The document discusses assessment of right ventricular systolic function. It begins by reviewing the anatomy and physiology of the right ventricle. Assessment techniques are then described, including echocardiography, MRI, and cardiac catheterization. Echocardiography is the main method used, allowing evaluation of dimensions, fractional area change, TAPSE, tissue Doppler imaging, and the myocardial performance index. Global and regional RV function provide important information for evaluating diseases affecting the right ventricle.

1. Right Ventricular Systolic
Assessment
Dr Joura Vishal
17th August 2016

2. Introduction
Sir William Harvey , 1616 , first described importance
of right ventricular function
̊̊̊̊̊̊̊̊̊̊̊̊̊̊̊̊
Thus the right ventricle may be said to be maid for
transmitting blood through the lungs , not for
nourishing them ̊̊̊̊̊̊̊̊̊̊̊̊̊̊̊̊
De Motu Cordis
Emphasis remained on left ventricle

3. Function of right ventricle
• Maintain adequate pulmonary perfusion
pressure under varying circulatory and loading
conditions in order to deliver desaturated
venous blood to the gas exchange membranes
of the lungs
• Maintain a low systemic venous pressure to
prevent tissue and organ congestion

4. Anatomy of Right Ventricle
• Most anteriorly situated cardiac chamber
• Lies immediately behind the sternum
• Delimited by tricuspid annulus and pulmonary
valve

5. Anatomy of Right Ventricle:
components
Three components
• Inlet : consists of TV , chordae tendinae,
papillary muscles
• Trabeculated apex
• Infundibulum : the smooth outflow region

6. Anatomy of Right Ventricle:
components

7. Anatomy of Right Ventricle:
muscular bands
• Parietal band ( along with infundibular septum
makes the crista supraventricularis )
• Septomarginal band extends inferiorly to
continue as
• Moderator band
Venriculoinfundibular fold separates TV and PV

8. Anatomy of Right Ventricle
Shape of RV : triangular in side view and
crescent in cross section
Septum is concave towards LV and convex
towards RV

9. RV hemodynamics
• Lower impedance , highly distensible
pulmonary circulation
• RV pressure tracings : early peaking , a rapid
declining pressure ( c.f rounded contour of LV )
• RV IVCT is shorter as RVSP rapidly exceeds
PADP and flow continues in +nce of negative
VA gradient

10. RV hemodynamics

11. Right ventricular function
RV function impaired in
• Primary right sided disease
• Secondary to left sided cardiomyopathy / valvular
heart disease
RV function can itself affect LV function
• Affecting LV preload
• Systolic / diastolic interaction via IVS
• Ventricular interdependence

12. RV failure : Causes

13. RV failure : Causes

14. Assessment of right ventricle
• Echocardiography including
2D / Tissue doppler imaging / Doppler –pulse wave
/colour wave : main stay in RV structure and
function
3D echo
• MRI : most accurate for RV volume assessment
MRI flow studies : calculate flow across AV valves /
semilunar ; regurgitant fractions ; shunt fractions;
CO

15. Assessment of right ventricle
• Radionuclide studies
• Pressure volume loops
• Cardiac catheterization
• Pressure volume loops : quantification RV
assessment – done with conductance catheter
RV elastance ; dP/dT ; ventricular compliance ;
stroke work ;

16. Assessment of right ventricle
Evaluation of RV function is an essential component
of clinical management
Challenges in RV assessment :
• Complex geometry of Right ventricle
• Limited definition of RV trabeculated myocardium
• Retrosternal position

17. Segmental anatomy of RV in
echocardiography

18. Echocardiographic RV assessment
• Done with various views as each view is
complimentary to other
• Discrepancies in structure and function should
be analyzed the echo cardiographer to gather
varied information in different views

19. Assessment of Right Ventricle

26. Right ventricle and Coronary supply

27. Right ventricle and Coronary supply
• The more proximal occlusion of RCA : more
the RV is involved
• PDA : affects RV inflow wall only – best seen in
RV inflow view
• PDA affects the posterior 1/3 rd of the
ventricular septum
• LAD supplies the RV apex

