J Cardiovasc Imaging.  2018 Dec;26(4):189-200. 10.4250/jcvi.2018.26.e28.

Assessment of Right Ventricular Function in Pulmonary Hypertension with Multimodality Imaging

• Seo HS
• Lee H

• KMID: 2429993
• DOI: http://doi.org/10.4250/jcvi.2018.26.e28

Abstract

Pulmonary hypertension (PH) is defined as resting mean pulmonary artery pressure ≥ 25 mmHg and is caused by multiple etiologies including heart, lung or other systemic diseases. Evaluation of right ventricular (RV) function in PH is very important to plan treatment and determine prognosis. However, quantification of volume and function of the RV remains difficult due to complicated RV geometry. A number of imaging tools has been utilized to diagnose PH and assess RV function. Each imaging technique including conventional echocardiography, three-dimensional echocardiography, strain echocardiography, computed tomography and cardiac magnetic resonance imaging has-advantages and limitations and can provide unique information. In this article, we provide a comprehensive review of the utility, advantages and shortcomings of the multimodality imaging used to evaluate patients with PH.

Keyword

Right ventricle; Pulmonary hypertension; Echocardiography; Computed tomography; Magnetic resonance imaging

MeSH Terms

Echocardiography
Echocardiography, Three-Dimensional
Heart
Heart Ventricles
Humans
Hydrogen-Ion Concentration
Hypertension, Pulmonary*
Lung
Magnetic Resonance Imaging
Prognosis
Pulmonary Artery
Ventricular Function, Right*

Figure

• 

  Figure 1 Methods of analysis of right ventricular (RV) structures and RV function. (A) RV dimension is measured at the basal level in the four-chamber view. RV fractional area change can be calculated as (RV end-diastolic area [RVEDA] - RV end-systolic area [RVESA]) / RVEDA × 100) and, is a simple way to evaluate RV systolic function. (B) RV thickness more than 5 mm is suspicious of RV hypertrophy secondary to pulmonary hypertension. (C) Tricuspid annular plane systolic excursion (TAPSE) is the distance of the tricuspid annulus during the cardiac cycle using M-mode. (D) The peak systolic velocity of the lateral tricuspid annulus (S′) is measured by pulsed tissue Doppler imaging.

• 

  Figure 2 Real-time three-dimensional echocardiography images using a commercially available system (EchoPAC PC, TomTec Imaging, Inc., Munich, Germany). (A) 3D images of RV are acquired in the RV focused four-chamber view. (B) Alignment of the LV / RV axis is based on the mitral valve, tricuspid valve, and apex. Aortic annulus and junction of the ventricle should be pointed identified manually. (C) Contour revision is edited at end-diastolic phase in four-chamber and short axis views from base to apex. (D) RV volume and RV function are measured by automatic analysis. LV: left ventricle, RV: right ventricle.

• 

  Figure 3 Longitudinal strain measured by two-dimensional speckle tracking echocardiography. (A) Right ventricular global longitudinal strain (RVGLS) is −23% with normal global RV function. (B) RVGLS is −14% suggestive of decreased RV function.

• 

  Figure 4 CT findings of pulmonary hypertension (PH). (A) Dilatation of the main pulmonary artery (MPA) and an MPA to ascending aorta (AA) diameter ratio > 1 are highly suspicious of PH. (B) Right ventricular dilation, hypertrophy, flattening and bowing of the interventricular septum are seen.

Reference

1. Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013; 62:D42–D50.

2. Parasuraman S, Walker S, Loudon BL, et al. Assessment of pulmonary artery pressure by echocardiography-A comprehensive review. Int J Cardiol Heart Vasc. 2016; 12:45–51.

3. Galiè N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J. 2009; 30:2493–2537.

4. Moceri P, Baudouy D, Chiche O, et al. Imaging in pulmonary hypertension: Focus on the role of echocardiography. Arch Cardiovasc Dis. 2014; 107:261–271.

5. Alkotob ML, Soltani P, Sheatt MA, et al. Reduced exercise capacity and stress-induced pulmonary hypertension in patients with scleroderma. Chest. 2006; 130:176–181.

6. Grünig E, Tiede H, Enyimayew EO, et al. Assessment and prognostic relevance of right ventricular contractile reserve in patients with severe pulmonary hypertension. Circulation. 2013; 128:2005–2015.

7. Ho SY, Nihoyannopoulos P. Anatomy, echocardiography, and normal right ventricular dimensions. Heart. 2006; 92:Suppl 1. i2–i13.

