardiographic parameters such as RV, right atrium, and inferior vena cava size, area of the regurgitant jet, width of the vena contracta, proximal isovelocity surface area, TR jet density and contour, as well as hepatic vein flow patterns.38 The vena contracta is a surrogate measurement for the effective regurgitant orifice area. Given the dynamic nature of TR, the effective regurgitant orifice area varies within the cardiac cycle (especially with irregular heart rhythms) or under different hemodynamic conditions, thereby highlighting the need to not rely on one measurement or one feature when grading TR. Quantitative assessment of the vena contracta area (VCA) based on 3D color Doppler acquisitions is feasible and obtainable in the majority of patients with mild or greater TR for grading TR severity.39 Using sequential cropping techniques that keep the cropping plane precisely parallel to the TV orifice, the VCA of the TR jet can be obtained. With this approach, Chen et al39 found a reasonable correlation between the 3D VCA and effective regurgitant orifice area, but only a moderate correlation with the width of the VC as measured by 2D TTE. Although similar 3D evaluation of regurgitant valvular jets is recommended for TEE,17 this approach likely deserves further study in the perioperative environment, as the implications of such measurements are unclear at this time.
Pulmonary Valve Obtaining high-quality images of the pulmonary valve (PV) with TEE is especially challenging given its anterior location in the chest and subsequent distant location from the esophageal probe. Conventional 2D images can be obtained from multiple positions with the best approach often varying from patient to patient. Dedicated images of the PV can be obtained from the upper esophageal aortic arch short axis view, the mid-esophageal RV inflow outflow view, and the transgastric basal RV view.17 Transthoracic 2D echocardiographic images obtained for PV replacement show reasonable agreement with cardiac magnetic resonance images.40 Three-dimensional TTE images of the PV can be reliably obtained.41 Visualization of the PV using 3D TEE can also be successfully performed (Figure 1), but attempts may be limited by poor visualization.
Right Ventricle Acute RV failure remains a much-feared complication in the intensive care unit and during cardiac surgery. Yet, the
Figure 1. Three-dimensional image of the pulmonary valve using perioperative transesophageal echocardiography.
RV is often still viewed more as a passive bystander than a driver of diseases affecting the heart. Technologies to monitor its function at the bedside are either becoming less common (pulmonary artery catheter) or require specialized skills (echocardiography). This has led to a disproportionately small amount of knowledge of the clinical presentation and pathophysiology of right heart failure compared with left heart failure. As a result, the US National Heart, Lung, and Blood Institute convened a working group on the RV that suggested a major effort was necessary to improve our understanding of pathophysiology, monitoring techniques, and interventions geared at preserving its function.4 Here, enhanced echocardiographic imaging techniques will play an essential role in advancing the field, for example, by reliably and dynamically measuring changes of RV function and differentiating the causes of acute RV failure, such as left ventricular failure, pulmonary embolism, valvular disease, pericardial disease, intrinsic myocardial disease, or a direct consequence of a surgical procedure.42 Conventional 2D TEE focuses on the mid-esophageal 4-chamber and the RV inflow–outflow views as well as the short- and long-axis transgastric views (including the transgastric RV inflow) for image acquisition.16,17 Some additional useful views include the mid-esophageal aortic valve short axis for visualization of the RV outflow tract, and deep transgastric views of the RV inflow and outflow.43,44 The anatomy of the RV is complex and has been described a triangular, crescent, or boot-shaped depending on the image plane used. Structured mapping of the right ventricular walls, as is routinely done to describe the 17 segments of the left ventricle,45 has not yet gained traction in clinical practice. Commonly, specific sections of the RV are described according to their relationship to the interventricular septum (free vs septal), and whether the locus of interest is positioned anterior versus inferior and basal,
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Figure 2. Xplane imaging with transesophageal echocardiography (TEE) as shown from the mid-esophageal position permits biplane evaluation of the right ventricle (RV). The white line showing in the left-sided image indicates the cutting plane for the rightside image. This cutting plane can be altered by moving the trackball on the keyboard. Furthermore, the multiplane angle (rotation) on the right sided image can be altered as well. This permits easy assessment of the entire right ventricle by rotational scanning without having to move the position of the TEE probe.
mid or apical. Obtaining additional, nonstandard 2D TEE views of the right heart can provide a more comprehensive assessment.44 A useful technique to simultaneously evaluate the RV in multiple planes uses Xplane imaging. This permits easy assessment of the entire RV by rotational scanning without having to move the position of the TEE probe (Figure 2). In current clinical practice, however, evaluation of right heart structure and function remains mostly qualitative in nature.46 In a normal heart, the RV is larger and has a smaller ejection fraction than the left ventricle. Using cine magnetic resonance imaging in a normal patient cohort, RV end-diastolic volume was on average 138 mL and thereby 17 mL greater than left ventricular volume. Ejection fraction was lower in the RV (61%) than in the left ventricle (67%), thereby allowing for matching of ejected volumes.47 RV volumes that are normalized to body surface area decline with aging and are larger in men than in women, while ejection fraction remains relatively preserved.48 A rule of thumb established by TTE technology is that the RV is deemed enlarged if the RV proportion of the septum exceeds two thirds of left ventricular basal to apical length in the mid-esophageal 4 chamber view. However, as current guidelines point out, not enough data exist to make similar recommendations for TEE.17 The importance of an accurate description of RV anatomy and function is highlighted by the fact that RV ejection fraction
is an independent predictor of survival in heart failure patients.3 Therapeutic approaches that decrease RV afterload are available and, for example, using sildenafil for pulmonary hypertension, actually improve patient outcomes.49 Clearly, more precise approaches and techniques that permit dynamic and comparative evaluation are needed in the operating room and the intensive care unit in order to inform successful therapeutic interventions. Additional information on RV anatomy and pathology can be obtained from 3D technology, for example when describing the morphology of a ventricular septal defect using 3D color flow.50 RV diastolic function can be assessed using pulsed-wave Doppler interrogation of the TV, the pulmonary and hepatic venous flow rates, as well as examination of the tricuspid annulus using tissue Doppler.51 In heart failure patients, RV diastolic function is frequently abnormal,52 and it has also been associated with difficult separation from cardiopulmonary bypass.51 Despite these findings, RV diastolic function is not yet routinely assessed during perioperative TEE. Full-volume loops of the RV using 3D TEE are obtained from 0° to 120° in the mid-esophageal position with the probe directed to center the RV in the image (Figure 3).32 Three-dimensional TTE has been found to have comparable accuracy to magnetic resonance imaging when used to quantify both RV volumes and ejection fraction in diverse patient cohorts.53-55 However, a meta-analysis of
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The best views to interrogate the TAPSE in TEE are a modified deep transgastric long axis and the mid-esophageal RV inflow–outflow view. Nevertheless, optimal alignment of the ultrasound beam with the direction of the TV excursion can be difficult. The Tei index or RV index of myocardial performance (RIMP) is defined as the sum of isovolumetric contraction and relaxation intervals divided by ejection time, and it is an indicator of systolic and diastolic RV dysfunction.62 Tei index =
Figure 3. Three-dimensional image of the right ventricle (RV) obtained in the mid-esophageal position with the 3-dimensional transesophageal echocardiography (TEE) probe directed to center the RV in the image.
