Recognizing poor right ventricular systolic function in echocardiography

Right ventricular failure is caused by left ventricular failure, heart attack, or hereditary right heart diseases. What are the echocardiography signs of systolic dysfunction in the right ventricle? How is the tricuspid anulus supposed to move in a healthy heart? What about the free wall of the right ventricle? In this video, Cristiana Monteiro—a cardiac physiologist from the University of Oxford—shares her expert approach to right heart echo.

We too often focus on the left ventricle and its pathologies when performing echo, forgetting that the right heart is also a significant source of symptoms and complications. It is an important prognostic predictor for many cardiac diseases. In this course, we’ll teach you the pearls and pitfalls of right-heart echocardiography so you can confidently assess the right heart and its pathologies. Master right-heart echocardiography and learn how to confidently assess the right heart and its pathologies with this course.

At the end of this Medmastery lesson, you will be able to quickly recognize a failing right ventricle on an echocardiogram. Up until this point we have discussed the normal right heart. In review, the size and shape of the right ventricle should be triangular, like a wedge of cheese, as seen here. The tricuspid annulus, where the tricuspid valve sits securely should move up towards the apex during systole and move back down during diastole.

The free wall of the ventricle should contract towards the interventricular septum during systole, making the chamber of the right ventricle smallest at the end of systole and then move away from the septum during diastole, making the chamber largest at the end of diastole. In comparison to that healthy pumping ventricle we just saw, this is an extreme case of ventricular dysfunction. If we focus on the right ventricle in this apical four chamber view, it looks and moves very differently from the previous one, doesn't it?

Let's take a look at this ventricle in a little more detail using a step by step approach. First, let's look at the size. So the right ventricle in this heart is very dilated. In fact, it is the same size or even slightly larger than the left ventricle. Now it's work, the muscle is not moving as much as it should. In the normal right ventricle, we should see the muscle move towards the interventricular septum during systole when it contracts, in this case, the motion of the three wall of the right ventricle is barely visible, and it is the interventricular septum that appears to be moving.

This is an extreme case of right ventricular failure. Right ventricular failure may happen as a consequence of left ventricular failure, a heart attack or inherited diseases affecting primarily the right heart. At this point, you can assess the other structures. For instance, in this image, you can see that the right atrium is significantly dilated.

Now that we know what to look for, let's apply it systematically to assess the function of the right ventricle using echocardiography. In the parasternal long axis view the right ventricle of this heart easily takes up half of the cardiac size, instead of the expected 1/3. It is significantly dilated, meaning it has more blood volume than it should and the muscle is overstretched. Put simply, the cardiac muscle does not like extremes, and this excessive stretch will affect how it works, making it less effective.

The same is true in the parasternal short axis view. Again, the right ventrical looks larger than the left and there is hardly any emotion during systole, when you would expect to see the ventricle contract. In the apical four chamber view, the dysfunctional right ventricle appears to be larger than the left. It has also lost its triangular shape. In addition, the apex is irregularly shaped with a really bulgy appearance. Zooming in on the right ventricle in the apical four chamber view, we can see that the tricuspid valve annulus is not moving towards the apex at all.

Similarly, the free wall of the right ventricle is not contracting. We would expect it to move towards the interventricular septum during systole. This means that blood ejection will not be as effective as it should be. As a result, blood will pool in the right ventricle, the inferior and superior vena cava and all of the veins around the body, leading to significant swelling of the legs, abdomen and other areas of the body. Well done. After reviewing this extreme case of right ventricular dysfunction, you now know how to visually assess right ventricular function using echocardiography.