T h e Ro l e of M u l t i m o d a l i t y

I m a g i n g i n Ri g h t
Ventricular Failure
Tom Kai Ming Wang, MBCHB, MD(res), Christine Jellis, MD, PhD*

KEYWORDS

Right ventricle
Echocardiography
Magnetic resonance imaging
Computed tomography

KEY POINTS

Sound understanding of the complex right heart anatomy and function is critical for interpretation of
right ventricle imaging and pathology.

Echocardiography remains the first-line imaging modality for right ventricular assessment, where
imaging for all standard views and accurate quantitative measurements are important.

Cardiac MRI is the gold standard for right ventricle dimensions and function, with the ability to eval-
uate flow, shuts, tissue characterization, and extracardiac structures.

Complete multimodality imaging evaluation includes the tricuspid valve, right atrium, systemic
veins, pulmonary circulation and disorders, left heart systolic and diastolic function, and congenital
heart defects.

INTRODUCTION wall abnormalities.3 Multimodality imaging evalua-

tion has therefore become essential to provide
Left ventricular physiology and pathology has long adequate assessment of RV structure and function
been the focus of cardiovascular medicine, for reliable diagnostic, management, and prog-
whereas the right ventricle (RV) has traditionally nostic purposes. This review provides a compre-
been neglected and viewed as less important.1,2 hensive overview of how to use multimodality
However, in more recent times, there has been imaging to evaluate for RV failure. Clinical cases
greater appreciation of the clinical significance of will be used to showcase the various noninvasive
RV pathologies, with abnormalities in size and techniques.
function having strong prognostic implications
across a wide range of cardiovascular diseases.2,3
RIGHT VENTRICLE ANATOMY
This broad spectrum of etiologies, which can man-
ifest as RV failure include intrinsic primary RV The RV is a complex and often underappreciated
myocardial failure due to ischemia, infiltrative pro- structure. It is typically the most anterior cardiac
cesses, and toxins; secondary RV failure due to chamber, located just behind the sternum, which
increased afterload from pulmonary hypertension increases its susceptibility to chest wall trauma.
or pulmonic valve stenosis; RV failure due to The RV does not follow a simple geometric shape,
increased volume load from valvular regurgitation but rather wraps around the more cylindrical left
or intracardiac shunts, other complex congenital ventricle (LV) and appears as triangular in the
heart abnormalities, pericardial disease, and chest vertical planes and crescentic in transverse
cardiology.theclinics.com

Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Desk J1-5, 9500 Euclid
Avenue, Cleveland, OH 44195, USA
* Corresponding author.
E-mail address: [email protected]

Cardiol Clin 38 (2020) 203–217

https://doi.org/10.1016/j.ccl.2020.01.006
0733-8651/20/Ó 2020 Elsevier Inc. All rights reserved.
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204 Wang & Jellis

planes. The normal adult RV has slightly larger vol- or the inferior, anterior, and infundibulum depend-
ume, but approximately one-sixth the mass of the ing on convention.5 Although the RV shares the
LV, reflecting the lower stroke work it performs.4 interventricular septum with the LV, the concave
Morphologically, the RV can be further distin- nature of the septum toward the LV, with a rela-
guished from the LV in several ways identifiable tively thin trabeculated RV portion, results in a pro-
with noninvasive cardiac imaging. First, it is more portionally smaller impact of septal motion on RV
trabeculated and has multiple prominent muscular function.
ridges, such as the moderator, septomarginal, and The right coronary supplies most of the RV
parietal bands.5,6 Second, there is no fibrous con- myocardium in right-dominant circulations (80% of
tinuity between the inlet tricuspid and outflow pul- population), with marginal branches typically sup-
monary valves, the former as part of the fibrous plying the anterior and lateral walls, the conal artery
skeleton along with the aortic and mitral valves, supplying the outflow infundibulum, and the poste-
whereas the latter from the infundibular myocar- rior descending artery supplying the inferior wall
dium. Furthermore, the septal tricuspid valve (Fig. 1).7 Interruption to this regional blood supply
leaflet is apically displaced relative to the anterior will result in segmental RV dysfunction and regional
mitral valve leaflet and the RV usually has 3 or perfusion abnormalities seen with multimodality RV
more papillary muscles compared with 2 in the LV. imaging. The RV inflow is demarcated from the right
The RV can be divided into the trabeculated inlet atrium by the tricuspid atrio-ventricular valve, while
portion, containing the tricuspid inflow valve and transition from the RV to the pulmonary artery is
subvalvular apparatus, along with the trabeculated separated by the outflow pulmonic valve. Dysfunc-
central chamber and smooth outflow infundib- tion in either of these right-sided valves can result in
ulum, which are separated by an embryologic volume or pressure loading of the RV, which can ul-
ridge called the crista supraventricularis.2 Altera- timately lead to RV failure.
tive nomenclature for this outflow portion of the
RV also includes the conus arteriosus, supracris- RIGHT VENTRICULAR FUNCTION
tal, or subvalvular segment. The RV free wall can
be divided into basal, mid, and apical segments, At the microscopic level, the RV free wall contains
circumferentially oriented muscle fiber layers,

