Echocardiographic assessment of the right heart in adults: a practical guideline from the British Society of Echocardiography

in Echo Research and Practice
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  • 1 University Hospital of Wales, Cardiff, UK
  • 2 Royal Free London NHS Foundation Trust, London, UK
  • 3 Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
  • 4 East Suffolk and North Essex NHS Foundation Trust, Essex, UK
  • 5 Liverpool John Moores University, Research Institute for Sports and Exercise Science, Liverpool, UK
  • 6 Wythenshawe Hospital, Manchester, UK
  • 7 West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
  • 8 North West Anglia NHS Foundation Trust, Peterborough, UK
  • 9 School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
  • 10 Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK

Correspondence should be addressed to A Zaidi: abbas.zaidi@wales.nhs.uk

D Oxborough and V Sharma are members of the editorial board of Echo Research and Practice. They were not involved in the review or editorial process for this paper, on which they are listed as authors.

*(A Zaidi and D S Knight contributed equally to this work and should be considered joint lead authors)

(D X Augustine and V Sharma are the Guidelines Chairs)

The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.

Abstract

The structure and function of the right side of the heart is influenced by a wide range of physiological and pathological conditions. Quantification of right heart parameters is important in a variety of clinical scenarios including diagnosis, prognostication, and monitoring response to therapy. Although echocardiography remains the first-line imaging investigation for right heart assessment, published guidance is relatively sparse in comparison to that for the left ventricle. This guideline document from the British Society of Echocardiography describes the principles and practical aspects of right heart assessment by echocardiography, including quantification of chamber dimensions and function, as well as assessment of valvular function. While cut-off values for normality are included, a disease-oriented approach is advocated due to the considerable heterogeneity of structural and functional changes seen across the spectrum of diseases affecting the right heart. The complex anatomy of the right ventricle requires special considerations and echocardiographic techniques, which are set out in this document. The clinical relevance of right ventricular diastolic function is introduced, with practical guidance for its assessment. Finally, the relatively novel techniques of three-dimensional right ventricular echocardiography and right ventricular speckle tracking imaging are described. Despite these techniques holding considerable promise, issues relating to reproducibility and inter-vendor variation have limited their clinical utility to date.

Introduction

A comprehensive evaluation of the right ventricle (RV) by echocardiography is essential for the diagnosis and management of conditions affecting the right heart. Indices of right ventricular size and function are prognostic in a range of congenital and acquired diseases of both left and right heart aetiologies (1, 2, 3, 4). The British Society of Echocardiography (BSE) Education Committee has previously published a minimum dataset for a standard adult transthoracic echocardiogram (5). The present document specifically aims to review, supplement and expand on the echocardiographic assessment of right heart size and function. The variable behaviours and limitations of these parameters across the spectrum of right heart diseases give rise to a range of sensitivities and specificities for discriminating between health and disease. Consequently, there is the potential to generate contradictory and discrepant echocardiography data, and it is therefore important to undertake a detailed assessment of the right heart while taking into account the underlying pathology. This document provides a practical guide to assist with the appropriate application of echocardiography to RV pathology, with the ultimate aim of a more robust assessment of the right heart by cardiac ultrasound.

This protocol has adopted normal reference intervals for cardiac dimensions based on the results of the Normal Reference Ranges for Echocardiography (NORRE) dataset (6). These prospectively obtained data provide a more contemporary basis for reference intervals than previously available. We have also included, for the first time in a BSE protocol, measurements suggested for RV diastolic function assessment. Although this is not current routine clinical practice, the sensitivity of the RV to even minor alterations in loading conditions makes the concept of RV diastolic function at least as physiologically relevant as that of the left ventricle (LV). Indeed, there is no single parameter of RV function by any imaging modality that is truly load independent. The purpose of this part of the document is to introduce the reader to this concept and to consider the influence of the loading conditions facing the right heart on its function, rather than to necessarily mandate a routine assessment across all echocardiography studies. Finally, in order to provide a comprehensive guide to right heart assessment, quantitative assessment of right-sided native valvular heart disease will also be summarised in this document.

