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com
i19

Assessing right ventricular function: the role of

echocardiography and complementary technologies
G B Bleeker, P Steendijk, E R Holman, C-M Yu, O A Breithardt, T A M Kaandorp, M J Schalij,
E E van der Wall, P Nihoyannopoulos, J J Bax
...............................................................................................................................

Heart 2006;92(Suppl I):i19–i26. doi: 10.1136/hrt.2005.082503

T
he physiological importance of the right ventricle (RV)
has been underestimated; the RV was considered mainly
as a conduit whereas its contractile performance was
thought to be haemodynamically unimportant.1 However, its
essential contribution to normal cardiac pump function is
well established with the primary RV functions being:

N to maintain adequate pulmonary perfusion pressure under

varying circulatory and loading conditions in order to
deliver desaturated venous blood to the gas exchange
membranes of the lungs
N to maintain a low systemic venous pressure to prevent
tissue and organ congestion.

RV function may be impaired either by primary right sided

heart disease, or secondary to left sided cardiomyopathy or
valvar heart disease.2 In addition, it should be considered that
RV dysfunction may affect left ventricular (LV) function, not
only by limiting LV preload, but also by adverse systolic and Figure 1 Subcostal projections without (left) and with (right)
intravenous contrast injection (SonoView). Notice the clear outline of the
diastolic interaction via the intraventricular septum and the right ventricular (RV) endocardial definition together with the RV
pericardium (ventricular interdependence). Moreover, RV trabeculations.
function has been shown to be a major determinant of
clinical outcome3–9 and consequently should be considered
throughout the cardiac cycle. Finally, the RV should also be
during clinical management and treatment.10 Thus, the need
evaluated from the subcostal projections. If the RV appears
for diagnosis of RV dysfunction is evident. In practice,
larger in length or diameter, RV dilatation is likely to be
clinicians largely rely on non-invasive imaging methods for
assessment of RV function. Two dimensional echocardiogra-
present.18 RV size (end systolic and end diastolic) and change
phy is the mainstay for analysis of RV function, but recently in size during the cardiac cycle (RV function) can also be
alternative techniques have been proposed, including tissue quantitatively assessed by tracing the RV endocardial border or
Doppler imaging (TDI) techniques,11 three dimensional measuring RV dimensions. However, this is often cumber-
echocardiography,12 magnetic resonance imaging (MRI), some and interobserver variability is high. A wide variety of
and even invasive assessment of pressure–volume loops.13–17 techniques have been proposed, but none is currently
An overview of these imaging modalities for assessment of considered as the gold standard.4 19–30 Studies using endocar-
RV function is provided in the current manuscript. dial tracing of the RV area report relatively high correlations
(0.69–0.88) between echocardiographically estimated RV size
and function compared to radionuclide angiography and
ECHOCARDIOGRAPHIC EVALUATION OF THE RIGHT MRI.21 22 26 However, the number of patients who could not be
VENTRICLE analysed because of failure to trace the (entire) RV
Due to its widespread availability, echocardiography is used myocardium is large21 22 27; RV tracing may be improved
as the first line imaging modality for assessment of RV size using intravenous contrast agents, that are commercially
and RV function. The quantitative assessment of RV size and available (fig 1). The most widely used quantitative technique
function is often difficult, because of the complex anatomy. is the area–length method in which a traced RV lumen area
Nevertheless, when used in a qualitative fashion, two in the four chamber view is combined with the RV dimension
dimensional echocardiography can easily obtain valuable in the parasternal short axis view.24 25 28 29 A different
information about RV size and function. quantitative approach to assess RV function is the measure-
ment of the tricuspid annular plane systolic excursion
Two dimensional echocardiography (TAPSE). The TAPSE estimates RV systolic function by
For qualitative evaluation, the RV size should be compared to measuring the level of systolic excursion of the lateral
the LV size. In the parasternal long axis and apical four tricuspid valve annulus towards the apex in the four chamber
chamber views, the normal RV is approximately two thirds view (fig 2). An excellent correlation between the TAPSE and
the size of the LV. If the RV appears larger than the LV and/or
shares the apex, RV dilatation may be present. Confirmation Abbreviations: LV, left ventricular, MRI, magnetic resonance imaging;
in other views is needed to avoid false positive findings. From RV, right ventricular; RT3DE, real time three dimensional
short axis projections, the RV should be smaller than the LV echocardiography; TAPSE, tricuspid annular plane systolic excursion;
while the LV shape should have a circular geometry TDI, tissue Doppler imaging

