This document provides guidelines for assessing right heart structure and function using echocardiography. It describes the basic views needed to evaluate the right ventricle and atria. Key measurements are outlined such as ventricular dimensions, tricuspid annular plane systolic excursion (TAPSE), and inferior vena cava (IVC) size and collapse. Methods for estimating pulmonary artery pressures from tricuspid regurgitation are presented. The document recommends routinely reporting right ventricular size and function on echocardiograms.

2. RIGHT HEART
ASSESMENT

4. Is It Important?
• Not just a conduit
• Connected and affected
• Risk stratification
• Therapy guidance
• Controversial
• Understudied
• Examiners favorite

5. The Purposes Of Guidelines
▪ Describe the acoustic windows
▪ Describe the echocardiographic parameters of RV size and
function.
▪ Advantages and disadvantages of each measure or technique.
▪ Recommend which right-sided measures should be included in
the standard echocardiographic report.
▪ Provide revised reference values

6. BASIC VIEWS

7. BASIC VIEWS

8. BASIC VIEWS

9. Segmental Nomenclature

10. Right Heart Dimensions
▪ Right ventricle-focused apical 4 chamber view
– Measured at end-diastole

12. Which of the following is an abnormal right
ventricular (RV) dimension in an adult 30
years old?
A. Basal RV diameter of 2.5 cm.
B. Mid RV diameter of 3.8 cm.
C. Right ventricular outflow tract (RVOT) diameterabove the aortic valve of 2.6 cm.
D. Base to apex RV length of 7.5 cm.

13. Right ventricular dimensions
1. Basal RV diameter
2. Mid cavitary RV diameter
3. RV longitudinal dimension
 4.2 cm indicates dilatation
 3.5 cm indicates dilatation
 8.6 cm indicates RV enlargement

18. ▪ RV size should be routinely assessed by conventional 2DE using
multiple acoustic windows
▪ Report should include both qualitative and quantitative parameters.
▪ In laboratories with experience in 3DE, 3D measurement of RV
volumes is recommended.
▪ RV EDVs of 87 mL/m2 in men and 74 mL/m2 in women
▪ RV ESVs of 44 mL/m2 for men and 36 mL/m2 for women

24. TAPSE
TAPSE and RV ejection fraction
TAPSE 2cm = RVEF 50%
TAPSE 1.5cm = RVEF 40%
TAPSE 1cm = RVEF 30%
TAPSE 0.5cm = RVEF 20%
Event free survival according
toTAPSE in patients with CHF

30. RV Diastolic Function
▪ From the apical 4-chamber view, the Doppler beam should
be aligned parallel to RV inflow
▪ Sample volume is placed at the tips of the tricuspid valve
leaflets
▪ Measure at held end-expiration and/or take the average of
≥ 5 consecutive beats
▪ Measurements are essentially the same as those used for
the left side

31. Recommendation
▪ 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 a marker for poor prognosis
▪ Transtricupsid E/A ratio, E/E’ ratio, and RA size have been
most validated are the preferred measures
Grading of RV Diastolic Dysfunction should be done as follows:
E/A ratio < 0.8 suggests impaired relaxation
E/A ratio 0.8-2.1 with an E/E’ > 6 or diastolic prominence in the hepatic veins
suggest pseudonormal filling
E/A ratio > 2.1 with deceleration time < 120 ms suggests restrictive filling

36. Recommendations
▪ The recommended parameter to assess RA size is RA volume,
calculated using single-plane area-length or disk summation
techniques in a dedicated apical four-chamber view.
▪ The normal ranges for 2D echocardiographic RA volume are :
▪ Males 25 ± 7 ml/m2
▪ Females 21 ± 6 ml/m2

37. RA Pressure
▪ Measurement of the IVC should be obtained at
end-expiration
▪ To accurately assess IVC collapse, the change in
diameter of the IVC with a sniff and also with
quiet respiration

38. Recommendations
For simplicity and uniformity of reporting, specific values of RA pressure ,
rather than ranges, should be used in the determination of SPAP
IVC diameter IVC collapsibility RA pressure
≤ 2.1 cm > 50% with a sniff 3 mmHg
> 2.1 cm < 50 % with a sniff 15 mmHg
In indeterminate cases in which IVC diameter and collapse do not fit this
paradigm, an intermediate value of 8 mmHg may be used, preferably with use of
secondary indices of RA pressures such as: RA dilatation, abnormal bowing of the
IAS into the left atrium throughout the cardiac cycle
Advantages Disadvantages
IVC dimensions are usually
obtainable from the subcostal
window
IVC collapse does not accurately
reflect RA pressure in ventilator-
dependent patients
It is less reliable for
intermediate values of RA
pressure

39. Which of the following is the correct measurement
of the IVC diameter in estimating RA pressure
A. A
B. B
C. C
D. None of the above ABC

