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12 Assessment ofLeft Ventricular Systolic Function inPatients withDicult or Poor Acoustic Windows
159
A. 1.5L/min/m
B. 3.5L/min/m
C. 7.0L/min/m
D. 6.3L/min/m
2
2
2
2
Answer: A
The stroke volume is calculated by multiplying the cross-sectional surface area of the
LVOT by the stroke distance (LVOT VTI).
π(d/2)2×LVOTVTI [d=LVOT diameter
(2.2cm); LVOT VTI = 8.0cm]
Therefore, the stroke volume is 30.4mL
and the cardiac output is 30.4mL×114 BPM
= 3.465L/min.
The cardiac index is 3.465L/min divided
by the body surface area (2.2m2) which equals
1.5L/min/m2.
(LVOT, left ventricular outow tract; VTI,
velocity time integral)
160
AB
2. A 55-year-old female presents to emergency
room with hypotension and fever. She receives
30cc/kg of IV uids but remains hypotensive.
Bedside cardiac ultrasound is performed, but
the acoustic windows are technically challenging. M-mode assessment of the mitral
valve is performed (A). Based on the M-mode
tracing, what is the next best step?
B. M. Wiley
A
A. Start epinephrine
B. Start dobutamine
C. Start milrinone
D. Start phenylephrine
Answer: D
AB
12 Assessment ofLeft Ventricular Systolic Function inPatients withDicult or Poor Acoustic Windows
161
The M-mode mitral valve tracing demonstrates a negligible EPSS distance (blue
arrow) in early diastole suggestive of normal
LV systolic function. However, note that the
anterior leaet of the mitral valve also touches
the ventricular septum during systole (red
arrow). This is a classic M-mode tracing of
systolic anterior motion of the mitral valve
causing left ventricular outow tract obstruction in a patient with hypertrophic obstructive
cardiomyopathy. The administration of inotropic agents in this patient can worsen the
outow obstruction and cause worsening
hypotension. The best agent for hypotension
in this situation is a vasopressor such as phenylephrine (or vasopressin) that will increase
the systemic vascular resistance without con-
comitant increase in heart rate. Figure B demonstrates a normal M-mode of the mitral valve
with negligible EPSS distance (green arrows).
However, note that the mitral leaets stay on
the closure line (yellow arrows) during systole. The orange arrow is the A-point that
reects mitral anterior leaet motion due to
atrial contraction (EPSS, E-point septal separation; LV, left ventricle)
3. The pulse wave Doppler tracings of the LVOT
are from a patient with a dilated cardiomyopathy that was admitted to the cardiac intensive
care unit with oliguria and elevated lactate.
The blood pressure at the time of admission
was 135/80 mmHg. What was the intervention that was performed to cause the change
from image A to image B?
A. Started phenylephrine
B. Started vasopressin
C. Started nitroprusside
D. Started esmolol
Answer: C
This was patient admitted to the cardiac
intensive care unit with normotensive cardiogenic shock (mean arterial pressure
98mmHg). The initial LVOT VTI (6.9cm) is
consistent severely reduced stroke volume.
The patient was started on a nitroprusside
infusion to target a mean arterial pressure of
65–70 mmHg. Image B is the repeat LVOT
VTI after reaching target mean arterial pressure. The LVOT VTI has increased to 14.1cm
which correlates with a doubling of stroke
volume. (LVOT, left ventricular outow tract;
VTI, velocity time integral).
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The Right Ventricle
SiddharthDugar
andSaraschandraVallabhajosyula
13
Learning Objectives
1. Describe techniques for the assessment of
right ventricular function
2. Discuss the utility of TAPSE (Tricuspid annulus plane systolic excursion) to assess right
ventricular function
3. Examine echocardiography-derived estimates
of pulmonary pressure including RVSP, SPAP,
DPAP, and mean PAP
The Right Ventricle
The right ventricle (RV) is the most anteriorly
positioned thin-walled cardiac chamber supplying blood to the highly compliant pulmonary
circulation. It is crescentic shaped, wrapping
around the left ventricle in a U-shaped manner
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978-3-031-80038-2_13.
