Download Assessment of the Right Ventricle by Echocardiography: A Primer for

REVIEW ARTICLE
Assessment of the Right Ventricle by
Echocardiography: A Primer for Cardiac Sonographers
Kenneth D. Horton, RDCS, RCS, RCIS, FASE, Rick W. Meece, RDCS, RCS, RCIS, FASE, and
Jeffrey C. Hill, BS, RDCS, FASE, Salt Lake City, Utah; Nashville, Tennessee; Worcester, Masschusetts
The assessment of right ventricular (RV) structure and function by echocardiography has been improved by
advancements that include Doppler tissue imaging, strain imaging, and three-dimensional imaging. Doppler
tissue imaging and strain imaging can be useful for the assessment of regional RV systolic and diastolic function. Three-dimensional imaging has been reported to determine RV volumes and ejection fraction, which have
previously been cumbersome to measure with conventional two-dimensional echocardiography. This article
addresses the role of conventional and newer methods of echocardiography to assist sonographers in understanding the technical considerations, limitations, and pitfalls of image acquisition and analysis of RV structure
and function. (J Am Soc Echocardiogr 2009;22:776-792.)
Keywords: Right ventricle, Doppler tissue imaging, Two-dimensional imaging, Three-dimensional imaging
Accreditation Statement:
The American Society of Echocardiography is accredited by the Accreditation Council for
Continuing Medical Education to provide continuing medical education for physicians.
The American Society of Echocardiography designates this educational activity for a maximum of 1 AMA PRA Category 1 CreditsÔ. Physicians should only claim credit commensurate with the extent of their participation in the activity.
ARDMS and CCI recognize ASE’s certificates and have agreed to honor the credit hours
toward their registry requirements for sonographers.
The American Society of Echocardiography is committed to ensuring that its educational
mission and all sponsored educational programs are not influenced by the special interests of any corporation or individual, and its mandate is to retain only those authors
whose financial interests can be effectively resolved to maintain the goals and educational integrity of the activity. While a monetary or professional affiliation with a corporation does not necessarily influence an author’s presentation, the Essential Areas and
policies of the ACCME require that any relationships that could possibly conflict with
the educational value of the activity be resolved prior to publication and disclosed to
the audience. Disclosures of faculty and commercial support relationships, if any, have
been indicated.
Target Audience:
This activity is designed for all cardiovascular physicians and cardiac sonographers with
a primary interest and knowledge base in the field of echocardiography: in addition, residents, researchers, clinicians, intensivists, and other medical professionals with a specific
interest in cardiac ultrasound will find this activity beneficial.
Objectives:
Upon completing the reading of this article, the participants will better be able to:
1. Effectively apply echocardiographic techniques to provide a comprehensive assessment of right ventricular function
2. Accurately identify normal right ventricular anatomy and define basic right ventricular physiology
3. Utilize practical technical tips to enhance right ventricular image acquisition and subsequent measurements
4. Recognize the developing role of 3D imaging for the assessment of right ventricular
structure and function
5. Confidently integrate tissue Doppler methods with strain imaging techniques to assess right ventricular mechanical function
Author Disclosure:
Mr. Hill reported that he receives grant/research support from Toshiba America Medical
Systems, Inc., is on the speaker’s bureau for Philips Healthcare and is a consultant to Medtronic, Inc.
Mr. Horton reported that he is a consultant to Lantheus Medical Imaging, Inc.
Mr. Meece reported that he receives grant/research support from TomTec and Toshiba
America Medical Systems, Inc. He also reported that he is a consultant to Philips Healthcare.
Conflict of Interest:
This activity has been peer-reviewed by a non-biased member of the ASE ACCME/CME
committee. No indication of an actual or potential bias in relation to the author disclosures was determined.
Estimated Time to Complete This Activity: 1 hour
INTRODUCTION
RV dysfunction has been associated with increased morbidity and
mortality in patients with congenital heart disease, valvular disease,
coronary artery disease, pulmonary hypertension, and heart failure.1-3
Conventional 2-dimensional (2D) determination of RV function is
often qualitative. Doppler methods of tricuspid inflow and pulmonary
artery flow velocities, which are influenced by changes in preload and
afterload, may not provide robust prognostic information for clinical
decision making. Recent advances in echocardiographic imaging of
the right ventricle include Doppler tissue imaging (DTI), strain imaging (SI), and volumetric 3-dimensional (3D) imaging, which can be
used for additional information beyond standard 2D measurements.
In this article, we compare the role of conventional and emerging
echocardiographic techniques for evaluating RV function (Table 1).
Technical considerations in using a systematic approach to image
acquisition and analysis are discussed.
RV ANATOMY AND PHYSIOLOGY
Normally, the right ventricle is located anterior in the thoracic cavity in
relation to the left ventricle, with echocardiographic assessment possible in the 3 traditional acoustic windows (parasternal, apical, and
subcostal). The right ventricle is anatomically subdivided into the inflow tract, the infundibulum (outflow tract), and the apex (Figure 1).4
From the Intermountain Medical Center, Salt Lake City, Utah (K.D.H.); Saint
Thomas Heart & Research Institute, Nashville, Tennessee (R.W.M.); and the
University of Massachusetts Memorial Medical Center, Worcester,
Masschusetts (J.C.H.).
Reprint requests: Kenneth D. Horton, RDCS, RCS, RCIS, FASE, Intermountain
Medical Center, Sorenson Heart & Lung Tower, Echo Lab LL-1, Murray, UT
84107 (E-mail: [email protected]).
0894-7317/$36.00
Copyright 2009 by the American Society of Echocardiography.
doi:10.1016/j.echo.2009.04.027
776
Horton et al 777
Journal of the American Society of Echocardiography
Volume 22 Number 7
Table 1 Echocardiographic methods used for the assessment
of RV size and function
2D echocardiography
Linear dimensions
Fractional area change
M-mode echocardiography
TAM
Conventional Doppler echocardiography
Myocardial performance index
PVR
DTI and SI
Tissue Doppler techniques
Speckle-tracking techniques
3D echocardiography
Segmental/global volumes
EF
Within the RV cavity, there are 3 muscular bands: the parietal band,
the septomarginal band, and the moderator band. In abnormal or
congenital heart disease, the moderator band may serve as a landmark
to differentiate the right from the left ventricle.
RV hemodynamic function is physiologically different than that of
the left ventricle. This is due primarily to lower afterload in the pulmonary vascular bed, which explains the lower RV pressures compared
with the left ventricle. An important principle regarding RV diastolic
filling is ventricular interdependence, whereby changes in pulmonary
vascular resistance (PVR) and extracardiac pressures are more often
affected by respiration. This interdependence may alter filling and systolic performance in both ventricles.5 During inspiration, transtricuspid inflow (RV preload) increases by approximately 20%, while
transmitral inflow (LV preload) is mildly decreased by approximately
10%, with the process reversing during expiration. Pathologies that affect loading conditions, such as pericardial constriction, pulmonary
embolus, and RV infarction, often affect this relationship. In some
instances, clinical conditions (eg, chronic lung disease, obesity, congenital heart disease) may lead to technical limitations that preclude
the adequate visualization of RV shape and structure, in addition to
associated abnormal loading conditions, for accurate the assessment
of RV performance.
ASSESSMENT OF RV STRUCTURE AND FUNCTION BY 2D
ECHOCARDIOGRAPHY
Commonly used methods for calculating diameters, areas, and volumes of the LV are difficult to implement for the right ventricle and
are typically not performed. Because of the complex morphology
of the right ventricle, no single view or imaging plane will provide
enough information to adequately evaluate RV structure and function. As such, sonographers should perform thorough assessments
of the right ventricle from standard two-dimensional (2D) acoustic
windows that include RV inflow tract and RV outflow tract (RVOT)
views, parasternal short-axis views, and apical views.