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i20 Bleeker, Steendijk, Holman, et al

diastolic velocities were significantly reduced when compared

to healthy individuals and patients without RV involve-
ment.35 36 In heart failure patients, the reduction of tricuspid
annular systolic velocity is associated with the severity of RV
dysfunction.37 Moreover, non-invasive estimation of right
atrial pressure is possible using trans-tricuspid pulsed wave
Doppler and TDI (E/E’, right atrial pressure = 1.76 (E/E’) –
3.7).38 In hypertrophic cardiomyopathy, subclinical involve-
ment of the RV is also evident by a reduction of tricuspid
annular peak systolic and early diastolic velocities and
reversal of tricuspid annulus E’/A’ ratio.39 Still, clinical
experience in patients is limited and further studies with
TDI assessing RV function are needed.
Besides assessment of RV function, TDI does also permit
assessment of ventricular dyssynchrony. This has been
extensively demonstrated in the LV, but the prevalence and
haemodynamic consequences of RV dyssynchrony in cardiac
Figure 2 Tricuspid annular plane systolic excursion (TAPSE) in a disease are not well defined. Theoretically, RV dyssynchrony
normal individual. In the four chamber view a straight line (M mode) is may affect the coordination of contraction in different RV
drawn through the lateral tricuspid valve annulus (arrow 1). The level of regions resulting in reduced cardiac output. However, this
excursion of the tricuspid valvar plane during systole (TAPSE, in mm) phenomenon may also be mediated by the change in
corresponds with RV ejection fraction (arrow 2) (5 mm , 20% RV
ejection fraction, 10 mm , 30% RV ejection fraction, 15 mm , 40% RV movement of the interventricular septum. Currently, the
ejection fraction, and 20 mm , 50% RV ejection fraction).21 number of RV segments that can be assessed by TDI is
limited, and only measurement of septum-to-RV free wall
dyssynchrony is feasible.40 In heart failure patients with a
RV ejection fraction as assessed by radionuclide angiography prolonged QRS duration on the ECG, septum-to-RV free wall
was shown.21 The approach appears reproducible and proved dyssynchrony has been observed, which was reversed after
to be a strong predictor of prognosis in heart failure.21 23 31 cardiac resynchronisation therapy.40 Also, RV dyssynchrony
The Doppler index of myocardial performance (Tei index or has been suggested to predict response to cardiac resynchro-
myocardial performance index) is yet another parameter that nisation therapy,41 although other studies did not confirm
can be used for evaluation of RV performance.32 It is this observation.42 Also, it is not clear whether patients with
expressed by the formula [(isovolumic contraction time + isolated RV dyssynchrony will benefit from cardiac resyn-
isovolumic relaxation time)/RV ejection time] (fig 3). It is chronisation therapy. In general, studies are needed to
established that is actually unaffected by heart rate, loading understand better the clinical meaning of RV dyssynchrony
conditions or the presence and the severity of tricuspid in cardiac disease.
regurgitation.33
Strain rate imaging
Tissue Doppler imaging While the assessment of longitudinal strain from the apical
TDI allows quantitative assessment of RV systolic and views is feasible in the clinical setting, the analysis of RV
diastolic function by means of measurement of myocardial radial deformation from the parasternal window turned out
velocities. The earlier studies used pulsed wave TDI to to be difficult. It is hampered by near-field artefacts caused
examine RV function (fig 4). Two dimensional colour coded by the close proximity to the transducer and by the thin wall
TDI, however, allows true offline analysis of multiple thickness, which requires an extremely small computational
segments simultaneously (fig 5). Peak systolic velocity distance of less than 5 mm for strain rate measure-
, 11.5 cm/s identifies the presence of RV dysfunction with ments.4 37 39 43–51 In healthy individuals, RV longitudinal
a sensitivity and specificity of 90% and 85%, respectively.34 velocities demonstrated the typical baso-apical gradient with
In patients with inferior myocardial infarction and RV higher velocities at the base; also, RV velocities are
involvement, the tricuspid lateral annular systolic and early consistently higher as compared to the LV.43 44 This can be
best explained by: (1) the differences in loading conditions
and compliance with a lower afterload in the RV; and (2) the
dominance of longitudinal and oblique myocardial fibres in
the RV free wall.52 In contrast to the homogenously
c distributed deformation properties within the LV, the strain
d
rate and strain values are more inhomogeneously distributed
in the RV and show a reverse baso-apical gradient, reaching
a the highest values in the apical segments and outflow
tract.43 51 This pattern can be best explained by the complex
geometry of the thin-walled, crescent shaped RV and the
IVCT b IVRT more inhomogenous distribution of regional wall stress if
ET compared to the thick-walled, bullet shaped LV. In an elegant
animal experiment, Jamal et al51 compared echocardiographic
strain rate imaging results to sonomicrometry and demon-
strated the feasibility of the echo technique to quantify
a–b (IVCT + IVRT)
Index = = changes in RV contractile function. Doppler derived strain
b ET
measurements correlated well to sonomicrometry segment
Figure 3 Schematic display of pulsed wave Doppler recordings from
length measurements both in the inflow and outflow tract of
RV inflow and outflow tract projections demonstrating the calculation of the RV and under different loading conditions. An acute
Myocardial Performance Index (Tei index). ET, ejection time; IVCT, increase in RV afterload led to an increase in RV myocardial
isovolumic contraction time; IVRT, isovolumic relaxation time. strain rate, a measure of contractile function,53 and to a