Fig. 1. RV blood supply. Ao, aorta; CS, coronary sinus; EV, Eustachian valve; LA, left atrium; LAD, left anterior de-
scending artery; LV, left ventricle; PA, pulmonary artery; RA, right atrium; RCA, right coronary artery; RV, right
ventricle; RVOT, right ventricular outflow tract.

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 Imaging in Right Heart Failure 205

which parallel the anterior atrioventricular groove reproducibility, so are less often used to for
and turn obliquely near the RV apex, before assessment. There are several challenging factors
continuing in a double-helix pattern into the LV .5 when imaging the RV by echocardiography,
The continuity of these muscle fibers allows for including its complex geometry, immediate retro-
RV free wall traction when the LV contracts, and sternal location, and obscured endocardial defini-
contributes to ventricular interdependence. RV tion due to its thin free wall with relatively
deep muscle fiber layers are oriented longitudinally prominent myocardial trabeculations.2 On transe-
from base to apex. These combine to enable sophageal echocardiogram, further supplemen-
sequential contraction of the RV starting with the tary views include the mid-esophageal 4-
inlet and the trabeculated myocardium followed chamber view, mid-esophageal RV inflow/outflow
by the infundibulum.7 RV contraction is predomi- view, and the transgastric short axis views from
nantly in the longitudinal direction, followed by base to apex.11 However, transesophageal echo-
radial. Unlike the LV, the RV has minimal contrac- cardiogram is not routinely performed for assess-
tion from rotational and twisting motion.8 ing the RV in the absence of other indications,
given its suboptimal location in image far-field on
ECHOCARDIOGRAPHY this orientation. Optimizing echo windows is crit-
Views of the Right Ventricle ical for RV assessment, and abnormalities in size
and function should generally be confirmed on at
Echocardiography remains the first-line imaging
least 2 views before making a qualitative
modality for assessment of the RV. On transtho-
conclusion.
racic echocardiogram there are 6 standard views
for imaging the RV : (1) standard parasternal long
Right Ventricular Dimensions
axis view, (2) parasternal RV /tricuspid inflow
view, (3) parasternal short axis view, (4) apical 4 Whenever possible, quantitative assessment of
chamber view optimized to the RV (apex at center the RV is preferred for assessing RV size and func-
of scanning sector with maximal RV basal diam- tion. The American Society of Echocardiography
eter), (5) reverse apical 3-chamber tilt-over view, and European Association of Cardiovascular Im-
and (6) subcostal long axis view (Fig. 2).9,10 Among aging guidelines for cardiac chamber quantifica-
these, (2) and (3) usually have limited windows and tion remain the preferred reference.12 The main

Fig. 2. Schematic representation of

the transthoracic echocardiographic
views for assessing the RV. (A) Para-
sternal long axis. (B) RV inflow. (C)
Parasternal short axis. (D) RV-focused
apical 4-chamber. (E) Reverse 3-cham-
ber. (F) Subcostal long axis.

