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Echocardiographic approach of right ventricle evaluation

Course on the right ventricle and the tricuspid valve organised by the Hellenic Working Group and OCSC


For many years, the right ventricle (RV) had been overshadowed by the left ventricle (LV). However, over the last 2 decades, the importance of the RV has been recognized and echocardiography has played a significant role in uncovering many secrets of RV function.
This session aimed to provide insight into RV mechanics and physiology, the prognostic impact of RV in heart failure, the role of RV function in the evaluation of candidates for RV assist device (RVAD) implantation and the involvement of RV in coronary artery disease (CAD). 

Anatomy and function of the right ventricle: an echocardiographic enigma begins to resolve (P. Margetis, Athens, GR)

During the last few years, RV structure and function have been found to be strong predictors of outcome in several cardiopulmonary diseases. Thus, the previously ignored RV should be evaluated in every echocardiographic study. However, imaging of the RV remains challenging despite the significant progress in imaging techniques.
Echocardiography can adequately assess most RV structural abnormalities, but echocardiographic evaluation of RV function is more challenging owing to the marked load dependence of current indices of RV function, and the complex RV anatomy. Therefore, the RV needs to be imaged from multiple acoustic windows and interpretation demands co-estimation of qualitative and quantitative parameters.
Advanced echocardiographic techniques such as 3D echocardiography and myocardial strain imaging might overcome the complexity of the RV shape, and seem to yield new insights into RV assessment, providing measurements comparable to MRI.
As we expand our knowledge of the RV, the need for further research and refinement of existing imaging techniques becomes clearer. Echocardiography still plays an important role, and will likely continue to gain importance, in RV functional assessment in the future. 
Right ventricular function: prognostic implications in heart failure (E. Anagnostou, Thessaloniki, GR)
Left-sided heart failure is the most common cause of RV dysfunction. RV dysfunction is present in about two-thirds of patients with this condition, termed group 2 pulmonary hypertension (PH). Several mechanisms may be involved in the concomitant presence of RV dysfunction and  left-sided heart failure: (1) similar cardiomyopathic process, (2) ventricular interdependence, (3) decreased coronary perfusion and, (4) increased RV afterload due to backward transition of high LV filling pressure.
Because of the high prevalence and its prognostic implications, the assessment of RV function (and PH) must be part of the initial screening and follow-up in all congestive heart failure patients.

Coronary artery disease: bringing the right ventricle on the scene (L. Rallidis, Athens, GR)

The RV is less vulnerable to ischemia than the LV. This is due to the lower oxygen consumption (much thinner walls, contraction against a low pressure system), the better oxygen supply due to homogeneous coronary blood flow both in systole and diastole, the greater oxygen extraction reserve and the rapid development of collateral circulation (mainly provided by left anterior descending artery through the moderator band artery) in case of proximal occlusion of right coronary artery (RCA).
RV acute myocardial infarction (AMI) complicates inferior AMI [14-84%, according to the diagnostic technique], is usually caused by proximal occlusion of the RCA and carries a worse prognosis. Not all proximal occlusions of the RCA result in RV ischemic insult. Tissue Doppler imaging (peak systolic velocity of the RV free wall at the level of the tricuspid annulus) helps to identify patients with RV involvement in the setting of inferior AMI.
Stress echocardiography is a useful tool to detect ischemia of the RV, which almost always occurs in association with inferior wall ischemia of the LV. The most commonly affected area of the RV is the inferior wall. Since the threshold for ischemia of the RV is higher compared to the LV, RV ischemia can be missed when stress echocardiography is terminated prematurely due to the earlier appearance of LV ischemia.

Evaluation of the right ventricle in candidates for right ventricular assist device implantation. Evaluation of RVAD function (I. Paraskevaidis, Athens, GR)

A substantial number of patients being considered for a LV Assist Device (LVAD) have some degree of RV dysfunction preoperatively, and many develop significant RV failure (RVF) in the perioperative period, resulting in significant adverse outcomes. RVADs are available for short-term support of patients with RVF. However, options for long-term mechanical circulatory support of the RV are lacking.
Therefore, identification of patients at high risk for the development of RVF is paramount. Such risk assessment is even more critical in the destination therapy population, in whom cardiac transplantation, a treatment option for refractory RVF, is not the ultimate goal.
Numerous preoperative variables predictive of RVF in patients with implanted LVADs have been identified, and several risk models have been developed in an effort to risk-stratify patients. Unfortunately, the lack of consistently identified predictors of RVF across these studies has made identification of patients who would benefit from biventricular support difficult. Future efforts to resolve such inconsistencies is vital, especially in light of recent data suggesting that planned use of biventricular mechanical support (BiVAD) may result in improved clinical outcomes when compared to delayed use of RVADs.


Nowadays, the RV should no longer be the forgotten cavity. The evaluation of the RV should be an integral part of daily echocardiographic practice. Assessment of RV functional condition provides valuable prognostic information in many heart diseases. In addition, RV involvement in CAD, especially in the setting of inferior AMI, should always be sought by echocardiography. Since the RV is more resistant to ischemia compared to the LV, this might pose some difficulties when triggering ischemia by stress echocardiography.




Echocardiographic approach of right ventricule evaluation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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