TAPSE AND RIGHT VENTRICLE SYSTOLIC FUNCTION

Coordinator: Prof. Jolanta Justina Vaškelytė 

Made: Surugiu Iulian

2nd year resident cardiology (Moldova )

RIGHT VENTRICLE

Due to the complex anatomy of the RV, assessment of its function can be problematic.

The right ventricle is a crescent shaped three dimensional cavity and its transverse axis is wrapped around the LV.

RV WALL MOTION

The RV wall motion is complex:

Isovolumic contraction phase: The subepicardial fibres, moves the ventricle in a circumferential direction, rotation of the ventricle.

During the ejection phase: longitudinal shortening and radial motion. Mainly is longitudinal shortening controlled by the subendocardial fibres. Secondary radial motion of the RV free wall towards the septum.

There is a wide angle between inflow and outflow, this is way longitudinal shortening and “peristaltic” movement is crucial to keep the intracavitary circulation and to direct blood into the pulmonary arterial tree.

Radial shortening

Longitudinal shortening

RV EJECTION FRACTION MEASUREMENT

RV ejection fraction its difficult to measure because of:

dependent on loading conditions, ventricular interaction , myocardial structure

(trabeculation), image quality, dependent on examiner opinion

about endocardium border, very approximately (wall motion

abnormalities).

TAPSE

TAPSE as a measure of RV ejection fraction was first proposed by Kaul et al. in 1984, who demonstrated a close correlation to RV ejection fraction determined by radionuclide technique.

Confirmed latter using thermo-dilution techniques, Magnetic Resonance Imaging and Simpson’s right ventricular EF.

TAPSE (2)

TAPSE is easily measured by M-mode, with the cursor aligned along the direction of the tricuspid lateral annulus in the apical four-chamber view.

TAPSE is related to RV EF, because the RV free wall consists predominantly of longitudinal and oblique myocardial fibers and, is the major contributor to the RV stroke volume.

TAPSE has a prognostic value confirmed in clinical trials.

ADVANTAGE

TAPSE is simple to measure, reproducible, yet robust measure of RV function in patients with pulmonary hypertension

Established prognostic value. Validated against radionuclide EF.

LIMITATIONS

Represents only the free wall implication. One-third of the pressure generated in the RV is made by septum and common muscle fibers with LV.

In patients with dilated cavity and volume overloaded RV, TAPSE can erroneously overestimate right ventricular function.

Angle dependency.

There are no big clinical study's on TAPSE cutoff and exact measures.

PROGNOSTIC VALUE

Samad et al. assessed TAPSE in patients after a first acute myocardial infarction, and showed that TAPSE ≤15 mm was associated with increased mortality (45% at 2 years) compared with patients having TAPSE >20 mm (4%). 

Decreased RV ejection fraction estimated by TAPSE is independently associated with mortality due to HF, even after adjusting for other known risk factors including LV ejection fraction or the presence of valvular disease.

Negative correlation between pulmonary artery systolic pressure (PASP) and TAPSE (r = −0.67).

A López-Candales et al. Postgrad Med J 2008;84:40-45

TAPSE CORELATION TO SHORT‐ AND LONG‐TERM MORTALITY IN PATIENTS WITH HEART

FAILURE

Kaplan Meier (817 patients)

PROGNOSTIC VALUE (2)

Right ventricular function estimated by TAPSE, is found to be a significant predictor of survival.

When adjusting for other known risk factors in HF as well as for the co-existence of COPD, TAPSE remained an independent predictor of survival, whereas left ventricular ejection fraction had no independent prognostic information when TAPSE is included in the model.

RECOMMENDATIONS FOR CARDIAC CHAMBER QUANTIFICATION JANUARY

2015

“Tricuspid annular longitudinal excursion by M-mode (mm), measured between end-diastole and peak-systole, with proper alignment of M mode cursor with the direction of RV longitudinal excursion should be achieved from the apical 4 chamber view approach.”

TAPSE (mm): Mean 24± 3.5

Abnormality threshold <17 mm

HOW TO MEASURE ?

V

ISOVOLUMIC CONTRACTION TIME

Under normal circumstances, the low end-diastolic pressure in the pulmonary artery is quickly exceeded by the pressure rise in the

RV, resulting in a very short or even absent isovolumic contraction time.

TAPSE < 17 mm - his cutoff limit prognostic value was taken from study's where TAPSE was measured from end-diastole to peak-systole.

There is no data about cutoff limits measured for “ejection period”.

ATRIAL CONTRIBUTION TO TAPSE

It was established that right atria contribute much more to RV filling than left atria to LV filling in diastole.

Under this circumstances TAPSE value is dependent on right atria proper function and contribution to RV volume load.

At this moment it is not known what are the cutoff value of TAPSE in atrial dysfunction (ex: atrial fibrillation), and prognostic power of TAPSE in such situation.

It is important that one should not judge severity of RV function impairment on the basis of one parameter. Instead, conclusions should be drawn on a complex and multilateral evaluation approach.