ReviewEchocardiographic assessment of the right ventricle: Impact of the distinctly load dependency of its size, geometry and performance
Introduction
Right ventricular (RV) performance is a reflection of contractility, preload and afterload, also being influenced by valvular function, heart rhythm, ventricular interdependence and synchrony of ventricular contraction. Acting more as a volume pump, the RV tolerates less pressure overload than volume overload and has higher sensitivity to afterload changes than the left ventricle (LV). Thus, RV performance is distinctly afterload-dependent and both reduction in systolic function and ventricular enlargement occur much earlier in the pressure overloaded RV than in the pressure overloaded LV [1], [2].
Pulmonary load is an important determinant of RV function in patients with congestive heart failure (CHF) due to primary impaired LV function and in those with pre-capillary pulmonary hypertension (PH). Indeed, the most common causes of RV failure (RVF) are left-sided HF and pre-capillary PH [3], [4], [5]. Because of the high variability in RV adaptation to pressure overload and its ability to improve during afterload reduction by a LV assist-device (LVAD) in patients with end-stage CHF or after lung transplantation (LTx) in patients with pre-capillary PH, the reliability of RV assessment is paramount for prognostic evaluations and therapeutic decisions [1], [6], [7].
Echocardiography (echo) is the mainstay for RV evaluation but the markedly load-dependency of RV size, geometry and function induce particular challenges in RV echo-assessment. The review summarizes knowledge about RV echo-assessment in patients with afterload-induced RVF. Special attention is focused on interpretation of RV geometry and function measurements in relation to loading conditions, aiming to evaluate RV adaptability to load and to predict the reversibility of RVF by reduction of RV afterload.
Section snippets
Pathophysiology of RV response to pressure overload
Pressure and volume overload are main causes of RV dysfunction [8], [9]. However, because the compliant thin-walled RV tolerates less pressure than volume overload, the most frequent initial cause of RVF is the pressure overload due to high filling pressures of the LV and/or high pulmonary vascular resistance (PVR) [3], [4], [8].
The onset of pressure overload-induced RVF can be abrupt like in acute massive pulmonary embolism because the RV is poorly constructed to compensate for acute afterload
Reversibility of right ventricular failure by RV afterload reduction
The high load-sensitivity of RV performance, related to the impact of preload and afterload on RV geometry and TR explains RV ability for reverse remodeling and functional improvement after normalization of loading conditions [16], [17]. Sustained afterload increase is associated with homeometric adaptation (without chamber dilation) of RV contractility in order to maintain an adequate SV [8]. After exhaustion of homeometric adaptation and adaptive remodeling (hypertrophy) the RV responds to
Echo-assessment of the RV: limitations and impact of RV load
Because of difficulties in RV volume measurements (complex three-dimensional RV shape, limited echo-window due to RV position, limited definition of RV endocardial surface), 2D-echo-derived RV ejection fraction (EF) is less reliable and therefore, 2D-echo-derived RV volume and EF calculations are not recommended for clinical use or as a standard reference in research [19], [20]. Three-dimensional (3D) echocardiography obviates geometric assumptions and is superior to standard 2D-echo for
RV echo-evaluation in relation with its loading conditions
RV function is proportional to its contractile force and inversely related to its afterload, whereas RV afterload is determined by the filling pressures of the LV and the resistance of the pulmonary circulation [46], [52]. Load-dependency of RV size, geometry and pump function indicates the necessity for RV evaluation in relation with its loading conditions.
In vitro myocardial fiber contractility can be defined by an active-tension to fiber-length relationship [8]. In vivo ventricular
Clinical usefulness of RV echo-evaluation in relation to load
Though limited because of variable methodology, several studies showed that RV systolic function correlates with prognosis across a wide spectrum of pathology [6], [17], [63], [64], [65]. However, although the importance of RV function in management and prognostic assessment of many cardiac diseases is incontestable, it remains yet challenging to incorporate RV systolic dysfunction into practical decision making. Nevertheless RV evaluation in relation to its actual loading conditions can be
Conclusions and future directions
In clinical praxis, echocardiography is the mainstay of RV evaluation. However, in addition to the well known particular challenges and limits in RV echo-assessment, the difficulties in proper interpretation of RV echo-data, due to their high dependence on RV loading conditions and the high variability in RV adaptation to pressure overload, seriously hamper the use of echocardiography for assessment of RV contractile function.