Background

The position of the RV within the thorax, along with its complex structure and contraction pattern, all pose additional challenges to echocardiography. The RV is the most anteriorly positioned cardiac chamber, located immediately behind the sternum. It is thin-walled with prominent trabeculations and a complex geometry. Under normal loading conditions, the RV has a triangular shape when viewed from the side, and a crescentic shape in the sagittal plane, wrapping around the conical left ventricle. The orientation of RV myofibres and their arrangement into layers is responsible for the distinct contraction pattern of this chamber, with an outer layer of circumferential subepicardial fibres, and an inner layer of longitudinal subendocardial fibres (7). These layers of differently aligned cardiomyocytes are responsible for the peristaltic, or wave-like, RV contraction pattern, starting at the inflow portion and progressing towards the infundibulum and outflow tract (8). The longitudinal motion drawing the base towards the apex is accompanied by a bellows effect of inward motion of the free wall towards the interventricular septum, which bulges into the RV cavity (9).

Despite the challenges of assessing the RV by echocardiography, it remains the most widely utilised clinical imaging modality for its assessment. A uniform approach to both data acquisition and post-processing steps is essential for ensuring the reproducibility of any imaging technique, with susceptibility to variation arising at both stages. In echocardiography, different sonographers need to acquire and post-process serial echocardiography studies in a reproducible manner in order for meaningful comparisons to be made. The standardisation of RV image acquisition is especially pertinent to echocardiography compared with cross-sectional imaging modalities, as a range of potential two-dimensional echocardiography views of this complex three-dimensional shape can be obtained. For example, foreshortening the apical window is a particular pitfall that can lead to overestimation of RV chamber size. The RV-focused view should be used to generate all apically acquired RV size and function metrics, since it has superior reproducibility for these parameters compared with the standard apical 4-chamber window (10, 11, 12). The RV-focused view can be obtained by a three-step process:

Finally, although the emphasis of this document is on echocardiography of the right heart, this should not neglect a comprehensive assessment of the left heart. For example, the most common cause of pulmonary hypertension (PH), a condition which primarily affects the right heart, is disease originating from the left heart. Many conditions of the RV either share common pathology with the LV or originate from left heart disease and are readily and routinely assessed by echocardiography.

Right ventricular systolic function

The echocardiographic evaluation of RV systolic function can be performed qualitatively and quantitatively, by two- and three-dimensional methods, and by regional and global assessment. There are benefits and limitations that are inherent in all of these approaches, the significances of which should be considered relative to the pathology being investigated. Accordingly, these guidelines recommend a disease-oriented approach to RV functional assessment and recognise the specific limitations of different RV systolic functional metrics, factors which are integral to the interpretation and application of reference intervals.

The evidence-base underpinning these reference intervals for RV functional indices should also be considered. Tricuspid annular plane systolic excursion (TAPSE), pulsed Doppler S wave (S′) and fractional area change (FAC) have, by far, the most abundantly available reference data to support their use (11). Therefore, at least one of these three metrics should be routinely reported when assessing RV systolic function. Furthermore, either a measurement that incorporates radial RV function, such as FAC, or at least a qualitative statement regarding radial RV function should be routinely made, since TAPSE and S′ only reflect longitudinal RV function.

More contemporary techniques such as 3-dimensional (3D) and speckle tracking (STE) echocardiography offer novel insights into RV function assessment, but with the caveats of less validation data and standardization across vendor platforms. These limitations should not hinder their development and dissemination in both clinical and academic echocardiography, but should nevertheless be taken into account to ensure the standardization of data acquisition, post-processing and interpretation. Consequently, this document places emphasis on recommending how to perform these techniques systematically and homogeneously in order to allow their reproducible application for assessing RV systolic function.

Right ventricular diastolic function

In comparison with LV diastolic function, there is a lack of guidance for the assessment and quantification of RV diastolic function, and these measures do not typically form part of a standard clinical echocardiographic study. However, a large number of conditions have been shown to be associated with RV diastolic dysfunction, including congenital heart diseases, cardiomyopathies, left-sided valvular heart diseases, and systemic conditions such as diabetes, rheumatoid arthritis and various vasculitides. Table 1 gives examples from the published literature of the utility of RV diastolic function assessment in diagnosis, prognostication, and in monitoring therapeutic response, in a broad range of clinical conditions.

Table 1

Clinical utility of RV diastolic function assessment.