23 studies on this subject found RV end-systolic volume, end-diastolic volume, and ejection fraction slightly underestimated (5.5 mL, 13.9 mL, and −0.9% respectively) using 3D echocardiography.56 Perioperative 3D TEE for RV volume determination is both feasible and has good correlation with 3D images obtained using TTE.57 Threedimensional TEE-generated data sets obtained from highrisk cardiac surgery patients have been successfully used to measure RV volumes with good correlation of left- and right-sided stroke volumes (Figure 4).58 In summary, these data suggest that 3D-generated assessments of RV volume and function are accurately and reliably obtained. Further studies are urgently needed to determine whether these improved imaging capabilities can be translated into novel treatment algorithms for acute RV failure and ultimately into better patient outcomes.
Alternative Indices of Right Ventricular Function The most prominent alternative indices of RV function (Table 1) are the tricuspid annular plane systolic excursion (TAPSE), and the Tei index. Tricuspid annular plane systolic excursion, or TAPSE, reliably predicts mortality in pulmonary hypertension59 and an association with perioperative mortality following cardiac surgery has also been made.60 The systolic movement of the tricuspid annulus toward the apex occurs predominantly within the free wall of the RV; the distance of this excursion can be quantified using M-mode (Figure 5). However, there is some evidence that the perioperative assessment of RV function with TAPSE using TEE may not be as reliable as initially expected.61
isovolumetric contraction time + isovolumetric relaxation time ejection time
With TTE, a RIMP > 0.40 by pulsed Doppler and >0.55 by tissue Doppler suggests RV dysfunction.15 The Tei index performs well to discriminate nonsurgical patients with primary pulmonary hypertension from healthy individuals and is a good predictor of clinical outcomes in this patient population.62 Although its utility to predict left ventricular fractional area change following mitral valve repair has been shown,63 the Tei index has not yet gained broad use in the perioperative assessment of RV failure. Given that the Tei index is independent of the ultrasound beam angle, its continued development as a tool for TEE imaging seems logical. At this time however, it is not used routinely in the perioperative assessment of RV function and its utility for anesthetized patients has been questioned.64 Speckle tracking implies the use of computerized algorithms to track specific, B-mode ultrasound-derived, groups of pixel patterns within the moving myocardium (Figure 6). This allows determination of regional myocardial strain and strain rate. Similar to the Tei index and 3D techniques, speckle tracking does not depend on optimal alignment of a Doppler ultrasound beam, which is often difficult to accomplish using TEE. Although the feasibility of this technology for intraoperative use has been shown,65 its clinical utility in the perioperative environment has yet to be proven. Tricuspid annular velocity can be reliably determined using intraoperative TEE during cardiac surgery,66 indicating a potential role for this technique in the development of perioperative RV assessment algorithms. The tissue Doppler–derived tricuspid lateral annular systolic velocity (S′) is an alternative parameter to assess RV function, which has been shown to correlate well with other measures of global RV systolic function (Figure 7).67 S′ is easy to measure, reliable and reproducible, and S′ velocity 0.4 (pulsed Doppler), >0.55 (tissue Doppler)15 Not dependent on ultrasound beam angle. Requires special software Noninvasive Doppler estimate of right ventricle pressure over time from tricuspid regurgitation jet
The rise of the RV to right atrial pressure gradient during systole (dP/dt) can be measured in the presence of an adequate continuous wave Doppler tracing of a TR jet.70
The correlation of Doppler-derived RV dP/dT with TAPSE and RV ejection fraction represents yet another easily obtained estimate of global RV function. Although
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Figure 5. Tricuspid annular plane excursion (TAPSE). The systolic movement of the tricuspid annulus toward the apex occurs predominantly within the free wall of the right ventricle (A). The distance indicated by the yellow arrow of the TAPSE is quantified using M-mode (B).
Figure 6. Right ventricular (RV) strain analysis. Currently available software options are designed for left ventricular (LV) strain analysis but permit also examination of RV strain and strain rate with minor adjustments. In this example using the TomTec software (2D Cardiac Performance Analysis, TomTec, Unterschleissheim, Germany), a 2D transesophageal echocardiographic (TEE) RV loop was obtained from a modified 4-chamber view. The manually traced endocardial border served as basis for semiautomatic speckle tracking. As a result, regional and global parameters can be obtained for velocity, displacement, strain, and strain rate. Because the septal RV wall is generally considered to be mainly influenced by LV dynamics, it is manually excluded from analysis of RV strain. (A) Visualization of representative speckle displacement allows visual verification of adequate tracking throughout cardiac cycle (free wall reference points are highlighted by red markers). (B) Strain is displayed as a curve of the manually selected free wall regions as individual segment curves or as a heat map. (C) Further peak strain analysis results are obtained, again after manually selecting the free wall segments. Note that the software is designed for LV analysis and for images obtained by transthoracic echocardiography (TTE); therefore, the automatic segment definition is not accurate and needs to be adjusted in some programs. Peak strain (PK%) and time to peak (TPk) are automatically calculated. The systolic duration was determined from a separate M-mode of the aortic valve in the mid-esophageal long-axis view (time from the beginning of the QRS to atrioventricular valve closure).
