From the Guidelines
The workup of right ventricular enlargement should begin with a thorough history and physical examination, followed by an electrocardiogram (ECG) and chest X-ray as initial screening tests, as recommended by the American Heart Association 1.
Initial Evaluation
The initial evaluation should include a comprehensive assessment of the patient's symptoms, medical history, and risk factors for pulmonary hypertension, congenital heart disease, cardiomyopathies, or valvular disease.
- A thorough physical examination should be performed to identify signs of right ventricular enlargement, such as jugular venous distension, hepatomegaly, and peripheral edema.
- Laboratory tests, including BNP or NT-proBNP, troponin, and D-dimer, should be ordered to assess for cardiac dysfunction and pulmonary embolism.
Imaging Studies
- Echocardiography is the cornerstone diagnostic tool, providing assessment of right ventricular size, wall thickness, systolic function, and estimated pulmonary artery pressure 1.
- Specific measurements include right ventricular basal diameter, mid-cavity diameter, and longitudinal diameter.
- Additional imaging modalities, such as cardiac MRI, may be ordered to provide superior quantification of right ventricular volume, mass, and function with high reproducibility.
- CT pulmonary angiography should be performed if pulmonary embolism is suspected.
Advanced Testing
- Right heart catheterization provides definitive hemodynamic assessment and is indicated when noninvasive testing is inconclusive or when specific measurements of pulmonary pressures, cardiac output, and vascular resistance are needed 1.
- The workup should be tailored to identify underlying causes of right ventricular enlargement, as treatment will depend on the specific etiology.
Recent Guidelines
The most recent guidelines from the American Heart Association recommend a comprehensive evaluation of patients with suspected right ventricular enlargement, including a thorough history and physical examination, laboratory tests, and imaging studies 1.
- The guidelines also emphasize the importance of identifying underlying causes of right ventricular enlargement, such as pulmonary hypertension, congenital heart disease, cardiomyopathies, or valvular disease, to guide treatment.
From the Research
Right Ventricular Enlargement Workup
The workup of right ventricular enlargement involves various diagnostic approaches to determine the underlying cause and assess the severity of the condition.
- The initial evaluation often includes transthoracic echocardiography (TTE) to detect right ventricular (RV) dilatation 2.
- Echocardiographic parameters such as RV end-diastolic area (RVEDA) and RV fractional area change (RVFAC) can be used to assess RV size and function, with RVEDA being the best parameter for identifying RV dilatation and RVFAC being the best parameter for diagnosing RV dysfunction 3.
- Cardiac Magnetic Resonance Imaging (cMRI) is considered the gold standard for RV assessment due to its high spatial resolution, allowing for accurate evaluation of RV size and function 3.
- Radiologic examination, including plain film and conventional contrast right ventriculography, can also be used to assess RV disease, although its sensitivity is limited due to the anterior location of the RV 4.
- Multiplanar MR imaging can provide direct demonstration of changes in RV size and wall morphology, as well as quantitative analysis of ventricular volume and myocardial mass 4.
Diagnostic Considerations
When evaluating a patient with suspected right ventricular enlargement, it is essential to consider various diagnostic possibilities, including:
- Pulmonary hypertension, which can lead to RV pressure overload and dilatation 5, 2.
- Congenital heart disease, which can cause RV volume overload or pressure overload 2.
- RV myocardial disease, which can result in RV dilatation or hypertrophy 2.
- Non-pathological RV dilatation, which can occur in certain conditions such as pregnancy or athleticism 2.
Clinical Implications
The workup of right ventricular enlargement has significant clinical implications, as it can guide treatment and management of the underlying condition.
- Patients with pulmonary hypertension may require specific therapies, such as pulmonary vasodilators, and close monitoring to prevent right ventricular failure 5.
- Those with congenital heart disease may require surgical or catheter-based interventions to correct the underlying defect 2.
- Accurate diagnosis and assessment of RV function are crucial to determine the best course of treatment and to predict patient outcomes 3, 4.