[1, 2]. The late adoption and incorporation of
RV as part of the comprehensive cardiac assessment are partly due to its unique shape and
retrosternal position limiting image acquisition
and quantitative assessment. There is no single
echocardiographic view that completely encompasses the entire RV [3, 4]. Hence, a comprehensive echocardiographic assessment of the
RV requires multiple windows including the
conventional apical four-chamber (A4C), parasternal long- (PLAX) and short-axis (PSAX),
RV inow and subcostal views, and RV-focused
view. On transesophageal echocardiogram
(TEE), mid- esophageal four-chamber, RV
inow-outow views, and the trans-gastric
short- and long-axis views are utilized for RV
assessment. In addition, the pronounced trabeculations compromise accurate endocardial
delineation. Despite the challenges of evaluating the RV using echocardiography, it remains
the most widely utilized imaging modality for
RV assessment.
S. Dugar
Department of Critical Care, Cleveland Clinic Lerner
College of Medicine, Respiratory Institute, Cleveland
Clinic, Cleveland, OH, USA
e-mail: dugars@ccf.org
S. Vallabhajosyula (*)
Cardiology Division, Warren Alpert Medical School
of Brown University, Providence, RI, USA
e-mail: svallabhajosyula@brownhealth.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_13
Echocardiographic Evaluation
oftheRight Ventricle
The comprehensive examination of the RV
includes the parasternal long-axis (PLAX), RV
inow view, RV outow view, parasternal shortaxis (PSAX) view, standard apical four-chamber
165
166
Fig. 13.1 The routinely used echocardiographic views to assess right ventricle size and function. PLAX parasternal
long axis, RV right ventricle, PSAX parasternal short axis, IVC inferior vena cava
S. Dugar and S. Vallabhajosyula
view, and subcostal views (Fig.13.1) [3, 5]. The
PLAX view produces views of the proximal
RVOT, and the PSAX view allows assessment of
the proximal and distal RVOT in the RV outow
view and RA and tricuspid valve in the RV inow
view. The linear dimension and area measurements of the RV along with regional and global
functional assessment of the RV are mostly performed in apical views. Traditionally, the subcostal view is utilized for the assessment of inferior
vena cava (IVC) size and collapsibility to estimate
right atrial pressures. In a critically ill patient, the
subcostal view is more frequently obtainable than
the apical view, a more comprehensive assessment
of the RV in the subcostal view has been suggested
including a strain with promising results [6–9].
Right Ventricular-Focused View
The conventional apical four-chamber view
(A4C) is obtained with the cardiac apex in the
center of the screen to avoid left ventricle (LV)
foreshortening (Video 13.1). This results in signicant variability of the RV dimension and
functional assessment. In addition, the RV-free
wall may be obscured by lateral artifacts limiting
precise RV assessment in a signicant proportion
of critically ill patients. The RV-focused view is
obtained by lateral displacement of the transducer from the conventional A4C view position
together with a probe rotation to obtain the largest RV dimension in its long axis (Video 13.2) [3,
4, 10]. The RV-focused view enhances RV cavity
and free wall visualization without foreshortening. The visualization of the entire RV both during systole and diastole in this view has been
shown to improve accuracy, hence is being recommended as the ideal view to assess the RV.In
a recent study, the RV size was larger and the RV
function quantied using RV Fractional area
change (FAC), Tricuspid annulus plane systolic
excursion (TAPSE), and Tricuspid annular systolic velocity (TASV) to be higher in the
RV-focused view in comparison to conventional
A4C view. Importantly, the authors established
RV-focused view had higher intra-rater and interrater accuracy for RV dimensions [10]. This is
especially important in critically ill patients,
where these measurements may be used in a
dynamic manner to determine response to interventions [11].
13 The Right Ventricle
167
Semi-Quantitative Right Ventricular Assessment
RV dimensions may be challenging to obtain and
inaccurate when the RV-free wall is not well
visualized. In such cases, qualitative measurement of RV dilation by comparing it to LV size in
an A4C view has been described.
• Normal (RV≤2/3 LV size)
• Mildly dilated (RV≥2/3 but <LV size)
• Moderately dilated (RV=LV area)
• Severely dilated (RV>LV area)
Orde etal. [12] showed a visual assessment of
RV size and function can be used as an initial
screening tool for the detection of RV pathology in
critical care settings when performed by an intensivist with expertise in critical care echocardiography. One must be careful in cases of LV size
abnormality, as it may lead to an incorrect assessment of RV dimension. However, if one is to use
RV assessment for dynamic monitoring, quantitative assessment is recommended. In a study by
Vallabhajosyula et al., quantitative parameters
failed to show any benet or semi- quantitative
assessment in predicting outcomes [13]. One can
also assess the apex to determine the presence of
RV dilation. The LV usually forms the apex. As the
RV enlarges, it displaces the LV and occupies the
apex, which can act as an indirect marker of RV
enlargement. RV can also be evaluated from the
subcostal view, where if the RV appears larger
than LV, RV dilatation is likely to be present. One
has to be careful to conrm subcostal ndings in
other views. McConnell’s sign is another visually
characteristic echocardiographic pattern with dyskinesia of the mid-RV-free wall with relative sparring of the RV apex observed in acute RV
dysfunction from increased afterload as in the case
of pulmonary embolism and ARDS (Video 13.3).