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Figure 7. Tissue Doppler images of the lateral tricuspid annulus. Tricuspid annular velocity associated with early diastole (E′), tricuspid annular velocity associated with atrial contraction (A′), and systolic tricuspid annular velocity (S′) is measured with tissue Doppler technology using transthoracic echocardiography (A) or transesophageal echocardiography (B).
appealing in concept, this approach has not gained a lot of traction at this time.
Summary The right heart has been recognized to be an active mediator and cause of perioperative cardiac morbidity and mortality—it is not just a mere bystander to left heart pathophysiology. Dedicated techniques to more accurately monitor its dimensions and function are geared to inform specific therapeutic interventions toward restoring and preserving RV performance. The development and increasing availability of 3D TEE has enabled novel approaches for more precise perioperative assessment of the right heart. These might overcome some of the specific challenges encountered when adopting TTE-derived techniques for TEE use. Future studies will need to rigorously assess whether these new techniques can also be translated to improved outcomes for our patients. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Bartels et al management in 6051 cardiac surgical patients. Ann Thorac Surg. 2008;85:548-553. 12. Reeves ST, Finley AC, Skubas NJ, et al. Special article: basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg. 2013;117:543-558. 13. Karas MG, Kizer JR. Echocardiographic assessment of the right ventricle and associated hemodynamics. Prog Cardiovasc Dis. 2012;55:144-160. 14. Eltzschig HK, Kallmeyer IJ, Mihaljevic T, Alapati S, Shernan SK. A practical approach to a comprehensive epicardial and epiaortic echocardiographic examination. J Cardiothorac Vasc Anesth. 2003;17:422-429. 15. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685-713. 16. Shanewise JS, Cheung AT, Aronson S, et al. ASE/ SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr. 1999;12:884-900. 17. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:921-964. 18. Quraini D, Pandian NG, Patel AR. Three-dimensional echocardiographic analysis of right atrial volume in normal and abnormal hearts: comparison of biplane and multiplane methods. Echocardiography. 2012;29:608-613. 19. Patel AR, Alsheikh-Ali AA, Mukherjee J, et al. 3D echocardiography to evaluate right atrial pressure in acutely decompensated heart failure correlation with invasive hemodynamics. JACC Cardiovasc Imaging. 2011;4:938-945. 20. Takahashi A, Funabashi N, Kataoka A, et al. Quantitative evaluation of right atrial volume and right atrial emptying fraction by 320-slice computed tomography compared with three-dimensional echocardiography. Int J Cardiol. 2011;146:96-99. 21. Faletra FF, Ho SY, Auricchio A. Anatomy of right atrial structures by real-time 3D transesophageal echocardiography. JACC Cardiovasc Imaging. 2010;3:966-975. 22. Tanaka J, Izumo M, Fukuoka Y, et al. Comparison of twodimensional versus real-time three-dimensional transesophageal echocardiography for evaluation of patent foramen ovale morphology. Am J Cardiol. 2013;111:1052-1056. 23. Taniguchi M, Akagi T, Watanabe N, et al. Application of real-time three-dimensional transesophageal echocardiography using a matrix array probe for transcatheter closure of
atrial septal defect. J Am Soc Echocardiogr. 2009;22:11141120. 24. D’Alonzo RC, Rodriquez E, Ryan JW. Percutaneous coronary sinus catheter placement aided by 3-dimensional transesophageal echocardiography. Anesth Analg. 2010;110:722-724. 25. Taniguchi M, Akagi T, Kijima Y, Sano S. Clinical advantage of real-time three-dimensional transesophageal echocardiography for transcatheter closure of multiple atrial septal defects. Int J Cardiovasc Imaging. 2013;29:1273-1280. 26. Taramasso M, Vanermen H, Maisano F, Guidotti A, La Canna G, Alfieri O. The growing clinical importance of secondary tricuspid regurgitation. J Am Coll Cardiol. 2012;59:703-710. 27. Kilic A, Saha-Chaudhuri P, Rankin JS, Conte JV. Trends and outcomes of tricuspid valve surgery in North America: an analysis of more than 50,000 patients from the Society of Thoracic Surgeons database. Ann Thorac Surg. 2013;96:1546-1552. 28. Tang GH, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA. Tricuspid valve repair with an annuloplasty ring results in improved long-term outcomes. Circulation. 2006;114(1 suppl):I577-I581. 29. Piacentino V 3rd, Troupes CD, Ganapathi AM, et al. Clinical impact of concomitant tricuspid valve procedures during left ventricular assist device implantation. Ann Thorac Surg. 2011;92:1414-1418. 30. Maltais S, Topilsky Y, Tchantchaleishvili V, et al. Surgical treatment of tricuspid valve insufficiency promotes early reverse remodeling in patients with axial-flow left ventricular assist devices. J Thorac Cardiovasc Surg. 2012;143:13701376. 31. Maslow AD, Schwartz C, Singh AK. Assessment of the tricuspid valve: a comparison of four transesophageal echocardiographic windows. J Cardiothorac Vasc Anesth. 2004;18:719-724. 32. Lang RM, Badano LP, Tsang W, et al. EAE/ASE recommendations for image acquisition and display using threedimensional echocardiography. J Am Soc Echocardiogr. 2012;25:3-46. 33. Anwar AM, Geleijnse ML, Soliman OI, et al. Assessment of normal tricuspid valve anatomy in adults by real-time threedimensional echocardiography. Int J Cardiovasc Imaging. 2007;23:717-724. 34. Badano LP, Agricola E, Perez de Isla L, Gianfagna P, Zamorano JL. Evaluation of the tricuspid valve morphology and function by transthoracic real-time three-dimensional echocardiography. Eur J Echocardiogr. 2009;10:477-484. 35. Sugeng L, Shernan SK, Salgo IS, et al. Live 3-dimensional transesophageal echocardiography initial experience using the fully-sampled matrix array probe. J Am Coll Cardiol. 2008;52:446-449. 36. Bartels K, Thiele RH, Phillips-Bute B, et al. Dynamic indices of mitral valve function using perioperative three-dimensional transesophageal echocardiography. J Cardiothorac Vasc Anesth. 2014;28:18-24. 37. Mahmood F, Kim H, Chaudary B, et al. Tricuspid annular geometry: a three-dimensional transesophageal echocardiographic study. J Cardiothorac Vasc Anesth. 2013;27:639-646.