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206 Wang & Jellis

measurement parameters and normal ranges are remembered that off-axis imaging of RV diameter
listed in Table 1. Linear measurements include will affect accuracy of RV size estimates (Fig. 3).
the RV basal, mid, and longitudinal diameters on RV wall thickness should be measured at end-
the apical 4-chamber RV-focused view, as well diastole using M-mode or 2-dimensional imaging
as the RV outflow tract diameter on parasternal and is conventionally performed on the subcostal
long axis, parasternal short axis proximal, and par- view at the level of the tricuspid valve chordae ten-
asternal short axis distal views. It must be dineae for reproducibility. Increased RV wall

Table 1
Normal ranges of right ventricular size and function measures on echocardiography

Echocardiographic Parameter Normal Range

Right heart size
Right ventricular diameter Basal 25–41 mm
Mid 19–35 mm
Longitudinal 59–83 mm
Right ventricular outflow tract diameter Parasternal long axis 20–30 mm
Proximal 21–35 mm
Distal 17–27 mm
Right ventricular end-diastolic area Men 10–24 cm2
Indexed to body surface area 5–12.5 cm2/m2
Women 8–20 cm2
Indexed to body surface area 4.5–11.5 cm2/m2
Right ventricular end-systolic area Men 3–15 cm2
Indexed to body surface area 2.0–7.4 cm2/m2
Women 3–11 cm2
Indexed to body surface area 1.6–6.4 cm2/m2
Right ventricular end-diastolic volume indexed to Men 35–87 mL/m2
body surface area Women 32–74 mL/m2
Right ventricular end-systolic volume indexed to Men 10–44 mL/m2
body surface area Women 8–36 mL/m2
Right ventricular wall thickness 1–5 mm
Right atrial volume Men <39 mL/m2
Women <33 mL/m2
Right ventricular systolic function
Tricuspid annular plane systolic excursion 17 mm
Right ventricular S0 wave (pulsed Doppler) 9.5 cm/s
Right ventricular S0 wave (color Doppler) 6.0 cm/s
Right ventricular free wall strain  20%
Fractional area change 35%
Ejection fraction (three-dimension) 45%
Right ventricular myocardial performance index 0.43
(pulsed Doppler)
Right ventricular myocardial performance index 0.54
(tissue Doppler)
Right ventricular diastolic function
Tricuspid inflow E/A ratio 0.8–2.0 (can be pseudonormal)
Tricuspid inflow E wave deceleration time 119–242 ms (can be pseudonormal)
Tricuspid E/e’ ratio 6.0
Tricuspid annular e’ 7.8 cm/s
Adapted from Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac
chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and
the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography: official pub-
lication of the American Society of Echocardiography. 2015 Jan;28(1):1-39.e14; with permission.

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 Imaging in Right Heart Failure 207

Fig. 3. Linear measurements of the RV include the basal, mid, and longitudinal diameters on the apical 4-cham-
ber RV-focused view (view 1). Care should be taken to optimize this view to avoid underestimation of RV dimen-
sions (views 2 and 3).