Figure 1 Diagram of the right ventricle demonstrating its 3 major
chamber components; inflow tract, infundibulum (outflow tract),
and apex. Image adapted and modified from Haddad F, Hunt
SA, Rosenthal DN, Murphy DJ. Right ventricular function in
cardiovascular disease, part I: anatomy, physiology, aging,
and functional assessment of the right ventricle. Circulation
2008;117:1436-48.
from the American Society of Echocardiography recommend the
use of the subcostal 4-chamber view for measurements of RV free
wall thickness, because it has demonstrated higher reproducibility
and correlates with RV systolic pressure.6,9 Measurements of RV
chamber dimensions should include the diameters above the tricuspid valve (TV) annulus and in the mid-RV cavity, as well as the
distance from the TV annulus to the RV apex (Figure 2A).10,11
Technical Tips
Images obtained for 2D measurements should focus on the right ventricle at the expense of visualizing other cardiac structures. Helpful tips
include (1) narrowing the 2D sector width to optimize only RV structures; (2) using harmonic imaging and adjusting gain and compression
for good contrast and endocardial edge detection; (3) making RV wall
thickness measurements at the level of the chordae tendineae; (4)
making all measurements at end-diastole, or the frame demonstrating
the largest chamber dimension; and (5) for 2D measurements, obtaining all acquisitions during quiet respiration or apnea.
Measurements of RV wall thickness must exclude the epicardial fat
layer that can be visualized on the RV free wall. An anterior fat pad or
liver usually appears echodense and brighter than the true RV wall
(Figure 2B). Foreshortening of the right ventricle may be minimized
by positioning the transducer down an intercostal space and laterally until the RV apex is clearly seen. Prominent trabeculations and moderator
bands can make identification of the endocardial borders challenging. If
clinically indicated, endocardial enhancement from the use of echocardiographic contrast agents may improve the accuracy of chamber and
wall thickness measurements and the assessment of systolic function.
RV WALL THICKNESS AND CHAMBER DIMENSIONS
RV FRACTIONAL AREA CHANGE
RV free wall assessment is best performed from the apical and subcostal 4-chamber views. Increased RV free wall thickness or hypertrophy
as measured by echocardiography has been well validated and usually
indicates pressure overload from pulmonary hypertension, RV outflow obstruction, or pulmonary valve (PV) stenosis.6-8 Guidelines
The assessment of RV systolic function by the calculation of RV fractional area change (RVFAC) has been compared with cardiac magnetic resonance (CMR) imaging of the RV ejection fraction (EF) in
patients with heart failure and previous myocardial infarctions.11-13
778 Horton et al
Journal of the American Society of Echocardiography
July 2009
Figure 2 (A) Three measurements of the right ventricle obtained at end-diastole in the apical 4-chamber view: D1 = basal RV measurement; D2 = mid-RV measurement; D3 = base-to-apex measurement. (B) RV free wall thickness measurement obtained at enddiastole at level of the TV chordae tendineae in the subcostal 4-chamber view. Both images are optimized by decreasing the depth or
using the zoom function. Note the clear border delineation (excluding pericardial border, fat, or liver [arrows]) of the RV wall in (B). RA,
Right atrium.
Figure 3 RVFAC measured at end-diastole (A) and end-systole (B). Both images are optimized by decreasing the depth or using the
zoom function. The RVFAC is calculated as (25 cm2 10 cm2)/25 cm2 100 = 60% (normal). RVAD, RV area at end-diastole; RVAS,
RV area at end-systole.
RV fractional area change represents a ‘‘surrogate’’ measurement of
RV EF and is expressed as a percentage change in the RV chamber
area from end-diastole to end-systole, rather than changes in volume
(Figure 3). The RVFAC is calculated as follows:
end-diastolic area ðcm2 Þ end systolic area ðcm2 Þ
end diastolic are ðcm2 Þ
Compared with other measures of RV systolic function, including
M-mode-derived tricuspid annular motion (TAM) and transverse
fractional shortening, RVFAC was found to correlate best with
CMR-derived RV EF (CMR vs RVFAC, r = 0.80, P < .0001; CMR
vs transverse fractional shortening, r = 0.12, P = .48; CMR vs TAM,
r = 0.17, P = .30).13 Measurements of RVFAC are obtained in the apical 4-chamber view. Planimetry of the RV cavity area is traced across
Horton et al 779
Journal of the American Society of Echocardiography
Volume 22 Number 7
Figure 4 TAM obtained before optimization (A) and after optimization (B) in the same patient. By zooming in on the TV annulus, accuracy and measurements of TAM were improved. The red line follows the contour of the annulus during the cardiac cycle. TAM in (B)
= 2.0 cm (normal).
nosis and increased mortality. Samad et al15 assessed TAM in 194 patients with first acute myocardial infarctions and RV involvement.
TAM was significantly decreased in patients with acute myocardial infarctions compared with healthy subjects (20.9 6 4 vs 21.6 6 4 mm,
P < .001). TAM # 15 mm showed an increase in mortality (>40%) compared with TAM $ 20 mm (<5%). TAM > 15 mm is generally normal.
However, TAM is a one-dimensional approach, reflecting regional
(basal), not global, RV systolic function. TAM is also influenced by disease states such as acute cor pulmonale or RV strain, in which annular
motion may be less dynamic or significant regional variation may be
present.
Figure 5 Diagram of the RVMPI. A, Transtricuspid A wave; a, time
from cessation of transtricuspid A wave to the following E wave; E,
transtricuspid E wave; ET, transpulmonary ejection time.
the TV annulus along the endocardium, then around the apex at the
end-diastolic and end-systolic frames.
M-MODE FOR THE ASSESSMENT OF RV SYSTOLIC
FUNCTION
As mentioned previously, M-mode echocardiography can be used in
evaluating RV systolic function by measuring TAM. With the M-mode
cursor aligned through the anterior tricuspid annulus in the apical 4chamber view, longitudinal displacement of the annulus toward the
apex during systole can be recorded (Figure 4).14 RV dysfunction in
the presence of acute myocardial infarction is associated with poor prog-
Technical Tips
To obtain TAM, use the apical 4-chamber view by adjusting the 2D
image to position the M-mode cursor through the tricuspid annulus
as parallel as possible. Using the zoom magnification function may assist in proper alignment of the cursor through the annulus, resulting in
improved visualization of the annulus (Figure 4B). Other optimization
techniques include decreasing the gain to eliminate erroneous signals
from the areas around the annulus and acquisition of the tracing at
a sweep speed of 75 to 100 mm/s. Because the accuracy of this measurement may be influenced by exaggerated cardiac motion during
normal respiration or in patients with large pericardial effusions,
TAM should be obtained during apnea.
RV MYOCARDIAL PERFORMANCE INDEX
RV myocardial performance index (RVMPI), or the ‘‘Tei index,’’ has
been reported to determine RV global systolic and diastolic function
by measuring time intervals using standard pulsed or continuouswave Doppler.6 The RVMPI is the ratio of the total isovolumic
time (isovolumic contraction time [ICT] and isovolumic relaxation
time [IRT]) divided by the RV ejection time and is calculated as
follows:
½ICT ðmsÞ þ IRT ðmsÞ=RVET ðmsÞ
The RVMPI has shown significant correlation with RV EF by
nuclear ventriculography and is reported to be less affected by
loading conditions than RVFAC, TAM, and SI.16,17 Tei et al18
780 Horton et al
Journal of the American Society of Echocardiography
July 2009
Figure 6 Echocardiographic estimation of PVR in a patient with RV dysfunction and high right atrial pressure (estimated at >20 mm
Hg). (A) Continuous-wave Doppler was obtained across the TV from an off-axis apical 4-chamber view and the peak TR velocity (TRV)
was measured. (B) Pulsed-wave Doppler sample volume was placed at the RVOT, and the TVI was measured. The PVR in this patient
was calculated as TRV/TVIRVOT = 2.78/11 = 0.25 10 + 0.16 = 2.68 (abnormal).
demonstrated abnormal RVMPIs in patients with primary pulmonary hypertension compared with age-matched controls (0.93 6
0.34 vs 0.28 6 0.04, P < .001). The sum of isovolumic time in
patients with primary pulmonary hypertension was significantly
increased and RV ejection time significantly decreased (P < .001
vs normal controls).