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38. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777802. 39. Chen TE, Kwon SH, Enriquez-Sarano M, Wong BF, Mankad SV. Three-dimensional color Doppler echocardiographic quantification of tricuspid regurgitation orifice area: comparison with conventional two-dimensional measures. J Am Soc Echocardiogr. 2013;26:1143-1152. 40. Brown DW, McElhinney DB, Araoz PA, et al. Reliability and accuracy of echocardiographic right heart evaluation in the U.S. Melody Valve Investigational Trial. J Am Soc Echocardiogr. 2012;25:383-392. 41. Kelly NF, Platts DG, Burstow DJ. Feasibility of pulmonary valve imaging using three-dimensional transthoracic echocardiography. J Am Soc Echocardiogr. 2010;23:1076-1080. 42. Lahm T, McCaslin CA, Wozniak TC, et al. Medical and surgical treatment of acute right ventricular failure. J Am Coll Cardiol. 2010;56:1435-1446. 43. Haddad F, Couture P, Tousignant C, Denault AY. The right ventricle in cardiac surgery, a perioperative perspective: I. Anatomy, physiology, and assessment. Anesth Analg. 2009;108:407-421. 44. Kasper J, Bolliger D, Skarvan K, Buser P, Filipovic M, Seeberger MD. Additional cross-sectional transesophageal echocardiography views improve perioperative right heart assessment. Anesthesiology. 2012;117:726-734. 45. Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105:539-542. 46. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440-1463. 47. Lorenz CH, Walker ES, Morgan VL, Klein SS, Graham TP Jr. Normal human right and left ventricular mass, systolic function, and gender differences by cine magnetic resonance imaging. J Cardiovasc Magn Reson. 1999;1:7-21. 48. Tamborini G, Marsan NA, Gripari P, et al. Reference values for right ventricular volumes and ejection fraction with real-time three-dimensional echocardiography: evaluation in a large series of normal subjects. J Am Soc Echocardiogr. 2010;23:109-115. 49. Galie N, Ghofrani HA, Torbicki A, et al. Sildenafil citrate therapy for pulmonary arterial hypertension. N Engl J Med. 2005;353:2148-2157. 50. Bartels K, Daneshmand MA, Mathew JP, Glower DD, Swaminathan M, Nicoara A. Delayed postmyectomy ventricular septal defect. J Cardiothorac Vasc Anesth. 2013;27:381-384. 51. Denault AY, Couture P, Buithieu J, et al. Left and right ventricular diastolic dysfunction as predictors of difficult
separation from cardiopulmonary bypass. Can J Anaesth. 2006;53:1020-1029. 52. Yu CM, Sanderson JE, Chan S, Yeung L, Hung YT, Woo KS. Right ventricular diastolic dysfunction in heart failure. Circulation. 1996;93:1509-1514. 53. Grewal J, Majdalany D, Syed I, Pellikka P, Warnes CA. Three-dimensional echocardiographic assessment of right ventricular volume and function in adult patients with congenital heart disease: comparison with magnetic resonance imaging. J Am Soc Echocardiogr. 2010;23:127-133. 54. Leibundgut G, Rohner A, Grize L, et al. Dynamic assessment of right ventricular volumes and function by real-time three-dimensional echocardiography: a comparison study with magnetic resonance imaging in 100 adult patients. J Am Soc Echocardiogr. 2010;23:116-126. 55. van der Zwaan HB, Helbing WA, McGhie JS, et al. Clinical value of real-time three-dimensional echocardiography for right ventricular quantification in congenital heart disease: validation with cardiac magnetic resonance imaging. J Am Soc Echocardiogr. 2010;23:134-140. 56. Shimada YJ, Shiota M, Siegel RJ, Shiota T. Accuracy of right ventricular volumes and function determined by threedimensional echocardiography in comparison with magnetic resonance imaging: a meta-analysis study. J Am Soc Echocardiogr. 2010;23:943-953. 57. Fusini L, Tamborini G, Gripari P, et al. Feasibility of intraoperative three-dimensional transesophageal echocardiography in the evaluation of right ventricular volumes and function in patients undergoing cardiac surgery. J Am Soc Echocardiogr. 2011;24:868-877. 58. Karhausen J, Dudaryk R, Phillips-Bute B, et al. Three dimensional transesophageal echocardiography for perioperative right ventricular assessment. Ann Thorac Surg. 2012;94:468-474. 59. Forfia PR, Fisher MR, Mathai SC, et al. Tricuspid annular displacement predicts survival in pulmonary hypertension. Am J Respir Crit Care Med. 2006;174:1034-1041. 60. Corciova FC, Corciova C, Georgescu CA, et al. Echocardiographic predictors of adverse short-term outcomes after heart surgery in patients with mitral regurgitation and pulmonary hypertension. Heart Surg Forum. 2012;15:E127-E132. 61. Tousignant C, Kim H, Papa F, Mazer CD. Evaluation of TAPSE as a measure of right ventricular ouptut. Can J Anaesth. 2012;59:376-383. 62. Tei C, Dujardin KS, Hodge DO, et al. Doppler echocardiographic index for assessment of global right ventricular function. J Am Soc Echocardiogr. 1996;9:838-847. 63. Mabrouk-Zerguini N, Leger P, Aubert S, et al. Tei index to assess perioperative left ventricular systolic function in patients undergoing mitral valve repair. Br J Anaesth. 2008;101:479-485. 64. Michaux I, Seeberger M, Schuman R, Skarvan K, Filipovic M. Feasibility of measuring myocardial performance index of the right ventricle in anesthetized patients. J Cardiothorac Vasc Anesth. 2010;24:270-274. 65. Tousignant C, Desmet M, Bowry R, Harrington AM, Cruz JD, Mazer CD. Speckle tracking for the intraoperative assessment of right ventricular function: a feasibility study. J Cardiothorac Vasc Anesth. 2010;24:275-279.