thickness suggests the presence of either RV Right Ventricular Systolic Function

pressure overload or infiltrative disease.
After assessing RV dimensions, RV systolic func-
RV area can be traced on the endocardial
tion is the next important step. Qualitative evalua-
border on either the focused RV apical 4-chamber
tion of the RV from all the aforementioned views
view or the RV outflow tract.12 Normative values
should always be performed; however, integration
differ by sex, end-diastolic or end-systolic phase
of quantitative measures is preferred. The pres-
(both should be measured), and whether they are
ence and pattern of RV segmental hypokinesis
indexed to body surface area. Both linear and
may point toward the underlying etiology of RV
area measurements are relatively easy and fast
dysfunction as characteristic features may assist
to obtain, but can be limited by poor endocardial
with differentiation between specific pathologies.
definition and malaligned imaging plane, and
The McConnell sign has been described in acute
may not accurately reflect global RV size with vary-
pulmonary embolism, where there is preserved
ing geometries. RV areas have been used to esti-
basal and apical RV free wall contractility with se-
mate volume by area-length or Simpson’s
vere hypokinesis of the mid-segment.15 The ratio-
methods in the past, but are no longer
nale for this is incompletely understood, but may
recommended.
reflect LV tethering, regional RV free wall ischemia,
Volumetric measurements are increasingly
or change in shape of the RV in the setting of
encouraged for assessing RV size, which cap-
acutely increased afterload. Regional RV hypoki-
tures the inflow, outflow, and apical regions
nesis also can be seen in the setting of myocardial
regardless of geometry. This involves 3-dimen-
infarction, with apical hypokinesis typically seen
sional multi-beat acquisition with the view con-
with left anterior descending artery infarction and
taining the entire RV cavity, with adequate
more global RV dysfunction seen when proximal
temporal resolution at least 20 to 25 volumes/s,
right coronary artery occlusion is the culprit.16
with end-diastole and end-systole frames clearly
Abnormal interventricular septal motion can be
established and RV trabeculae and moderator
seen with prior cardiac surgery, and conduction
band included in the cavity calculation.12 Limita-
abnormalities including pacing and interventricular
tions include the need for 3-dimensional probe,
dependence with constrictive or tamponade phys-
software, adequate training, and particularly
iology. Septal flattening during systole is usually
adequate image quality, and larger population
reflective of increased RV pressure, whereas
studies for validation of existing reference ranges.
septal flattening during diastole is seen in the
Echocardiographic RV volumes tend to underes-
setting of RV volume overload due to valvular
timate compared with MRI, often because of
regurgitation or a left-to-right interatrial shunt.
poor visualization of the RV walls and difficulty
Arrhythmogenic RV cardiomyopathy is hallmarked
to incorporate the entire the infundibulum, which
by fibrofatty replacement of the RV, with less
may be up to 30% of RV volume.13,14

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208 Wang & Jellis

frequent LV involvement. Over time, this results in although is limited by its inability to account for
aneurysmal deformation of the RV free wall and the RV outflow tract (Fig. 7). For this same reason,
associated regional wall motion abnormalities, calculation of RVEF fraction using 2-dimensional
particularly at the apex and mid-wall segment.17 (2D) echo cannot be performed. Three-
At the extreme end of the spectrum, congenital dimensional echo capturing all borders of the RV
absence of RV myocardium, known as the Uhl without geometric assumptions has been vali-
anomaly, is a rare condition resulting in pathogno- dated against MRI as an accurate measure of RV
monic severe dilation and dysfunction of the RV18 function; however, it is rarely included in clinical
(Fig. 4). practice, as it requires optimal simultaneous visu-
Quantitative measures of longitudinal and global alization of all RV walls, which is often technically
RV systolic function are summarized in Table 2.12 difficult, even in the hands of an experienced so-
Longitudinal measures reflect the pistonlike action nographer (Fig. 8).12,21 As the RV is typically larger
of the RV free wall and are often simpler and there- than the LV, RVEF is normally slightly lower than
fore more commonly performed. These include LV ejection fraction. The RV myocardial perfor-
tricuspid annular plane systolic excursion (TAPSE) mance index, also known as the RIMP or Tei index,
and myocardial tissue Doppler imaging at the provides global estimate of RV systolic and
tricuspid annulus during systole (RVS0 ). However, diastolic function.22 It can be measured by using
these parameters neglect to account for RV radial either pulsed wave or tissue Doppler at the lateral
function and can be affected by loading conditions annulus of the tricuspid valve, with the formula
and overestimated due to RV translational motion (tricuspid closure to opening time – ejection
without true contraction when LV function remains time)/ejection time or (isovolumetric relaxation
preserved.19 TAPSE is performed using M-mode time 1 isovolumetric contraction time)/ejection
at the lateral tricuspid annulus to measure the time. RIMP measures are less affected by heart
displacement between end-diastole and peak- rate and geometric assumptions, but can be
systole on apical views20 (Fig. 5). RVS0 is taken falsely abnormal in elevated right atrial pressure
on the same view and location using pulsed (Fig. 9).
wave or color tissue Doppler imaging, to obtain Most recently, global longitudinal strain (GLS) of
the peak systolic velocity of the lateral tricuspid the RV has provided frame-by-frame speckle
annulus as it moves toward the RV apex (Fig. 6). tracking of RV deformation, taking the average of
To gain better appreciation of true RV function, percentage systolic shortening of the RV walls
more global measures of RV systolic function, basal, mid, and apical segments on the RV-
including fractional area change (FAC), RV ejection focused apical 4-chamber view, whereas the
fraction (RVEF), and RV index of myocardial per- strain rate is the rate of the percentage short-
formance (RIMP), should also be considered.12 ening.19 The RV septum may or may not be
FAC is the fractional decrease in the right ventric- included in the RV GLS calculation, because
ular area from end-diastole to end-systole traced although it adds to the complete picture of RV sys-
on the RV-focused apical 4-chamber view. It re- tolic function, it is also influenced by LV systolic
flects both longitudinal and radial RV function, function or other disease or postoperative states

