Evaluating right ventricular size and function with the help of echo

In this video, you will learn to recognize right ventricular dilatation, significant hypertrophy and hyper- and hypokinesis using transthoracic echo. You will also learn to recognise a pulmonary embolism.

After completing this course, you’ll be able to perform a basic transthoracic echo (TTE) exam without the help of a more senior colleague. Using practical demos, we’ll teach you echo anatomy and show you how to operate the machine, obtain the standard TTE views, differentiate normal from abnormal, and confidently assess and report anything you find!

[00:00:00] So, let's start at looking at the size of the right ventricle. So, this is a four-chamber apical view and if the right ventricle is as big as the left, in this view, you can assume it's dilated. And if you think it's dilated, we need to make three measurements. The first is RV1, which we record at the base of the ventricle, so at the tricuspid annulus and we would usually expect this to this to be less than 4.2 cm. We'll measure RV2 in the mid-cavity of the right ventricle

[00:00:30] and we'd expect this to be less than 3.5 cm. And then we will go on to measure RV3, which measures from the apex to the plane of the tricuspid annulus and we would expect this to be less than 8.6 cm. We don't use gender-specific normal ranges but obviously, we do have different normal ranges for adult and pediatric practice. So, now we're going to think about the wall of the right ventricle and whether there's any hypertrophy. And the best place to measure this is in the subcostal view.

[00:01:00] We measure it, here, very close to the tricuspid valve. We have to be very careful not to include fat in the measurement. We increasingly see a layer of fat around the right heart, so we need to make sure we're just measuring myocardium and this is normally 5 mm or less. So, now we're going to think about right ventricular function. So, how well is the right ventricle pumping? It's difficult to assess the right ventricle because it's a strange crescent shape structure, wrapped around the front of the heart. It also behaves

[00:01:30] quite differently to the left. It changes shape and then the free wall contracts. So, longitudinal movement precedes transverse movement. And what I mean here, is this is longitudinal movement, so this is motion. I'm looking at the side of the tricuspid valve up and down in this direction. So, movement of the annulus towards the apex and that's the longitudinal function of this ventricle. The motion inwards is its transverse motion and it's the longitudinal movement that makes the RV more globular

[00:02:00] and then it makes the inward motion more effective. We have two ways of looking at the longitudinal function of the right ventricle. One of them is TAPSE, which is the tricuspid annular plane systolic excursion. We measure this on a zoomed M mode of the lateral side of the tricuspid annulus. And what we look for is a really nice clear echo, that we can see throughout systole. We'll measure this distance, so in this case, we've measured it and it's 1.9 cm

[00:02:30] and anything above 1.6, we would consider normal. The other way we can measure the longitudinal function is to use tissue Doppler. It's using the same principle but obviously, it's measuring the velocity of the myocardium at this point. And we can see here that in systole, we can tell it's systole because our ECG is systole, our velocity is above 10 cm per second. And that will be the cutoff for normality. Anything below 10 cm per second will suggest you have abnormal longitudinal function. So, now I want to think

[00:03:00] about the transverse function of the right ventricle. So this is a modified four-chamber view, so that the view has been adjusted slightly to focus on the right ventricle. You can see we got a dilated RV. And whilst this longitudinal motion looks preserved, this is moving up and down quite nicely, we can see that the free wall, here, isn't moving inwards in systole. So, we would report this ventricle as obviously dilated but with preserved longitudinal function but abnormal

[00:03:30] transverse right ventricular function. So, there is some degree of RV systolic impairment here. So, another thing we need to think about for the right ventricle, a clinically important area is if there's an acute pulmonary embolism. And the thing to look for, here, is actually the left ventricle. So, this is a short-axis parasternal view. And we've got a D shaped left ventricle, instead of it being its normal nice circle, it's D shaped. So, the ventricular septum is flattened. So, we expect to see septal flattening in systole,

[00:04:00] if there's a pressure load on the right heart, so such as an acute PE and we'd expect to see flattening in diastole if there's a volume load. So for example, tricuspid regurgitation. In reality, these situations often co-exist and you just get a flattened septum. In acute PE, the right ventricular free wall will be hypokinetic and we'd see this best in an apical four-chamber view or subcostally. But sometimes the apex will still be contracting. There'll be other echo signs of increased pulmonary artery systolic

[00:04:30] pressure. Very occasionally, you might see thrombus in transit through the right heart or within the pulmonary artery.