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Bartels et al 66. David JS, Tousignant CP, Bowry R. Tricuspid annular velocity in patients undergoing cardiac operation using transesophageal echocardiography. J Am Soc Echocardiogr. 2006;19:329-334. 67. Meluzin J, Spinarova L, Bakala J, et al. Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion; a new, rapid, and non-invasive method of evaluating right ventricular systolic function. Eur Heart J. 2001;22:340-348. 68. Iriart X, Horovitz A, van Geldorp IE, et al. The role of echocardiography in the assessment of right ventricular systolic function in patients with transposition of the great arteries
and atrial redirection. Arch Cardiovasc Dis. 2012;105:432441. 69. Maffessanti F, Gripari P, Tamborini G, et al. Evaluation of right ventricular systolic function after mitral valve repair: a two-dimensional Doppler, speckle-tracking, and three-dimensional echocardiographic study. J Am Soc Echocardiogr. 2012;25:701-708. 70. Anconina J, Danchin N, Selton-Suty C, et al. Noninvasive estimation of right ventricular dP/dt in patients with tricuspid valve regurgitation. Am J Cardiol. 1993;71:14951497.
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Update on Perioperative Right Heart Assessment Using Transesophageal Echocardiography Karsten Bartels, Jörn Karhausen, Breandan L. Sullivan and G. Burkhard Mackensen SEMIN CARDIOTHORAC VASC ANESTH published online 13 February 2014 DOI: 10.1177/1089253214522326 The online version of this article can be found at: http://scv.sagepub.com/content/early/2014/02/12/1089253214522326
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522326 research-article2014
SCVXXX10.1177/1089253214522326Seminars in Cardiothoracic and Vascular AnesthesiaBartels et al
Review
Update on Perioperative Right Heart Assessment Using Transesophageal Echocardiography
Seminars in Cardiothoracic and Vascular Anesthesia 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1089253214522326 scv.sagepub.com
Karsten Bartels, MD1,2, Jörn Karhausen, MD2, Breandan L. Sullivan, MD1, and G. Burkhard Mackensen, MD, PhD, FASE3
Abstract Purpose of the review. This review aims to summarize recent findings relevant for perioperative 2- and 3-dimensional imaging of the right heart with transesophageal echocardiography. Special attention is given to developments that are likely to affect future approaches for prevention and therapy of perioperative right heart failure. Recent findings. Threedimensional transesophageal echocardiography techniques are becoming more common for the evaluation of anatomy, volumes, and functional indices. Summary. Right heart failure continues to contribute to morbidity and mortality in the context of cardiothoracic surgery. The advent and widespread clinical use of innovative tools permitting more accurate echocardiographic assessment of the right heart will open the door to renewed interest in novel therapeutic strategies. Keywords transesophageal echocardiography, 3-dimensional echocardiography, right ventricle, perioperative, cardiothoracic anesthesia, ultrasound imaging Those therefore which I hear denying that blood, yea the whole mass of blood, may pass through the substance of the lungs, as well as the nutritive juyce through the liver, as if it were impossible and no ways to be believed—it is thought that those kind of men [ . . . ], they are afraid.1 —Dr William Harvey (1628), in the section of his epic piece De Motu Cordis that describes the flow of blood from the right heart to the left heart.
Introduction Assessment of right ventricular function is of particular interest to the perioperative clinician. Acute or chronic right heart failure from myocardial ischemia, pulmonary embolism, pulmonary hypertension, congenital heart disease, or cardiomyopathy continues to be a significant source of morbidity and mortality.2-5 In fact, postoperative cardiac patients who suffer from low cardiac output syndrome, have concomitant right ventricular (RV) systolic dysfunction in up to 42% of cases, and affected patients have an in-hospital mortality rate of 44%.6 Acute RV failure leading to difficult separation from cardiopulmonary bypass has been recently shown to be an independent predictor of mortality in high-risk cardiac surgery patients.7 The clinical challenge to accurately diagnose RV failure is immense: For example, a patient may present with exaggerated pulse pressure variation/systolic pressure
variation on his or her arterial line tracing, which would usually indicate fluid responsiveness. However, a failing dilated RV may lead to underfilling of the left ventricle and subsequently to exaggerated stroke volume variation. In this case, an intravascular fluid bolus would be the wrong treatment—echocardiography is a powerful tool to guide therapy in such a clinical scenario. Indeed, echocardiography is a cornerstone of contemporary perioperative cardiac surgical care.8-11 Accordingly, the recent consensus statement of the Society of Cardiovascular Anesthesiologists and the American Society of Echocardiography recommends monitoring of RV function as part of even basic perioperative transesophageal echocardiography (TEE) examinations in at-risk patients.12 Acquisition and interpretation of echocardiographic images of the right heart have traditionally been challenging because of the complex anatomic structure of the RV. With TEE, 1
Department of Anesthesiology, University of Colorado Denver, Aurora, CO, USA 2 Department of Anesthesiology, Duke University, Durham, NC, USA 3 Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA Corresponding Author: G. Burkhard Mackensen, MD, PhD, FASE, Department of Anesthesiology & Pain Medicine, University of Washington, Box 356540, Seattle, WA 98195-6540, USA. Email: [email protected]
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the ultrasound probe is at a strategically disadvantageous position in the posterior thorax. Therefore, in contrast to transthoracic13 and epicardial14 echocardiography, image quality of right heart structures located in the anterior chest is often limited. Three-dimensional (3D) TEE imaging offers additional views of the right heart and advanced applications of 3D TEE permit improved perioperative imaging of the RV. Since comprehensive guidelines for the transthoracic echocardiographic assessment of the right heart have been published by the American Society of Echocardiography,15 this review will highlight recent developments, mostly as they pertain to the utilization of perioperative TEE.