Fig. 4. Seen on this short axis para-

sternal view is extremely severe RV
enlargement in the Uhl anomaly, a
rare condition characterized by
congenital absence of RV
myocardium.

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 Imaging in Right Heart Failure 209

Table 2
Strengths and limitations of imaging modalities for right ventricular failure assessment

Modality Advantages Disadvantages

Transthoracic
First-line assessment tool
Low spatial resolution
echocardiography
Availability
Technically difficult windows

Low cost frequently encountered, right

Portable including bedside ventricle incompletely assessed

Hemodynamic assessment
Operator dependent
(though modest accuracy)
Limited tissue characterization

No radiation or contrast
Limited extracardiac assessment
Cardiac MRI
Gold standard tool for chamber
Low availability
size and function quantification
High cost

High spatial resolution
Contrast use

Flow and shunt assessment
Nonportable, stable patients

Tissue characterization
Long scan time, breath-hold

Extracardiac assessment (thoracic
Contraindications: incompatible
organs/vasculature) devices, claustrophobia
Computed tomography
Adjunct or backup modality
Radiation

High spatial resolution
Contrast use

Short scan time
Nonportable, stable patients

Extracardiac assessment (best for
Breath-hold
lung parenchyma, also other or-
Limited tissue characterization
gans/vasculature)
Limited hemodynamics

Coronary and calcification
assessment

Procedural planning

that lead to abnormal septal motion (Fig. 10). RV cardiac cycle difficult. Patients with hyperinflated
strain can be influenced by image quality, artifacts, lungs due to chronic obstructive airways disease
and correct positioning of reference points.12 are often the most challenging for echo imaging,
Strain measures are less subject to the impact of which can be especially problematic due to the
variation in loading conditions than some of the need for accurate assessment of RV function and
other RV functional parameters; however, it can pulmonary pressures in this cohort. There are
be challenging to perform because of the thin na- multiple vendor proprietary software options for
ture of the RV free wall and suboptimal views in calculation of GLS, some of which have RV
certain patients with poor acoustic windows, strain-specific options. Range values for
which can make tissue tracking throughout the normal free wall RV strain can vary depending on

Fig. 5. TAPSE is performed using

M-mode at the lateral tricuspid
annulus to measure the longitudinal
displacement of the RV free wall be-
tween end-diastole and peak-systole
as a measure of RV function. Normal
should be greater than 1.7 cm.