Technical Tips
To calculate RVMPI, (1) obtain pulsed or continuous-wave Doppler
recordings of the TV inflow and PVoutflow; (2) measure the time duration from the cessation of the A wave to beginning of the subsequent E wave on the basis of the tricuspid inflow Doppler spectral
velocity envelope; (3) measure the RV ejection time from the pulmonary Doppler tracing; (4) subtract the RV ejection time from the time
duration (TV A wave to E wave): the difference in time is the sum of
isovolumic time; and (5) divide by the RV ejection time (Figure 5). In
patients with holosystolic tricuspid regurgitation (TR) and clear spectral Doppler envelopes, the duration of the regurgitation can be
substituted for the interval between cessation and onset of TV inflow.
Because Doppler recordings of TV inflow and PV outflow are not
simultaneous, the information should be acquired with the cardiac cycle R-R interval duration difference < 5%.16 Using the parasternal
short-axis view permits the rapid acquisition of both tracings. Lower
wall filters may improve the demarcation of valve opening and closure timing on the Doppler spectral envelopes. A 75 to 100 mm/s
sweep speed may improve accuracy.
PVR BY DOPPLER ECHOCARDIOGRAPHY
The assessment of pulmonary vascular resistance (PVR) is important
for management in patients with cardiovascular disease. To determine
invasive hemodynamic measurements of PVR, a catheter is placed in
the pulmonary artery; measurements include mean pulmonary artery
pressure, pulmonary capillary wedge pressure, and cardiac output. To
determine the noninvasive estimation of PVR by echocardiography,
the peak TR velocity (TRV) and time-velocity integral (TVI) of the
RVOT is measured (Figure 6). Estimation of PVR by echocardiography is calculated as follows:
TRVðm=sÞ=TVIRVOT ðcmÞ 10 þ 0:16 ðWoods unitsÞ
Abbas et al19 compared both invasive and noninvasive measures of
PVR in 44 patients with various cardiovascular diseases. Their results
showed an excellent correlation (r = 0.929) between the two
methods, demonstrating that PVR by echocardiography is reliable
and highly feasible.
Technical Tips
Assessment of the TR jet should be attempted in several views
(including the subcostal views) to ensure that peak velocities are accurate. In patients with difficulty obtaining peak velocities, the use of
agitated saline contrast is recommended to enhance the TR jet.
Pulsed-wave rather than continuous-wave Doppler is used for the
measurement of TVIRVOT. The sample volume should be placed in
the RVOT just proximal to the PV. A summary of RV measurements
and normal values is reported in Table 2.
DTI AND SI FOR THE ASSESSMENT OF RV FUNCTION
DTI and SI (ie, myocardial deformation) are newer echocardiographic
methods that provide objective assessments of global and regional RV
function. DTI and SI can complement 2D methods and have been
shown to be applicable in patients with right coronary artery disease,
congenital defects, pulmonary hypertension, and pulmonary embolism.20-27 Both methods are not significantly affected by volume loading
conditions, and both have demonstrated acceptable reproducibility.
DTI and SI are relatively easy to obtain from the tricuspid annulus
and RV free wall. This section describes technical aspects, pitfalls, and
caveats of using DTI and SI for the evaluation of RV function.
PULSED-WAVE DTI
Pulsed-wave DTI is used to measure low-frequency Doppler systolic
and diastolic velocities that reflect longitudinal RV myocardial motion. The sample volume is usually placed at or below (ventricular
Horton et al 781
Journal of the American Society of Echocardiography
Volume 22 Number 7
Table 2 Normal values of the right ventricle
Parameter
RV 2D free wall thickness
(subcostal 4-chamber
view) (cm)
RV 2D chamber dimensions
(apical 4-chamber view)
(cm)
Base
Mid
Base to apex
RV 2D area (cm2)
Systolic
Diastolic
RVFAC (2D) (%)
RV TAM (mm)
RVMPI (Doppler)
PVR (Doppler)
RV DTI systolic (S0 ) velocity
(obtained from the
apical 4-chamber view)
(cm/s)
Annulus
Base
Mid
Apex
RV DTI strain (obtained
from the apical
4-chamber view) (%)
Base
Mid
Apex
RV 2D speckle strain
(obtained from the
apical 4-chamber
view) (%)
Base
Mid
Apex
RV 3D volumes and EF
BSA indexed;
DS method (mL/m2)
EDV
ESV
SV
EF
Value
<0.5
Reference
Matsukubo et al6
Foale et al7
2.0-2.8
2.7-3.3
7.1-7.9
Weyman et al10
7.5-16
11-28
32-60
15-20
0.28 6 0.04
<0.175
Weyman et al10
Samad et al15
Tei et al18
Abbas et al19
Kukulski et al27
4.95 6 1.76†
11.03 6 2.06‡
8.48 6 2.04
9.96 6 1.97
Figure 7 Color DTI waveforms obtained from the RV free wall
describing the various phases in ventricular systole and diastole.
There are 5 discrete waveforms occurring within the cardiac cycle, as seen on the Doppler display: (1) ICT velocity, (2) systolic
(S0 ) velocity, (3) IRT velocity, (4) early diastolic velocity (E0 ), and
(5) late diastolic velocity (A0 ). Dotted vertical lines represent PV
opening (PVO) and PV closure (PVC).
Teske et al39
19 6 6*
27 6 6
32 6 6
Teske et al39
22.8 6 7.4
24.4 6 7.7
27.6 6 8.9
Gopal et al45
42.2-97.8
12.8-54.0
18.0-45.9
32.8-62.5
BSA, Body surface area; DS, disc summation; EDV, end-diastolic volume; ESV, end-systolic volume.
Data are expressed as mean 6 SD or as ranges.
*P < .01, base versus mid versus apical (analysis of variance).
†P = .04, RV annulus versus RV basal segment.
‡P < .001, basal segments versus medial versus apical segments (analysis of variance).
side) the tricuspid annulus. Other sites include positioning the sample
volume at the mid-RV free wall, apex, and the ventricular septum
in the apical 4-chamber view to assess myocardial contraction and
relaxation.
In patients with normal sinus rhythm, 5 distinct waveforms can be
seen on the Doppler display: (1) the ICT waveform occurs in early
systole and can be displayed above or below the zero baseline;
(2) the systolic (S0 ) peak waveform occurs during RV mechanical systole (PV opening to closure time), after ICT, and is always displayed
above the zero baseline; (3) the IRT waveform occurs in early diastole
Figure 8 Color DTI with 3 sample volumes placed over the RV
free wall (top left) in a patient with RV dysfunction. Sample volumes placed at the base and mid-RV allow for measurement
of systolic and diastolic function. The highest velocities occur
before PV opening (PVO; ICT [arrows]), and the absolute velocities are decrease from base to mid-RV. PVC, PV closure.
(end of the T wave on electrocardiography [ECG]) and can be displayed above or below the zero baseline; (4) the early diastolic (E0 )
waveform occurs during peak RV relaxation (after IRT) and is always
displayed below the zero baseline; and (5) the peak late diastolic (A0 )
waveform represents atrial contraction and is always displayed below
the zero baseline (just after the P wave on ECG) (Figure 7).
COLOR DTI
Color encoding of myocardial velocities improves spatial resolution of
RV wall motion during 2D imaging in the apical 4-chamber view. It is
important to recognize that non-color-encoded–derived pulsed-wave
DTI represents maximum instantaneous velocities, whereas color DTI
displays the average velocities within a specific region of interest and
782 Horton et al
Journal of the American Society of Echocardiography
July 2009
Figure 9 The role of observing aliasing in color DTI sector and its relationship to peak DTI velocities. (A) During atrial systole (circle on
electrocardiogram), there is a heterogeneous (yellow) display within the color DTI sector with aliasing of the basal RV free wall (arrow).