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Assessing right ventricular function i21

Figure 4 Tracing derived from pulsed

wave tissue Doppler with the sample
placed at the level of the tricuspid
annulus of the RV free wall,
demonstrating peak systolic velocity
(PSV), and diastolic parameters (E9 and
A9).

decrease in peak systolic strain, indicating a decrease in RV pulmonary artery pressure and that regional function will
stroke volume. Importantly, not only the absolute values first exhibit depression in the smooth inlet portion of the
changed, but also the strain profile after pulmonary artery RV.54 In this setting, regional analysis of myocardial function
constriction demonstrated a shift of myocardial shortening may enable the early diagnosis of imminent RV failure before
from early-mid to end systole or even early diastole (post- irreversible damage will occur.
systolic shortening).51 In summary, the available experience on strain rate
Dambrauskaite et al50 published a case study on the imaging for the assessment of RV function is limited to
changes in regional RV myocardial function after bilateral small single centre studies and case reports. The technique
lung transplantation in a patient with primary pulmonary seems feasible for the quantitative assessment of RV function
hypertension. Conventional echocardiography showed a and may improve understanding of the pathophysiology of
significant improvement in RV size and global function after different diseases. However, the clinical value for patient
successful transplantation, but strain rate imaging revealed management remains to be proven.
that the functional improvement was limited to the apical,
trabecularised portion of the RV and that the smooth inlet Three dimensional echocardiography
segment did not improve after afterload reduction. Before The clinical use of three dimensional echocardiography has
transplantation, peak systolic strain in the apical segment been hindered by the prolonged and tedious nature of data
was significantly delayed and occurred in the early diastolic acquisition. The recent introduction of real time three
phase after tricuspid valve opening. After transplantation dimensional echocardiography (RT3DE) has revolutionised
with afterload reduction, it was shifted towards the systolic echocardiography as images may be obtained in just one beat.
ejection period and occurred even before pulmonary valve This has been achieved by the development of a full matrix
opening, thus confirming the experimental findings by Jamal array transducer (X4, Philips Medical Systems, Andover,
et al.51 Furthermore, preliminary data in patients with Massachusetts, USA), which utilises 3000 elements. This has
pulmonary hypertension suggested that in a compensated resulted in (1) improved image resolution, (2) higher
patient, peak systolic strain rate correlated with peak systolic penetration and (3) harmonic capabilities, that may be used