8. Grapsa J, Dawson D, Nihoyannopoulos P. Assessment of right ventricular structure and function in pulmonary hypertension. J Cardiovasc Ultrasound. 2011; 19:115–125.

9. Burgess MI, Mogulkoc N, Bright-Thomas RJ, Bishop P, Egan JJ, Ray SG. Comparison of echocardiographic markers of right ventricular function in determining prognosis in chronic pulmonary disease. J Am Soc Echocardiogr. 2002; 15:633–639.

10. van Wolferen SA, Marcus JT, Boonstra A, et al. Prognostic value of right ventricular mass, volume, and function in idiopathic pulmonary arterial hypertension. Eur Heart J. 2007; 28:1250–1257.

11. 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.

12. Hinderliter AL, Willis PW 4th, Long WA, et al. Frequency and severity of tricuspid regurgitation determined by Doppler echocardiography in primary pulmonary hypertension. Am J Cardiol. 2003; 91:1033–1037.

13. Lee JZ, Low SW, Pasha AK, Howe CL, Lee KS, Suryanarayana PG. Comparison of tricuspid annular plane systolic excursion with fractional area change for the evaluation of right ventricular systolic function: a meta-analysis. Open Heart. 2018; 5:e000667.

14. Kind T, Mauritz GJ, Marcus JT, van de Veerdonk M, Westerhof N, Vonk-Noordegraaf A. Right ventricular ejection fraction is better reflected by transverse rather than longitudinal wall motion in pulmonary hypertension. J Cardiovasc Magn Reson. 2010; 12:35.

15. Shiran H, Zamanian RT, McConnell MV, et al. Relationship between echocardiographic and magnetic resonance derived measures of right ventricular size and function in patients with pulmonary hypertension. J Am Soc Echocardiogr. 2014; 27:405–412.

16. Sato T, Tsujino I, Ohira H, et al. Validation study on the accuracy of echocardiographic measurements of right ventricular systolic function in pulmonary hypertension. J Am Soc Echocardiogr. 2012; 25:280–286.

17. Ueti OM, Camargo EE, Ueti Ade A, de Lima-Filho EC, Nogueira EA. Assessment of right ventricular function with Doppler echocardiographic indices derived from tricuspid annular motion: comparison with radionuclide angiography. Heart. 2002; 88:244–248.

18. Kjaergaard J, Petersen CL, Kjaer A, Schaadt BK, Oh JK, Hassager C. Evaluation of right ventricular volume and function by 2D and 3D echocardiography compared to MRI. Eur J Echocardiogr. 2006; 7:430–438.

19. 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.

20. Mathai SC, Sibley CT, Forfia PR, et al. Tricuspid annular plane systolic excursion is a robust outcome measure in systemic sclerosis-associated pulmonary arterial hypertension. J Rheumatol. 2011; 38:2410–2418.

21. Moceri P, Dimopoulos K, Liodakis E, et al. Echocardiographic predictors of outcome in Eisenmenger syndrome. Circulation. 2012; 126:1461–1468.

22. Hsiao SH, Lin SK, Wang WC, Yang SH, Gin PL, Liu CP. Severe tricuspid regurgitation shows significant impact in the relationship among peak systolic tricuspid annular velocity, tricuspid annular plane systolic excursion, and right ventricular ejection fraction. J Am Soc Echocardiogr. 2006; 19:902–910.

23. Meluzín J, Spinarová 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.

24. Calcutteea A, Chung R, Lindqvist P, Hodson M, Henein MY. Differential right ventricular regional function and the effect of pulmonary hypertension: three-dimensional echo study. Heart. 2011; 97:1004–1011.

25. Tamborini G, Brusoni D, Torres Molina JE, et al. Feasibility of a new generation three-dimensional echocardiography for right ventricular volumetric and functional measurements. Am J Cardiol. 2008; 102:499–505.

26. Shimada YJ, Shiota M, Siegel RJ, Shiota T. Accuracy of right ventricular volumes and function determined by three-dimensional echocardiography in comparison with magnetic resonance imaging: a meta-analysis study. J Am Soc Echocardiogr. 2010; 23:943–953.

27. Morikawa T, Murata M, Okuda S, et al. Quantitative analysis of right ventricular function in patients with pulmonary hypertension using three-dimensional echocardiography and a two-dimensional summation method compared to magnetic resonance imaging. Am J Cardiol. 2011; 107:484–489.

28. Di Bello V, Conte L, Delle Donne MG, et al. Advantages of real time three-dimensional echocardiography in the assessment of right ventricular volumes and function in patients with pulmonary hypertension compared with conventional two-dimensional echocardiography. Echocardiography. 2013; 30:820–828.

