This document discusses the assessment of right ventricular function using echocardiography. It covers right ventricular anatomy, segments, size estimation, wall thickness measurement, and qualitative and quantitative functional assessment including fractional area change, TAPSE, S', Tei index, and Doppler. Causes of right ventricular volume and pressure overload are described. The document emphasizes that right ventricular function is clinically important but challenging to assess due to the heart's complex shape.

1. Echo Assessment of Right
ventricular function
Presented by:
Dr. Md Al-Amin
Chairperson:
Professor CHOWDHURY MESHKAT AHMED
Cardiology
BSMMU

2. RV function is strongly associated with Clinical
outcome although being neglected.
Limited data regarding normal dimensions of RV
because of its complex shape.

3.  RV is a thin walled pyramidal structure which
wraps around LV .
 RV size < LV size
 RV Mass = 1/6th of LV mass
Right
ventricular
anatomy

4. Right
ventricular
anatomy
Composed of three distinct portion :
1. Smooth muscular Inflow- composed of TV, Chordae
tendineae and papillary muscles
2. Infundibulum/Conus-Outflow Region
3. Trabeculated apical myocardium

5. Right
ventricular
anatomy
Additional Unique structures of RV
1. Crista supraventricularis
2. Prominent trabeculations.
3. Moderator band

6. Segments of RV in
Echocardiography

7. Segmental
nomenclature of
the right
ventricular walls
along with their
coronary supply

8.  Structurally complex cavity.
 Fits no simple geometric figure.
 RV size estimation requires integration of multiple views
and qualitative and quantitative assessment.
 Endocardial border delineation difficult due to well
developed trabeculation.
 Image acquisition difficult due to it’s position just behind
sternum. Problems with
RV imaging

9.  Significantly affects symptoms, exercise
capacity and mortality rates in various
cardiovascular lesion.

10.  Primary Pulmonary Arterial Hypertension
 Pulmonary Thromboembolism
 Secondary to - Left heart failure, Left sided valve diseases,
Myocardial infarction with RV involvement
 Congenital Heart Diseases
 ARVD/Other Systemic Diseases

11.  PLAX view
 RV inflow view
 Short axis view
 Apical 4 chamber View
 Focused RV view
 Subcostal view
Possible imaging
planes for RV
function assessment

12. PLAX

13. PSAX

15. A4CV

19. Size : Is RV dilated?
• Right ventricle should appear smaller than the left ventricle
and usually no more than two thirds the size of the left
ventricle in A4CH view.
• RV enlarged but < LV : Mildly enlarged.
• RV=LV : Moderately enlarged
• RV> LV enlarged: Severely enlarged.
In the standard transthoracic apical 4-chamber window, the
left ventricle is considered the ‘‘apex-forming’’ ventricle. As
the right ventricle enlarges,it may displace the left ventricle
and occupy the apex. This usually signifies that the right
ventricle is at least moderately dilated.
Qualitative
assessment of
RV

20.  Useful measurement for RVH ( Pressure
overload)
 Increased RV thickness : in infiltrative and
hypertrophic CM.
 Measured at end-diastole by M-mode or 2D
echo from the subcostal window (normally ≤
5mm) preferably at the level of the tip of the
anterior tricuspid leaflet.
 Certain conditions are associated with RV wall
thinning : ARVD.
 There are no accepted echocardiographic
criteria to define abnormally thin RV wall

21. Normally : 5 or less.
Measured at the level of TV
chordae & at the peak of R wave
on ECG on sub-costal view.

22.  Advantages:
 RV wall thickness can be measured by M-mode or
2D echocardiography from either the subcostal or
left parasternal window.
 Disadvantages:
 There is a lack of established prognostic
information.