Figure 5 Tracing derived from colour

coded tissue Doppler imaging with the
sample placed at the level of the
tricuspid annulus of the RV free wall,
demonstrating peak systolic velocity
(PSV), and diastolic velocities (E9 and
A9).

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i22 Bleeker, Steendijk, Holman, et al

Figure 6 Three dimensional

acquisition of the right ventricle using
an automated disk algorithm for volume
calculations.

for both grey scale and contrast imaging. In addition, this evaluation. Data analysis may be performed on-line or off-
transducer displays ‘‘on-line’’ three dimensional volume line with dedicated three dimensional software (4D LV
rendered images and is also capable of displaying two analysis, TomTec GMBH, Munich, Germany) (fig 6). Since
simultaneous orthogonal two dimensional imaging planes. a data set comprises the entire RV volume, multiple slices
The major advantage of RT3DE is that volumetric analysis may be obtained from the base to the apex of the heart as in
does not rely on geometric assumptions, as has been the case the method of discs. This acquisition can then be combined
with two dimensional echocardiography. Quantification of with intravenous contrast agents to improve endocardial
LV volumes and mass using RT3DE has successfully been border delineation and RV end diastolic and end systolic
performed from an apical wide angled acquisition using volumes can be calculated by tracing the endocardial borders
different methods. A similar approach can be applied for RV similar to MRI (figs 7 and 8).

Figure 7 Three dimensional representation of end diastolic right Figure 8 Three dimensional representation of end systolic right
ventricular volume. ventricular volume.

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Assessing right ventricular function i23

