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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 RegistryUtility of Echo for ARVD
=
The echo diagnosis of arrhythmogenic right =
ventricular dysplasia (ARVD) is possible only in <=
/span>=
the absence of other causes of dilatation of the <=
/span>=
right ventricle such as:
=
1)
congenital heart disease (such as atrial septal defect, Ebsteins anomaly)
=
2) right ventricular infarction=
3;
=
3)
volume overload due to significant tricuspid regurgitation
=
4) pulmonary embolism
<=
/span>
=
5) primary pulmonary hypertension&=
#13;
=
6)
secondary pulmonary hypertension from causes such as mitral stenosis, COPD, or =
PE
Echo exam for ARVD
General Considerations
General Considerations
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.)
<=
span
style=3D'mso-special-format:bullet;position:absolute;left:-4.13%'>=
Set
depth appropriately so all structures of interest in view
<=
span
style=3D'mso-special-format:bullet;position:absolute;left:-4.3%'>E=
ach
recording should have a clear ECG and scale markers
=
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
Parasternal Long Axis
<=
/span>Initially
focus on left sided structures
<=
/span>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
LV/LA/AV
LV/LA/AV
<=
![if !ppt]>![](3D"slide0009_image001.gif")
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
Structu=
res of
interest include:
Tricusp=
id
Valve
structure and function
Color a=
nd CW
Doppler of TR
The inferoposterior wall of t=
he
RVIT under the tricuspid valve is the most important structure =
in
this view
<=
/span>
Often
affected in ARVD with WMA, thinning or aneurysms
Optimize
depth/zoom to ensure adequate visualization
Parasternal Long Axis
RV Inflow
RV Inflow
<=
![if !ppt]>![](3D"slide0010_image002.gif")
ARVD example of aneurysm of posterior RV wall under=
TV
![](3D"slide0037_image004.jpg")
![](3D"slide0037_image005.gif")
Parasternal Short Axis
AoV/RVIT/RVOT/PV Le= vel
AoV/RVIT/RVOT/PV Le= vel
<=
/span>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
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 R=
VOT
Parasternal Short Axis
AoV/RVIT/RVOT/PV
AoV/RVIT/RVOT/PV
<=
![if !ppt]>![](3D"slide0012_image006.gif")
Parasternal Short Axis
AoV/RVIT/RVOT/PV2
AoV/RVIT/RVOT/PV2
<=
![if !ppt]>![](3D"slide0034_image007.gif")
ARVD example of dilated <=
/span>RVOT
compared to Aorta
![](3D"slide0039_image009.jpg")
Parasternal Short Axis
MV/TV/LV
MV/TV/LV
<=
/span>Structure
and function of:
=
Mitral
valve
=
Tricuspid
valve
<=
/span>LV
wall motion at:
=
Base
=
Mid-ventricle
=
Apex
Parasternal Short Axis
Mitral/Tricuspid Level
Mitral/Tricuspid Level
<=
![if !ppt]>![](3D"slide0013_image010.gif")
Parasternal Short Axis
Midventricle
Midventricle
![](3D"slide0033_image011.gif")
ARVD
example of RV dilatation and increased
trabeculations from SAX view
![](3D"slide0036_image013.jpg")
Parasternal Short Axis
Apex
Apex
![](3D"slide0015_image014.gif")
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)
Apical 4 Chamber
![](3D"slide0020_image015.gif")
PW + CW of MV
![](3D"slide0032_image017.jpg")
![](3D"slide0032_image019.jpg")
![](3D"slide0038_image022.gif")
CW of TV and PV for RV myocardial
performance index
RVMPI =
=3D (TR
duration Pulm ET) / Pulm ET
If no TR record 3 E/A complexes of TV inflow
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 5 Chamber
<=
![if !ppt]>![](3D"slide0022_image023.gif")
Apical 2 Chamber - LV + RV
<=
/span>Left
ventricle:
=
structure and function
=
Color
Doppler of MR
<=
/span>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 + RV
![](3D"slide0024_image025.jpg")
![](3D"slide0024_image027.jpg")
From
apical 2 ch transducer position (panel A) slide and angle transducer
toward RV (panel B) to visualize RV apex and free wall
A
B
Subcostal Long Axis
Subxiphoid
transducer position, angled upward and left
<=
/span>Structures
of interest:
=
RV
free wall motion
=
RV
apical wall motion
=
RV
dimension
Subcostal Long Axis
<=
![if !ppt]>![](3D"slide0026_image028.gif")
Subcostal Short Axis
<=
/span>At
the TV/RVIT/RVOT/PV/AoV level
<=
/span>Structures
of interest:
RVIT:
WMA, aneurysms, sacculations, thinning
RVOT:
WMA, aneurysms, sacculations, thinning
Subcostal Short Axis
![](3D"slide0028_image029.gif")
Tissue Doppler
If your center has Tissue
Doppler capabilities
Change machine settings to
optimize Tissue Doppler acquisition
Place cursor at the TV annul=
us
(both free wall annulus and medial annulus)
PW at both of these sites=
3;
Optimize scale (< 20cm)&#=
13;
3 beats including Ea, Aa and
systolic wave
Tissue Doppler of the Tricu=
spid
Annulus
![](3D"slide0031_image031.jpg")
![](3D"slide0031_image033.jpg")
![](3D"slide0031_image034.gif")
![](3D"slide0031_image035.gif")
Lateral (free wall) annular velocities
Medial (septal) annular velocities
Conclusions
<=
span
class=3DBB style=3D'position:absolute;left:-4.54%'>Record at least=
3 beats
(more is better)
<=
span
class=3DBB style=3D'position:absolute;left:-4.21%'>Focus on optimi=
zing
structures of interest
Use Harmonics a=
nd
Contrast to optimize structures
<=
span
class=3DBB style=3D'position:absolute;left:-4.57%'>Dont forget PW=
, CW,
color Dopplers
' + ENDSHOW_MESG + '
![](3D"notes_flag.gif")
No=
tes![](3D"buttons.gif")
