Written by Andrea Fields, MHA, RDCS

Introduction to Right Heart Assessment

CardioServ is dedicating the month of April to right heart quantification awareness!  This month we will present a series of blogs to review the proper methods to quantify right ventricular size and function.

The right heart has jokingly been referred to as the step-child of the heart with often little attention paid to the size, function and prognostic implications of right heart findings.  Over the years, ASE had written papers on the right heart that often had conflicting information and reference ranges.  In 2015, ASE released the updated ‘Chamber Quantification Guidelines’ that included a detailed description on the right heart to replace past conflicting information.

This week we will review:
1. ASE general recommendation updates for right heart
2. How to perform a comprehensive 2D assessment of the right heart
3. Correct imaging windows to visualize the RV
4. Tips to better visualize the RV

ASE General Recommendations Updated

  • All studies should include a comprehensive examination of the RV & RA.
  • The echo report should include both qualitative and quantitative parameters for right heart assessment.
    • RV & RA Size
    • RV Systolic Function (via one or combination of the following)
      • Fractional Area Change (FAC)
      • TAPSE
      • S’ Wave
      • RIMP
    • RV Systolic Pressure
      • Tricuspid Regurgitation (TR) Jet
      • Estimated Right Atrial Pressure (RAP)
        • Based upon Inferior Vena Cava (IVC) Size & Collapsibility
  • Abnormal cutoff values were changed for: RV Dimensions, S’ Wave, TAPSE and RIMP.

Comprehensive Assessment of RV

The RV has 3 wall segments, which include:

  1. Anterior Wall
  2. Inferior Wall
  3. Lateral Wall

There are 5 imaging views required to obtain, in order to properly evaluate all segments of the RV.

  1. Parasternal Long Axis (PLAX)
  2. Parasternal Short Axis (PSAX)
  3. RV Inflow Tract (RVIT)
  4. Apical 4 Chamber
  5. Subcostal 4 Chamber

PLAX

PSAX

RVIT

AP4

Imaging Windows

Why is the RV so hard to image?!

The RV is the most anterior portion of the heart within the thorax, ending up in our near field of the ultrasound beam—which causes limited scanning windows and poor resolution.

The ASE explained 3 different scanning views we can obtain from the AP4 window to properly quantify the RV & RA.

  1. Standard AP4
  2. RV Focused AP4
  3. RV Modified AP4

Standard AP4:

RV Focused AP4:

RV Focused AP4

RV Modified AP4:

**Note: Quantitative methods should not be measured in this view. The purpose of this view is to qualitatively evaluate function of RV.

How can I better visualize the RV with difficult/limited patients?!

There are a few techniques if we are having difficulty visualizing the RV:

  1. Change the angle of the transducer!
    • Try to go more lateral or move up/down a rib space!
  2. Push IV Saline! (Just as you would for a Bubble Study)
    • Help facilitate visualization of RV, but only last a few seconds.
  3. IV Echo Contrast (Just as you would for using it for LV Endocardium)
    • It requires slower injection to prevent attenuation artifact.

Conclusion

We should now have a better understanding of:

  • Reasoning for updated for right heart chamber quantification from ASE
  • Basic RV wall segment review
  • Specific imaging windows to obtain for evaluation of right heart

The goal of this blog was to review the recommendations from ASE regarding right heart assessment and to lay the foundation for the basics of correct right heart visualization.  We will use the material we learned today and apply it further in our upcoming blogs that will discuss in detail the correct methods for right heart size and function quantification.  Next week, for the right heart blog series, we are going to discuss the proper way of measuring the RV.

Andrea Fields, MHA, RDCS,  Clinical Cardiac Director

Connect with me on LinkedIn

 

 

 

References

Lang, R. M., MD, Badano, L. P., MD, & Mor-Avi, V., PhD. (2015). Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. JASE, 28(1), 1-53. Retrieved March 1, 2017, from http://asecho.org/wordpress/wp-content/uploads/2015/01/ChamberQuantification2015.pdf

ASE guidelinescardiac chamber quantificationechoechocardiographyRA Sizeright ventricleRV SizeRV systolic pressureRVSPS'TAPSE

LET US KNOW WHAT YOU THINK...

Lisbeth Robelo
Thank for this info. I've been doing these images just because. But I realize the importance of continuing. Keep up the GREAT work. Thanks
Meena Sumathy
Very colorful and informative article.Thanks.In RV assessment do you perform all these above mentioned methods? Presume TAPSE and RV S' become unreliable in case of significant tricupsid regurgitation. In that case which is the more appropriate method of assessing RV function.
Dale Myers
Excellent article! For years the LV got most of the attention. It's time for the RV to move center stage! Your excellent descriptions are greatly appreciated!
Hasam Uddin
Fabulous article .Thanks
Mohammad lbrahim
It's a good learning course.
Mohammad lbrahim
It's a good learning course. It will be helpful.
Helen Polito
Nice article!
Abderrahmani lilya
Excellent
Patricia Restrepo
It´s very important and is very clear this article. Thank you.
Kathy
Thank you...I love it as I am a visual learner like most echo techs...keep it coming. Seeing the 3 different RV views clearly makes it understood why you don't measure things in the modified views. I really like the color coding to differential walls.

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