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170
Table 13.1 (continued)
Regional measurement
Normal
49±7%
Abnormal
<35%
Normal
24±3.5mm
Abnormal
<17mm
S. Dugar and S. Vallabhajosyula
• Measured by tracing endocardium
in RV-focused view
• End-diastole and end-systole
• Needs optimal image with clear
denition of endocardial border
• Incorporates both longitudinal and
radial components of RV
contraction
• Established prognostic value in
critically ill patients including sepsis,
PH, pulmonary embolism, ARDS,
and heart failure
• Limited inter-rater reliability and
reproducibility
• Measures displacement of lateral
tricuspid annulus toward cardiac
apex in systole
• Can be acquired in suboptimal
images
• Excellent inter-rater reliability and
reproducibility
• Established prognostic value in
critically ill patients including
sepsis, PH, pulmonary embolism,
ARDS, and heart failure
• Regional measurement
• Angle dependent
(continued)
13 The Right Ventricle
Table 13.1 (continued)
Global measurement
Normal
14.1±2.3cm/s
Abnormal
<9.5cm/s
Normal
0.38±0.08
Abnormal
>0.54
171
• Measures peak tissue velocity of
lateral tricuspid annulus movement
toward cardiac apex in systole
• Can be acquired in suboptimal
images
• Excellent inter-rater reliability and
reproducibility
• Established prognostic value in
critically ill patients including
sepsis, PH, pulmonary embolism,
ARDS, and heart failure
• Regional measurement
• Angle dependent
• Measures time spent in nonejection
time of total ejection time
• Measured in A4C view using tissue
Doppler or pulsed wave Doppler
• Avoid geometric assumptions
• Limited literature on critical illness
• Angle dependent
• Not accurate in severe TR and
elevated RA pressure
(continued)
172
S. Dugar and S. Vallabhajosyula
Table 13.1
(continued)
Normal
−29±4.5%
Abnormal
>−20%
Normal
≤2.8m/s
Abnormal
>2.8m/s
• Measures movement of speckles
toward each other in systole
• Angle independent
• Needs optimal image with a clear
denition of the endocardial border
• Needs strain analysis platform
• Emerging prognostic value in
critically ill patients including
sepsis, PH, pulmonary embolism,
ARDS, and heart failure
• May have a role in the
identication of subclinical
dysfunction
• Measured from RV inow, PSAX,
A4C views
• Measures the RV-RA gradient
• Utilized to measure SPAP
• Highest value is considered Angle
dependent
A4C apical four-chamber view, RV right ventricle, RVOT right ventricle outow tract, PLAX parasternal long axis, PSAX
parasternal short axis, LV left ventricle, PH pulmonary hypertension, ARDS acute respiratory distress syndrome, TR
tricuspid regurgitation, RA right atrium, SPAP systolic pulmonary arterial pressure
reference range of 21–35mm. Distal RV outow
diameter (RVOT distal) is measured just proximal to the pulmonic valve at end-diastole with a
normal reference range of 17–27mm [3, 4].
measurement can be improved with a zoomed
image of RV mid-wall with the endocardium and
epicardium perpendicular to the ultrasound beam
and the exclusion of trabeculations, papillary
muscle, and epicardial fat pad from the
measurement.
Right Ventricular Wall Thickness
In the setting of chronically elevated right-sided
pressure, adaptive RV hypertrophy ensues which
can be identied by RV-free wall thickness of
>0.5cm. The measurement is performed in subcostal view using either M-mode or 2D image on
the free wall at the tip of the fully open tricuspid
leaet at end-diastole [4, 17]. The accuracy of
Right Ventricular Area/Volume
LV volumes are routinely measured to determine
the presence of LV dilation and to obtain LV ejection fraction. Volumetric assessments are limited
due to the complex RV anatomy. The disk summation method has been applied for RV volume
13 The Right Ventricle
173
and RVEF similar to LVEF in A4C but remains
technically challenging and has limited data to
support its routine use. RV EF<44% is considered abnormal [4].
