All right, thank you all for having me. I'm going to talk about assessing the RV in VV ECMO patients. I'm at Wake Forest in Winston-Salem, North Carolina, lots of cigarettes around there, we love it. I really only have one objective today and that's really to talk about how to assess the RV in VV ECMO patients. That being said, really assessing the RV whether you're on ECMO or not on ECMO is pretty much the same. I only have 10 minutes to teach you things, so realize that you may need to do some practice on your own. Right there, that's an RV. Anybody that likes Cousin Eddie, I just love that quote. It reminds me of just how much that we don't really think about the RV, but really in my practice I've come to realize the RV is in control. Even though it's a low pressure system that is really just in charge of getting blood to the lungs, it's very difficult to deal with. If you look, there's the shape of the RV. It's a very complex shape and it changes obviously beat to beat, and so it can be very difficult to assess both size and function. What we really care about is function. The main method to assess the RV is going to be with echo. If you're great at point of care ultrasound, POCUS, or if you've got transesophageal echo, fantastic, or if you need an echo tech, any way will get you images. I tend to use a lot of POCUS because I'm trying to make decisions at the bedside, but really you got to get a lot of practice. Also we'll go through visual assessment, TAP-C, S-prime, fractional area change, and PAPI, but really you want to make sure that you're looking at more than one image. Making a decision based off of one image really, if you can't get the other image, maybe it's time to call in your sonographer. The first thing that we do is eyeball method. It's involuntary. We look at something, we try and make an assessment. Again, it's really not a great way to evaluate the RV unless you've seen a lot of normals. There are a couple of different views that you would like to look at. The peristernal long axis or the apical four chamber are usually preferred. Now there is the rule of thirds, and here in the peristernal long axis, you can also do a subxiphoid axis view. The size of the RV, the LVOT, and the left atrium are all going to take up about a third of the image. You see here, you've got the RV, the LVOT, and the LA there. Sorry, I'm hearing somebody laughing behind me. That's kind of weird. Here you look, RV, maybe a hair big, but really looks okay. LVOT looking fine, and then the left atrium there. If you go here, you see that the RV is a bit bigger, taking up more than a third, so that points you towards the, hey, there's some increased RV size. Another visual assessment for the RV size is really looking at the ratio of the RV to the LV in the apical four chamber view. Normal, two-thirds of the LV, moderate is the same size of the LV, and severe is greater than the LV. You can add some objectivity to these findings if you track the end-diastolic area of the RV and the LV and compare them to each other, but if you're like me and you have no patience whatsoever, that takes a little time. Here you can see the RV. You can't see all of the LV, but I would say the RV is at least as big as the LV, if not a little bit bigger, so I would call this at least moderate RVH. In this slide, you can't really see all of the RV, but even what I can see looks to be bigger than the LV, so I would, again, say this is a severe RVH. And then you look at this image, and to me, that's just somebody that's not long for this world unless we do something, they've got severe RVH. LV's not doing much either, so they might need VA ECMO. All right, so TAPSI, this is the first way we're going to look at RV function, tricuspid annulus plain systolic excursion. It is so much easier to say TAPSI. I always have to look up and see what TAPSI stands for because I just say it so often. Another term you may hear is tricuspid annular motion or TAM, they're essentially the same. These are ways to look at measuring function, even though you're looking at one area of longitudinal function, TAPSI really does correlate well with global function. You want to make sure that you place the cursor through the lateral annulus of the tricuspid valve. It is pretty easy to calculate, but if you get your angle wrong, you may be off on your calculation. So here you see that the cursor goes through the lateral annulus. You then check the height. Now the computer is smart enough to realize if you are measuring from vertically or the slope, it will give you the number that you're looking for. Again TAPSI here, you see this, this is 2.6, that's normal. TAPSI at 1.7 here, it's on the lower end of normal. Again here, lower end of normal at 1.7. Similar to TAPSI, there's S prime or systolic excursion velocity. Some people call it TDI. Another way to look at RV function. Again you're looking at one specific area, but it correlates well with global function. The measurement is essentially the same, except instead of using M mode, you're using pulse wave Doppler. This way you're measuring velocity instead of distance. Here again, here's our S prime wave, E prime, A prime. You get the velocity there. You can see here that 11 centimeters per second, that's normal. Here again, 11 centimeters per second, normal. Here we've got 8 centimeters per second, which would indicate that the RV function is decreased. Fractional area change, similar to an EF for the LV. Anything less than 35% indicates RV dysfunction. What you want to do here, it's more objective, but it does take a lot longer. You want to make sure that you get the entire RV in the picture. Once you've done this, you track the area in systole and then in diastole. You have to make sure that you're avoiding the trabeculations. Here we see the diastolic area, 38.6 centimeters, systolic area, 24.1, 38.6 minus 24.1 over 38.6, 37.5%. That's normal function there. Is anybody using PAPI? This is a newer thing that's come out. Really the easiest way, I see in the back there, awesome. Really a newer way to evaluate systolic function in the RV. The easiest way to do it is put a SWAN in. I have SWANs in most of my patients because they're kind of complex. We're not going to discuss SWANs here. That being said, one of the issues I have with a PAPI is there are a lot of variables, specifically RV afterload, PVR, your wedge pressure, obesity. There are all these numbers, but there's no one specific number that tells me that, all right, this patient has RV dysfunction. It really depends on the patient disease process and the different patient populations. Now you can calculate a PAPI using ECHO. For me, I'm not that good at ECHO, so I would most likely get a tech to come and do these things. Would I get a tech to come and do it, or would I put a SWAN in? I'd probably come and get a tech if I just wanted to know what the PAPI is. All right, in summary, really quickly, these are the different ways to assess the RV. Again, we're talking about ECMO, VV ECMO, but really it'll work in any patient. Obviously you're going to look at the patient, look at the RV, you're going to look at your rule of thirds. And then moving on towards TAP-C, measuring with your M-mode through lateral annulus. Also get your S-prime velocities to see how the function is. Fractional area chain is probably your best bet with objective parameters or objective data, but again, it does take a little longer. And then PAPI, if I've got a SWAN in, I definitely do it. If I don't have a SWAN in, then I've got to call somebody to give me a hand. All right, thank you all very much.

right ventricle

RV assessment

veno-venous ECMO

RV function

echo