29. Jenkins C, Chan J, Bricknell K, Strudwick M, Marwick TH. Reproducibility of right ventricular volumes and ejection fraction using real-time three-dimensional echocardiography: comparison with cardiac MRI. Chest. 2007; 131:1844–1851.

30. 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.

31. Lu KJ, Chen JX, Profitis K, et al. Right ventricular global longitudinal strain is an independent predictor of right ventricular function: a multimodality study of cardiac magnetic resonance imaging, real time three-dimensional echocardiography and speckle tracking echocardiography. Echocardiography. 2015; 32:966–974.

32. Freed BH, Tsang W, Bhave NM, et al. Right ventricular strain in pulmonary arterial hypertension: a 2D echocardiography and cardiac magnetic resonance study. Echocardiography. 2015; 32:257–263.

33. Park JH, Negishi K, Kwon DH, Popovic ZB, Grimm RA, Marwick TH. Validation of global longitudinal strain and strain rate as reliable markers of right ventricular dysfunction: comparison with cardiac magnetic resonance and outcome. J Cardiovasc Ultrasound. 2014; 22:113–120.

34. Lee JH, Park JH. Strain analysis of the right ventricle using two-dimensional echocardiography. J Cardiovasc Imaging. 2018; 26:111–124.

35. Mukherjee M, Mercurio V, Tedford RJ, et al. Right ventricular longitudinal strain is diminished in systemic sclerosis compared with idiopathic pulmonary arterial hypertension. Eur Respir J. 2017; 50:1701436.

36. Haeck ML, Scherptong RW, Marsan NA, et al. Prognostic value of right ventricular longitudinal peak systolic strain in patients with pulmonary hypertension. Circ Cardiovasc Imaging. 2012; 5:628–636.

37. Fine NM, Chen L, Bastiansen PM, et al. Outcome prediction by quantitative right ventricular function assessment in 575 subjects evaluated for pulmonary hypertension. Circ Cardiovasc Imaging. 2013; 6:711–721.

38. Shukla M, Park JH, Thomas JD, et al. Prognostic value of right ventricular strain using speckle-tracking echocardiography in pulmonary hypertension: a systematic review and meta-analysis. Can J Cardiol. 2018; 34:1069–1078.

39. Vitarelli A, Conde Y, Cimino E, et al. Assessment of right ventricular function by strain rate imaging in chronic obstructive pulmonary disease. Eur Respir J. 2006; 27:268–275.

40. Ayach B, Fine NM, Rudski LG. Right ventricular strain: measurement and clinical application. Curr Opin Cardiol. 2018; 33:486–492.

41. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015; 28:1–39.

42. Werther Evaldsson A, Ingvarsson A, Waktare J, et al. Right ventricular speckle tracking assessment for differentiation of pressure- versus volume-overloaded right ventricle. Clin Physiol Funct Imaging. 2018; 38:763–771.

43. Mukherjee M, Chung SE, Ton VK, et al. Unique abnormalities in right ventricular longitudinal strain in systemic sclerosis patients. Circ Cardiovasc Imaging. 2016; 9:e003792.

44. Smith BC, Dobson G, Dawson D, Charalampopoulos A, Grapsa J, Nihoyannopoulos P. Three-dimensional speckle tracking of the right ventricle: toward optimal quantification of right ventricular dysfunction in pulmonary hypertension. J Am Coll Cardiol. 2014; 64:41–51.

45. Addetia K, Maffessanti F, Yamat M, et al. Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging. 2016; 17:564–575.

46. Moceri P, Duchateau N, Baudouy D, et al. Three-dimensional right-ventricular regional deformation and survival in pulmonary hypertension. Eur Heart J Cardiovasc Imaging. 2018; 19:450–458.

47. Tonelli AR, Arelli V, Minai OA, et al. Causes and circumstances of death in pulmonary arterial hypertension. Am J Respir Crit Care Med. 2013; 188:365–369.

48. Frazier AA, Burke AP. The imaging of pulmonary hypertension. Semin Ultrasound CT MR. 2012; 33:535–551.

49. Devaraj A, Wells AU, Meister MG, Corte TJ, Wort SJ, Hansell DM. Detection of pulmonary hypertension with multidetector CT and echocardiography alone and in combination. Radiology. 2010; 254:609–616.

50. Freed BH, Collins JD, François CJ, et al. MR and CT imaging for the evaluation of pulmonary hypertension. JACC Cardiovasc Imaging. 2016; 9:715–732.