Given the complexity of obtaining RV volume,
Jardin and colleagues proposed comparing the area
measurement of both ventricles and using the ratio
to diagnose RV dilation [18]. The ventricular areas
are traced at end-diastole in the A4C view. RV enddiastolic area to left ventricular end-diastolic area
(RVEDA: LVEDA) >0.6 to be highly suggestive of
moderate RV dilation, while area of (RVEDA:
LVEDA) ≥1 suggests severe RV dilation. RVEDA/
LVEDA ≥1 has been shown to be associated with
high morbidity and mortality in pulmonary embolism and acute respiratory distress syndrome
(ARDS) patients [19–21]. In the study, the authors
noted RVEDA/LVEDA may be not feasible in
1/4th of ARDS patients with TTE, as area measurement requires complete visualization of ventricles
and suggested routine use of TTE.RV end-diastolic
dimension to left ventricular end-diastolic dimension (RVEDD: LVEDD), a more easily measured
value above 1 has also been studied in pulmonary
embolism and may be an alternative to more complex RVEDA/LVEDA ratio [20].
Regional Systolic Functional Assessment
TAPSE (Tricuspid Annulus Plane Systolic Excursion)
Traditionally, the longitudinal ber shortening
has been postulated to account for most of the RV
contraction [22]. TAPSE or TAM (tricuspid
annular motion) is a simple and easily obtainable
quantitative measurement of RV systolic function
[3–5]. The contraction of these longitudinally
oriented RV muscle bers results in systolic displacement of the tricuspid annulus toward the RV
apex providing one of the most visible estimations of RV systolic function. TAPSE is obtained
by measuring the distance of this excursion at
peak systole. M-mode cursor is placed on the
junction of the tricuspid valve plan along the
RV-free wall in orientation toward the cardiac
apex in A4C and RV-focused view [3, 4, 10]. The
normal value is >17mm based on 46 studies with
over 2300 patients; a lower value is suggestive of
RV systolic dysfunction [3]. Reduced TAPSE has
been shown to be a poor prognostic maker in
inferior wall myocardial infarction, pulmonary
embolism, ARDS, sepsis, and in the general
patient population [21, 23–27]. TAPSE has also
been validated as an accurate measurement of RV
systolic function to gold standard measures
including radionuclide angiography, biplane
Simpson RV ejection fraction, and RV fractional
area shortening [28, 29]. In addition to ease of
measurement with minimal training, high interrater and intra-rater reliability and repeatability
are the main reasons for its widespread use [30].
SEATAK (Systolic Excursion
Assessment ofTricuspid Annular
Kick) or sTAPSE (Subcostal TAPSE)
Subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) or subcostal TAPSE
(sTAPSE) has recently been proposed as an alternative to conventional TAPSE in critically ill
patients with morbid obesity, chronic lung disease,
mechanical ventilation, or in patients where apical
view may be inadequate [8, 9]. Studies have shown
SEATAK and sTAPSE from a subcostal view to be
more easily obtainable in these cohorts. M-mode
or B-mode can then be used to measure the linear
displacement of tricuspid annulus from end-diastole to end-systole. Both SEATAK and sTAPSE
have been shown to have excellent correlation to
conventional TAPSE [8, 9] and other echocardiographic markers of RV function. Subcostal TAPSE
was shown to accurately detect abnormal longitudinal shortening with a sensitivity of 97.8% and
specicity of 87.5% in critically ill.
Tricuspid Annular Systolic Velocity (Right Ventricular S′)
Tricuspid annular systolic velocity (TASV) or
RV S′ measures the peak myocardial tissue
velocity of systolic displacement of the tricuspid
174
ET
OE
ET
S. Dugar and S. Vallabhajosyula
annulus toward the RV instead of distance as
measured with TAPSE.It is measured at the tricuspid annulus on the RV-free wall (same as
TAPSE) using tissue Doppler (TDI). In a conventional A4C or RV-focused view, TDI is activated
highlighting the RV-free wall with pulsed wave
Doppler sample volume placed at the lateral tricuspid annulus [4]. The highest resultant tissue
velocity at the tip of the clear signal is measured.