AuthorConditionMain findings
Fenster et al. (13)Chronic obstructive pulmonary diseaseTV E/A ratio, RV E′, post-bronchodilator FEV1/FVC, and use of oxygen during 6-minute walk test were independent predictors of exercise capacity.
Pagourelias et al. (14)Hypertrophic cardiomyopathy RV E/E′ >6.9 was an independent predictor of heart failure mortality and total cardiovascular mortality.
Gan et al. (15)Pulmonary hypertension (PH)RV IVRT was reduced by Sildenafil therapy.
Agha et al. (16)Beta thalassaemiaReduced RV E′/A′ ratio was a more sensitive indictor of iron overload than LV diastolic parameters.
Kosmala et al. (17)Type-2 diabetesPre-clinical RV dysfunction was seen in asymptomatic diabetic patients (increased RV IVRT and decreased RV E′/A′) compared with controls.

Right ventricular diastole commences with closure of the pulmonary valve. There then ensues a brief period of RV isovolumic relaxation, followed by opening of the tricuspid valve which allows RV filling. Analogous to LV filling, RV filling consists of an early passive phase, and a late active phase driven by right atrial contraction. When RV pressure increases above that of right atrial (RA) pressure, the tricuspid valve closes marking the end of RV diastole. Echocardiographic assessment of RV diastolic function involves four main components:

As with the assessment of LV diastolic function, no single measure should be interpreted in isolation. Assessment of RV diastolic function requires the integration of data from different echocardiographic views and modalities (primarily 2-dimensional, PW, and tissue Doppler). We have not attempted to be too rigid in defining grades of RV diastolic dysfunction in this document. Rather, we would encourage the echo practitioner as a minimum to consider whether RV diastolic function is likely to be normal or abnormal. Figure 2 summarises key indices in the echocardiographic assessment of RV diastolic function.

Figure 2
Figure 2

Echocardiographic assessment of right ventricular diastolic function. * Indicates values which may be ‘pseudonormal’ (Grade 2 RV diastolic dysfunction) if other indicators are in keeping with impaired RV filling.

Citation: Echo Research and Practice 7, 1; 10.1530/ERP-19-0051

Disease-oriented approach

There is considerable heterogeneity of RV structural and functional changes across the spectrum of congenital and acquired diseases affecting the right heart. Consequently, routinely measured echocardiographic metrics will have varying sensitivities and specificities for the detection of different conditions involving the RV. A disease-oriented approach should, therefore, be considered for the investigation of right heart disease by echocardiography, rather than the uniform application of generic parameters and cut-offs across all diseases. This is illustrated by considering the relative performance of different RV indices in distinct groups of common pathologies affecting the RV such as pressure-overload, infiltrative conditions and heart muscle disease:

  • Longitudinal dysfunction measured by tricuspid annular plane systolic excursion (TAPSE) is prognostic in pulmonary hypertension (PH) (18) and is attractive to measure given its relative simplicity to obtain. However, radial contraction is more predictive of global RV function in states of raised RV afterload (19, 20). As such, either a qualitative statement regarding radial function or formal quantification through measures which incorporate it, such as fractional area change (FAC), should be utilised when evaluating the RV in PH.
  • The functional consequences of cardiac amyloidosis, a disorder of myocardial infiltration and an exemplar restrictive cardiac condition, are especially well described by RV longitudinal function. In this condition, TAPSE is more prognostic than RV ejection fraction by cardiovascular magnetic resonance and is also more sensitive to changes in disease severity across the spectrum of disease burden (21). The probability of TAPSE becoming abnormal at low burdens of myocardial infiltration likely relates to the infiltration of subendocardial longitudinal fibres, whereas the increasing probability of abnormal TAPSE values at higher disease burdens probably reflects the additional effects of progressive LV disease and consequent post-capillary PH. In cardiac amyloidosis, TAPSE is an excellent functional marker of disease and is highly reflective of the underlying pathophysiology.
  • Arrhythmogenic right ventricular cardiomyopathy (ARVC) has a spectrum of structural and functional manifestations that range from subtle changes localised to any region of the RV to overt global RV chamber dilatation and/or dysfunction. The echocardiographic criteria that contribute to the diagnosis of ARVC require the assessment of regional wall motion abnormalities (RWMA; specifically akinesia and dyskinesia, not hypokinesia) and aneurysms, the measurement of specific right ventricular outflow tract (RVOT) dimensions in parasternal long axis (PLAX) and parasternal short axis (PSAX) views and the quantification of fractional area change (22). Therefore, it is unsurprising that metrics focusing solely on basal longitudinal function have a poor sensitivity for identifying this disease (23).

