16/11/2023
Tips and Tricks in Echocardiographic assessment of right heart
1-Full assessment of right heart should include:
I-Right atrial size(RA area, major axis, minor axis)
II-Right ventricular size(Basal, mid and longitudinal RV linear dimensions, RV volume by 3D Echo if available)
III-Right ventricular wall thickness
IV-RVOT diameter(Proximal and distal)
V-Right ventricular systolic function(TAPSE, tricuspid annular velocity, FAC)
VI-Shape of interventricular septum(Flattening, D shaped LV, pressure vs volume overload, eccentricity index)
VII-Hemodynamics(RA pressure, systolic, mean and diastolic pulmonary artery pressure, PA acceleration time)
2-According to 2010 ASE guidelines for Assessment of Right Heart
-Upper normal limit for RA area in endsystole(18cm2)
-Upper normal limit for RV dimensions at end-diastole (4.2,3.5,8.6 cm at the basal, mid and longitudinal RV dimensions respectively)
Upper normal limit for RV dimensions According to 2015 Guidelines for chamber qunatification
41,35,83 mm at the basal, mid and longitudinal levels respectively
-Upper normal limit for RV wall thickness is 5mm(assess in zoomed subcostal view).
3-According to 2015 guidelines for chamber qunatification
-Lower normal limit for TAPSE 1.7 cm
-Lower normal limit for Tricuspid annular velocity (S wave) is 9.5 cm/sec
-Lower normal limit for normal fractional area change (FAC) is 35%
In another words, RV is considered dysfunctional if TAPSE is less than 1.7cm,or S wave less than 9.5cm/sec or FAC less than 35%
4-RV dimensions should be assessed in RV focused apical 4-chamber view
5-Use tricuspid regurgitation jet to assess pulmonary artery systolic pressure only if the doppler waveform is complete or at least partial and try to make cursor parallel to the TR jet or not exceeding 40 degree to gain the correct measurment
6-You can calculate mean pulmonary artery pressure from early pulmonary regurgitation velocity (4xV2)+RA pressure
And diastolic pulmonary artery pressure from late pulmonary regurgitation velocity (4xV2)+RA pressure
7-IVC diameter should be measured just distal to the opening of hepatic veins (or 1-2 cm from junction between RA and IVC)
8-In some healthy young atheletes, IVC looks dialted without right sided pathology. In this case, reassessment in left lateral position will restore actual size of IVC
9-Normal IVC diameter is 2.1 cm or less and at least 50% collapse with inspiration
-If both are present: RA pressure value from 0-5mmHg(average 3)
-If one of them is lost: RA pressure value :5-10mmHg(8mmHg in average)
-If both are lost: RA pressure value=10-20mmHg(15mmHg in average)
20mmHg value is used is IVC is markedly dilated and did not show any inspiratory collapse
10-In absence of RVOT obstruction or pulmonary stenosis; RVSP=PASP
11-Pulmonary artery acceleration time
Normal more than 130msec
100-130msec: borderline
Less than 100 msec; pulmonary hypertension is likely present
12-Global RV dysfunction despite preserved TAPSE is seen in patients with pulmonary arterial hypertension
13-Preserved global RV function despite abnormal TAPSE is seen in postoperstive cardiac surgery
14-in general, PASP more than 35mmHg in young or 40mmHg in Elderly is considered abnormal especially in patients evaluated for dyspnea
15-Correlation between pulmonary pressure estimated by Echo and Pressure obtained by cath does not exceed 40%.Echo can either Over or underestimae pulmonary pressure but overestimation is more common
16-Exclude RAA, IVC, SVC from measurment of RA area
16-Exclude RV trabeuclation and moderator band, involve apex when you measure RV area to calculate FAC
