Echocardiographic Assessment of

the Right Heart, Pulmonary

Hypertension and Right heart
Valves in Adults
 Outlines
• Right Chamber Views
• RV function assessment
• Pulmonary Hypertension assessment
• Tricuspid and Pulmonal regurgitation
 RIGHT VENTRICLE
not anymore an innocent bystander ofRIGHT
the left VEN
COMPLEX GEOMETRY ! Challenges for conventio
• thin-walled chamber behind the Ao PV

sternum
IVSm
• separate inflow and outflow portions
• asymmetrical, crescentic shape, TV
RA
wrapped around LV MB

• variations of shape with loading

conditions
• heavily trabeculated Courtesy of Prof. Cristina Basso, Cardiovascula

• thin-walled
Owing to the incomplete visualization of the RV in a single 2D echo view,
chamber more than
behind theonestern
projection is needed for a comprehensive evaluation of RV structure and function.
• separate inflowLancelotti
and P,outflow portions
EACVI Echo Handbook 2015
Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.
 Function of The Right Ventricle
➢ Generate pressure to facilitate blood flow against the resistive
forces of the pulmonary vasculature
➢ Particularly influenced by loading conditions
➢ Estimate of load ( especially pulmonary artery pressures)
should be included in RV assessment
➢ Affect LV function
• limit LV preload in RV dysfunction
• Ventricular interdependence

Lancelotti P, EACVI Echo Handbook 2015

 RV echocardiographic views

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author Ruxandra Jurcut et al. Eur J Echocardiogr 2010;11:81-96
2010. For permissions please email: journals.permissions@oxfordjournals.org
 RV dedicated views
Apical 4 chamber RV Focused Apical 4 chamber

RV Modified Apical 4 chamber

Lancelotti P, EACVI Echo Handbook 2015

Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.
 Right ventricular dimensions
Measured at end-diastole

1. Basal RV diameter > 4.1 cm indicates dilatation

2. Mid cavitary RV diameter > 3.5 cm indicates dilatation
3. RV longitudinal dimension > 8.3 cm indicates RV enlargement
Lancelotti P, EACVI Echo Handbook 2015
Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.
 RVOT measurement
• Can be measured in the PSAX views, proximal to the
pulmonary valve, as well as from a modified PLAX angled
superiorly and subcostal windows.
• Should be measured at end-diastole on the QRS
deflection

Normal RVOT Prox Ø < 35 mm Normal RVOT Distal Ø < 27 mm

Lancelotti P, EACVI Echo Handbook 2015

Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.
 RV Wall Thickness
• Useful measurement of RVH Normal < 0.5 cm
• From the subcostal view, align the u/s beam
perpendicular to the RV free wall
• Below the tricuspid annulus at a distance
approximating the length of anterior tricuspid leaflet,
when it is fully open and parallel to RV free wall

Lancelotti P, EACVI Echo Handbook 2015

 RV Systolic Function
• All studies should include a measure of RV
systolic function using at least one of the
following:
– Tricuspid annular plane systolic excursion (TAPSE)
– S´ velocity
– Fractional area change (FAC)

Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.

 TAPSE
• An useful index for evaluating RV longitudinal function.
• Acquired by placing an M-mode cursor through the lateral
tricuspid annulus and measuring the amount of longitudinal
motion of the annulus at peak systole

Normal > 16 mm

Lancelotti P, EACVI Echo Handbook 2015

Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.
Tissue Doppler Imaging S’ Velocity
• An apical four chamber view is used
• PW DOPPLER : ROI placed in the lateral annulus parallel to
free wall
• Advantage : simple, reproducible
• Disadvantages : Dependent on alignment

Normal s’ > 9.5 cm/s

Lancelotti P, EACVI Echo Handbook 2015

 Fractional area change
• Expresses the percentage change in RV area between end-diastole
and end-systole
• Defined as : End diastolic area – End systolic area X 100
End-diastolic area
• Obtained by tracing RV endocardium both in systole and diastole
from the annulus, along the free wall to the apex, and then back to
the annulus, along the interventricular septum
• Avoid trabeculations

Normal RVFAC > 35 %

Lancelotti P, EACVI Echo Handbook 2015

Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.
 Right Atrial assessment
• Apical 4-chamber view
• Estimation of right atrial area by planimetry
• The maximum long distance of the RA is from the
center of the tricuspid annulus to the superior RA
wall, parallel to the interatrial septum
• A mid RA minor distance is defined from the mid
level of the RA free wall to the interatrial septum
perpendicular to the long axis
• RA area is traced at the end of ventricular systole,
excluding the IVC, SVC, and RAA

Normal values : Women Men

RA minor axis dimension (cm/m²) < 1.9 < 1.9
RA major axis dimension (cm/m²) < 2.5 < 2.5

Lancelotti P, EACVI Echo Handbook 2015

Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.
 RA pressure determination
• Measurement of the IVC obtain at end-expiration and
just proximal to the junction of the hepatic veins that lie
approximately 0.5 to 3.0 cm proximal to the ostium of
the right atrium

To accurately assess IVC

collapse, the change in
diameter of the IVC with a sniff
and also with quiet respiration
should be measured

Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.