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210 Wang & Jellis

at the tricuspid annulus during diastole (RVE0 ),

which in combination with the E wave can be
used as a noninvasive estimate of RV filling pres-
sures (RV E/E0 ).24 Suggested diastolic function
grading from guidelines include tricuspid ratio E/
A ratio less than 0.8 as impaired relaxation (grade
1, mild), E/A ratio 0.8 to 2.1 with E/E0 ratio greater
than 6 or hepatic vein diastolic flow predominance
as pseudonormal (grade 2, moderate), and E/A ra-
tio greater than 2.1 with deceleration time less than
120 ms as restrictive (grade 3 severe).10 Right
atrial size and filling pressure, RV wall thickness
and RV systolic parameters can provide additional
Fig. 6. RV systolic tissue velocity (RVS0 ) is measured on
an apical 4-chamber view using pulsed wave or color insights into RV diastolic function. However, the
tissue Doppler imaging, to obtain the peak systolic ve- presence of atrial fibrillation and/or significant
locity of the lateral tricuspid annulus as it moves to- tricuspid regurgitation reduces the reliability of
ward the RV apex as a measure of longitudinal RV noninvasive measurements.
function. Normal should be greater than 10 cm/s. Right-sided intracardiac pressures can be esti-
mated using the size of the inferior vena cava
(IVC) on subcostal views, with larger diameters
the vendor software used, and reported at and reduced collapsibility on inspiration suggest-
26%  4% in one meta-analysis, and at less ing elevated right atrial pressure.2,10 Current
than 20% (more negative) in current guidelines estimate normal right atrial pressure
guidelines.12,23 (RAP) at mean 3 mm Hg, intermediate RAP at
mean 8 mm Hg (if IVC 2.1 cm and IVC collaps-
Other Considerations of Right Ventricular
ibility <50% or IVC >2.1 cm and IVC collaps-
Assessment
ibility >50%) and elevated RAP at 15 mm Hg
Diastology measurements of the RV can be (IVC >2.1 cm and IVC collapsibility <50%).25 He-
measured using a number of parameters analo- modynamic information needs to be further sought
gous to LV diastology parameters. The tricuspid when evaluating the RV, which can be in part
inflow pulsed wave Doppler provides a starting assessed on echocardiography noninvasively. Es-
point for diastolic assessment, whereby the peak timates of RV stroke volume (which when multi-
early diastolic (E wave) and late diastolic (A plied by heart rate gives cardiac output) can be
wave) flow velocities, along with the inflow decel- performed with echocardiography. This is per-
eration and isovolumetric relaxation times, can formed using pulse wave Doppler within the RV
be calculated.10 This can be combined with mea- outflow tract (RVOT) to estimate the velocity time
surement of myocardial tissue Doppler imaging integral (VTI), along with the area of the RVOT

Fig. 7. FAC is the fractional decrease in the RV area from end-diastole (ED) to end-systole (ES) traced on the RV-
focused apical 4-chamber view. It reflects both longitudinal and radial RV function, although is limited by its
inability to account for the RVOT. Normal should be greater than 35%.

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 Imaging in Right Heart Failure 211

Fig. 8. Full-volume acquisition of the RV (right) allows semiautomated tracing of the RV endocardium during sys-
tolic and diastole to calculate RV volumes and RVEF.

(Fig. 11). This correlates well with invasive deter- is equal to 4  peak velocity2 (Fig. 12).27 In the
minants of RV cardiac output in the absence of case of the RV, the peak velocity of the tricuspid
significant pulmonic valve regurgitation.26 regurgitant jet gives the difference between the
The most common noninvasive RV hemody- RVSP and RAP, which in absence of RVOT or pul-
namic parameter calculated by echo is RV systolic monary stenosis, is a surrogate for pulmonary
pressure (RVSP). This is performed by applying the arterial systolic pressure.10 Application of the
simplified Bernoulli equation, where peak pressure same equation to the end-diastolic pulmonary
regurgitant jet velocity estimates the pulmonary
artery diastolic pressure. The mean pulmonary ar-
tery pressure can then be determined. Several
other methods using the pulmonary artery acceler-
ation time, early pulmonary regurgitation velocity,
and tricuspid regurgitation VTI have been devised
to estimate right heart pressures. These include
formulae for the noninvasive estimate of pulmo-
nary vascular resistance, such as those described
by Abbas and colleagues26 and more recently
Dahiya and colleagues.28 LV diastolic function by
echo provides a surrogate marker of left atrial
pressure. When combined with pulmonary arterial
pressure estimates, this can also build an overall
impression of pulmonary vascular resistance.29
For all these calculations, it must always be
remembered that inaccuracies can occur due to
adequate image quality, regurgitation jets, valvular
pathologies, and loading conditions. The gold
standard test for estimation of right heart pres-
sures and pulmonary capillary wedge pressure re-
mains an invasive catheter right heart
hemodynamic study.
In addition to estimation of RVSP, assessment
of tricuspid regurgitation (TR) mechanism and
severity is integral to the understanding of RV
Fig. 9. RV myocardial performance index, also known pathophysiology.30 In certain cases, specific etiol-
as the RIMP or Tei index, provides global estimate of ogies of tricuspid valve dysfunction and resultant
RV systolic and diastolic function. It can be measured
TR are evident on 2D echo imaging, such as carci-
by using either pulsed wave (PW) or tissue Doppler
noid disease, infective endocarditis, or Ebstein
(TDI) at the lateral annulus of the tricuspid valve using
the formula: tricuspid closure to opening time [TCO] – anomaly (Fig. 13). However, notably, secondary
ejection time [ET])/ejection time [ET]. Normal should functional causes remain the most common
be <0.40 (PW); less than 0.55 (TDI). mechanism for TR. Whatever the mechanism of