(B) During ICT (circle on electrocardiogram), after atrial systole, there is minimal color aliasing in the RV free wall (arrow). (C) After ICT
(circle on electrocardiogram), during early ejection, there is a homogeneous display with no significant aliasing within the color DTI
sector. This is an indication that the velocities within the color sector do not exceed the color scale. (D) Corresponding pulsed-wave
DTI waveforms with the sample volume place at the area of aliasing with a color scale pulse repetition frequency (PRF) set at
13.5 cm/s. The peak A0 and ICT waveforms measure 15 and 15.5 cm/s, respectively. Aliasing within the color sector occurred because
both A0 and ICT waveforms exceed the color scale PRF (13.5 cm/s). This indicates that the color scale may be too low and therefore
View video clip online.
needs to be increased to reduce or eliminate aliasing before measuring peak color DTI velocities.
will result in lower values in systolic and diastolic velocities. Pulsedwave DTI, however, has limitations, with the placement of a single
sample site along a fixed scan line, whereas color DTI allows the placement of multiple sample sites in various myocardial segments,
enabling simultaneous regional evaluation within the same cardiac
cycle (Figure 8). In addition, the region of interest samples may be repositioned to apply further postanalysis of the Doppler spectral signals
on the same image.
TECHNICAL ASPECTS OF DTI
Accurate DTI measurements of RV systolic and diastolic function require clear understanding of the waveforms, as noted above, and their
relationship to the timing of hemodynamic events (Figure 9, Video 1).
Myocardial velocities often vary during the cardiac cycle. For example, color DTI–derived myocardial velocities may exceed the color
scale threshold (Nyquist limit) and result in aliasing of the signals. Postprocessing of color DTI waveforms is highly dependent on the settings
at the time of acquiring the images. Temporal and spatial resolution
may be improved by narrowing the 2D color sector and adjusting
the velocity scale, resulting in increased frame rate and better displaying signals without aliasing.
Abnormalities in RV structure and function can reduce the peak
systolic and diastolic velocities (Figure 10, Video 2). Sonographers
should not mistake the peak ICT waveform for the peak S0 waveform.
The peak ICT waveform occurs before PV opening during the QRS
deflection. The peak S0 waveform occurs during mechanical systole
following PV opening and represents active RV contraction. Likewise,
it is important to distinguish the peak IRT waveform from the peak E0
waveform (Figure 11) for measurements of RV diastolic function. The
peak IRT waveform will be displayed below the baseline just after the
cessation of S0 waveform. It can be difficult to differentiate when IRT
is shortened and merges with E0 ; conversely, prolonged IRT may result in multiple early diastolic peak velocity waveforms. Measurement
from the onset of the Q wave (QRS) to PV closure may help detect
the peak IRT from E0 . In acquiring and choosing the correct peak
DTI waveforms, optimizing cursor alignment, overall gain, and respiration phase can affect peak DTI velocities. A summary of the technical factors influencing the DTI waveforms is provided in Table 3.
Journal of the American Society of Echocardiography
Volume 22 Number 7
Horton et al 783
Figure 10 Example of a 41-year-old man with severe pulmonary hypertension. (A) Three standard measurements of the RV chamber
from the apical 4-chamber view showed significant dilation, especially at the mid-RV level (4.18 cm). (B) Severe TR, with pulmonary
artery systolic pressures averaging 72 mm Hg (not including right atrial pressure), continues with severe pulmonary hypertension. (C)
Although overall RV function was difficult to assess, pulsed-wave DTI for the assessment of systolic and diastolic from the basal RV
free wall was abnormal (S0 = 7.4 cm/s, E0 = 10 cm/s, A0 = 6 cm/s). (D) Pulsed-wave DTI of the septum was within normal limits (S0 = 10.7
cm/s, E0 = 9.5 cm/s, A0 =8.1 cm/s).
View video clip online.
PULSED-WAVE DTI FOR THE ASSESSMENT OF RV
FUNCTION
Early investigation of pulsed Doppler DTI velocities of RV contraction (S0 ), relaxation (E0 ,) and atrial (A0 ) velocities was reported by
Alam et al.24 Recordings obtained at both the tricuspid and mitral
annuli in the apical 4-chamber view were compared. The RV
systolic and diastolic DTI velocities were higher compared with
those of the left ventricle, with the lowest velocities at the ventricular septum. The early diastolic (E0 ) tricuspid annular velocity was
significantly lower, and the late diastolic tricuspid annular velocity
was significantly higher in older subjects than in younger subjects,
demonstrating an inverse correlation with age.
COLOR DTI ASSESSMENT OF RV FUNCTION
Kukulski et al27 demonstrated the use of color DTI in measuring
regional velocities at the TV annular, basal, mid, and apical regions
of the RV free wall in 32 normal subjects. Similar to Alam et al,24
color DTI measurements were obtained in all subjects. The results
showed significant variability in S0 velocities in all regions (annular,
9.96 6 1.97 cm/s; basal, 11.03 6 2.06 cm/s; mid, 8.48 6 2.04
cm/s; apical, 4.95 6 1.76 cm/s; P < .001). The RV velocities
were consistently higher than those recorded in corresponding
LV segments. Interobserver and intraobserver variability was
variable between the TV annulus (7%), mid RV (12%), and RV
apical (14%) segments. Both studies demonstrated that the use
of DTI for the assessment of RV function was a highly feasible
and reproducible technique. Normal DTI values are reported in
Table 2.
DTI ASSESSMENT OF RV DIASTOLIC FUNCTION
There has been little published information regarding DTI and RV
diastolic function. One study evaluated pulsed-wave DTI measurements of E0 corrected for the TVearly filling velocity (E/E0 ) to estimate
RV filling pressures compared with invasive hemodynamics.28 The
TV E/E0 ratio was correlated with right atrial pressure (r = 0.75),
but with a standard deviation of difference of 4 mm Hg. A separate
study reported that increased right atrial pressure was associated
with shortened IRT, independent of RV end-diastolic pressure.29
Therefore, DTI may be useful for the assessment of RV diastolic function, combined with pulsed-wave Doppler TV inflow, but further
investigation is needed.
784 Horton et al
Journal of the American Society of Echocardiography
July 2009
Figure 11 Prominent ICT and IRT waveforms. (A) A pulsed-wave Doppler sample volume was placed at the PV level (circle) to obtain
the peak velocities. Gain was adjusted and filter decreased to identify PV opening (PVO) and PV closure (PVC) demarcations. Measurement from the onset of Q (QRS) to PVO was made (Q to PVO = 95 ms). (B) Pulsed-wave DTI obtained from the RV free wall. There
are 2 peaks, with one slightly higher than the other, occurring in the early part of systole as seen on the Doppler display. Measurement
of time from onset of Q to the first peak was less than the time to PVO (88 ms), indicating that the highest peak is the ICT, not S0 , and
the peak S0 is just afterward (180 ms). (C) Similar to (A), a sample volume was placed at the PV level (circle) in a different patient. Automated PV measurements are made by placing a caliper at the onset of valve opening and closure. (D) Color TDI sample volume was
placed at the basal RV free wall (left). To the right are the corresponding waveforms with automatic transfer of the measurements
made from (C). To the right of the second dotted line is a peak waveform occurring after PVC. The peak S0 waveform occurs during
the ejection period (between dotted lines). Peak DTI velocities noted during the QRS or after PVC do not represent the active myocardial contraction, and relaxation and should not be measured.
Table 3 Technical factors that may affect estimation of peak
pulsed-wave and color DTI velocities
1. Suboptimal image quality
2. Beam alignment
3. Sample site location
4. Doppler gain
5. Respiration
6. Frame rate (color DTI)
7. Signal-to-noise ratio (color DTI)
Limitations of DTI
Color DTI is highly dependent on image quality and frame rate in
contrast to pulsed-wave DTI. Signal noise can be a problem with either pulsed-wave or color DTI and may influence the accuracy of
measurements (Figure 12). As with any Doppler technique, limitations regarding the insonation angle and translational myocardial
motion will affect measurements.