Recent approaches to assess the RV in relation with its actual
Conflicts of interest
No conflicts of interest or grant for this article.
References (106)
- et al.
Who needs an RVAD in addition to an LVAD?
Cardiol. Clin. J.
(2011) - et al.
Assessment of right ventricular adaptability to loading conditions can improve the timing of listing to transplantation in patients with pulmonary arterial hypertension
J. Heart Lung Transplant.
(2015) - et al.
Left ventricular vs. biventricular mechanical support: decision making and strategies for avoidance of right heart failure after left ventricular assist device implantation
Int. J. Cardiol.
(2015) - et al.
Impaired endothelium-mediated vasodilatation in the peripheral vasculature of patients with congestive heart failure
Am. J. Cardiol.
(1992) - et al.
The right ventricle under pressure: cellular and molecular mechanisms of right heart failure in pulmonary hypertension
Chest
(2009) - et al.
Acute impact of left ventricular unloading by left ventricular assist device on right ventricle geometry and function: effect of nitric oxide inhalation
J. Thorac. Cardiovasc. Surg.
(2011) - et al.
Guidelines for echocardiographic assessment of right heart in adults: a report of the American Society of Echocardiography
J. Am. Soc. Echocardiogr.
(2010) - et al.
Ventricular-arterial coupling, remodelling and prognosis in chronic heart failure
J. Am. Coll. Cardiol.
(2013) - et al.
Feasibility and accuracy of a routine echocardiographic assessment of right ventricular function
Int. J. Cardiol.
(2007) - et al.
Right ventricular dP/dt/P(max), noninvasively derived from tricuspid regurgitation velocity is a useful index of right ventricular contractility
J. Am. Soc. Echocardiogr.
(2002)
Utility of Tei Index in the non-invasive evaluation of chronic thromboembolic pulmonary hypertension before and after pulmonary thrombendarterectomy
JACC
Pseudonormalized Doppler total ejection isovolume (Tei) index in patients with right ventricular acute myocardial infarction
Am. J. Cardiol.
Echocardiographic predictors of adverse outcomes after continuous left ventricular assist device implantation
J. Am. Coll. Cardiol. Imag.
Assessment of right ventricular systolic function: comparison between cardiac magnetic resonance derived ejection fraction and pulsed-wave tissue Doppler imaging of the tricuspid annulus
Int. J. Cardiol.
Echocardiographic strain and strain rate imaging — clinical applications
Int. J. Cardiol.
A simple method to predict impaired right ventricular performance and disease severity in chronic pulmonary hypertension using strain rate imaging
Int. J. Cardiol.
Right intraventricular dyssynchrony in idiopathic heritable and anorexigen-induced pulmonary arterial hypertension
J. Am. Coll. Cardiol. Img.
RV longitudinal deformation correlates with myocardial fibrosis in patients with end-stage heart failure
J. Am. Coll. Cardiol. Img.
Echocardiographic assessment of right ventricular function
J. Am. Coll. Cardiol. Img.
Consistencies of 3D TTE global longitudinal strain of both ventricles between assessors were worse for 2D, but better for 3D ventricular EF
Int. J. Cardiol.
Two dimensional global longitudinal strain of the right ventricle using transthoracic echocardiography can detect right ventricular fibrosis confirmed by 320 slice CT in pulmonary hypertension
Int. J. Cardiol.
Right atrial volume index in chronic systolic heart failure and prognosis
JACC Cardiovasc. Imaging
Advancing knowledge of right ventricular physiology in chronic pressure overload: insights from experimental studies
Arch. Cardiovasc. Dis.
Anatomy and physiology of the right ventricle
Cardiol. Clin.
Hemodynamic measurements after cardiac surgery: transesophageal Doppler versus pulmonary artery catheter
J. Cardiothorac. Vasc. Anesth.
Echocardiographic evaluation of right ventricular stroke work index in advanced heart failure: a new index?
J. Card. Fail.
Relationship between echocardiographic and magnetic resonance derived measures of right ventricular size and function in patients with pulmonary hypertension
Am. Soc. Echocardiogr.
Guidelines for the use of ehocardiography as a monitor for therapeutic interventions in adults: A report of the American Society of Echocardiography
Am. Soc. Echocardiogr.
Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure
J. Heart Lung Transplant.
The right ventricular failure risk score a preoperative tool for assessing the risk of right ventricular failure in left ventricular assist device candidates
J. Am. Coll. Cardiol.
Tricuspid incompetence and geometry of the right ventricle as predictors of right ventricular function after implantation of a left ventricular assist device
J. Heart Lung Transplant.
Right ventricular failure in patients with the HeartMate II continuous flow left ventricular assist device: incidence, risk factors and effect on outcomes
J. Thorac. Cardiovasc. Surg.
Preoperative risk factors for right ventricular failure after implantable left ventricular assist device insertion
Ann. Thorac. Surg.
Right heart failure and “failure to thrive” after left ventricular assist device implantation: clinical predictors and outcome
J. Heart Transplant.
Tricuspid annular motion as a predictor of severe right ventricular failure after left ventricular assist device implantation
J. Heart Lung Transplant.
Postoperative right ventricular failure after left ventricular assist device placement is predicted by preoperative echocardiographic structural, hemodynamic and functional parameters
J. Card. Fail.
Independent and incremental role of quantitative right ventricular evaluation for prediction of right ventricular failure after ventricular assist device implantation
J. Am. Coll. Cardiol.
Assessment of right ventricular dysfunction predictors before the implantation of a left ventricular assist device in end-stage heart failure using echocardiographic measures (ARVADE): combination of left and right ventricular echocardiographic variables
Arch. Cardiovasc. Dis.
Predicting right ventricular failure in the modern, continuous flow left ventricular assist device era
Ann. Thorac. Surg.
Increased right-to-left diameter ratio is a strong predictor of right ventricular failure after left ventricular assist device
J. Heart Lung Transplant.
Serial echocardiography using tissue Doppler and speckle tracking imaging to monitor right ventricular failure before and after left ventricular assist device surgery
JACC Heart Fail.
Risk score derived from preoperative data analysis predicts the need for biventricular mechanical circulatory support
J. Heart Lung Transplant.
“Who'll be the next in line?” The lung allocation score in patients with pulmonary arterial hypertension
J. Heart Lung Transplant.
Treatment goals of pulmonary hypertension
J. Am. Coll. Cardiol.
Carbon monoxide diffusing capacity and mortality in pulmonaly arterial hypertension
J. Heart Lung Transplant.
Validation study on the accuracy of echocardiographic measurements of right ventricular systolic function in pulmonary hypertension
J. Am. Soc. Echocardiogr.
Clinical and prognostic relevance of echocardiographic evaluation of right ventricular geometry in patients with idiopathic pulmonary arterial hypertension
Am. J. Cardiol.
Survival of Chinese patients with pulmonary arterial hypertension in the modern treatment era
Chest
Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension
J. Am. Coll. Cardiol.
Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension
Am. J. Cardiol.
Cited by (50)
How Would We Treat Our Own Cystic Fibrosis With Lung Transplantation?
2024, Journal of Cardiothoracic and Vascular AnesthesiaRight Ventricle Function in Patients With Anterior Myocardial Infarction: Are We Sure it Is Not Involved?
2022, Current Problems in CardiologyCitation Excerpt :The RV3D EF has shown good correlation with MRI. The volumetric semi-automated border detection approach is the recommended method.30-33 RV EF of <45% usually reflects abnormal RV systolic function, even if these values are age- and gender-specific.
Ventricular systolic dysfunction with and without altered myocardial contractility: Clinical value of echocardiography for diagnosis and therapeutic decision-making
2021, International Journal of CardiologyCitation Excerpt :RV systolic function correlates with prognosis across a wide spectrum of cardiovascular and cardio-respiratory pathology and ECHO facilitates individual risk stratification and selection of appropriate therapies [91,126,127]. Although the high load dependency of systolic parameters complicates the in-corporation of RV systolic dysfunction into clinical decision-making, due to the high sensitivity of the RV to increased PVR, surveillance of RV size and function can provide essential information for the distinction between primary (myocardial damage-induced) and secondary (afterload mismatch-induced) RV dysfunction [16,91,102,126–132]. This issue has recently become particularly important after detection that small pulmonary vessel thrombosis associated with pulmonary blood flow alterations followed by right heart dilation and RVF are often the major cause of death related to COVID-19 [133–137].
Right Ventricular Dysfunction on Transthoracic Echocardiography and Long-Term Mortality in the Critically Unwell: A Systematic Review and Meta-Analysis
2024, Journal of Intensive Care MedicineMonitoring of the right ventricular responses to pressure overload: prognostic value and usefulness of echocardiography for clinical decision-making
2024, Cardiovascular Diagnosis and Therapy