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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

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
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
echo exam for arvd general considerations
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)
general considerations cont
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
general considerations cont5
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 !!
desired views
Desired Views
  • Parasternal long axis
  • Parasternal short axis
  • Apical 4 chamber
  • Apical 5 chamber
  • Apical 2 chamber
  • Subcostal long axis
  • Subcostal short axis
parasternal long axis
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
parasternal long axis of rv
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
parasternal long axis of rvit
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
parasternal short axis aov rvit rvot pv level
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
parasternal short axis cont aov rvit rvot pv level
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
parasternal short axis mv tv lv
Parasternal Short AxisMV/TV/LV
  • Structure and function of:
    • Mitral valve
    • Tricuspid valve
  • LV wall motion at:
    • Base
    • Mid-ventricle
    • Apex
apical 4 chamber
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)
cw of tv and pv for rv myocardial performance index
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

apical 5 chamber
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)
apical 2 chamber lv rv
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
apical 2 chamber lv rv30
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

subcostal long axis
Subcostal Long Axis
  • Subxiphoid transducer position, angled upward and left
  • Structures of interest:
    • RV free wall motion
    • RV apical wall motion
    • RV dimension
subcostal short axis
Subcostal Short Axis
  • At the TV/RVIT/RVOT/PV/AoV level
  • Structures of interest:
    • RVIT: WMA, aneurysms, sacculations, thinning
    • RVOT: WMA, aneurysms, sacculations, thinning
tissue doppler
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
tissue doppler of the tricuspid annulus
Tissue Doppler of the Tricuspid Annulus

Lateral (free wall) annular velocities

Medial (septal) annular velocities

conclusions
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