A value of <9.5cm/s indicates RV systolic dysfunction [3]. Validation studies comparing pulsed
TASV with radionuclide angiograph have shown
good correlation and excellent discriminative
ability of TASV to differentiate normal and
abnormal RV systolic function [4, 31].
Unlike volumetric assessments, TAPSE and
TASV do not require distinct endocardial border
denitions. However, it assumes that the displacement of the tricuspid annulus is representative of the function of the entire RV, an assumption
that is not valid in many disease states or with
regional RV wall motion abnormalities. These
measurements are also angle-dependent.
Global Systolic Functional Assessment
Right Ventricular Fractional Area Change
Fractional area change (FAC) is the percentage
change in RV area at the end of systole from the
end of diastole and is calculated as:
RV FAC
RVFAC is usually measured in conventional
A4C or RV-focused view in transthoracic echocardiography and the mid-esophageal 4C view in
transesophageal echocardiography. A key
requirement for accurate RVFAC is a welldened endocardial border denition, limiting its
application and reproducibility in a critically ill
patient. The heavy trabeculations in RV should
also be excluded during tracing the true apex and
RV-free wall. The major benet of RVFAC over
other measurements is it is not angle-dependent
RVEDARVESA
=
−
RVEDA
∗100
and accounts for both the longitudinal and radial
components of RV contraction. RVFAC has also
been validated against cardiac magnetic resonance (CMR) obtained RV ejection fraction and
3D EF [32, 33]. An FAC <35% is considered
abnormal. A reduced RV FAC is associated with
poor outcome in ARDS, pulmonary embolism,
sepsis, and myocardial infarction [32, 34–36].
Right Ventricular Index ofMyocardial
Performance
Right ventricular index of myocardial performance (RIMP) also known as Tei index is a global
estimate of RV systolic and diastolic function. It
is the ratio of time spent during nonejection time
(isovolumetric contraction and isovolumetric
relaxation) to total ejection time. RIMP being the
ratio of time intervals, is independent of the complex RV geometry. The measurement can be
obtained using either tissue Doppler at the lateral
annulus or pulsed wave Doppler at the tricuspid
leaet tips. The benet of using the tissue Doppler
technique is that the isovolumetric contraction
time (IVCT), the isovolumetric relaxation time
(IVRT), and ejection time (ET) can be obtained
from the same heartbeat. The pulsed Dopplerderived RIMP is obtained over two separate cardiac cycles; hence one needs to make sure the RR
interval of the cardiac cycle used is the same
length for accurate results.
IVRT IVCT
RIMP
=
RIMP
As the RV decompensates, the time spent during nonejection of total ejection time increases
[37]. The upper reference limits for RIMP
obtained using the pulsed wave technique are
0.43 and 0.54 when calculated by tissue Doppler
imaging. RIMP is affected by pressure and loading conditions, which limits its utilization in the
presence of severe TR and elevated RA pressure
(RAP), conditions frequently observed in critically ill patients.
+
TC
=
T
+
()
13 The Right Ventricle
175
Right-Sided Hemodynamics
RV systolic pressure (RVSP) is the most frequently documented right-sided pressure in the
critically ill cohort and general population. RVSP
is calculated from peak TR jet velocity, using the
simplied Bernoulli equation and combining this
value with an estimate of the RA pressure
SPAPRVSPPeak TR jetvelocity
==
+
4
RAP
Peak TR jet velocity is usually obtained by
continuous-wave Doppler from the RV inow or
the A4C view and is reective of the pressure difference between RV and RA during systole.
Hence, the addition of RA pressure to the equation to obtain RVSP.In spontaneously breathing
patients, the RA pressure can be estimated from
IVC diameter and collapsibility. However, no
echocardiographic measurements have been validated for RA pressure measurement in patients on
positive pressure ventilation. During the use of
positive pressure, the RA pressure should be
obtained from central venous access with a tip
located in the right atrium. RVSP and Systolic
pulmonary artery pressure (SPAP) are equal in the
absence of pulmonary stenosis or RVOT obstruction. The velocity measurements are angle-dependent, hence it is recommended to gather TR
signals from several windows and to use the signal with the highest velocity. In cases of weak or
incomplete TR signal, enhancement of signal
with agitated saline or blood-saline contrast has
been shown to improve measurement accuracy.
