EASY TO LEARN RV FUNCTION BY ECHO

1. ECHO ASSESMENT OF RV FUNCTION
DR. DEEPAK AGRAWAL
SIR GANGARAM HOSPITAL DELHI

2. RIGHT VENTRICULAR ANATOMY

4. Limitations of Echocardiography in The
Evaluations of RV Function
▶Difficulties in the estimation of RV volume
: crescentic shape of RV
: separation between RV inflow and outflow
: no uniform geometric assumption for measuring volume
▶Difficulties in the delineation of endocardial border owing to
well developed trabeculation
▶Difficulties in the adequate image acquisition owing to the
location just behind the sternum

5. Limitations of Echocardiography in The
Evaluations of RV Function
▶ Difficult to standardize the evaluation method of RV function
: Variations in the direction or location of the RV are common
: Easily affected by preload, afterload, or LV function
▶Different complex contraction-relaxation mechanism among
the segments of the RV
▶Cannot image the entire RV in a single view

6. Function of the Right Ventricle
Why should we measure RV function?
▶ RV is not just a conduit of blood flow
: has its unique function
▶Prognostic significance in various clinical settings
▶Risk stratification or guide to optimal therapy

7. Function of the Right Ventricle
▶ Conduit of blood flow▶ Maintain adequate pulmonary artery perfusion pressure to
improve gas exchange
▶ Maintain low systemic venous pressure to prevent
congestion of tissues or organs
▶ Affect LV function
: limit LV preload in RV dysfunction
: Ventricular interdependence
▶ Prognostic significance in various clinical settings

8. RV WALL THICKNESS AND CHAMBER SIZE
RV INFERIOR
WALL
SUBCOSTAL
VIEW
N=<0.5cm
Measured at
peak r wave

9. 2D and M-mode: Thickness of RV Free Wall
▶ Normal: less than 0.5 cm
▶ Measure at the level of TV chordae and at the peak of R wave of
ECG on subcostal view
▶ Well correlated with peak RV systolic pressure

10. RV DIMENTIONS
DIAMETERS ABOVE THE TRICUSPID VALVE ANNULUS
MID RV CAVITY
DISTANCE FROM THE TV ANNULUS TO RV APEX

11. RV DIMENTIONS

12. 2D and M-mode: RV Dimension
Referencerange Mild abnormal Moderate abnormal Severe abnormal
Basal RV diameter (RVD1) 2.0-2.8 2.9-3.3 3.4-3.8 ≥3.9
Mid-RV diameter (RVD2) 2.7-3.3 3.4-3.7 3.8-4.1 ≥4.2
Base–to-apex (RVD3) 7.1-7.9 8.0-8.5 8.6-9.1 ≥9.2

13. 2D and M-mode: RVOT and PA Size

14. 2D and M-mode: RVOT and PA Size
Referencerange Mild abnormal Moderate abnormal Severe abnormal
RVOT diameters, cm
Above aortic
valve(RVOT1)
2.5-2.9 3.0-3.2 3.3-3.5 ≥3.6
Above pulmonic
valve(RVOT1)
1.7-2.3 2.4-2.7 2.8-3.1 ≥3.2
PA Diameters, cm
Below pulmonic valve
(PA1)
1.5-2.1 2.2-2.5 2.6-2.9 ≥3.0

15. 2D and M-mode: RV Size
▶ Normal RV is approximately 2/3 of the size of the LV
▶ RV Dilatation
: appears similar or larger than LV size
: shares the apex

16. 2D and M-mode: Fractional Area Change (FAC)
(End-diastolic area) – (end-systolic area)
x 100
(end-systolic area)

17. 2D and M-mode: RV Area and FAC in A4C
▶ Well correlated with RV function measured by radionuclide
ventriculography or MRI
▶ Good predictor of prognosis
▶ Limitations: fail to measure FAC due to inadequate RV tracing
Referencerange Mild abnormal Moderate abnormal Severe abnormal
RV diastolic area (cm2) 11-28 29-32 33-37 ≥38
RV systolic area (cm2) 7.5-16 17-19 20-22 ≥23
RV FAC (%) 32-60 25-31 18-24 ≤17

18. Tricuspid Annular Plane Systolic Excursion
▶ Degree of systolic excursion of TV lateral annulus on A4C
: 1.5-2.0 cm in normal
: Value less than 1.5 cm is considered as abnormal
▶ Well correlated with RVEF measured by RVG
▶ Reproducible
▶ Strong predictor of prognosis in patients with CHF

21. REGIONAL ASSESSMENT OF RIGHT VENTRICLE :
TAPSE

22. Tricuspid Annular Plane Systolic Excursion
※ 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
to TAPSE in patients with CHF

23. TISSUE DOPPLER IMAGING
• An apical four chamber view is used
• The pulsed Doppler sample volume is placed in either the tricuspid annulus or the middle of
the basal segment of the RV free wall
• The S´ velocity is read as the highest systolic velocity without over-gaining the Doppler
envelope
Normal > 10 cm/s

