An Evidence-Based Echocardiographic Image Acquisition Protocol for Evaluating Right Ventricular Function

Summary

The present protocol proposes and describes an evidence-based image acquisition sequence for multi-parametric assessment of right ventricular function.

Abstract

A major risk factor for morbidity and mortality in critical illness is the presence of right ventricular dysfunction (RVD). However, characterizing and grading the severity of RVD remains highly subjective, with significant inter-operator and intra-operator variability and the potential for the inappropriate treatment of patients. To address these issues, this study aimed to synthesize multiple echocardiographic parameters, which have been demonstrated to affect clinical outcomes, into a framework for the comprehensive evaluation of RVD. During the study's first phase, a scoping review of the literature was conducted and identified four routinely obtained echocardiographic findings that had been validated as part of multi-parametric scoring methods for scoring the severity RVD: (1) RV systolic dysfunction; (2) RV dilation; (3) RV-PA uncoupling; and (4) interventricular septal flattening. In the second phase described in the present manuscript, these four echocardiographic findings were operationalized into an image acquisition protocol and integrated into a proposed RVD scoring system compatible with the constraints of either point-of-care or consultative ultrasound workflows.

Introduction

In a wide range of clinical contexts, cardiovascular mortality and morbidity are strongly associated with right ventricular dysfunction (RVD)^1,2,3,4,5. However, grading the severity of RVD remains highly subjective because the crescentic anatomic shape and thin walls of the RV make an accurate evaluation of volume and ejection fraction challenging using standard two-dimensional assessment⁴. Recognizing these difficulties, the most recent guidelines on RV assessm....

Protocol

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Duke University Health System institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards¹⁶. All images/clips were obtained from a de-identified internal library of educational ultrasound clips, so written consent was not possible (all images/clips in this library are fully de-identified with no way of identifying or contacting individual patients). This protocol applies to adult patients in a variety of clinical settings, including, but not limited to, periope....

Results

The resulting protocol assigns a point for each of the following: (1) RV dilation; (2) RV systolic dysfunction; (3) RV-pulmonary artery (PA) uncoupling; and (4) the combination of RV dilation and interventricular pressure equilibration (see definitions for each point below). For ease of recall, the essence of the RVD score can be summarized using the mnemonic "CISS": Coupling, Interventricular Septal Motion, Squeeze, and Size.

Of these four parameters, at least three should be scorable as eith.......

Discussion

Significance of the method with respect to alternatives
There exists a large unmet need to add objectivity to assessing and grading RVD. To address this need, a two-phase project was conducted. In the first phase, a scoping review of the literature identified only three published, prospectively-validated, multi-parametric RV severity grading systems that utilize only routinely obtained echocardiographic data. The scoping review further compared these studies to reveal that they overlap significantl.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
CX50	Philips	https://www.philips.com/healthcare/product/HC795076GI/cx50-xmatrix-general-imaging-ultrasound-system
Edge 1	Sonosite	https://www.sonosite.com/products/ultrasound-machines-and-accessories
Epic 7C	Philips	https://www.philips.com/healthcare/product/HC795200C/epiq-7-ultrasound-system-for-cardiology
HS60	Samsung	https://www.samsunghealthcare.com/products/UltrasoundSystem/HS60/General%20Imaging/benefit
Logiq E10	GE	https://www.gehealthcare.com/products/ultrasound/logiq/logiq-e10