Interventricular Septum
The interventricular septum functions as part of
the LV in the normal heart. A qualitative examination of the septal motion in the PSAX view at
the papillary muscles level may help to distinguish normal RV dysfunction from RV dysfunction due to volume and pressure overload. In the
absence of RV dysfunction, the LV chamber
appears circular during both systole and diastole.
RV pressure overload (RV hypertrophy with a
nondilated chamber) results in a leftward shift of
septal motion throughout the cardiac cycle with
the maximum reversed curvature at end-systole,
while RV volume overload (RV dilatation) results
in septal attening (D-shaped pattern) at enddiastole [3, 14, 15].The abnormal pattern of septal motion can be easily appreciated in 2D
imaging. In cases, where the pattern is not clear,
M-mode imaging with higher temporal resolution can be utilized (Video 13.4) [16].
Right Ventricular Dimensions
One of the challenges in the uniform calculation
of RV dimension stems from the absence of specic right-sided anatomic landmarks to be used
as a reference point (Table 13.1). One must be
careful in assessing RV dimension in standard
apical view as small probe manipulations may
result in signicant variation in linear dimension
and chamber size, hence RV-focused view is recommended for linear dimension and area measurement [10]. RV basal dimensions are measured
at the base of RV at the point of insertion of a
tricuspid leaet to RV-free wall and interventricular septum (IVS) at end-diastole. It comprises
the maximal short-axis dimension in the basal
one-third of the RV.RV mid-cavity dimension is
obtained on RV-free wall at the level of completely open anterior tricuspid leaet tip and routinely corresponds to LV papillary muscle level.
The longitudinal dimension is drawn from the
plane of the tricuspid annulus to the RV apex. In
the RV-focused view, RV enlargement is identied when RV basal diameter >41mm, mid- cavity
dimension >35 mm, or longitudinal dimension
>86mm. Proximal RV outow diameter (RVOT
prox) is measured in PLAX or PSAX at the aortic
valve level from the RV-free wall to the interventricular septal-aortic junction (PLAX) or the aortic valve (PSAX) at end-diastole with normal
168
S. Dugar and S. Vallabhajosyula
Table 13.1
Linear dimension
Measurement of right ventricular function in critical care echocardiography
Normal
33±4mm (basal)
27±4mm (mid)
71±6mm (long)
Abnormal
>41mm (basal)
>35mm (mid)
>83mm (long)
Normal
28±3.5mm (Prox)
22±2.5mm (Dist)
Abnormal
>35mm (Prox)
>27mm (Dist)
• Measured in A4C or preferably in
RV-focused view
• End-diastole
• Inner edge to inner edge
• Avoid foreshortening
• Signicant variability in obtained
measurement with minimal probe
rotation
• RVOT proximal is measured in
PLAX and PSAX view
• RVOT distal is measured in PSAX
and RV outow view
• End-diastole
• Inner edge to inner edge
• Avoid obliquely oriented image
• Inner edge to inner edge
• Limited data on normal values
(continued)
13 The Right Ventricle
169
Table 13.1
Area
(continued)
Normal
3±1mm
Abnormal
>5mm
Normal
18±7cm
Abnormal
2
>25cm
• Measured in zoomed-in subcostal
view using M-mode or B-mode
imaging
• At the level of tip of open anterior
tricuspid leaet on RV free wall
• End-diastole
• Exclude trabeculae, papillary
muscles, and epicardial fat
• Single site measurement may limit
accuracy
2
RV end-diastolic area
• Measured by tracing endocardium
in RV-focused view
• End-diastole
• Trabeculations, papillary muscles,
and moderator band are included
in the cavity area
• Needs optimal image with a clear
denition of the endocardial border
• Avoid foreshortening
Normal
RVEDA/LVEDA
>0.6
Abnormal
RVEDA/LVEDA
≥0.6
RV end-diastolic area/LV enddiastolic area
• Measured by tracing endocardium
in A4C view
• End-diastole
• Needs optimal image with a clear
denition of the endocardial border
• Avoid foreshortening
• Established prognostic values in
critically ill patients
(continued)