atrial chamber quantification obtained through computer tomography imaging.20 Nonetheless, accurate representations of specific right atrial structures such as the crista terminalis or the cavotricuspid isthmus are of special interest to the invasive cardiologist performing ablation procedures and can be more reliably obtained using real-time 3D TEE.21 The superior accuracy of 3D TEE compared with conventional 2D TEE originated descriptions of patent foramen ovale morphology has also been established.22 In addition, 3D TEE facilitates real-time guidance of various interventional procedures, such as placement of a coronary sinus catheter and the percutaneous closure of interatrial septal defects.23-25
Right Atrium
Tricuspid Valve
Accurate representation of right atrial anatomy is receiving increased attention. Many current invasive procedures, such as trans-septal approaches to left-sided catheterization, or coronary sinus catheter placement via the right internal jugular vein, use the right atrium as a conduit to other structures of the heart. Successful and timely conclusion of such procedures depends on precise guidance by a skilled echocardiographer. Recommended standard 2D TEE views for imaging of the right atrium are the midesophageal 4-chamber view and the mid-esophageal bicaval view.16,17 Specific attention is given to the size of the right atrium and adjacent structures, such as the interatrial septum, the superior and inferior vena cava, the coronary sinus, the crista terminalis, and the right atrial appendage. Right atrial size as estimated by 2D transthoracic echocardiography (TTE) planimetry is considered enlarged if it exceeds 18 cm2 or is greater than 4.4 × 5.3 cm in the shortand long-axis dimensions, respectively.15 Volumetric assessment is more accurate if more than only 2 planes of the right atrium are interrogated.18 The interatrial septum is examined for atrial septal defects, such as a patent foramen ovale, other secundum type defects, primum type defects, or sinus venosus defects. Left atrial pressure is usually slightly higher than right atrial pressure, leading to a bulge of the septum toward the right atrium. Although dynamic indices such as arterial pulse pressure variation are usually more accurate to guide perioperative fluid therapy, right atrial pressure remains an important clinical measurement in heart failure patients. Since central venous catheterization is not always available, noninvasive estimation of right atrial pressure often forms the basis of clinical decision making. Measurement of right atrial size using 3D TTE in conjunction with 2D echocardiographic evaluation of the diameter and respirophasic collapse of the inferior vena cava is more accurate in predicting right atrial pressure than conventional 2D evaluation alone.19 Although it seems that 3D measurements are more accurate than 2D measurements, 3D TTE–derived assessments still slightly underestimates atrial size compared with right
In light of the increasing interest in tricuspid valve (TV) repair techniques, there is an enhanced desire to better understand the changes that occur in the TV apparatus anatomy and the correlation of these changes with the severity of tricuspid regurgitation.26,27 The perioperative significance of TV dysfunction has been highlighted in recent years by data supporting improved outcomes following TV annuloplasty27,28 and the expanding role of its repair as a concomitant part of other cardiac surgical procedures, such as left ventricular assist device implantation.29,30 The 3 leaflets of the TV are anterior, septal, and posterior. Together with the TV annulus, chordae tendineae, and papillary muscles they form the TV. With 2D TEE, imaging from multiple windows is required to obtain a more comprehensive assessment of TV anatomy and function. The 3 leaflets of the TV are best assessed in the midesophageal 4-chamber view, the mid-esophageal RV inflow–outflow view, the mid-esophageal modified bicaval view, and the transgastric RV inflow view.16,17,31 The mid-esophageal inflow–outflow view and the mid-esophageal modified bicaval TV view are commonly chosen for Doppler interrogation of transvalvular flow.17 For 3D examinations, a 0° to 30° mid-esophageal 4-chamber view and a 40° transgastric view with anteflexion is recommended.32 Annulus area normally ranges from 8 to 12 cm2 in 2D examinations,32 which is consistent with reported annular areas averaging 10 cm2 in normal individuals using 3D echocardiography.33 Examination of the TV with 3D TTE is performed reliably and reproducibly yielding realistic images in real time.33,34 However, visualization of the TV apparatus with 3D TEE is much less reliable, mainly because of its thin leaflets and anterior position.35 A novel application of 3D echocardiographic imaging involves automated tracking of specific cardiac structures over time.36 Quantitative descriptions of these temporospatial relationships have been termed 4D echocardiography. Although the clinical application of this technology is not yet widespread, its ability to more precisely define
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Bartels et al tricuspid annular morphology seems highly promising.37 Three-dimensional TEE also permits the precise description of the elliptical shape of the TV annulus and its dimensions in a clinically feasible fashion.37 Conventional assessment of tricuspid regurgitation (TR) severity includes integration of several echocardiographic parameters such as RV, right atrium, and inferior vena cava size, area of the regurgitant jet, width of the vena contracta, proximal isovelocity surface area, TR jet density and contour, as well as hepatic vein flow patterns.38 The vena contracta is a surrogate measurement for the effective regurgitant orifice area. Given the dynamic nature of TR, the effective regurgitant orifice area varies within the cardiac cycle (especially with irregular heart rhythms) or under different hemodynamic conditions, thereby highlighting the need to not rely on one measurement or one feature when grading TR. Quantitative assessment of the vena contracta area (VCA) based on 3D color Doppler acquisitions is feasible and obtainable in the majority of patients with mild or greater TR for grading TR severity.39 Using sequential cropping techniques that keep the cropping plane precisely parallel to the TV orifice, the VCA of the TR jet can be obtained. With this approach, Chen et al39 found a reasonable correlation between the 3D VCA and effective regurgitant orifice area, but only a moderate correlation with the width of the VC as measured by 2D TTE. Although similar 3D evaluation of regurgitant valvular jets is recommended for TEE,17 this approach likely deserves further study in the perioperative environment, as the implications of such measurements are unclear at this time.