Technical Tips
Basic technical tips that sonographers should use when acquiring Doppler tissue images include the following: (1) the timing of PVopening and
closing should be defined to determine RV mechanical systole for measurements of the peak S0 velocity, because the timing of ICT is always
shorter than the time from QRS onset to PV opening; (2) in the apical
4-chamber view, the transducer should be repositioned so that the
RV free wall is as parallel as possible with the Doppler cursor and
sampling site(s); (3) the color sector should be positioned over the right
ventricle and the sector width decreased to the maximize color DTI
frame rate (ie, $120 frames/s); (4) DTI velocities should be obtained
during apnea to minimize translational motion; and (5) $3 beats should
be measured and the velocities averaged.
SI FOR THE ASSESSMENT OF RV FUNCTION
Strain is a measure of deformation in myocardial thickening or shortening and provides additional measurements of myocardial
Horton et al 785
Journal of the American Society of Echocardiography
Volume 22 Number 7
Figure 12 Difficult-to-measure DTI waveforms. Pulsed-wave (PW) TDI (A) and color TDI (B) waveforms obtained in the same patient.
(A) Increased spectral broadening and artifact creating two peaks. (B) Noisy waveforms that are difficult to measure.
Figure 13 Strain calculation from the radial (short) axis. The wall
thickness increased from 10 mm at end-diastole to 14 mm at
end-systole. Therefore, the 4-mm increase in wall thickness accounts for the 40% strain.
mechanical function independent from myocardial velocity. Strain is
expressed as the percentage change in length from the original length
(Figure 13). Strain is calculated as follows:
Figure 14 Color DTI SI with 4 sample volumes placed over the
RV free wall (top left) in a patient with normal RV function.
Peak systolic RV strains occur at or near PV closure (PVC) and
are displayed below the Doppler baseline (arrow). PVO, PV
opening.
ðL1 L2 Þ=L2 ¼ DL=L2 ;
where L1 is the instantaneous myocardial length, L2 is the original
myocardial length, and DL is the absolute change in myocardial
length. SI is not significantly affected by translational cardiac motion
and therefore offers an advantage compared with DTI velocity for
evaluation of myocardial function.
using color DTI SI have been limited to the apical 4-chamber view
and therefore measures of longitudinal strain only. However, longitudinal strain is 1 of 3 vectors of myocardial deformation. Radial thickening or circumferential shortening measures must be determined in
short-axis or transverse planes and remain a research area that
requires further study.
COLOR DTI SI
TWO-DIMENSIONAL SPECKLE SI
Color DTI is used to measure strain and strain rate in multiple RV
myocardial segments (Figure 14). Color DTI SI has been compared
with CMR SI, demonstrating a good correlation, and normal valuesfor the right and left ventricles have been published (see Table 2).30-33
Technical issues regarding the angle of acquisition, signal-to-noise
ratio, frame rate, and image quality affect the accuracy and reproducibility of strain tracings. For the right ventricle, current applications
A recent development in echocardiography based on ultrasonic backscatter for tracking the ‘‘speckle pattern’’ of myocardial deformation is
now being investigated (Figure 15, Video 3). This technique is less dependent on frame rate and angle, offering potential measurement of
RV strain in both long-axis and short-axis planes (all 3 vectors of myocardial deformation). Excellent correlation between 2D speckle strain
and CMR SI for the left and right ventricles has been reported.34-39
786 Horton et al
Journal of the American Society of Echocardiography
July 2009
Figure 15 Apical 4-chamber view with 2D speckle imaging of the LV septum and RV free wall in a normal older patient. The images
display longitudinal velocity (A), strain (B), strain rate (SR) (C), and displacement (D) curves. A0 , Late diastolic waveform; AR, apical
right ventricle; AS, apical septum; BR, basal right ventricle; BS, basal septum; E0 , early diastolic waveform; MR, mid right ventricle;
View video clip online.
MS, mid septum; S0 , systolic waveform.
Table 4 Comparison of DTI SI and 2D speckle SI
DTI
Angle dependent
Dependent on 2D image quality
Frame rate dependent (color
flow imaging)
Apical views only
2D speckle tracking
Not angle dependent
Less dependent on
2D image quality
Less frame rate dependent
Apical and cross-sectional
views
A recent study compared measurements of strain, strain rate, velocity, and displacement in patients with RV dysfunction, athletes,
and control subjects using color DTI and 2D speckle SI.39 Both strain
techniques yielded 93% technical feasibility, which was in line with
previous reports from Alam et al24 and Kukulski et al27 for the assessment of DTI. Interobserver and intraobserver variability was similar
between methods. Two-dimensional speckle SI for the assessment
of RV function is accurate and highly feasible. A comparison of results
of 2D speckle SI and color DTI SI is presented in Table 4. Although
CMR SI is considered the ‘‘gold standard’’ for quantifying RV function,30 there are significant limitations that have prevented its widespread application. Limitations include portability, the availability of
suitable scanners, and its inability to be performed on patients with
pacemakers and prosthetic valves.
Technical Tips
Color DTI peak systolic longitudinal strain occurs normally at or near
end-systole (end of the T wave on ECG) and is negative and displayed
below the Doppler baseline. To determine peak strain, the following
procedure is undertaken: (1) The onset of QRS to PV opening and
closure is measured from spectral pulsed-wave Doppler. Some ultrasound systems permit automatic entry of the measurement from time
to onset of QRS to PV opening and closure that can be directly transferred to the strain display (Figure 14). (2) The transducer should be
positioned in the apical 4-chamber view, with the RV free wall visualized and as parallel as possible to the Doppler interrogation. (3)
The color sector should be positioned over the right ventricle and
the sector width decreased to maximize color frame rate (>120
Hz). (4) The color Doppler tissue image should be obtained during apnea to minimize translational motion. In severe disease states, peak
strains are reduced, and the time to peak may be shortened or prolonged, occurring well after PV closure. This abnormality is consistent
with ‘‘postsystolic’’ shortening, and both clinical and structural data
should be considered. For 2D speckle SI, different ultrasound
Horton et al 787
Journal of the American Society of Echocardiography
Volume 22 Number 7
Figure 16 Biplane imaging of the right ventricle using 3D matrixarray transducer obtained from an off-axis apical window. The
orthogonal (A) and transverse (B) planes intersect at 90 (top).
Both the rotation and elevation of the planes can be manipulated
by the sonographer to enhance the imaging from nontraditional
angles.
View video clip online.
Figure 17 Transthoracic 3D matrix image from the apical 4
chamber view (A). Transesophageal 3D (MTEE) of the RV demonstrates excellent detail of trebeculations and tricuspid apparatus (B). The coronary sinus (CS) is easily identified in the
View view clip online.
right atrial septal region.
full-volume data sets derived from either a single capture or successive narrow-angle volumes, which are digitally reconstructed or
‘‘stitched’’ together; and (4) multiplanar or 2D cut-plane views that
are reconstructed from a full-volume data set.
platforms require different settings, and no overall consensus has
been established. Two-dimensional frame rates between 40 and 80
Hz appear to be adequate for accurate speckle tracking,35-37 but further investigation is needed.
THREE-DIMENSIONAL BIPLANE IMAGING WITH
ORTHOGONAL ANGLE STEERING
THREE-DIMENSIONAL AND FOUR-DIMENSIONAL IMAGING
OF THE RV FUNCTION
An immediate advantage of real-time 3D biplane or triplane imaging
is the ability to visualize simultaneous orthogonal 2D imaging planes
from traditional transducer acoustic windows. Using steerable imaging, sonographers can immediately visualize short-axis and oblique
angles of RV structure and wall motion that are technically challenging using traditional imaging techniques (Figure 16, Video 4).
Echocardiographic assessment of the right ventricle has been advanced with the use of unique three-dimensional (3D) echocardiography cardiac ultrasound imaging transducers combined with
enhanced 4-dimensional (4D) software applications. The use of
3D has been validated for the measurement of RV volumes, EF,
and stroke volume and compares favorably with CMR imaging.4045
Recent publications report the use of 3D for pathologies including RV cardiomyopathies, dysplasia, and calculation of regurgitant
volumes, and normal values for adults have been published (Table
2).45-50 This section focuses on advancements in the use of 3D
echocardiography for measuring RV dimensions and function, as
well as the technical considerations of image acquisition and optimization.