23.  Using 2D echocardiography, RV size can be
measured from a 4-chamber view obtained from
the apical window at end-diastole.
 Taken at 3 level :
 Basal RV cavity
 Mid RV cavity
 Distance from Plane of Tricuspid annulus to RV
apex.
RV dimensions
RV dilatation :
Basal diameter : > 4.2 cm
Mid cavity diameter : > 3.5 cm
Longitudinal diameter : > 8.6
cm

24. To optimize imaging of the RV
lateral wall, the 4-chamber
image may require adjustment
from its usual attention on the
left ventricle to a focus on the
right ventricle(RV focused
view).
Advantages:
RV linear dimensions are easily obtained on an A4C view
Markers of RV dilatation.
Disadvantages:
RV dimensions are highly dependent on probe rotation by the user,
which can result in an underestimation of RV width.

25. RVOT Normal diameters
RVOT- proximal 21-35 mm
RVOT- distal 17-27 mm
Best viewed from PLAX, PSAX & subcoastal view.
Measurement is taken at end-diastole.
In PLAX view, Proximal RVOT can be measured ( RVOT- Prox)
In PSAX view, RVOT linear diameter can be measured from
1. Anterior aortic wall to RV wall : RVOT– Prox
2. Just proximal to PV : RVOT- Distal
RVOT is important in congenital heart disease & Arrhythmia.
It is often the first segment of RV to show diastolic inversion
in temponade.

26.  Advantages :
 Easily obtained in PSAX view.
 Certain lesion may primarily affect RVOT
 Disadvantages :
 Oblique Imaging may underestimate or
overestimate the measurement.
 Endocardial definition of anterior wall often
suboptimal.

27.  RV systolic function is assessed by 6 parameters :
 2D assessment
 -FAC and
 -Visual assessment of RV free wall
& tricuspid annular motion
 2.M mode assessment -TAPSE or TAM
 3.Doppler assessment
 - S’
 - RIMP/ Tei Index
Global
Assessment of RV
-RV dP/dt Systolic Function
 RV diastolic function assessment:

28.  FAC is obtained by tracing the RV endocardium
both in systole and diastole from the annulus,
along the free wall to the apex, and then back to
the annulus, along the IVS.
 Trabeculations should be excluded while tracing
the chamber.
2D assessment: RV Area and
Fractional area change

29. RV FAC correlates well with RV
EF by MRI
Normal > 35 %

31.  It is a method to measure the distance of systolic
excursion of the RV annular segment along its
longitudinal plane, from a standard A4C window.
Acquired by placing an M-mode
cursor through the tricuspid
annulus and measuring the
amount of longitudinal motion of
the annulus at peak systole.

32.  Advantages:
 Simple, less dependent on optimal image quality, and
reproducible.
 It does not require sophisticated equipment or prolonged
image analysis.
 Disadvantages:
 TAPSE assumes that the displacement of a single segment
represents the function of a complex 3D structure.
 It is angle dependent, and there are no large-scale
validation studies.
 Finally, TAPSE may be load dependent.
TAPSE……

33.  An apical four chamber view
 The PW Doppler sample volume is placed in either
the tricuspid annulus or the middle of the basal
segment of the RV free wall
 The velocity S’ is read as the highest systolic
velocity, without overgaining the Doppler envelope. Normal > 10 cm/s

34.  Advantages :
 Simple, reproducible technique with good
discriminatory ability to detect normal versus
abnormal RV function.
 Pulsed Doppler is available on all modern
ultrasound equipment and does not require
additional software.
 Disadvantages:
 Less reproducible for non basal segments
 Angle dependent.
 Moreover, it assumes that the function of a single
segment represents the function of the entire RV,
which is not likely in conditions that include
regionality, such as RV infarction.

35.  RV index of myocardial performance.
 Global estimate of both systolic and diastolic
function of the right ventricle.
 The MPI is defined as the ratio of isovolumic time
divided by ET, or
 [(IVRT + IVCT)/ET] or
 Tei index =
 Tricuspid Closure to Open(TCO) time
 Ejection Time(ET)
 Obtained by two methods: PW Doppler & Tissue
Doppler.
Doppler assessment of RV systolic
function by RIMP or Tei index

