Echocardiographic Exam for ARVD

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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

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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, Ebsteins 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

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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)

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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

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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 !!

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Desired Views

• Parasternal long axis
• Parasternal short axis
• Apical 4 chamber
• Apical 5 chamber
• Apical 2 chamber
• Subcostal long axis
• Subcostal short axis

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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

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Parasternal Long AxisLV/LA/AV
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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

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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

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Parasternal Long AxisRV Inflow
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ARVD example of aneurysm of posterior RV wall
under TV
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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

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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

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Parasternal Short AxisAoV/RVIT/RVOT/PV
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Parasternal Short AxisAoV/RVIT/RVOT/PV2
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ARVD example of dilated RVOT compared to Aorta
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Parasternal Short AxisMV/TV/LV

• Structure and function of
• Mitral valve
• Tricuspid valve
• LV wall motion at
• Base
• Mid-ventricle
• Apex

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Parasternal Short Axis Mitral/Tricuspid Level
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Parasternal Short AxisMidventricle
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ARVD example of RV dilatation and increased
trabeculations from SAX view
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Parasternal Short AxisApex
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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)

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Apical 4 Chamber
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PW CW of MV
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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
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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)

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Apical 5 Chamber
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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

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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
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Subcostal Long Axis

• Subxiphoid transducer position, angled upward and
  left
• Structures of interest
• RV free wall motion
• RV apical wall motion
• RV dimension

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Subcostal Long Axis
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Subcostal Short Axis

• At the TV/RVIT/RVOT/PV/AoV level
• Structures of interest
• RVIT WMA, aneurysms, sacculations, thinning
• RVOT WMA, aneurysms, sacculations, thinning

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Subcostal Short Axis
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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 (lt 20cm)
• 3 beats including Ea, Aa and systolic wave

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Tissue Doppler of the Tricuspid Annulus
Lateral (free wall) annular velocities
Medial (septal) annular velocities
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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
• Dont forget PW, CW, color Dopplers