TECHNICAL ASPECTS OF 3D IMAGING
The 3D matrix-array transducer is constructed with orthogonally intersected dense array beam formers that enable the capture of small
3D volumes of data, or ‘‘voxels.’’ A voxel represents the cube of a conventional 2D pixel. Newer ultrasound systems with this capability
yield dynamic (ie, real-time) 3D renditions or full-volume images
with voxel rates ranging from 20 to 60 Hz that are comparable
with conventional 2D frame rates. A full-volume 3D data set can
be acquired in real time, reconstructed, and analyzed immediately
with various on-cart or offline methods. At present, the primary applications for using 3D and 4D imaging include (1) real-time biplane or
triplane imaging with a steerable orthogonal plane; (2) real-time or
live narrow-angle imaging for visualizing structure and function; (3)
REAL-TIME 3D NARROW-ANGLE IMAGING
An optimal approach for viewing RV structural abnormalities is using
the real-time or live imaging application of the 3D transducer.
Because aperture depth (elevation) is significantly greater than 2D,
enhanced imaging of the RV structure and RVOT can be performed.
Sonographers can maximize spatial and temporal resolution using
choices in penetration depth and scan line density. Postprocessing
software tools enhance brightness, smoothing, compression, and
tissue gain to improve the diagnostic value of the images. Further
advances using matrix-array transesophageal 3D transducers have
enabled higher resolution images of RV anatomy that will influence
diagnostic capabilities in the future (Figure 17, Videos 5 and 6).
THREE-DIMENSIONAL MULTIPLANE RECONSTRUCTION
FROM FULL VOLUMES
A less used but important technique is the use of 3D and 4D data sets
that may be cropped or sliced into multiple 2D planes (C-mode) and
analyzed using on-cart or offline software for the display of coronal
(4-chamber), sagittal (2-chamber), and transverse (short-axis) planes
(Figure 18, Video 7). Multiplanar reconstruction (MPR) provides
a rapid method to create multiple, simultaneous 2D views of the right
ventricle that can be useful for direct ‘‘en face’’ planimetry of diameters and areas as well as evaluation of RV structural and physiological
788 Horton et al
Journal of the American Society of Echocardiography
July 2009
Figure 18 MPR derived from a single 3D full-volume acquisition of the right ventricle. The 3 orthogonal planes are cropped and displayed simultaneously: (A) coronal plane, (B) sagittal plane, (C) transverse plane. From the 3 planes, several measurements can be
View video clip online.
made to evaluate RV size, which was not previously available from 2D imaging. SAX, Short axis.
abnormalities. MPR from full-volume data sets is common in the use
of CMR imaging and computed tomographic techniques.45 The MPR
can be performed in a limitless fashion to determine the desired cut
planes to view within the cardiac chambers.
or biplane locking function fixes the longitudinal planes from the original placement, allowing for discrete dynamic 2D viewing while rotating on a centered basal to apical axis.
Technical Tips
THREE-DIMENSIONAL AND FOUR-DIMENSIONAL
VOLUMETRIC ANALYSIS OF THE RIGHT VENTRICLE
Measurements of the right ventricle from MPR can be performed as
follows: (1) Place two longitudinal orthogonal planes from the center
of the TV annulus and then tilt the planes to the true RV apex at the
septal junction with the left ventricle. The corrected 90 orthogonal
alignment allows for the construction of a third transverse plane
across the orifice or chamber to measure accurate direct planimetry
of en face anatomic dimensions such as the RVOT. (2) An orthogonal
Published studies have reported excellent correlation between 3D
imaging and CMR imaging for the analysis of volumes and EF in
both children and adults.41,45,51 Gopal et al45 obtained RV end-systolic, end-diastolic, stroke volume, and EF by means of 2D and 3D imaging and compared them with CMR imaging in 71 healthy
Journal of the American Society of Echocardiography
Volume 22 Number 7
Horton et al 789
Figure 19 (A) Graphic demonstrating the 5 cut-plane images (sagittal base, mid, and apex; apical 4-chamber; coronal) used to trace
3D RV morphology. (B) After the RV end-diastolic volume (EDV) and end-systolic volume (ESV) are automatically traced in the 5
planes, software-enhanced analysis is performed, resulting in a moving 3D model that displays volumes, EF, and stroke volume
(SV).
View video clip online.
ability of 3D to include important volumes contributed by the RV inflow tract and the RVOT, which may appear to be discontinuous (ie,
missing information) even when viewed from a short-axis orientation
by 2D imaging.
Recent advancements in 3D echocardiography may overcome
previous limitations and permit the accurate calculation of RV volume
and EF with semiautomated border detection and dynamic volumetric analysis capabilities. Current RV analysis software has a step-bystep workflow that guides sonographers in identifying the center of
the TV, mitral valve, and RV apex. The software then divides the
RV into the traditional diastolic and systolic cut planes that include
the RVOT volume. Volumetric contribution from the RVOT is a critical component in determining accurate systolic and diastolic RV volumes. The RV end-diastolic and end-systolic borders are traced in the
coronal, sagittal, and transverse planes, permitting analysis of wall
motion throughout the cardiac cycle. Derived data include RV
end-diastolic volume, end-systolic volume, stroke volume, and EF
(Figure 19, Video 8). Full-volume 3D and 4D data sets may be archived and postprocessed in a limitless fashion, offering capabilities
for retrospective analysis and comparison when serial examinations
of the right ventricle are performed.
Figure 20 Stitching artifact in a 3D transverse (short-axis) cutplane image. A distinct horizontal line is seen dissecting the
full volume (arrows), indicating a significant spatial stitching artifact caused from respiration during acquisition. Stitching artifact
is best assessed from the transverse plane in volumes captured
from the apex because the beam array on subvolumes (4-7 per
full volume) are directed from apex to base, then stitched from
an automatic horizontal sweep across the chamber. Stitching
artifact renders full volumes nondiagnostic, and the acquisition
View video clip online.
should be repeated.
individuals.45 Data measured by 3D showed better correlation than
2D with CMR imaging by the methods of apical rotation and disc
summation (P < .001). This was thought to be due to the enhanced
Technical Tips
Certain conditions present difficulty in obtaining quality multicycle
volumetric data sets, including a patient’s inability to perform sufficient apnea, abnormal cardiac rhythm, or other compliance issues.
In such situations, real-time biplane or triplane imaging can be an excellent backup approach. Three-dimensional and 4D matrix-array
transducers are generally 2 to 3 times larger than conventional 2D
transducers. This may offer a challenge for sonographers with smaller
hands. Use of the second hand to steady the probe position can be
helpful, especially in conjunction with an accessory foot pedal or
voice command, to acquire the images. Because the larger probe possesses an incrementally larger ‘‘footprint,’’ there may be an increased
degree of artifact from costal shadowing. However, 3D transducers
790 Horton et al
Journal of the American Society of Echocardiography
July 2009
Table 5 Stepwise approach for 3D and 4D full-volume acquisition
Step
1
2
3
4
5
6
7
8
9
10
Process
Observe electrocardiogram
for regular rhythm;
adjust for upright R wave
Position patient comfortably
and instruct on breathing
maneuvers
Determine optimal acoustic window
for full-volume image
Check initial 2D reference
image and use TE image
balance filter application
if available, or use TGC
Adjust TGC/lateral gain
compensation for final
balance from near field
to maximum depth
Maintain stable transducer
scanning position
View reference orthogonal/transverse
planes to determine left ventricle
(volume) is in 3D sector
Set preacquisition full-volume
density to highest level
and voxel rate
Instruct patient to slowly inhale
and exhale to determine best
part of respiratory cycle for
optimal image acquisition
Have patient perform breath
arrest (without taking a
deep breath) and acquire
images
Pitfall
Ectopy, atrial fibrillation, low voltage
Solution
Poor compliance, inadequate apnea
Reposition electrodes; use timed
based triggering based on average
heart rate
Decrease number of acquired cycles
May require unconventional (ie,
lateral/apical) acoustic windows
Balance image (TE, TGC) before
obtaining best 2D reference
for 3D acquisition
Obtain window that encompasses right
ventricle with best resolution
Optimize acoustic window and have
patient perform apnea before
balancing
Apical or near field overgained
Decrease TGC or move focal zone region
to central region of interest
Moving hand will change acoustic
resolution and negate steps 3-5
Only part of ROI will be in final
volume for analysis/interrogation
Repeat steps 3-5
Higher density decreases volume width
and elevation
Go to next lowest density to ensure ROI is
completely within volume
Respiratory-induced cardiac motion
will affect quality and spatial resolution
Rehearse before acquiring full volume
Patient moves or breathes; stitching
artifact noted in volumes
Repeat step 10 or reposition patient
and retry; attempt real-time image
acquisition
Rotate transducer slowly or readjust
scanning position
ROI, Region of interest; TE, tissue equalization; TGC, time gain compensation.
have more elements (>2500) that ultimately will acquire a greater
depth and number of returning echoes, albeit with some loss of spatial
resolution due to the nature of the transducer architecture.