Contemporary echocardiography techniques to evaluate the right ventricle

Deformation imaging

Speckle-tracking echocardiography (STE) has been widely utilised to provide information about RV myocardial deformation. For example, STE-derived RV longitudinal strain has been shown to be feasible, reproducible (33) and prognostic in a variety of conditions (34, 35, 36, 37). However, the clinical utility of RV speckle-tracking analysis is predominantly limited by variability between vendor hardware and the STE software algorithms that they employ. Accordingly, efforts have recently been made by the EACVI/ASE/Industry Task Force to standardise RV deformation imaging using 2D STE (38). This is the most contemporaneous attempt to harmonise STE practice and technology, the principle recommendations of which include:

Although several timing and functional parameters can be evaluated by RV STE, the majority of the available literature for this technique describes the measurement of peak systolic values for RV deformation and displacement. There is no definitive unifying cut-off value for normality of RV global longitudinal strain that is reliably and consistently applicable across vendor platforms. However, a tentative cut-off of −23% for RV free wall global longitudinal strain could be considered to define normality (39, 40).

It should be noted that RV deformation may also be quantified using tissue Doppler echocardiography; normal values exist for regional RV velocities, strain and strain rate. These appear consistent across different gender and age groups, with the exception of slightly decreasing strain with increasing age. Changes in preload and afterload alter regional RV myocardial velocities, but do not appear to affect strain or strain rate. Tissue Doppler-derived regional RV deformation has been shown to provide prognostic information, and predict adverse events, in patients with acute pulmonary embolism (41).

Three-dimensional echocardiography

The complex anatomical shape and contraction pattern of the RV can only be fully appreciated using three-dimensional cardiac imaging. Furthermore, global volumetric assessment is preferential in scenarios in which impairment in longitudinal function (comprising the majority of conventional two-dimensional RV metrics) either confer a false-positive result (such as post-cardiothoracic surgery) or may not best reflect global RV systolic function (such as in PH). For these reasons, three-dimensional echocardiography (3DE) is an attractive technique for RV assessment. As the technique has matured, data regarding its prognostic value have also emerged across a range of conditions of both left- and right-heart aetiologies (42, 43).

Right ventricular quantification by 3DE requires experience of both the dataset acquisition and post-processing steps:

Acquisition

A full-volume 3DE RV dataset is acquired from the RV-focused apical window while ensuring that the entire RV is included within the pyramidal scan volume. Different 3DE acquisition methods have been developed including (i) the acquisition of multiple sub-volumes over serial ECG-gated heartbeats and (ii) full-volume acquisition in a single heartbeat. A problem of the former technique is the requirement of long breath-holds and regular R-R intervals in order to avoid stitching artefact when the sub-volumes are combined. Although the acquisition and post-processing steps both contribute to the accuracy of RV 3DE, a 2010 meta-analysis of studies in which 3DE RV datasets were acquired over several consecutive cardiac cycles and long breath-holds showed a bias to underestimate RV size versus cardiovascular MRI (CMR) (44). More contemporary transducer technology allows the acquisition of a full-volume 3DE dataset in a single heartbeat (45). This overcomes the issues of long breath-holding and arrhythmia, while also eliminating the issue of stitching artefact. Furthermore, the real-time nature of single heartbeat full-volume acquisition allows the operator to view orthogonal 2DE images typically in 4-chamber, coronal and sagittal planes prior to dataset acquisition. This helps the operator to identify if the relevant structures in the RV are within the acoustic window.

A particular challenge when acquiring a 3DE RV dataset is the ability to completely visualise the RVOT in the coronal view. This is because the anterior retrosternal position of the RVOT in the thorax means that sternum or lung tissue can commonly shadow the RVOT, even if an alternative rib space is attempted (Fig. 3). One technique is to tilt the tail of the probe backwards, potentially introducing the aortic root into the RV-focused image, which might help to also capture the RVOT as part of the full-volume dataset.

Figure 3
Figure 3

RVOT dropout by 3DE: (A) sternum or lung tissue commonly shadows the anterior RVOT; (B) due to the anterior retrosternal position and morphology of the RVOT, the anterior RVOT still might not be included in the 3DE pyramidal volume despite moving rib spaces in an attempt to avoid this shadowing. Data from Ostenfeld et al. (46).