40. The end-systolic and end-diastolic parasternal short-
axis views of a 75-year-old patient are shown. Which of
the following statements is more likely to be true?
A.This patient likely has carcinoid heart disease.
B.This patient likely has Eisenmenger physiology.
C.There is evidence of a restrictiveVSD.
D. Pulmonic stenosis is suspected.
E.These images are classic for Ebstein anomaly

41. Other Recommendations
▪ Visual assessment of ventricular septal curvature looking for a
D-shaped pattern in systole and diastole should be used to
help in the diagnosis of RV volume an/or pressure overload
RV pressure overload-septal shift throughout
cardiac cycle with most marked distortion of LV
at end systole
RV volume overload-septal shift occurs
predominately in mid to late diastole

42. Pulmonary Artery Pressures
▪ PASP should be estimated and reported in all subjects with
reliable tricuspid regurgitant jets

43. Which of the following parameters are used to
calculate Pulmonary artery systolic pressure?
A. TR only
B. TR and PR only
C. TR andVSD only
D. TR, PR, andVSD only
E. TR, AR, PR, andVSD

44. What is the PA systolic pressure of the patient with
pulmonary stenosis, where peak TR velocity is 4
m/sec, peak velocity across pulmonic valve 3 m/sec,
and RA pressure 10 mm Hg?
A. PA systolic pressure 46 mm Hg.
B. PA systolic pressure 74 mm Hg.
C. PA systolic pressure 38 mm Hg.
D. PA systolic pressure 50 mm Hg.

45. What is the PA systolic pressure of the patient with
pulmonary stenosis, where peak TR velocity is 4
m/sec, peak velocity across pulmonic valve 3 m/sec,
and RA pressure 10 mm Hg?
A. PA systolic pressure 46 mm Hg.
B. PA systolic pressure 74 mm Hg.
C. PA systolic pressure 38 mm Hg.
D. PA systolic pressure 50 mm Hg.
RVSP
4 (4)2 + 10
64 + 10
74
74 – PSPG
74 – 4 (3)2
74 - 36
38
PASP = RVSP - PSPG

46. 28-year-old man with liver disease
presents with jugular venous distensions
A. Right ventricular systolic function is markedly diminished.
B. Peak velocity of 2.2 m/sec excludes the diagnosis of pulmonary HTN
C. Tricuspid regurgitation is likely mild.
D. There is right ventricular midcavitary gradient during systole.
E. Right ventricular systolic function can not be accurately assessed.

47. A patient with holosystolic murmur at the left sternal
border. What is RVSP?
Blood Pressure 150/80 mmHg
RA Pressure 15 mmHg
A. 35 mmHg
B. 65 mmHg
C. 50 mmHg
D. Can not be calculated

48. Other Recommendations
1/3 (SPAP) + 2/3 (PADP)1. Mean PA pressure =
2. Mean PA pressure = 79 – (0.45 x AT)
3. Mean PA pressure = 90 – (0.62 x AT)
4. Mean PA pressure = 4 x (early PR vel²) + est. RAP

49. What is the PA diastolic pressure in this
patient with dyspnea on exertion? The IVC is
dilated and does not collapse with sniffing.
A. PA diastolic pressure 14 mm Hg.
B. PA diastolic pressure 17 mm Hg.
C. PA diastolic pressure 28 mm Hg.
D. PA diastolic pressure 19 mm Hg.

50. Pulmonary Vascular Resistance
PVR =TRV max / RVOTTVI x 10 + 0.16
Significant PHTN exists when PVR is > 3 Wood units

51. RV dP/dt
▪ The rate of pressure rise in the right ventricle
▪ Estimated from the ascending limb of the tricuspid
regurgitant CW Doppler signal
RV dP/dt < 400 mmHg/s is
likely abnormal

52. Hepatic Vein Doppler
The normal HV waveform has three antegrade waves
▪ A larger systolic “S wave”
▪ A smaller diastolic “D wave”
▪ A small retrograde flow reversal from atrial contraction “A wave”

53. The following statement is TRUE regarding
below given Hepatic vein Doppler:
A. Abnormal interventricular septal motion is
due to right ventricular volume overload.
B. Inspiratory increase in forward hepatic vein
flow velocities is abnormal.
C. Above M-mode recordings are diagnostic of a
large pericardial effusion and tamponade
D. Patient has ventricular interdependence.

54. Which of the following is most compatible
with the hepatic venous flow in Figure below:
A. 56-year-old man with systemic hypertension
under control with medical therapy.
B. 39-year-old woman with hypotension in the
setting of acute inferior wall MI.
C. 25-year-old man with recurrent septic pulmonary
embolism.
D. 63-year-old man in atrial fibrillation

56. Thanks for your patience