THREE-DIMENSIONAL ACQUISITION LIMITATIONS
The number of cardiac cycles required when obtaining a full-volume
dataset (1-7) with or without an electrocardiographic tracing (for R-R
tracking) will vary as according to ultrasound machine configuration
and desired resolution quality for a particular diagnostic application.
In general, increasing the number of cycles will increase scan line density and voxel rate, improving spatial and temporal resolution. Conversely, the requirement for more cardiac cycles and longer capture
time introduce the possibility of ‘‘stitching’’ artifact from the reconstructed volume (Figure 20, Video 9).
Patients with atrial fibrillation, sinus arrhythmia, or frequent ventricular extra-systoles are more difficult to accurately evaluate because
of variance in the R-R timing interval. Even in the use of single-cycle
full-volume capture, R-R variance on ECG will affect accurate measurement of global volume displacement when comparing one beat
with the next. In situations in which a quality electrocardiographic
tracing is difficult to obtain, the preset ‘‘time’’ interval (2-8 seconds)
for a full-volume capture may be used. However, the same challenges
during acquisition are present, and other echocardiography-based
methods may serve as better surrogates for measuring RV function.
The scan line density architecture of current 3D matrix transducers
is inherently lower compared with conventional 2D transducers
and may produce some loss of spatial and temporal resolution
when used in 2D or biplane mode.
A key advantage of a full-volume data set of the right ventricle is
the ability to acquire from one of any traditional parasternal, apical,
or subcostal views. In fact, nontraditional angles between parasternal and apical views are often useful for the evaluation of RV structure and function. Most technical pitfalls can be successfully
overcome with an acquisition protocol (Table 5). As 3D and 4D
transducer architecture and software-driven capabilities continues
to advance, 3D echocardiography will become an increasingly
routine method available for the assessment of RV anatomy and
function.
SUMMARY
The assessment of RV function by echocardiography is an area that is
undergoing much research, as the development and implementation
of new modalities are now readily available. Sonographers should
become familiar with both traditional and newer, quantitative
techniques such as 3D, DTI, and SI for more comprehensive assessments of RV function.
Journal of the American Society of Echocardiography
Volume 22 Number 7
Supplementary data
Supplementary data associated with this article can be found in the
online version, at doi:10.1016/j.echo.2009.04.027
REFERENCES
1. Matthews JC, Dardas TF, Dorsch MP, Aaronson KD. Right-sided heart failure: diagnosis and treatment strategies. Curr Treat Options Cardiovasc
Med 2008;10:329-41.
2. de Groote P, Millaire A, Foucher-Hossein C, Nugue O, Marchandise X,
Ducloux G, et al. Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure. J Am Coll Cardiol
1998;32:948-54.
3. Voekel NF, Quaife RA, Leinwand LA, Barst RJ, McGoon MD,
Meldrum DR, et al. Right ventricular function and failure: report of
a National Heart, Lung, and Blood Institute and working group on cellular
and molecular mechanisms of right heart failure. Circulation
2006;114:1883-91.
4. Ho SY, Nihoyannopoulos P. Anatomy, echocardiography, and normal
right ventricular dimensions. Heart 2006;92(suppl):i2-13.
5. Klima UP, Lee M, Guerrero JL, LaRaia PJ, Levine RA, Vlahakes GJ. Determinants of maximal right ventricular function: role of septal shift. J Thorac
Cardiovasc Surg 2002;123:72-80.
6. Matsukubo H, Matsuura T, Endo N, Asayama J, Watanbe T. Echocardiographic measurement of right ventricular wall thickness. A new
application of subxiphoid echocardiography. Circulation 1977;56:27884.
7. Foale R, Nihoyannopoulos P, McKenna W, Kleinebenne A, Nadazdin A,
Rowland E, et al. Echocardiographic measurement of the normal adult
right ventricle. Br Heart J 1986;56:33-44.
8. Prakash R. Echocardiographic diagnosis of right ventricular hypertrophy:
correlation with ECG and necropsy findings in 248 patients. Cathet Cardiovasc Diagn 2005;7:179-84.
9. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA,
et al. Recommendations for chamber quantification: a report from the
American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in
conjunction with the European Association of Echocardiography, a branch
of the European Society of Cardiology. J Am Soc Echocardiogr
2005;18:1440-63.
10. Weyman A. Practices and principles of echocardiography. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 1994.
11. Schenk P, Globits S, Koller J, Brunner C, Artemiou O, Klepetko W, et al.
Accuracy of echocardiographic right ventricular parameters in patients
with different end-stage lung diseases prior to lung transplantation. J Heart
Lung Transplant 2000;19:145-54.
12. Zornoff LAM, Skali H, Pfeffer MA, Sutton M, Rouleau JL, Lamas GA, et al,
for the SAVE Investigators. Right ventricular dysfunction and risk of heart
failure and mortality after acute myocardial infarction. J Am Coll Cardiol
2002;39:1450-5.
13. Anavekar NS, Gerson D, Skali H, Kwong RY, Yucerl K, Solomon SD.
Two-dimensional assessment of right ventricular function: an
echocardiographic-MRI correlative study. Echocardiography 2007;24:
452-6.
14. Kaul S, Tei C, Hopkins JM, Shah PM. Assessment of right ventricular
function using two-dimensional echocardiography. Am Heart J
1984;107:526-31.
15. Samad BA, Alam M, Jensen-Urstad K. Prognostic impact of right ventricular involvement as assessed by tricuspid annular motion in patients with
acute myocardial infarction. Am J Cardiol 2002;90:778-81.
16. Karnati PK, El-Hajjar M, Torosoff M, Fein SA. myocardial performance index correlates with right ventricular ejection fraction measured by nuclear
ventriculography. Echocardiography 2008;25:381-5.
17. Dyer KL, Pauliks LB, Das B, Shandas R, Ivy D, Shaffer EM, et al. Use of
myocardial performance index in pediatric patients with idiopathic pulmonary arterial hypertension. J Am Soc Echocardiogr 2006;19:21-7.
Horton et al 791
18. Tei C, Dujardin KS, Hodge DO, Bailey KR, McGoon MD, Tajik AJ, et al.
Doppler echocardiographic index for assessment of global right ventricular function. J Am Soc Echocardiogr 1996;9:838-47.
19. Abbas AE, Fortuin FD, Schiller NB, Appleton CP, Moreno CA, Lester SJ. A
simple method for estimation of pulmonary vascular resistance. J Am Coll
Cardiol 2003;41:1021-7.
20. Dokainish H, Abbey H, Gin K, Ramanathan K, Lee PK. Usefulness of tissue Doppler imaging in the diagnosis and prognosis of acute right ventricular infarction with inferior wall acute left ventricular infarction. Am J
Cardiol 2005;95:1039-42.
21. Watanabe M, Ono S, Tomomasa T, Okada Y, Kobayashi T, Suzuki T, et al.
Measurement of tricuspid annular diastolic velocities by Doppler tissue imaging to assess right ventricular function in patients with congenital heart
disease. Pediatr Cardiol 2003;24:463-7.
