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THE RIGHT VENTRICLE

The right ventricle used to be seen as an appendage to the left and was mostly ignored. But in the last decade it has had a lot more attention and guidelines now even go as far as discussing RV ejection fraction (1,2,3,4). 

In ED, the main qualitative assessments of the RV are: RV contractility, evidence of RV volume or pressure overload and whether this is acute or chronic. The IVC is intimately connected to this assessment. 

The RV is normally 2/3 the size of the LV. Because it is the low pressure chamber, the septum normally bows into the RV. The A4C and subxyphoid are probably the best views for RV size assessment.

RV DIMENSIONS (A rough guide) (5)

A4C (RV view) Base <42mm, Length <69mm

PLAx Height <3cm 

SUBXYPHOID wall <6mm

CHARACTERISTICS OF THE RV

The RV is a triangular chamber which seems to hang off the RV. The tip of the RV ends just below the LV apex. The RV walls are normally trabeculated and a thick band of muscle (moderator band) traverses the cavity from the anterior wall to the septum. The moderator band is usually seen in A4C and PSAx. Unlike the MV, the TV does not have papillary muscles. 

A4C

With the RV in view in A4C, assess the base and length of the RV. These measurements should be made at end diastole. The basal measurement is at the TV leaflet tips and the length measurement is perpendicular to this. The upper limit of normal for the base is 42mm and 86mm for length. 

RV base and length measurement A4C

RV focus A4C

PLAx

In PLAx, the RV vertical height should be 1:1:1 with the aorta and LA at approximately 3cm. The measurement should be vertical from the root of the aorta to the RV free wall endocardoium (dotted line in PLAx image below). 

SUBXYPHOID

In the subxyphoid view the most helpful measurement is the free wall thickness. Chronic RV pressure overload leads to RV hypertrophy --> free wall ≥ 6mm. The free wall is measured at end diastole. 

Zoomed view of the RV in the subxyphoid showing a thick and trabeculated free wall. Right: measurement

RV SYSTOLIC FUNCTION

Unlike the LV where the walls come in like clapping hands in long axis and like a shrinking tunnel in short axis, the RV tends to move in a spiral in systole kind of like a wet towel being rung out. This is best seen in the A4C where the RV free wall seems to move up and down with each systole and diastole. An good marker of RV systolic function is the degree of vertical excursion of the lateral wall of the RV with systole. 

The normal excursion is >16mm. This can be measured by placing the M Mode line parallel with the RV lateral wall intersecting with the tricuspid valve annulus. As M mode is a single line of sight represented over time, you will get the vertical displacement of the tricuspid annulus over time. This is called the TAPSE (Tricuspid Annular Plane Systolic Excursion).  Measure the height of the excursion. Always ensure the M mode line is parallel with the vertical movement of the RV, otherwise you will get an erroneously low reading.

Normal TAPSE

Off Axis measurement of TAPSE

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REFERENCES

1. Zaidi A, Knight DS, Augustine DX, Harkness A, Oxborough D, Pearce K, Ring L, Robinson S, Stout M, Willis J, Sharma V; Education Committee of the British Society of Echocardiography. Echocardiographic assessment of the right heart in adults: a practical guideline from the British Society of Echocardiography. Echo Res Pract. 2020 Feb 27;7(1):G19-G41

2. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010 Jul;23(7):685-713

3. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1-39

4. Galderisi M, Cosyns B, Edvardsen T, Cardim N, Delgado V, Di Salvo G, Donal E, Sade LE, Ernande L, Garbi M, Grapsa J, Hagendorff A, Kamp O, Magne J, Santoro C, Stefanidis A, Lancellotti P, Popescu B, Habib G; 2016–2018 EACVI Scientific Documents Committee; 2016–2018 EACVI Scientific Documents Committee. Standardization of adult transthoracic echocardiography reporting in agreement with recent chamber quantification, diastolic function, and heart valve disease recommendations: an expert consensus document of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2017 Dec 1;18(12):1301-1310

5. Kou S, Caballero L, Dulgheru R, Voilliot D, De Sousa C, Kacharava G, Athanassopoulos GD, Barone D, Baroni M, Cardim N, et al. Echocardiographic reference ranges for normal cardiac chamber size: results from the NORRE study. European Heart Journal Cardiovascular Imaging 2014 15 680–690.