Pulmonary Valve Obtaining high-quality images of the pulmonary valve (PV) with TEE is especially challenging given its anterior location in the chest and subsequent distant location from the esophageal probe. Conventional 2D images can be obtained from multiple positions with the best approach often varying from patient to patient. Dedicated images of the PV can be obtained from the upper esophageal aortic arch short axis view, the mid-esophageal RV inflow outflow view, and the transgastric basal RV view.17 Transthoracic 2D echocardiographic images obtained for PV replacement show reasonable agreement with cardiac magnetic resonance images.40 Three-dimensional TTE images of the PV can be reliably obtained.41 Visualization of the PV using 3D TEE can also be successfully performed (Figure 1), but attempts may be limited by poor visualization.
Right Ventricle Acute RV failure remains a much-feared complication in the intensive care unit and during cardiac surgery. Yet, the
Figure 1. Three-dimensional image of the pulmonary valve using perioperative transesophageal echocardiography.
RV is often still viewed more as a passive bystander than a driver of diseases affecting the heart. Technologies to monitor its function at the bedside are either becoming less common (pulmonary artery catheter) or require specialized skills (echocardiography). This has led to a disproportionately small amount of knowledge of the clinical presentation and pathophysiology of right heart failure compared with left heart failure. As a result, the US National Heart, Lung, and Blood Institute convened a working group on the RV that suggested a major effort was necessary to improve our understanding of pathophysiology, monitoring techniques, and interventions geared at preserving its function.4 Here, enhanced echocardiographic imaging techniques will play an essential role in advancing the field, for example, by reliably and dynamically measuring changes of RV function and differentiating the causes of acute RV failure, such as left ventricular failure, pulmonary embolism, valvular disease, pericardial disease, intrinsic myocardial disease, or a direct consequence of a surgical procedure.42 Conventional 2D TEE focuses on the mid-esophageal 4-chamber and the RV inflow–outflow views as well as the short- and long-axis transgastric views (including the transgastric RV inflow) for image acquisition.16,17 Some additional useful views include the mid-esophageal aortic valve short axis for visualization of the RV outflow tract, and deep transgastric views of the RV inflow and outflow.43,44 The anatomy of the RV is complex and has been described a triangular, crescent, or boot-shaped depending on the image plane used. Structured mapping of the right ventricular walls, as is routinely done to describe the 17 segments of the left ventricle,45 has not yet gained traction in clinical practice. Commonly, specific sections of the RV are described according to their relationship to the interventricular septum (free vs septal), and whether the locus of interest is positioned anterior versus inferior and basal,
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Figure 2. Xplane imaging with transesophageal echocardiography (TEE) as shown from the mid-esophageal position permits biplane evaluation of the right ventricle (RV). The white line showing in the left-sided image indicates the cutting plane for the rightside image. This cutting plane can be altered by moving the trackball on the keyboard. Furthermore, the multiplane angle (rotation) on the right sided image can be altered as well. This permits easy assessment of the entire right ventricle by rotational scanning without having to move the position of the TEE probe.
mid or apical. Obtaining additional, nonstandard 2D TEE views of the right heart can provide a more comprehensive assessment.44 A useful technique to simultaneously evaluate the RV in multiple planes uses Xplane imaging. This permits easy assessment of the entire RV by rotational scanning without having to move the position of the TEE probe (Figure 2). In current clinical practice, however, evaluation of right heart structure and function remains mostly qualitative in nature.46 In a normal heart, the RV is larger and has a smaller ejection fraction than the left ventricle. Using cine magnetic resonance imaging in a normal patient cohort, RV end-diastolic volume was on average 138 mL and thereby 17 mL greater than left ventricular volume. Ejection fraction was lower in the RV (61%) than in the left ventricle (67%), thereby allowing for matching of ejected volumes.47 RV volumes that are normalized to body surface area decline with aging and are larger in men than in women, while ejection fraction remains relatively preserved.48 A rule of thumb established by TTE technology is that the RV is deemed enlarged if the RV proportion of the septum exceeds two thirds of left ventricular basal to apical length in the mid-esophageal 4 chamber view. However, as current guidelines point out, not enough data exist to make similar recommendations for TEE.17 The importance of an accurate description of RV anatomy and function is highlighted by the fact that RV ejection fraction
is an independent predictor of survival in heart failure patients.3 Therapeutic approaches that decrease RV afterload are available and, for example, using sildenafil for pulmonary hypertension, actually improve patient outcomes.49 Clearly, more precise approaches and techniques that permit dynamic and comparative evaluation are needed in the operating room and the intensive care unit in order to inform successful therapeutic interventions. Additional information on RV anatomy and pathology can be obtained from 3D technology, for example when describing the morphology of a ventricular septal defect using 3D color flow.50 RV diastolic function can be assessed using pulsed-wave Doppler interrogation of the TV, the pulmonary and hepatic venous flow rates, as well as examination of the tricuspid annulus using tissue Doppler.51 In heart failure patients, RV diastolic function is frequently abnormal,52 and it has also been associated with difficult separation from cardiopulmonary bypass.51 Despite these findings, RV diastolic function is not yet routinely assessed during perioperative TEE. Full-volume loops of the RV using 3D TEE are obtained from 0° to 120° in the mid-esophageal position with the probe directed to center the RV in the image (Figure 3).32 Three-dimensional TTE has been found to have comparable accuracy to magnetic resonance imaging when used to quantify both RV volumes and ejection fraction in diverse patient cohorts.53-55 However, a meta-analysis of
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The best views to interrogate the TAPSE in TEE are a modified deep transgastric long axis and the mid-esophageal RV inflow–outflow view. Nevertheless, optimal alignment of the ultrasound beam with the direction of the TV excursion can be difficult. The Tei index or RV index of myocardial performance (RIMP) is defined as the sum of isovolumetric contraction and relaxation intervals divided by ejection time, and it is an indicator of systolic and diastolic RV dysfunction.62 Tei index =
Figure 3. Three-dimensional image of the right ventricle (RV) obtained in the mid-esophageal position with the 3-dimensional transesophageal echocardiography (TEE) probe directed to center the RV in the image.