 Recommendations
For simplicity and uniformity of reporting, specific values of RA pressure , rather than
ranges, should be used in the determination of SPAP
IVC diameter IVC collapsibility RA pressure
≤ 2.1 cm > 50% with a sniff 3 mmHg
> 2.1 cm < 50 % with a sniff 15 mmHg
In indeterminate cases in which IVC diameter and collapse do not fit this paradigm, an
intermediate value of 8 mmHg may be used, preferably with use of secondary indices of
RA pressures such as: RA dilatation, abnormal bowing of the IAS into the left atrium
throughout the cardiac cycle

Advantages Disadvantages
IVC dimensions are usually obtainable from IVC collapse does not accurately reflect RA
the subcostal window pressure in ventilator-dependent patients
It is less reliable for intermediate values of
RA pressure
Lancelotti P, EACVI Echo Handbook 2015
Rudski L, et al. J Am Soc Echocardiogr 2010;23:685-713.
RV Volume and Pressure Overload
When the RV is overloaded, the crescent shape is lost and the
septum becomes flat, the LV taking the shape of the letter ‘D’,
resulting in an impaired LV filling and a decrease in cardiac output.

RV pressure overload RV volume overload

septal shift throughout cardiac cycle with most septal shift occurs predominately in mid to late
marked distortion of LV at end systole diastole
 RV Volume and Pressure Overload
▪ Based on LV Eccentricity Index (interventricular interaction,
changes in RV shape)
▪ Defined as = LV antero-posterior diameter ( in SAX view )
LV septo-lateral diameter

▪ VALUE > 1 at end diastole : RV volume overload

▪ VALUE > 1 at end systole and end diastole : RV pressure overload.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author Ruxandra Jurcut et al. Eur J Echocardiogr 2010;11:81-96
2010. For permissions please email: journals.permissions@oxfordjournals.org
 RV PRESSURE OVERLOAD (= TR Vmax)
• RV SYSTOLIC PRESSURE
Should be estimated and reported in all subjects with reliable
tricuspid regurgitant jets

RVSP = 4 (V TR)2 + estimated RA pressure

 Assessment of PH
Transthoracic echocardiography is used to image the effects of PH
on the heart and estimate PAP from continuous wave Doppler
measurements

Peak tricuspid regurgitation Presence of other echo Echocardiographic

velocity (m/s) ‘PH signs’ probability of pulmonary
hypertension
≤2.8 or not measurable No Low
≤2.8 or not measurable Yes Intermediate
2.9 – 3.4 No
2.9 – 3.4 Yes High
>3.4 Not required

2015 ESC/ERS Guidelines for the diagnosis and

treatment of pulmonary hypertension.
European Heart Journal (2016) 37, 67–119
 Other Echocardiographic signs suggesting
pulmonary hypertension
A: The ventricles B: Pulmonary artery C: Inferior vena cava and
right atrium
Right ventricle/ Right ventricular outflow Inferior cava diameter >21
left ventricle basal diameter doppler acceleration time mm with decreased
ratio >1.0 <105 msec and/or inspiratory collapse (<50 %
midsystolic notching with a sniff or <20 % with
quiet inspiration)
Flattening of the Early diastolic pulmonary Right atrial area (end-
interventricular septum (left regurgitation velocity >2.2 systole) >18 cm2
ventricular eccentricity m/sec
index
>1.1 in systole and/or
diastole)
PA diameter >25 mm.

Echocardiographic signs from at least two different categories (A/B/C) from the list
should be present to alter the level of echocardiographic probability of pulmonary
hypertension.
 Peak tricuspid regurgitation velocity
(TR Vmax)
o A coaxial TR jet is
identified in :
• parasternal long axis
(RV inflow),
• parasternal short axis,
• apical 4-chamber view

o Use a sweep speed

of 100 mm/s

o Assess with the help

of colour Doppler.
 The Ventricle

LV Eccentricity Index >1.1 :

Right ventricle/ left ventricle
Measurement of the LV in end-diastole and
basal diameter ratio >1.0
end-diastole (D2/D1) .
D1= antero-posterior axis; D2 = Septo-lateral axis
 Pulmonary artery

Right ventricular outflow

Early diastolic pulmonary
doppler acceleration time
regurgitation velocity >2.2 m/sec

PA diameter >25 mm.

midsystolic notching
Inferior vena cava and right atrium

Inferior cava diameter

Right atrial area (end-systole) >18 cm2

 Images can be found in Right Chambers

Crista Terminale Chiari Network.