One has to be careful to avoid overestimation of
the spectral envelope by ensuring that only the
well-dened, dense spectral prole is measured.
In patients with severe TR, the Doppler envelope
may be cut off early due to the equalization of RV
and RA pressures. The simplied Bernoulli equation assumes the proximal velocity to be small
and is ignored, in the situation of severe TR with
elevated RA pressure, the equation underestimates the RV-RA gradient. The normal cutoff
value for mean PA pressure is 25mmHg, which
correlates to a peak TR gradient of 2.8–2.9m/s.
2
TR gradients higher than 2.9m/s are highly suggestive of pulmonary hypertension. The development of pulmonary hypertension has been shown
to independently predict mortality in sepsis [38],
ARDS [39], and myocardial infarction [40].
Diastolic pulmonary artery pressure (DPAP)
is estimated from the velocity of the end-diastolic pulmonary regurgitant jet using the modied Bernoulli equation. The systolic and
diastolic pulmonary artery pressure can then be
utilized to obtain mean pulmonary artery pressure (mPAP).
2
++ RAP
DPAP
pulmonary
regurgitant enddiastolic
=−
4
velocity
PASP PADP
mPAP
=
+ 2
3
Right Ventricular Outow Tract (RVOT)
Pulse Wave (PW) Doppler Indices
RV outow tract (RVOT) pulse wave (PW)
Doppler has been studied as a surrogate for RV
function and (RV-pulmonary artery) RV-PA interaction. It can be imaged from multiple transthoracic views including the PSAX, RV outow
view, modied PLAX view, or a modied subcostal approach interrogating the RVOT [41].
The PW gate is placed just below the pulmonic
cusp in the middle of the RVOT.Normal RVOT
VTI shows a slower acceleration, a longer time
from the onset of ow to peak ow, and a more
“rounded” velocity curve. As pulmonary vascular
resistance increases, the shape of the RV ejection
curve resembles more closely to the LVOT VTI
curve, with a shorter time to peak velocity from
downstream resistance or impedance. A value
below 105ms is very suggestive of signicant
pulmonary hypertension [4]. Mean pulmonary
artery pressure can also be estimated from pulmonary artery acceleration [42].
176
()
()
S. Dugar and S. Vallabhajosyula
mPAP AT if AT ms=− ∗
mPAP AT=− ∗
79 045.
<90 062 120.,
Right Ventricular-Pulmonary Artery Coupling
In physiological conditions, the right heart is
“coupled” to the pulmonary circulation as a single cardiopulmonary unit, keeping a relative
matching between contractility and afterload. As
pulmonary hypertension (PH) develops, the vascular bed becomes a high-resistance, and lowcompliance system adding additional load on the
ventricular contraction and altered RV-PA coupling. Right heart catheterization is the gold standard for assessment of RV-PA coupling, yet
echocardiography is increasingly being used due
to its noninvasive nature. Composite echovariables incorporating RV systolic function and
loading condition have been suggested to overcome the load dependency of most echocardiographic variables in assessing RV-PA coupling.
One of them is the TAPSE/SPAP ratio, which
assesses RV systolic function as a ratio of RV
longitudinal shortening in relation to loading
condition and has been an important prognostic
marker in critical illness [43, 44].
Hemodynamically signicant acute PE can be
diagnosed by using a combination of PASP
<60mmHg and PVAT <60ms (the “60/60 sign”)
with high positive predictive value. TAPSE/PVR
incorporates the relationship between afterload
increase and RV function and is termed as RV
ejection efciency (RVEe) and has been used for
early identication of RV-PA uncoupling in pulmonary hypertension [45, 46].