36.  In PW Doppler method:
 Tricuspid Closure to Open(TCO) time is measured
with either of –
 PWD in the tricuspid inflow and measure the time
from the end of the transtricuspid A wave to the
beginning of the transtricuspid E wave or
 CW of the TR jet (time from the onset to the
cessation of the jet).
 Ejection Time(ET) is measured with Pulsed
Doppler of RV outflow (time from the onset to
the cessation of flow)

37. Normal value :
< 0.40 in PW Dopple

38. In the tissue Doppler method, all
time intervals are measured from
a single beat by pulsing the
tricuspid annulus
Normal value :
< 0.55 in Tissue doppler

39.  Advantages :
 This approach is feasible in a large majority of
subjects both with and without TR
 Reproducible
 It avoids the geometric assumptions and
limitations of complex RV geometry.
 Disadvantages :
 Unreliable when RV ET and TR time are measured
with differing R-R intervals, as in atrial fibrillation.
 It is load dependent and unreliable when RA
pressure is elevated.(eg RV infarction)

40.  The rate of pressure rise in the RT ventricles
(dP/dt) is an index of ventricular contractility or
systolic function.
 RV dP/dt can be accurately estimated from the
ascending limb of the TR continuous-wave Doppler
signal.
 RV dP/dt is commonly calculated by measuring
the time required for the TR jet to increase in
velocity from 1 to 2 m/s.( represents 12mmHg
increase of pressure)

41.  Advantages :
 This is a simple technique with a sound
physiologic basis.
 Disadvantages :
 There are limited data in both normal subjects and
pathologic conditions.
 RV dp/dt is load dependent.
 RVdp/dt will be less accurate in severe TR
because of neglect of the inertial component of the
Bernoulli equation and the rise in RA pressure.
Recommendations:
Because of the lack of data in
normal subjects, RV dP/dt cannot
be recommended for routine uses.
It can be considered in subjects
with suspected RV dysfunction.

42.  Measurements are essentially the same as those
used for the left side.
 From the A4C view & Doppler beam should be
parallel to RV inflow.
 Sample volume is placed at the tip of tricuspid
valve leaflets.
 Measure at end-expiration and/or take the
average of ≥ 5 consecutive beats.
RV diastolic function

44.  Measurement of RV diastolic function should be
considered in patients with suspected RV
impairment as a marker of early or subtle RV
dysfunction, or in patients with known RV
impairment as marker of poor prognosis.
 Transtricuspid E/A ratio, E/E’ ratio, and RA size
have been most validated and are the preferred
measures.

45. RV Diastolic function

46.  Assessed in A4C view
 Estimation of RA area by
planimetry
 RA area is traced at the end of
ventricular systole, excluding
IVC, SVC & RAA.
 Maximum long distance of RA
is measured from centre of
the Tricuspid cusps to the
superior wall of RA, parallel to
the inter-atrial septum.
 A mid RA minor dimension is
measured from mid level of
RA free wall to mid level of
IAS, perpendicular to major
dimension.
Right atrial assessment

47. RA enlargement :
RA area > 18 cm2
Major dimension > 53 mm
Minor dimension > 44 mm

48.  Most commonly estimated by IVC diameter and
compressebility of IVC.
 Subcostal view is most useful for imaging the IVC,
with the IVC viewed in its long axis.
RA pressure determination

49. Measurement should be made at
end-expiration and just proximal
to the junction of the hepatic
veins that lie approximately 0.5 to
3.0 cm proximal to the ostium of
the right atrium.
To accurately assess IVC collapse,
diameter of the IVC with quiet
respiration and with a sniff
maneuver should be measured.
M mode canbe placed on the IVC
for more accurate quantification.

51.  In patients who are unable to adequately perform
a sniff, an IVC that collapses
 < 20% with quiet inspiration suggests elevated
RA pressure. This method of assigning an RA
pressure is preferable to assuming a fixed RA
pressure value for all patients.
 In normal young athletes ,the IVC may be dilated
with normal RA pressures.
 Ventilated patients may have dilated and non
collapsible IVC, therefore it should not be used to
estimate RA pressure in those cases.