Eustachian Valve
Pacemaker lead
 Appropriate Use Criteria for Echocardiography of
Pulmonary Hypertension

Pulmonary Hypertension With TTE

Appropriate Evaluation of suspected pulmonary hypertension

including evaluation of right ventricular function and
estimated pulmonary artery pressure
Routine surveillance (≥1 y) of known pulmonary
hypertension without change in clinical status or cardiac
exam
Re-evaluation of known pulmonary hypertension if
change in clinical status or cardiac exam or to guide
therapy

J Am Soc Echocardiogr 2011;24:235

 Summary of Right Heart, Pulmonary
Hypertension Assessment

• RV should be assessed using multiple acoustic windows, and the

report should present an assessment based on both qualitative
and quantitative parameters.
• Parameters that can be measured include RV and RA size and a
measure of RV systolic function
• assessment of probability of PH Should be assessed and include
in final report
Tricuspid Regurgitation
 Anatomy of Tricuspid Valve (TV)
➢ TV is located slightly more apical
than mitral valve
➢ TV complex:
➢ three leaflets of unequal size
(anterior usually the largest,
Ant
posterior, and septal)
➢ annulus Post

➢ subvalvular apparatus (chordae and

Septal
papillary muscles)
➢ RV and RA
 TV imaging - TTE

Parasternal short-axis (SAX) views Parasternal inflow views

Yellow = septal leaflet

Blue = anterior leaflet
Rebecca T. Hahn, R T. Circ Cardiovasc
Green = posterior leaflet Imaging.2016;9:e005332.
 TV imaging - TTE

red = anterior or posterior leaflets 4 Chamber View

Yellow = septal leaflet
Blue = anterior leaflet
Green = posterior leaflet
Rebecca T. Hahn, R T. Circ Cardiovasc
Imaging.2016;9:e005332.
Assessment of TR severity
➢ Structural
➢ TV morphology
➢ RA, RV size
➢ IVC diameter (normal <2 cm)
➢ Qualitative
➢ CW jet
➢ Jet are
➢ Semiquantitative
➢ VCW
➢ PISA radius
➢ Hepatic vein flow
➢ Tricuspid inflow
➢ Quantitative
➢ EROA
J Am Soc Echocardiogr. 2017 Apr;30(4):303-371.
Tricuspid valve morphology

➢ Visual assessment
➢ Multiple views

Interpretation
➢ Flail or uncoaptated valve
is specific for significant
TR
➢ Other abnormalities are
non-specific of significant
TR

Lancelotti et al. EAE Recommendations for the assessment of valvular regurgitation. 2010
Colour-flow imaging

➢ Good screening test for

mild vs severe TR

Limitations
➢ Can be inaccurate for
estimation of TR severity
➢ Influenced by technical and
haemodynamic factors
➢ Underestimates eccentric jet
adhering the RA wall (Coanda
effect)

Lancelotti et al. EAE Recommendations for the assessment of valvular regurgitation. 2010
TR jet—CW Doppler

➢ Severe TR -- > more full CW Doppler envelope

➢ A triangular CW → elevated RA pressure/ prominent pressure wave
in the RA due to severe TR
➢ TR Velocity ≠ severity of TR
➢ Complete CW Doppler signal difficult to obtain in eccentric jet
Lancelotti et al. EAE Recommendations for the assessment of valvular regurgitation. 2010
VCW and Proximal flow convergence

Proximal flow convergence VCW

Hepatic vein flow
➢ Subcostal view
➢ Sample volume of PW places into the hepatic vein

Advantage
➢ Simple

Limitations
➢ Affected by RA pressure
➢ Affected by atrial fibrillation

Interpretation
➢ Systolic flow reversal is specific for
severe TR
 Algorithm for the integration of multiple parameters of
TR severity

J Am Soc Echocardiogr. 2017 Apr;30(4):303-371.

Pulmonic regurgitation
 Etiology
• Most : functional due to PA dilatation
• Others:
– Congenital → abnormal cusp, hypoplastic
– Post intervention : post TOF repair, valvulotomy
– Valve problem : rheumatic, endocarditis,
carcinoid, myxomatous, etc
 Qualitative measurement
• Pulmonic valve morphology
– Abnormal, destroyed valve → severe

• PR jet width
Mild Moderate Severe
Small, jet length, narrow In between Large, wide origin
origin Jet width > 70% RVOT diam

Diastolic reversal in main PA

100% sensitivity, low specificity
for severe PR
 Qualitative measurement
• CW signal PR jet
Mild Moderate Severe
Faint In between Dense
Slow deceleration Steep deceleration
 Semi quantitative measurement
• Pressure half time
– PSAX
Severe
< 100 msec

VCW/PV annular diameter ratio

Parasternal short- axis view
Zoomed view Optimize
visualization of proximal PA
 Quantitative measurement
• Vena contracta and PISA method
– Not validated for PR
 Grading PR severity

J Am Soc Echocardiogr. 2017 Apr;30(4):303-371.