28. Assessment of Right Ventricle
RV wall thickness : a useful measurement for
RVH
Seen in
• PAH
• Infiltrative and hypertrophic cardiomyopathies
• LVH even in absence of PH

29. Assessment of Right Ventricle
RV wall thickness :measured
• End diastole
• M mode / subcoastal view
Abnormal > 0.5 cm from either view

30. RV wall thickness : subcostal view

33. RV wall thickness : M Mode

34. RV linear dimensions
• RV dilates in response to chronic volume and
/or pressure overload and RV failure
• Indexed RV end diastolic diameter : predictor
of survival in COPD Burgess MI et al J Am Soc Echocardiogr 2002
• RV / LD end diastolic diameter ratio :
predictor of adverse clinical events and /or
hospital survival in acute PE
Quiroz R et al Circulation 2004

35. RV linear dimensions
• 4 chamber view at end diastole
Qualitatively
• RV appears smaller than LV
• Not more than 2/3 rd of size of LV
• Not an apex forming ventricle
Note : avoid 5 chamber view for RV linear
dimensions

36. RV linear dimensions
• Basal diameter : maximal short axis diameter in
basal 1/3 rd of RV seen on 4 chamber view
( URL is 4.2 cm )
• Mid cavity diameter : middle third of RV at level of
papillary muscles
• Longitudinal diameter : from plane of tricuspid
annulus to RV apex
Basal diameter serves as a standard for interstudy
comparisons

37. RV linear dimensions

38. RVOT
• Include the sub pulmonary infundibulum , or
conus and the pulmonary valve
• sub pulmonary infundibulum : extends from crista
semilunaris to pulmonary valve
Importance
• First segment to show diastolic inversion in
cardiac temponade
• Congenital heart disease and arrhythmias

39. RVOT
Best view
• Left parasternal
• Subcostal
Measured at end diastole on the QRS deflection
In short axis measure :
RVOT prox : anterior aortic wall to RV free wall
RVOT distal : just proximal to Pulmonary valve

40. RVOT proximal

41. RVOT distal
• Used to calculate stroke volume for
calculation of Qp/Qs or regugitant fraction
• Most reproducible
• Important is case for ARVD
• URL : PLAX ( 33mm) ; PSAX ( 27mm)

42. Fractional area change
• Defined as EDA –ESA / EDA X 100
• Correletes with RV EF measured by MRI
Anavekar NS et al Echocardiography 2007
• Quantitatively estimation of RV function
• Lower reference value is 35%

43. Fractional area change

44. Fractional area change

45. RV dilatation
RV cavity dilation can be seen as
• Base to apex lengthening
• Free wall to septum with RV apex progressively
replacing the LV as true apex
In PSAX LV assumes a D shaped cavity
Predominantly end diastole : volume overload
Predominantly end diastole : pressure overload

46. RV dilation
Eccentricity index : ratio of LV anteroposterior
diameter and septolateral diameter
Eccentricity Index >1.0 : signifies RV dilatation

47. Hemodynamic Assessment

48. Hemodynamic Assessment
• Systolic pulmonary artery pressure
• PA diastolic pressure
• Mean PA pressure
• Pulmonary vascular resistance
• Measurement of PA pressure during exercise

49. 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

50. Systolic Pulmonary artery pressure

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

52. Hemodynamic Assessment
Mean Pulmonary Pressure
Can be measured :
• MAP = 1/3 (SPAP ) + 2/3 (PADP)
• Using pulsed Doppler of Pulmonary artery using
AT
MAP = 79-(0.45XAT )
Note : shorter the AT (measured from the onset of Q wave on ECG to onset of
peak pulmonary flow velocity ) , the higher the PVR and hence the PAP

