ALBERTA SONO
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The other chamber
(RV)

Assessment of right ventricular function in critically ill patients

VIdeo tutorial

RV assessment on PLAX

As a practical rule, you can divide the left atrium, aorta, and right ventricular outflow tract by 1/3 in a well-acquired PLAX view. If an off-axis view is acquired, then this view is less accurate. While this view if less sensitive for RV dilatation (more sensitive for RVOT dilatation), it is very specific if the RV/RVOT segment is clearly enlarged.
Picture

Normal septum

A normal inter-ventricular septum is convex towards the RV with that convexity maintained as it shifts inwards to the LV during systole. 
Picture

RV pressure overload

In RV pressure overload you can see the septum at its maximal flatness in systole, but it can remain flattened during diastole. This is often referred to as a "D-shaped" septum.
Picture

RV volume overload

In RV volume overload the septum is at its maximal flatness in diastole. It can be seen to "pop out" during systole as the pressure gradient in the LV easily overcomes the RV.
Picture

RV enlargement

As a quick rule, an RV size that is >2/3 size of the LV is enlarged. As a main caveat however, it must be a non-foreshortened LV (Apex can be seen). This view is the most challenging for novices to be acquired and is most likely to be confounded.
Picture

RV function

The predominant movement of the RV is longitudinal, that is from the base to the apex. Tricuspid annular systolic plane excursion (TAPSE) measures vertical displacement of the tricuspid annulus in systole. A normal vertical displacement is ~1.7 cm and greater. Notably, this is only one element of RV function and can easily be incorrect.
Picture

TAPSE In real-time

You can see in time time-motion M-mode recording that we are recording movement of the lateral annulus. Measurement should start at the trough and measure to the peak, but being sure you are measuring the same tissue plane.
Picture

RV dysfunction with normal TAPSE

Here is an example of RV dysfunction with preserved TAPSE. The lateral annulus appears to be moving well, but

Advanced topics

Right atrial dilatation

RA dilatation is a helpful feature to recognize as it tells you that the RV problem, while may be at least partially acute, has a chronic element. RA dilatation requires at least >72 hours.
Picture

Ventricular interdependence

The most challenging aspect of managing a patient with RV dysfunction is the acute patient with obstructive shock. In this case, RV dilatation prevents diastolic filling of the LV. Although the LV may be hyper-dynamic, its diastolic filling may be exceptionally low. Management of this problem is exceptionally complex and requires a multi-disciplinary approach.
Picture

SPontaneous echo contrast

If the RV pressure is higher than the right sided filling pressure, you may see "spontaneous echo contrast" or "smoke" as a consequence of an unfavourable gradient for filling. In this condition, blood or occasionally infused saline microbubbles may swirl around the right sided circulation. This is more common in cardiac arrest and terminal PE/ severe pulmonary hypertension.
Picture
  • Home
  • About
    • The Team
    • Social Media
    • Research >
      • COVID Shunt Study
      • Echo-AKI
      • Curriculum design & implementation
    • Events >
      • ABSono Rounds >
        • ABSono Rounds Recordings
      • Joint Rounds
      • CRUS West 2021
    • Training >
      • CCUS Rotation
      • Clinical CCUS Fellowship
      • eCLass Ultrasound
  • Sonology
    • Physics of ultrasound
    • Transducer manipulation
    • Image optimization
    • Machines >
      • X-Porte
      • EDGE
    • Quality >
      • Essentials QPath E
      • Submitting for QA
    • Critical Thinking
  • Echo
    • Standard echo views >
      • Echo in shock VR
    • LV Function Assessment >
      • Regional cardiac anatomy
    • Pitfalls in LV assessment
    • Pericardial space
    • RV function assessment
    • Inferior vena cava
    • Cardiac Output
    • Echo in VTE
    • The Echo Lab >
      • Standard acquisition
      • Key references
    • TEE >
      • Focused 4-view
      • Shunts and Bubble Studies
  • Lung US
    • Overview
    • Pneumothorax detection
    • Interstitial diseases
    • LUS in respiratory failure
    • Pleural Effusion Assessment
    • LUS in Covid-19
  • Whole-body Ultrasound
    • RUSH exam
  • Procedural US
    • VR in HALO
    • Central line (IJ)
    • Central line (Subclavian)
    • Central line (Femoral)
    • Thoracentesis
    • Paracentesis
    • U/S-guided PIV
    • Radial Arterial line
  • Trauma US
    • eFAST fundamentals
    • eFAST Core Knowledge
    • The Thorax
    • The Heart
    • The Abdomen
  • Neuro
    • Optic nerve sheath diameter
    • Transcranial Doppler
  • GIMUS
    • GIMUS Rounds
    • Rules of GIMUS
  • References and links
    • References
    • Helpful links