Right Ventricular Diastolic Function
An emerging concept in the eld of cardiology
and critical care is assessment of RV diastolic
dysfunction. It stems from multiple studies showing RV diastolic dysfunction to precede RV sys-
tolic dysfunction and may serve as an early and
easily available quantiable variable of subclinical RV dysfunction [47, 48]. The assessment is
similar to LV diastolic function; however, the
numerical value may differ due to the greater area
of the tricuspid valve and lower velocity of transtricuspid blood ow. One can obtain E (Early diastolic lling velocity) and A (Late diastolic lling
velocity) by placing a pulse wave Doppler at the
tip of the tricuspid leaet in the A4C view at endexpiration. RV E′ velocity is then obtained by TDI
at the level of the tricuspid lateral annular plane.
One can calculate E/E′ and E/A ratios to identify
and quantify RV diastolic dysfunction. An E/E′
ratio>4 has been shown to have good sensitivity
and specicity for predicting an RAP ≥10mmHg
in critically ill patients. The presence of moderate
to severe TR, atrial brillation, and tachycardia
may confound diastolic parameters [4].
Grading of RV diastolic dysfunction
• Impaired relaxation: E/A ratio<0.8
• Pseudo-normal lling: E/A ratio of 0.8–2.1
and E/E′>6 or diastolic ow predominance in
the hepatic veins
• Restrictive lling: E/A ratio > 2.1 with a
DCT<120ms
Right Ventricular Strain
Myocardial deformation (strain) imaging is a relatively novel echocardiographic technique to
assess RV myocardial function and, unlike other
echo techniques can identify subtle RV dysfunction [6, 20, 49–51]. Speckle tracking (STE) tracks
the movement of grayscale-based “speckles”
(known as “kernels”); an ultrasound artifact evaluates the degree of deformation of the kernels
relative to each other. The closer the speckles
move toward each other, the higher the deformation. Since STE evaluates how close the speckles
move toward each other from their original position, the more negative the value of strain, the
higher the systolic function. The most commonly
performed RV strain is a longitudinal strain (in the
base to apex direction) measured from apical windows assessing the RV-free wall with the exclu-
13 The Right Ventricle
177
sion of the interventricular septum. For proper
strain assessment, the entire myocardium should
be clearly visualized throughout the cardiac cycle
with a frame rate of the image ranging between 60
and 80frames/s. Foreshortening of the echocardiographic image may further compromise the
accuracy of the measurement. These image
requirements for strain analysis are challenging to
meet in critically ill patients, limiting its widespread use in clinical decision-making.
Conclusion
The integration of RV assessment using echocardiography is vital in the appropriate management of critically ill patients. Echocardiography
allows rapid qualitative or in-depth quantitative
assessment of RV including dimensions, septal
morphology, regional and global RV systolic
function, and an estimation of RV hemodynamics. This chapter details various echocardiographic assessments that are easy to obtain
providing comprehensive insight into the underlying pathophysiology. The emergence and
increased accessibility to novel tools including
strain imaging, trans-esophageal echocardiogram, and 3-D echocardiography have the potential to provide more precise assessments of the
RV with higher reliability in critically ill patients.
Summary Points
• RV dysfunction is routinely observed in
patients with critical illness.
• RV dysfunction has been shown to be independently associated with poor outcomes in
sepsis, acute respiratory failure, COVID-19,
myocardial infarction, and heart failure.
• Echocardiography is the preferred modality to
assess RV in the critically ill patient
population.
• The complex geometry of RV requires assessment of RV in multiple views for an accurate
assessment of both size and function.
• A RV size >2/3 size of the left ventricle in apical four-chamber is suggestive of RV
dilation.
• TAPSE <16.5 mm, TASV <9.5 cm/s, and
RVFAC <35% are suggestive of RV
dysfunction.
• Echocardiography-derived pulmonary pressure
including RVSP, SPAP, DPAP, and mean PAP
have been validated against RHC and found to
have high accuracy except in extreme cases.
• RV-PA coupling incorporates assessment of
RV systolic function in relation to loading
conditions.
• RV strain imaging may be able to recognize
subclinical RV dysfunction.
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