53. Hemodynamic Assessment
Pulmonary vascular resistance
• Elevation in SPAP does not imply high PVR
• As pressure = flow X resistance
• It distinguishes elevated SPAP due to high flow vs
due to high vascular resistance.
• Measured as ratio of peak TR velocity( in m/s) to
RVOT velocity time integral ( in cm )
Note : valid for PVR <8 Wood unit , not a substitute for invasive measurement

54. Hemodynamic Assessment
Measurement of PAP during exercise
• Exercise increase the stroke volume and
decrease PVR
• Normal <43mmHg
• aged >55yrs and athletes 55 to 60mmHg
• IN COPD and CHD patients this decrease in PVR may be limited

55. Hemodynamic Assessment
• In patients with dyspnea of unknown origin and
with normal CAG and normal resting
Echocardiography this exercise induced changes
in PAP can be a useful measure
• Stress echocardiography is performed to
estimate the stress induced PH
• An upper limit of 43 mmHg is used

56. Non volumetric assessment of
Right Ventricle
• Global assessment of RV
• Regional assessment of RV
 inward bellow movement due to superficial
circumferential muscle fibres
 base to apex contraction inner longitudinal
fibers ( play a major role in RV c.f LV )

57. Global Assessment of Right Ventricle
– Myocardial performance index
– RV dp/dT
– Right ventricular ejection fraction ( RVEF )
– Fractional area change ( FAC )

58. Global Assessment of Right Ventricle
RV dP/dT
Developed by Gleason and Braunwalds in 1962
• Rate of pressure rise in ventricles ( dP) versus
time
• Calculated as time required for the TR jet to
increase in velocity from 1 to 2 m/s
• Equals to 12mmHg divided by time
Values <400mmHg/s is abnormal
Note : load dependent ; cannot be used in severe TR

59. Global Assessment of Right Ventricle
Myocardial performance index ( also called Tei
index )
• Ratio of isovolumic time to ejection time
i.e RIMP = IVCT +IVRT / ET
Measured by
• Pulsed doppler
• Tissue doppler

60. Global assessment of RV : Tei Index
Pulsed Doppler
• RV outflow time ET : Time from onset to
cessation of flow across RVOT
• Tricuspid closure opening time ( TCO ) time from
end of transtricuspid A wave to beginning of
transtricuspid E wave
Ejection time doesnot include IVCT and IVRT

61. Tei Index : TDI
• Calculation of all times are done across a
single beat

62. Tei index : TDI

63. IVCT /IVRT

64. Tei index

65. Tei Index : Tissue Doppler

66. Tei Index
• Prognostic value
• Changes across time has relation with clinical status
Seebag I et al Am j Cardio 2001
• URL 0.40 by pulsed doppler and 0.55 by TDI
• Note : Unreliable when RA pressures are elevated as
there is more equilibration of pressures between RV
and RA , shortening of IVRT hence inappropriately
low Tei index

67. Regional Assessment Of
Right Ventricle
– TAPSE or tricuspid annular motion
– Doppler tissue imaging
– Myocardial acceleration during isovolumicv
contraction
– Regional RV strain

68. Regional Assessment Of Right
Ventricle : TAPSE
• Measure the systolic excursion of RV annular
segment along its longitudinal plane
• Assunption: displacement of basal and
adjacent segment in representative of entire
RV function
• Measured across TV annulus in M mode

69. Regional Assessment Of Right
Ventricle : TAPSE
Correlates with radinuclide angiography
Kaul et al Am Heart J

70. Regional Assessment Of Right
Ventricle : TDI
• Most reliable and reproducible region of RV are
tricuspid annulus and basal free wall segment
• measures the longitudinal velocity of excursion
termed a S’
• S’ by pulsed TDI < 10cm/s is abnormal
• Simple reproducible technique but less reliable
for non basal segments and it is angle dependent

72. Regional Assessment Of Right
Ventricle : TDI

73. 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

76. 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

77. Conclusion
• Visual assessment provides qualitative evaluation
of RV
• 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 / strain rate , IVA are not routinely
recommended