From the Guidelines
Assessing right heart disease with transthoracic echocardiography (TTE) involves a systematic approach focusing on right ventricular structure and function, as outlined in the 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension 1. To assess right heart disease with TTE, begin with a visual assessment of right ventricular size in multiple views, including apical 4-chamber, parasternal long-axis, and subcostal views, noting chamber enlargement which suggests chronic pressure or volume overload.
- Measure right ventricular dimensions, including basal diameter (<42mm is normal), mid-cavity diameter, and longitudinal dimension.
- Evaluate right ventricular wall thickness at end-diastole (normal <5mm) to detect hypertrophy.
- Assess systolic function using multiple parameters:
- Tricuspid annular plane systolic excursion (TAPSE, normal >17mm)
- Right ventricular fractional area change (normal >35%)
- S' velocity by tissue Doppler (normal >9.5 cm/s)
- Right ventricular free wall strain (normal >-20%)
- Evaluate the tricuspid valve for regurgitation and measure the peak velocity to estimate pulmonary artery systolic pressure using the modified Bernoulli equation plus estimated right atrial pressure, as recommended by the European Association of Cardiovascular Imaging (EACVI) 1.
- Assess for flattening of the interventricular septum (D-shaped left ventricle), which indicates right ventricular pressure or volume overload.
- Examine the inferior vena cava size and collapsibility to estimate right atrial pressure, using the guidelines provided by the EACVI, which suggest an IVC diameter <2.1 cm that collapses >50% with a sniff indicates a normal RA pressure of 3 mmHg (range 0–5 mmHg) 1.
- Finally, look for additional findings such as pericardial effusion, right atrial enlargement, or pulmonary valve abnormalities. This comprehensive assessment allows for accurate diagnosis of conditions like pulmonary hypertension, right ventricular failure, and congenital heart disease affecting the right heart, and is supported by the ACR Appropriateness Criteria for known or suspected congenital heart disease in the adult 1.
From the Research
Assessment of Right Heart Disease with TTE
To assess right heart disease with transthoracic echocardiography (TTE), several steps can be taken:
- Evaluate right ventricular (RV) size and function, including measurements of end-diastolic and end-systolic area, RV fractional area change, Tei index, Tricuspid Annular Plane Systolic Excursion (TAPSE), and speckle tracking derived free wall strain 2
- Assess tricuspid regurgitation (TR) velocity at pulmonary valve opening time and calculate end-diastolic pulmonary artery pressure, which can be obtainable in most patients and add prognostic information on top of clinical and routine haemodynamic and diastolic parameters 2
- Examine the degree of tricuspid regurgitation and its correlation with clinical indicators of right-sided heart failure, as well as qualitative and quantitative measures of right-sided heart morphology and function 3
- Evaluate right heart remodelling and pulmonary hypertension, which can have a significant impact on prognosis in patients with severe tricuspid regurgitation 4
- Consider the assessment of RV dysfunction and TR in the context of other cardiac conditions, such as left heart disease, and their potential impact on outcomes after procedures like transcatheter aortic valve replacement (TAVR) 5
Key Parameters to Evaluate
Some key parameters to evaluate when assessing right heart disease with TTE include:
- RV size and function
- TR velocity and calculated end-diastolic pulmonary artery pressure
- Degree of tricuspid regurgitation
- Right heart remodelling and pulmonary hypertension
- RV dysfunction and its impact on prognosis
Prognostic Value
The prognostic value of these parameters can be significant, with elevated end-diastolic pulmonary artery pressure and severe TR associated with increased mortality and worse outcomes 2, 4, 5. Therefore, careful assessment of right heart function and disease is crucial for clinical decision-making and management of patients with right heart disease.