Citation: Echo Research and Practice 7, 1; 10.1530/ERP-19-0051

Post-processing

Different commercially available post-processing methods are used for RV 3DE analysis:

Although previous reference intervals for RV cavity volumes and RVEF quote generic intervals for all individuals, these parameters do vary with patient age and sex and, as such, should be referenced accordingly (11, 50). In general, RVEF ≥45% by 3DE can be considered a cut-off to define normal RV systolic function. Numerous studies have compared RV volumetric quantification by 3DE with the reference-standard technique of CMR (44, 47). These generally demonstrate a tendency for underestimation of RV cavity sizes by 3DE, albeit the majority were performed using multiple-beat ECG-gated acquisition techniques rather than the more contemporary full-volume single-heartbeat technology. Blurring of the endocardium due to the lower spatial resolution of 3DE datasets versus 2D imaging is a potential reason for operators to trace too far into the cavity, thereby underestimating RV chamber volumes (51). Tracing the RV endocardium on the ‘white side’ of the blood pool/myocardial boundary may help to reduce this limitation of RV 3DE post-processing (52). Currently, the wide limits of agreement for accuracy (when measured against CMR) and reproducibility of RV 3DE may also render this technique as insensitive to small changes in RV function that are known to be clinically significant in RV disease and identifiable by cross-sectional cardiac imaging modalities (53).

Overall, the requirement for good acoustic windows and high image quality, the inherent learning curve and the requirement for satisfactory test-retest reproducibility should all be considered in order to reliably implement 3DE RV analysis as a clinical routine in echocardiography laboratories (45). As such, previously published guidelines have consistently emphasised that RV volumetric quantification by 3DE should be performed in laboratories with appropriate experience (11, 39, 54). More recently, the use of intravenous contrast has been shown to better delineate the RV endocardium and reduce the bias for RV cavity volume underestimation (48). However, the previously quoted normal intervals are based upon non-contrast enhanced 3DE RV studies, and so further validation of contrast enhanced 3DE RV assessment, along with the revision of normal reference intervals, would be required before it is integrated as part of a standard 3DE RV dataset.

Common limitations of specific right heart parameters

The appropriate application and interpretation of RV parameters by echocardiography is dependent upon understanding their relative limitations. Although by no means exhaustive, the following caveats should be considered when assessing RV size and function by echocardiography:

  • Comparing the ratio of LV and RV basal dimensions in the 4-chamber view is a simple means of visually judging RV dilatation, but may not be valid if the LV itself is dilated. The most reproducible two-dimensional parameter for RV size is the RV basal diameter (RVD1), an important consideration when different sonographers perform serial studies (55). However, as with all two-dimensional RV measurements, the normal consensus values provided in most guideline statements are unindexed, not categorised by sex, and can be altered in athletic individuals (56, 57). See also BSE guideline for echocardiography in the cardiac screening of sports participants (58).
  • The importance of acquiring a standardised RV-focused view is reflected by the test-retest reproducibility of FAC, which can vary significantly amongst sonographers if different echocardiography windows are used (59).
  • The Tei index (RIMP), as with all RV functional indices, is load-dependent and may pseudo-normalise in conditions with elevated right atrial pressure. In such cases, raised RA pressure causes the tricuspid valve to open earlier, thus reducing isovolumic relaxation time and thereby underestimating the Tei index.
  • Both S′ and TAPSE are angle dependent and only reflect the longitudinal function of the basal portion of the RV, neglecting the contributions of the apical and outflow tract components to RV ejection. Furthermore, these variables both reflect myocardial motion rather than contraction. This gives rise to susceptibility of measuring translational RV motion, such as that which occurs in PH, rather than true contraction. In such cases where the RV demonstrates a rocking motion, consideration should be given to providing a value for TAPSE corrected to the amount of RV apical motion (60). Finally, both S′ and TAPSE are commonly reduced following cardiothoracic surgery (30), due often to true impairment of longitudinal function, as well as the effects of post-operative geometric alterations. Alternative measurements should therefore be considered to assess RV function.
  • Right ventricular systolic pressure can be underestimated in cases of an inadequate CW Doppler profile of the TR jet, and in such circumstances should be avoided. Conversely, RA pressure tends to be overestimated when assessing IVC size and reactivity, and agrees poorly with invasively measured pressures in some studies (61, 62). Estimated RA pressure should therefore be specified separately from the TR Vmax value, and echocardiographic assessment for pulmonary hypertension should not rely solely on TR velocity and IVC dimensions (25).
  • The level at which the eccentricity index is measured should be the same between studies as the arrangement and configuration of interventricular septal myofibres varies at different levels.
  • Indices of RV diastolic function are sensitive to changes in preload and afterload and must be interpreted with caution in the presence of significant pulmonary hypertension.