24. TISSUE DOPPLER (S´)
Advantages Disadvantages
• A simple, reproducible technique with
good discriminatory ability to detect
normal versus abnormal RV function
• Pulsed Doppler is available on all modern
systems
• Maybe obtained and analyzed off-line
• Less reproducible for nonbasal segments
• Is angle dependent
• Limited normative data in all ranges' and
in both sexes
• It assumes that the function of a single
segment represents the function of the
entire right ventricle

25. RV IMP (TEI INDEX)
• RV index of Myocardial Performance
• Global index of both systolic and diastolic function of the right ventricle
IVRT + IVCT
ET
Normal < 0.40 Normal < 0.55

27. If Heart rate > 100

28. Advantages Disadvantages
• This approach is feasible in a large
majority of subjects
• The MPI is reproducible
• It avoids geometric assumptions and
limitations of the complex RV geometry
• The pulsed TDI method allows for
measurement of MPI as well as S´, E´, and
A´ all from a single image
• The MPI is 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 pressures are elevated

29. 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

30. RV DIASTOLIC FUNCTION
Variable Lower reference value Upper reference value
E (cm/s) 35 73
A (cm/s) 21 58
E/A ratio 0.8 2.1
Deceleration time (ms) 120 229
IVRT (ms) 23 73
E’ (cm/s) 8 20
A’ (cm/s) 7 20
E’/A’ ratio 0.5 1.9
E/E’ 2 6

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’ ratio > 6 or diastolic prominence in the hepatic veins suggest
pseudonormal filling
E/A ratio > 2.1 with deceleration time < 120 ms suggests restrictive filling

32. RIGHT ATRIAL ASSESSMENT
• Apical 4-chamber view
• Estimation of right atrial area by planimetry
The maximum long distance of the RAis from
the center of the tricuspid annulus to the
superior RA wall, parallel to the interatrial
septum
A mid RA minor distancve is defined from the
mid level of the RA free wall to the interatrial
septum perpendicular to the long axis
RA area is traced at the end of ventricular
systole, excluding the IVC, SVC, and RAA
Normal area < 18 cm²

33. RA PRESSURE DETERMINATION
• Measurement of the IVC should be obtained 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, the
change in diameter of the IVC with a
sniff and also with quiet respiration
should be measured, ensuring that the
change in diameter does not reflect a
translation of the IVC into another plane

34. 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:
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

35. HEMODYNAMIC ASSESSMENT
Systolic pulmonary artery pressure
• Estimated with TR jet velocity using simplified Bernoulli equation ( provided there is no RVOT
obstruction )
RVSP = 4(V)2+RA pressure
• Normal peak RVSP is 35 to 36 mmHg assuming RA pressure of 3 to 5 mmHg
Note : Measure TR jet velocity from various views to get the highest velocity

36. SYSTOLIC PULMONARY ARTERY PRESSURE

37. HEMODYNAMIC ASSESSMENT
Pulmonary artery diastolic pressure ( PADP )
• Estimated from velocity of end diastolic pulmonary regurgitant jet using
PADP = 4(V)2+ RA pressure

38. HEMODYNAMIC ASSESSMENT
Mean Pulmonary Pressure
Can be measured :
• MAP = 1/3 (SPAP ) + 2/3 (PADP)

39. PULMONARY VASCULAR RESISTANCE
PVR = TRV max / RVOT TVI x 10 + 0.16
2.78 m/sec ÷ 11 cm x 10 + 0.16 = 2.68 Wood units
Significant PHTN exists when PVR is > 3 Wood units

40. PVR
• The estimation of PVR is not adequately established to be recommended for routine use
but may be considered in subjects in whom pulmonary systolic pressure may be
exaggerated by high stroke volume or misleading low by reduced stroke volume
• The noninvasive estimation of PVR should not be used as a substitute for the invasive
evaluation of PVR when this value is an important guide to therapy

41. RV STRAIN / STRAIN RATE
• Defined as percentage change in myocardial deformation
• Strain rate is rate of deformation of myocartdium over time
• Mainly for basal , mid and to a lesser degree apical segments of RV free wall
• Less load dependent and applicable across broad range of pathologies

44. CLINICAL AND PROGNOSTIC
SIGNIFICANCE
• Conditions such as Acute PE cause increase in RV size prior to augmentation of
pulmonary pressures
• Quantitative assessment can guide us more towards quality of life and adds
information for functional outcome

45. SUMMARY OF RECOMMENDATIONS
FOR THE ASSESSMENT OF RIGHT
VENTRICULAR SYSTOLIC FUNCTION
• Visual assessment provides qualitative evaluation of RV function.
• Quantitative assessment measures :
FAC , TAPSE , Pulsed tissue Doppler S’ and Tei index are reliable , reproducible
methods.
• Combining more than one measure can reliably distinguish normal from abnormal.
• Strain and strain rate are not routinely recommended.

46. THANK YOU