MRI TO ASSESS RIGHT VENTRICULAR FUNCTION MRI can currently be considered the most accurate method
In recent years, MRI scanners and imaging protocols have for assessment of RV size and function and may be well
developed rapidly. At present, imaging is generally performed suited for quantification of RV scar tissue following infarc-
on 1.5 Tesla systems, using dedicated cardiac phased-array tion.
coils with multiple elements and ECG triggering. Optimal
results are obtained using fast breath-hold techniques, echo- PRESSURE–VOLUME LOOPS TO ASSESS RIGHT
planar or balanced fast field echo. Mogelvang et al55
VENTRICULAR FUNCTION
demonstrated the accuracy of MRI to assess RV volumes.
Analysis of RV function by pressure–volume loops is
The reproducibility of the technique was shown by Grothues
attractive because it quantifies various determinants of
et al56 who evaluated 60 individuals (20 healthy subjects, 20
ventricular function in a relatively independent fashion.62–64
heart failure patients, 20 patients with ventricular hyper-
Figure 10 depicts typical steady state RV pressure–volume
trophy) on two different occasions. The authors demon-
signals and the corresponding pressure–volume loops.
strated an excellent reproducibility for assessment of RV
Conventional indexes such as end systolic and end diastolic
function and RV volumes using MRI. Functional (and
pressures and volumes, stroke volume, stroke work and
anatomical) images of both the LV and RV are commonly
ejection fraction can be directly derived from the loops.
obtained in the short axis direction. Alfakih and colleagues57
Furthermore, differentiation of the volume signal (dV/dt)
compared RV volume measurements in the short axis and in
yields RV in- and outflow signals, from which early and late
axial directions. The axial orientation resulted in a better
filling rates and ejection rate can be obtained. Analysis of the
intra- and inter-observer reproducibility and may be con-
pressure decay during relaxation yields the relaxation time
sidered as the preferred direction for assessment of RV
constant t, whereas differentiation of the pressure signal
function.
yields dP/dtMIN and dP/dtMAX. These indexes reveal impor-
MRI can also be used for measurement of flow velocity and tant information on systolic and diastolic RV function, but it
volume by phase velocity mapping. Phase velocity mapping is should be noted that they not only depend on intrinsic RV
based on gradient-echo pulse sequences in combination with function, but are also affected by loading conditions. This is
ECG triggering. The phase contrast allows velocity encoding clearly illustrated in fig 11, which shows pressure–volume
and therefore flow measurements. loops obtained during a preload reduction. In contrast, the
Contrast enhanced MRI for imaging of myocardial scar pressure–volume relations, which may be derived from the
tissue was first described more than 20 years ago.58 59 With an pressure–volume loops during the loading intervention,
inversion recovery turbo field echo pulse, a heavily T1 provide indexes of RV function that are largely independent
weighted image is obtained that maximises the contrast of loading conditions and thus more specifically reflect
between the scarred (dead) and normal myocardium; intrinsic myocardial function. The position and slope (end
accordingly scarred myocardium appears bright whereas systolic elastance) of the end systolic pressure–volume
normal myocardium is dark. Recent studies have reported relation are sensitive indicators of RV systolic function.
excellent correlations between scar tissue on MRI and Alternative indexes are the slope of the relation between
postmortem analysis of infarcted myocardium.60 The majority stroke work and end diastolic volume, the preload recruitable
of studies focused on assessment of scar tissue in the LV, but stroke work, and the slope of the relation between dP/dtMAX
Sato and colleagues61 demonstrated the feasibility of MRI for and end diastolic volume.65 Diastolic function is derived from
assessment of scar tissue in the RV. An example of contrast the end diastolic pressure–volume points. The linear slope of
enhanced MRI to assess RV scar formation in a patient with this relation represents diastolic stiffness or, more commonly,
inferior infarction with RV involvement is shown in fig 9. diastolic compliance (1/stiffness). When obtained over a
Despite the excellent image quality and reproducibility, wider range, the end diastolic pressure–volume relation is
MRI has some disadvantages: the data acquisition and generally non-linear and better approximated by an expo-
analysis is rather time consuming, and some patients groups nential fit, such as EDP = A?exp(k?EDV) and characterised
(for example, pacemaker patients) cannot undergo MRI. Still, by the diastolic stiffness constant (k).16
Construction of pressure–volume relations requires pres-
sure–volume loops obtained during various loading condi-
tions, preferably induced by interventions that minimally
affect intrinsic myocardial function. An elegant means to
achieve this is temporary balloon occlusion of the inferior
vena cava. This procedure enables a rapid, purely mechanical,
reduction in preload, and prevents reflex mechanisms.
Alternatively, methods have been proposed that provide
estimates of systolic pressure–volume relations based on
steady state pressure–volume loops.66 Likewise, diastolic
compliance may be estimated by considering multiple
pressure–volume points during the late filling phase. These
single-beat approaches are attractive because they avoid the
need for a loading intervention, but the accuracy of the
derived indexes especially in the diseased RV needs further
study.
Currently, the conductance catheter is the most frequently
used instrument to assess RV pressure–volume loops.67 This
catheter contains a high fidelity pressure sensor, and up to 12
electrodes to measure RV electrical conductance from which
instantaneous RV cavity volume is determined.68 Pressure–
Figure 9 Contrast enhanced magnetic resonance image; short axis
volume loop analysis is extensively used in experimental
view showing right ventricular scar tissue in a patient with acute inferior studies14 17 69–73 and is generally considered the optimal way to
infarction (arrow). A second infarcted area is present in the anterolateral quantify RV function. In patients, this approach has been
region of the left ventricle. validated15 and used to assess RV function in congenital heart

