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Echocardiographic Exam for ARVD

Echocardiographic Exam for ARVD. Danita M. Yoerger, M.D. and Michael H. Picard, M.D. Cardiac Ultrasound Laboratory Massachusetts General Hospital Core Echo Lab, North American ARVD Registry. Utility of Echo for ARVD.

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Echocardiographic Exam for ARVD

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  1. Echocardiographic Exam for ARVD Danita M. Yoerger, M.D. and Michael H. Picard, M.D. Cardiac Ultrasound Laboratory Massachusetts General Hospital Core Echo Lab, North American ARVD Registry

  2. Utility of Echo for ARVD • The echo diagnosis of arrhythmogenic right ventricular dysplasia (ARVD) is possible only in the absence of other causes of dilatation of the right ventricle such as: • 1) congenital heart disease (such as atrial septal defect, Ebstein’s anomaly) • 2) right ventricular infarction • 3) volume overload due to significant tricuspid regurgitation • 4) pulmonary embolism • 5) primary pulmonary hypertension • 6) secondary pulmonary hypertension from causes such as mitral stenosis, COPD, or PE

  3. Echo exam for ARVDGeneral Considerations • Centers concentrate on image quality; core lab does the measurements • Patient in left lateral decubitus position • Record on 1/2 inch video tape (VHS) • If planning digital acquisition instead of videotape: • Check with core echo lab regarding compatibility prior to acquisition • Formats accepted - DICOM or Philips Enconcert • If using digital capture, watch for PVCs/PACs • Record at least 3 beats (5 if Afib or other arrhythmia)

  4. General considerations (cont.) • Optimize gain and compression for best delineation of structures of interest • Set depth appropriately so all structures of interest in view • Each recording should have a clear ECG and scale markers • Use harmonics if necessary

  5. General Considerations (cont.) • Use echocardiographic contrast agents if RV is not well visualized • For M-mode and Doppler recordings, sweep speed of at least 100. • For PW and CW Doppler: baseline and scale adjusted to allow complete visualization of flow velocity profiles • Remember what is being measured in each view so as to optimize the images appropriately !!

  6. Desired Views • Parasternal long axis • Parasternal short axis • Apical 4 chamber • Apical 5 chamber • Apical 2 chamber • Subcostal long axis • Subcostal short axis

  7. Parasternal Long Axis • Initially focus on left sided structures • Structures of interest in this view include: • Left Ventricle: dimension and wall motion • Aortic Valve: structure and function • Mitral Valve: structure and function • Left atrium: dimension

  8. Parasternal Long AxisLV/LA/AV

  9. Parasternal Long Axis of RV • Initially decrease depth in previous image to view the RVIT • Then angle the transducer to the RV inflow view to facilitate visualization and measurement of • Right atrium • Tricuspid Valve leaflets (anterior and posterior) • Infundibulum of RV for wall motion/aneurysms

  10. Parasternal Long Axis of RVIT • Structures of interest include: • Tricuspid Valve • structure and function • Color and CW Doppler of TR • The inferoposterior wall of the RVIT under the tricuspid valve is the most important structure in this view • Often affected in ARVD with WMA, thinning or aneurysms • Optimize depth/zoom to ensure adequate visualization

  11. Parasternal Long AxisRV Inflow

  12. ARVD – example of aneurysm of posterior RV wall under TV

  13. Parasternal Short Axis AoV/RVIT/RVOT/PV Level • Structures of interest include: • RVIT: structure and function • RVOT: dimension and wall motion • PV: structure and function • AoV: structure and function • Color and Spectral (CW) Doppler of the TV, and PV

  14. Parasternal Short Axis (cont)AoV/RVIT/RVOT/PV Level • Anterior wall of RVOT is important to visualize. • Optimize depth • Use contrast if necessary to adequately assess the anterior wall of the RVOT

  15. Parasternal Short AxisAoV/RVIT/RVOT/PV

  16. Parasternal Short AxisAoV/RVIT/RVOT/PV2

  17. ARVD – example of dilated RVOT compared to Aorta

  18. Parasternal Short AxisMV/TV/LV • Structure and function of: • Mitral valve • Tricuspid valve • LV wall motion at: • Base • Mid-ventricle • Apex

  19. Parasternal Short Axis Mitral/Tricuspid Level

  20. Parasternal Short AxisMidventricle

  21. ARVD – example of RV dilatation and increased trabeculations from SAX view

  22. Parasternal Short AxisApex

  23. Apical 4 Chamber • LV and RV • Structure, function and wall motion • Color Doppler of: • TR • MR • Spectral Doppler of: • TR (CW for RVSP) • MR (CW) • Tricuspid and Mitral inflow (PW at the leaflet tips) • Pulmonic vein flow (PW)

  24. Apical 4 Chamber

  25. PW + CW of MV

  26. CW of TV and PV for RV myocardial performance index RVMPI = (TR duration – Pulm ET) / Pulm ET If no TR record 3 E/A complexes of TV inflow

  27. Apical 5 Chamber • Main structure of interest is LVOT and Aortic valve • Structure and function • Color Doppler for AS/AI • Spectral Doppler of: • LVOT velocity (PW below AoV) • Aortic velocity (CW through AoV)

  28. Apical 5 Chamber

  29. Apical 2 Chamber - LV + RV • Left ventricle: • structure and function • Color Doppler of MR • Right ventricle • Rotate to RV 2 chamber from 4 chamber with transducer positioned over RV • Structures of interest: RV inferoposterior wall, RV apex, RV trabecular pattern

  30. Apical 2 Chamber LV + RV A B From apical 2 ch transducer position (panel A) slide and angle transducer toward RV (panel B) to visualize RV apex and free wall

  31. Subcostal Long Axis • Subxiphoid transducer position, angled upward and left • Structures of interest: • RV free wall motion • RV apical wall motion • RV dimension

  32. Subcostal Long Axis

  33. Subcostal Short Axis • At the TV/RVIT/RVOT/PV/AoV level • Structures of interest: • RVIT: WMA, aneurysms, sacculations, thinning • RVOT: WMA, aneurysms, sacculations, thinning

  34. Subcostal Short Axis

  35. Tissue Doppler • If your center has Tissue Doppler capabilities • Change machine settings to optimize Tissue Doppler acquisition • Place cursor at the TV annulus (both free wall annulus and medial annulus) • PW at both of these sites • Optimize scale (< 20cm) • 3 beats including Ea, Aa and systolic wave

  36. Tissue Doppler of the Tricuspid Annulus Lateral (free wall) annular velocities Medial (septal) annular velocities

  37. Conclusions • Record at least 3 beats (more is better) • Watch for ectopy • Focus on optimizing structures of interest • Use Harmonics and Contrast to optimize structures • Use the checklist • Don’t forget PW, CW, color Dopplers

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