Key messages

  • Accurate and reproducible right heart quantification by echocardiography often necessitates specific imaging planes and techniques, such as the RV-focused apical 4-chamber view.
  • Comprehensive right heart assessment should include quantification of RV and RA dimensions, RV systolic and diastolic function, pulmonary and tricuspid valve morphology and function, and estimation of pulmonary artery pressures.
  • Novel dimensional reference intervals are presented in this document, based on data from the NORRE study (6). These cut-offs should however be used in a disease-oriented manner, given the considerable heterogeneity of right heart remodelling across a range of pathological and physiological states.

Conclusion

Assessment of right heart dimensions and functional parameters can play an important role in diagnosis, prognostication, and monitoring of therapeutic response, across a variety of pathologies. Echocardiography remains the first-line imaging modality for right heart assessment. There is a growing evidence base to guide right heart quantification, and more robust normal values are being developed, including those for emerging techniques such as RV diastolic function assessment, strain and three-dimensional echocardiography. Attention to specific technical considerations is required for the accurate and reproducible quantification of right heart parameters by echocardiography.

Declaration of interest

Daniel S Knight is supported by the National Institute for Health Research University College London Biomedical Research Centre. David Oxborough and Vishal Sharma are members of the editorial board of Echo Research and Practice. They were not involved in the review or editorial process for this paper, on which they are listed as authors. The other authors have nothing to disclose.

Funding

This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

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    British Society of Echocardiography

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  • View in gallery

    RV-focused apical window. Once in the apical 4-chamber view, rotating the transducer will allow the operator to obtain the maximal RV diameter (green line) while the internal LV diameter will remain relatively constant. The red line and the blue line show two variations of the standard apical 4-chamber view, optimised for the left ventricle, but failing to demonstrate maximal RV dimensions. Data from Rudski et al. (12).

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    Echocardiographic assessment of right ventricular diastolic function. * Indicates values which may be ‘pseudonormal’ (Grade 2 RV diastolic dysfunction) if other indicators are in keeping with impaired RV filling.

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    RVOT dropout by 3DE: (A) sternum or lung tissue commonly shadows the anterior RVOT; (B) due to the anterior retrosternal position and morphology of the RVOT, the anterior RVOT still might not be included in the 3DE pyramidal volume despite moving rib spaces in an attempt to avoid this shadowing. Data from Ostenfeld et al. (46).

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    Endocardial borders visualised in reconstructed apical 4-chamber (A4C, yellow dashed line), coronal (purple dashed line) and sagittal (turquoise dashed line = basal, blue dashed line = mid, green dashed line = distal) views in a patient with pulmonary hypertension. Note how the coronal view (bottom right) corresponds with the imaging plane delineated by the purple dashed line intersecting the tricuspid valve and RVOT in the sagittal views.

  • View in gallery

    The most recent version of this 3DE RV post-processing software automatically identifies and tracks the RV endocardium using speckle-tracking software. The user can adjust the endocardial borders using end-diastolic and end-systolic frames in the 4-chamber view and two short-axis views (negating the need for interpreting a coronal RV view as required in previous post-processing algorithms). Any manual corrections are automatically propagated to all other frames of the cardiac cycle.

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    Knight DS, Zumbo G, Barcella W, Steeden JA, Muthurangu V, Martinez-Naharro A, Treibel TA, Abdel-Gadir A, Bulluck H, Kotecha T, et al. Cardiac structural and functional consequences of amyloid deposition by cardiac magnetic resonance and echocardiography and their prognostic roles. JACC: Cardiovascular Imaging 2019 12 823833. (https://doi.org/10.1016/j.jcmg.2018.02.016)

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    Marcus FI, McKenna WJ, Sherrill D, Basso C, Bauce B, Bluemke DA, Calkins H, Corrado D, Cox MG, Daubert JP, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. Circulation 2010 121 15331541. (https://doi.org/10.1161/CIRCULATIONAHA.108.840827)

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