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i24 Bleeker, Steendijk, Holman, et al

20
End diastole End systole
RV pressure
15

(mm Hg) 10
5
0 20
50
40
RV volume

Ejection
30 15
(ml)

RV pressure (mm Hg)

20
10
End systole
Area = stroke work
0
10
400
Stroke volume
dP/dt max
(mm Hg/s)
RV dP/dt

200
5
0
Filling
dP/dt min
–200 End diastole
300 0
Tricusp flow E A 0 10 20 30 40 50
200
RV dV/dt

100 RV volume (ml)

(ml/s)

0
–100
–200 PA flow
–300
0.0 1.0 2.0
Time (s)

Figure 10 Steady state right ventricular (RV) pressure–volume signals and pressure–volume loops obtained by conductance catheter in a 25 kg sheep.

20 disease74 and postoperative RV function.15 In summary, it is

concluded that pressure–volume analysis of RV function in
patients is feasible but requires invasive measurements.
Importantly, pressure–volume loops provide load-indepen-
15 dent indexes that enable accurate diagnosis of systolic and
diastolic RV function.
RV pressure (mm Hg)

ESPVR
CONCLUSION
10 RV function is an important parameter in cardiac disease. In
the clinical arena, two dimensional echocardiography can be
used to assess RV dysfunction. Several new echocardio-
graphic techniques, including TDI, strain rate imaging,
5 RT3DE and contrast echocardiography, may further enhance
our capability of assessing RV function. MRI is highly
accurate for the assessment of RV function; however,
EDPVR availability is still limited and data analysis is time consum-
0 ing. Finally, RV function can be evaluated invasively using
0 10 20 30 40 50
pressure–volume loop analysis, which has the advantage of
RV volume (ml)
being relatively load independent.

.....................
Authors’ affiliations
Stroke work (ml.mm Hg)

400 500 G B Bleeker, P Steendijk, E R Holman, M J Schalij, E E van der Wall,

RV dP/dt (mm Hg/s)

400 J J Bax, Department of Cardiology, Leiden University Medical Center,

300 PRSW Leiden, The Netherlands
300 G B Bleeker, Interuniversity Cardiology Institute of the Netherlands
200
200 (ICIN), Utrecht, The Netherlands
dP/dtmax – EDV C-M Yu, Division of Cardiology, Prince of Wales Hospital, Shatin, NT,
100
100 Hong Kong
0 0 O A Breithardt, Department of Cardiology, Klinikum Mannheim,
0 10 20 30 40 50 0 10 20 30 40 50 University of Heidelberg, Germany
RV end diastolic volume (ml) RV end diastolic volume (ml) T A M Kaandorp, Department of Radiology, Leiden University Medical
Center, Leiden, The Netherlands
Figure 11 Right ventricular (RV) pressure–volume loops during a P Nihoyannopoulos, Imperial College London, NHLI & Cardiothoracic
loading intervention (preload reduction by gradual vena cava occlusion) Directorate, Hammersmith Hospital, London, UK
and derived pressure–volume relations. dP/dtmax – EDV, dP/dtMAX –
end diastolic volume relation; EDPVR, end diastolic pressure–volume Correspondence to: Dr Gabe B Bleeker, Department of Cardiology,
relation; ESPVR, end systolic pressure–volume relation; PRSW, preload Leiden University Medical Center, Leiden, 2333ZA, The Netherlands;
recruitable stroke work relation. [email protected]

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Assessing right ventricular function i25

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Assessing right ventricular function: the role of

echocardiography and complementary
technologies
G B Bleeker, P Steendijk, E R Holman, C-M Yu, O A Breithardt, T A M
Kaandorp, M J Schalij, E E van der Wall, P Nihoyannopoulos and J J Bax

Heart 2006 92: i19-i26

doi: 10.1136/hrt.2005.082503

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http://heart.bmj.com/content/92/suppl_1/i19

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