51. Chan AL, Juarez MM, Shelton DK, et al. Novel computed tomographic chest metrics to detect pulmonary hypertension. BMC Med Imaging. 2011; 11:7.

52. Simonneau G, Robbins IM, Beghetti M, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2009; 54:S43–S54.

53. Haddad F, Kudelko K, Mercier O, Vrtovec B, Zamanian RT, de Jesus Perez V. Pulmonary hypertension associated with left heart disease: characteristics, emerging concepts, and treatment strategies. Prog Cardiovasc Dis. 2011; 54:154–167.

54. Sánchez Nistal MA. Pulmonary hypertension: the contribution of MDCT to the diagnosis of its different types. Radiologia (Madr). 2010; 52:500–512.

55. Ascha M, Renapurkar RD, Tonelli AR. A review of imaging modalities in pulmonary hypertension. Ann Thorac Med. 2017; 12:61–73.

56. Willemink MJ, van Es HW, Koobs L, Morshuis WJ, Snijder RJ, van Heesewijk JP. CT evaluation of chronic thromboembolic pulmonary hypertension. Clin Radiol. 2012; 67:277–285.

57. Grothues F, Moon JC, Bellenger NG, Smith GS, Klein HU, Pennell DJ. Interstudy reproducibility of right ventricular volumes, function, and mass with cardiovascular magnetic resonance. Am Heart J. 2004; 147:218–223.

58. Roeleveld RJ, Marcus JT, Faes TJ, et al. Interventricular septal configuration at MR imaging and pulmonary arterial pressure in pulmonary hypertension. Radiology. 2005; 234:710–717.

59. McLure LE, Peacock AJ. Cardiac magnetic resonance imaging for the assessment of the heart and pulmonary circulation in pulmonary hypertension. Eur Respir J. 2009; 33:1454–1466.

60. Goerne H, Batra K, Rajiah P. Imaging of pulmonary hypertension: an update. Cardiovasc Diagn Ther. 2018; 8:279–296.

61. Swift AJ, Rajaram S, Hurdman J, et al. Noninvasive estimation of PA pressure, flow, and resistance with CMR imaging: derivation and prospective validation study from the ASPIRE registry. JACC Cardiovasc Imaging. 2013; 6:1036–1047.

62. Johns CS, Rajaram S, Capener DA, et al. Non-invasive methods for estimating mPAP in COPD using cardiovascular magnetic resonance imaging. Eur Radiol. 2018; 28:1438–1448.

63. Peacock AJ, Crawley S, McLure L, et al. Changes in right ventricular function measured by cardiac magnetic resonance imaging in patients receiving pulmonary arterial hypertension-targeted therapy: the EURO-MR study. Circ Cardiovasc Imaging. 2014; 7:107–114.

64. Baggen VJ, Leiner T, Post MC, et al. Cardiac magnetic resonance findings predicting mortality in patients with pulmonary arterial hypertension: a systematic review and meta-analysis. Eur Radiol. 2016; 26:3771–3780.

65. Shehata ML, Lossnitzer D, Skrok J, et al. Myocardial delayed enhancement in pulmonary hypertension: pulmonary hemodynamics, right ventricular function, and remodeling. AJR Am J Roentgenol. 2011; 196:87–94.

66. Bessa LG, Junqueira FP, Bandeira ML, et al. Pulmonary arterial hypertension: use of delayed contrast-enhanced cardiovascular magnetic resonance in risk assessment. Arq Bras Cardiol. 2013; 101:336–343.

67. Sanz J, Dellegrottaglie S, Kariisa M, et al. Prevalence and correlates of septal delayed contrast enhancement in patients with pulmonary hypertension. Am J Cardiol. 2007; 100:731–735.

68. Sanz J, Kuschnir P, Rius T, et al. Pulmonary arterial hypertension: noninvasive detection with phase-contrast MR imaging. Radiology. 2007; 243:70–79.

69. Sanz J, García-Alvarez A, Fernández-Friera L, et al. Right ventriculo-arterial coupling in pulmonary hypertension: a magnetic resonance study. Heart. 2012; 98:238–243.

70. Stevens GR, Garcia-Alvarez A, Sahni S, Garcia MJ, Fuster V, Sanz J. RV dysfunction in pulmonary hypertension is independently related to pulmonary artery stiffness. JACC Cardiovasc Imaging. 2012; 5:378–387.

71. Mahapatra S, Nishimura RA, Sorajja P, Cha S, McGoon MD. Relationship of pulmonary arterial capacitance and mortality in idiopathic pulmonary arterial hypertension. J Am Coll Cardiol. 2006; 47:799–803.