23 studies on this subject found RV end-systolic volume, end-diastolic volume, and ejection fraction slightly underestimated (5.5 mL, 13.9 mL, and −0.9% respectively) using 3D echocardiography.56 Perioperative 3D TEE for RV volume determination is both feasible and has good correlation with 3D images obtained using TTE.57 Threedimensional TEE-generated data sets obtained from highrisk cardiac surgery patients have been successfully used to measure RV volumes with good correlation of left- and right-sided stroke volumes (Figure 4).58 In summary, these data suggest that 3D-generated assessments of RV volume and function are accurately and reliably obtained. Further studies are urgently needed to determine whether these improved imaging capabilities can be translated into novel treatment algorithms for acute RV failure and ultimately into better patient outcomes.
Alternative Indices of Right Ventricular Function The most prominent alternative indices of RV function (Table 1) are the tricuspid annular plane systolic excursion (TAPSE), and the Tei index. Tricuspid annular plane systolic excursion, or TAPSE, reliably predicts mortality in pulmonary hypertension59 and an association with perioperative mortality following cardiac surgery has also been made.60 The systolic movement of the tricuspid annulus toward the apex occurs predominantly within the free wall of the RV; the distance of this excursion can be quantified using M-mode (Figure 5). However, there is some evidence that the perioperative assessment of RV function with TAPSE using TEE may not be as reliable as initially expected.61
isovolumetric contraction time + isovolumetric relaxation time ejection time
With TTE, a RIMP > 0.40 by pulsed Doppler and >0.55 by tissue Doppler suggests RV dysfunction.15 The Tei index performs well to discriminate nonsurgical patients with primary pulmonary hypertension from healthy individuals and is a good predictor of clinical outcomes in this patient population.62 Although its utility to predict left ventricular fractional area change following mitral valve repair has been shown,63 the Tei index has not yet gained broad use in the perioperative assessment of RV failure. Given that the Tei index is independent of the ultrasound beam angle, its continued development as a tool for TEE imaging seems logical. At this time however, it is not used routinely in the perioperative assessment of RV function and its utility for anesthetized patients has been questioned.64 Speckle tracking implies the use of computerized algorithms to track specific, B-mode ultrasound-derived, groups of pixel patterns within the moving myocardium (Figure 6). This allows determination of regional myocardial strain and strain rate. Similar to the Tei index and 3D techniques, speckle tracking does not depend on optimal alignment of a Doppler ultrasound beam, which is often difficult to accomplish using TEE. Although the feasibility of this technology for intraoperative use has been shown,65 its clinical utility in the perioperative environment has yet to be proven. Tricuspid annular velocity can be reliably determined using intraoperative TEE during cardiac surgery,66 indicating a potential role for this technique in the development of perioperative RV assessment algorithms. The tissue Doppler–derived tricuspid lateral annular systolic velocity (S′) is an alternative parameter to assess RV function, which has been shown to correlate well with other measures of global RV systolic function (Figure 7).67 S′ is easy to measure, reliable and reproducible, and S′ velocity 0.4 (pulsed Doppler), >0.55 (tissue Doppler)15 Not dependent on ultrasound beam angle. Requires special software Noninvasive Doppler estimate of right ventricle pressure over time from tricuspid regurgitation jet
The rise of the RV to right atrial pressure gradient during systole (dP/dt) can be measured in the presence of an adequate continuous wave Doppler tracing of a TR jet.70
The correlation of Doppler-derived RV dP/dT with TAPSE and RV ejection fraction represents yet another easily obtained estimate of global RV function. Although
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Bartels et al
Figure 5. Tricuspid annular plane excursion (TAPSE). The systolic movement of the tricuspid annulus toward the apex occurs predominantly within the free wall of the right ventricle (A). The distance indicated by the yellow arrow of the TAPSE is quantified using M-mode (B).
Figure 6. Right ventricular (RV) strain analysis. Currently available software options are designed for left ventricular (LV) strain analysis but permit also examination of RV strain and strain rate with minor adjustments. In this example using the TomTec software (2D Cardiac Performance Analysis, TomTec, Unterschleissheim, Germany), a 2D transesophageal echocardiographic (TEE) RV loop was obtained from a modified 4-chamber view. The manually traced endocardial border served as basis for semiautomatic speckle tracking. As a result, regional and global parameters can be obtained for velocity, displacement, strain, and strain rate. Because the septal RV wall is generally considered to be mainly influenced by LV dynamics, it is manually excluded from analysis of RV strain. (A) Visualization of representative speckle displacement allows visual verification of adequate tracking throughout cardiac cycle (free wall reference points are highlighted by red markers). (B) Strain is displayed as a curve of the manually selected free wall regions as individual segment curves or as a heat map. (C) Further peak strain analysis results are obtained, again after manually selecting the free wall segments. Note that the software is designed for LV analysis and for images obtained by transthoracic echocardiography (TTE); therefore, the automatic segment definition is not accurate and needs to be adjusted in some programs. Peak strain (PK%) and time to peak (TPk) are automatically calculated. The systolic duration was determined from a separate M-mode of the aortic valve in the mid-esophageal long-axis view (time from the beginning of the QRS to atrioventricular valve closure).
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Figure 7. Tissue Doppler images of the lateral tricuspid annulus. Tricuspid annular velocity associated with early diastole (E′), tricuspid annular velocity associated with atrial contraction (A′), and systolic tricuspid annular velocity (S′) is measured with tissue Doppler technology using transthoracic echocardiography (A) or transesophageal echocardiography (B).
appealing in concept, this approach has not gained a lot of traction at this time.
Summary The right heart has been recognized to be an active mediator and cause of perioperative cardiac morbidity and mortality—it is not just a mere bystander to left heart pathophysiology. Dedicated techniques to more accurately monitor its dimensions and function are geared to inform specific therapeutic interventions toward restoring and preserving RV performance. The development and increasing availability of 3D TEE has enabled novel approaches for more precise perioperative assessment of the right heart. These might overcome some of the specific challenges encountered when adopting TTE-derived techniques for TEE use. Future studies will need to rigorously assess whether these new techniques can also be translated to improved outcomes for our patients. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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