52.  RV Volume overload :
 Typically seen as a result of L → R shunt (atrial septal defect,
anomalous pulmonary venous return, arteriovenous malformation)
 Tricuspid regurgitation
 Functional: secondary to RV dilatation, Secondary to atrial fibrilation
and atrial dilatation.
 Primary: Intrinsic valve pathology, valve disruption due to pacing leads;
rare: Rheumatic,congenital, carcinoid
 Severe pulmonary insufficiency mostly in context of repaired congenital
heart diaseases.
 Typical Echo findings are :
 RV dilatation
 Diastolic IVS flattening ( D shaped LV )
 Concurrent elevation of RA pressure
 Decreased RV function with chronicity.

53.  RV pressure overload :
 Results from high pulmonary artery pressures due
to Pulmonary hypertension, pulmonary stenosis
or when the RV is the systemic ventricle in
congenital heart disease.
 Aetiology:
 1.PH due to left heart disease(most
common,Group 2 PH)
 2.PH associated with lung disease ‘Cor Pulmonali’.
 3.PAH due to pulmonary vascular disease.
 4.PH associated with pulmonary emboli or
Chronic thromboembolism.
 5.Pulmonary valve stenosis.

54.  Typical findings are :
 Dilated Pulmonary arteries
 RVH ( in chronic case)
 Systolic IVS flattening ( D shaped LV)
 High-velocity TR jet
 Short RVOT acceleration time (AT) ( < 90 msec)
 Shortened RVOT VTI
 Mid systolic closure of Pulmonic valve flow (Notched RV
outflow through pulmonary valve by PW doppler.)
 In the absence of gradient across the pulmonic valve (i.e
pulmonic stenosis) RV pressure estimates PA pressure.
 Normal RV pressure/PASP < 36 mmhg

56.  The Eccentricity Index (EI) is an echocardiographic
measurement of the left ventricle that can quantify
the amount of right ventricular strain and
overload affecting the left ventricle.
 Eccentricity Index (EI) = D2/D1.
 D2= Antero-posterior diameter
 D1=Septo-lateral diameter
 Interpretation of Eccentricity Index ( EI )
 EI < 1: Normal
 EI > 1: RV Overload with resulting “D Sign”
D sign of RV overload

59.  Acute increase of PA pressure –Acute Pulmonary
Embolism leads to RV failure as RV can not adapt
to quickly to changes in afterload.
 Chronic elevated PA pressure – RV hypertrophies
and can maintain systemic function in higher
pressure.

60. "60:60 sign "-Normal pulmonary accelaration time is
> 90 ms. A short RVOT acceleration time < 60 ms
means increase of MPAP. In the setting of an acute
pulmonary embolism, the RVOT acceleration time
may be shortened (< 60 ms), secondary to local fluid
hemodynamic changes and does not accurately
reflect mean PA pressure. This phenomenon is
confirmed by a low velocity TR jet, reflecting only a
modest increase in peak PA systolic pressure (< 60
mmHg gradient) .

61. -In addition to changes in
pulmonary hemodynamics, acute
pulmonary embolism can produce
regional RV wall motion
abnormalities, with severe
hypokinesis of the RV basal to
mid free wall and hyperdynamic
apical contraction.

62.  Pulmonary artery systolic pressure ( PASP)
 PASP should be estimated and reported in all
subjects with reliable tricuspid regurgitant jets.
 PASP = 4×( peak velocity of TR Jet)2+ RA pressure
 Normal PASP : < 36mmHg
PASP = 4×( peak velocity of TR
Jet)2+ RA pressure
Normal PASP : < 36mmHg

64.  Visual assessment provides qualitative evaluation of
RV function.
 Quantitative assessment such as : FAC, TAPSE, S’,
Tei index are reliable & reproducible.
 Combining more than one measures can reliably
distinguish normal vs abnormal.
 At least one of the above quantitative measures be
incorporated into the routine echocardiographic
examination and report, and this is particularly
important when RV dysfunction is suspected and or
when the clinical indication for the study relates to a
condition that may affect the right ventricle.

65. THANK YOU