22. Hsiao SH, Lee CY, Chang SM, Yang SH, Lin SK, Huang WC. Pulmonary
embolism and right heart function: insights from myocardial Doppler tissue imaging. J Am Soc Echocardiogr 2006;19:822-8.
23. Urheim S, Cauduro S, Frantz R, McGoon M, Belohlavek M, Green T, et al.
Relation of tissue displacement and strain to invasively determined right
ventricular stroke volume. Am J Cardiol 2005;96:1173-8.
24. Alam M, Wardell J, Andersson E, Samad BA, Norlander R. Characteristics
of mitral and tricuspid annular velocities determined by pulsed wave
Doppler tissue imaging in healthy subjects. J Am Soc Echocardiogr
1999;12:618-28.
25. Gondi S, Dokainish H. Right ventricular tissue Doppler imaging and strain
imaging: ready for clinical use? Echocardiography 2007;24:522-32.
26. Lindqvist P, Calcutteea A, Henein M. Echocardiography in the assessment
of right heart function. Eur J Echocardiogr 2007;4:1-12.
27. Kukulski T, Hubbert L, Arnold M, Wranne B, Hatle L, Sutherland G. Normal regional right ventricular function and its change with age: a Doppler
myocardial imaging study. J Am Soc Echocardiogr 2000;13:194-204.
28. Nageh MF, Kopelen HA, Zoghbi WA, Quinones MA, Nagueh SF. Estimation of mean right atrial pressure using tissue Doppler imaging. Am J
Cardiol 1999;84:1448-51.
29. Abbas A, Lester S, Moreno FC. Noninvasive assessment of right atrial pressure
using Doppler tissue imaging. J Am Soc Echocardiogr 2004;17:1155-60.
30. Yousseff A, Ibrahim EH, Korosoglou G, Abraham MR, Weiss R, Osman NF.
Strain-encoding cardiovascular magnetic resonance for assessment of rightventricular regional function. J Cardiovasc Magn Reson 2008;10:1-10.
31. Sun JP, Popovic ZB, Greenberg NL, Xu XF, Asher CR, Stewart WJ, et al.
Noninvasive quantification of regional myocardial function using Doppler-derived velocity, displacement, strain rate, and strain in healthy volunteers: effects of aging. J Am Soc Echocardiogr 2004;17:132-8.
32. Urheim S, Edvardsen T, Torp H, Angelsen B, Smiseth OA. Myocardial
strain by Doppler echocardiography. Validation of a new method to quantify regional myocardial function. Circulation 2000;102:1158-64.
33. Kowakski M, Kukulski T, Jamal F, D’Hooge J, Weidemann F,
Rademakers F, et al. Can natural strain and strain rate quantify regional
myocardial deformation? A study in healthy subjects. Ultrasound Med
Biol 2001;27:1087-97.
34. Leitman M, Lysyansky P, Sidenko S, Shir V, Peleg E, Binenbaum M, et al.
Two-dimensional strain—a novel software for real-time quantitative echocardiographic assessment of myocardial function. J Am Soc Echocardiogr
2004;17:1021-9.
35. Korinek J, Wang J, Sengupta PP, Miyazaki C, Kjaergaard J, McMahon E,
et al. Two-dimensional strain—a Doppler-independent ultrasound method
for quantitation of regional deformation: validation in vitro and in vivo.
J Am Soc Echocardiogr 2005;18:1247-53.
36. Langeland S, Wouters PF, Claus P, Leather HA, Bijnens B, Sutherland GR,
et al. Experimental assessment of a new research tool for the estimation of
two-dimensional myocardial strain. Ultrasound Med Biol 2006;32:1509-13.
37. Amundsen BH, Helle-Valle T, Edvardsen T, Torp H, Crosby J, Lyseggen E,
et al. Noninvasive myocardial strain measurement by speckle tracking
echocardiography: validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol 2006;47:789-93.
38. Hurlburt HM, Aurigemma GP, Hill JC, Narayanan A, Gaasch WH,
Vinch CS, Meyer TE, Tighe DA. Direct ultrasound measurement of
792 Horton et al
39.
40.
41.
42.
43.
44.
longitudinal, circumferential, and radial strain using 2-dimensional strain
imaging in normal adults. Echocardiography 2007;24:723-31.
Teske AJ, De Boeck BWL, Olimulder M, Prakken NH, Doevendans PAF,
Cramer MJ. Echocardiographic assessment of regional right ventricular
function: a head-to-head comparison between 2-dimensional and tissue
Doppler-derived strain analysis. J Am Soc Echocardiogr 2008;21:275-83.
Jenkins C, Chan J, Bricknell K, Strudwick M, Marwick TH. Reproducibility
of right ventricular volumes and ejection fraction using real-time three-dimensional echocardiography: comparison with cardiac MRI. Chest
2007;131:1844-51.
Lu X, Nadvoretskiy V, Bu L, Stolpen A, Ayres N, Pignatelli RH, et al.
Accuracy and reproducibility of real-time three-dimensional echocardiography for assessment of right ventricular volumes and ejection fraction in
children. J Am Soc Echocardiogr 2008;21:84-9.
Grison A, Maschietto N, Reffo E, Stellin G, Padalino M, Vida V, et al.
Three-dimensional echocardiographic evaluation of right ventricular volume and function in pediatric patients: validation of the technique.
J Am Soc Echocardiogr 2007;20:921-9.
Jiang L, Siu SC, Handschumacher MD, Guererro JL, Vazquez de Prada JA,
King ME, et al. Three-dimensional echocardiography. In vivo validation for
right ventricular volume and function. Circulation 1999;89:2342-50.
Niemann PS, Pinho L, Balbach T, Galuschky C, Blankenhagen M,
Silberbach M, et al. Anatomically oriented right ventricular volume measurements with dynamic three-dimensional echocardiography validated
by 3-tesla magnetic resonance imaging. J Am Coll Cardiol
2007;50:1668-76.
Journal of the American Society of Echocardiography
July 2009
45. Gopal AS, Chukwu EO, Iwuchukwu CF, Katz AS, Toole RS, Schapiro W,
et al. Normal values of right ventricular size and function by real-time
three-dimensional echocardiography: comparison to cardiac magnetic
resonance imaging. J Am Soc Echocardiogr 2007;20:445-55.
46. Kjaergaard J, Svendsen JH, Sogaard P, Chen X, Nielsen HB, Kober L, et al.
Advanced quantitative echocardiography in arrhythmogenic right ventricular cardiomyopathy. J Am Soc Echocardiogr 2007;20:27-35.
47. Prakasa KR, Dalal D, Wang J, Bomma C, Tandri H, Dong J, et al. Feasibility and
variability of three dimensional echocardiography in arrhythmogenic right
ventricular dysplasia/cardiomyopathy. Am J Cardiol 2006;97:703-9.
48. Aggarwal M, Drachenberg C, Douglass L, deFilippi C. The efficacy of realtime 3-dimensional echocardiography for right ventricular biopsy. J Am
Soc Echocardiogr 2005;18:1208-12.
49. Li X, Jones M, Irvine T, Rusk RA, Mori Y, Hashimoto I, et al. Real-time 3dimensional echocardiography for quantification of the difference in left
ventricular versus right ventricular stroke volume in a chronic animal
model study: improved results using C-scans for quantifying aortic regurgitation. J Am Soc Echocardiogr 2004;17:870-5.
50. Hock M, Vasilyev NV, Soriano B, Gauvreau K, Marx G. Variables influencing the accuracy of right ventricular volume assessment by real-time 3-dimensional echocardiography: an in vitro validation study. J Am Soc
Echocardiogr 2007;20:456-61.
51. Grothues F, Moon JC, Bellenger NG, Smith GS, Klein HU, Pennell DJ.
Interstudy reproducibility of right ventricular volumes, function, and
mass with cardiovascular magnetic resonance imaging. Am Heart J
2004;147:218-23.