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212 Wang & Jellis

Fig. 10. Two-dimensional GLS of the RV can be calculated in 6 segments to measure RV percent deformation as a
measure of systolic function. Pk, peak strain (%); Seg, segment; TPk, time to peak (milliseconds).

TR, progressive TR begets RV dilation, which over valvular pathologies, pericardial diseases, and
time contributes to annular dilation and further congenital heart lesions to provide insight into
worsening of TR severity. This chicken and egg the underlying mechanism of secondary right heart
scenario is usually compensated for initially, but dysfunction.12,30
as TR progresses into the severe range, decom-
pensated right-sided heart failure can develop CARDIAC MRI
with resultant fluid retention, hepatic congestion,
and associated symptoms will require pharmaco- Cardiac magnetic resonance imaging (CMR) is the
therapy and consideration of valvular intervention. gold standard for the assessment of right-sided
Importantly in the setting of significant tricuspid cardiac chamber size and function.12 The relative
regurgitation, the lower boundary for normal advantages and disadvantages of various imaging
RVEF should be raised to account for the modalities are listed in Table 2. MRI has high
increased forward flow.31 Typically, those present- spatial resolution, superior to transthoracic echo-
ing with severe TR and RV failure will have cardiography, with adequate temporal resolution.
increased perioperative risk during cardiac sur- RV volumes can be quantitated from a short-axis
gery.32 This is due to reduced LV preload from or 4-chamber cine stack. This is most typically
RV dysfunction, along with underlying liver
dysfunction, which can result in coagulopathy,
especially if there is underlying unrecognized
cirrhosis. Percutaneous tricuspid valve interven-
tions, including replacement and clip repairs,
may provide a viable alternative for these higher
surgical risk candidates in the future. In all patients
with RV pathology, it is always important to pro-
vide a complete echocardiographic assessment
of left heart structure and function, left-sided

Fig. 12. The peak velocity (Vmax) of the tricuspid re-

Fig. 11. RV stroke volume can be estimated using gurgitant jet on continuous wave Doppler plus RAP
pulse wave Doppler within the RVOT to estimate the can be used to estimate the RVSP via the modified
VTI, which is then multiplied by the area of the RVOT. Bernoulli equation.

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 Imaging in Right Heart Failure 213

Fig. 13. Significant tricuspid valve

leaflet thickening and restriction in
carcinoid disease on this RV inflow
view, results in failure of leaflet coap-
tation (A) and severe TR (B).

performed using a steady-state free precession accumulating within regions of chronic fibrosis or
sequence. The RV endocardium is traced on active inflammation. The pattern, distribution,
each image at both end-diastole and end-systole and extent of DGE can be exploited to detect
to give RV end-diastolic and end-systolic volumes. and diagnose the underlying cause of LV dysfunc-
The difference between these volumes is used to tion in conditions such as RV infarction and
calculate the RVEF33 (Fig. 14) Additional data arrhythmogenic RV cardiomyopathy, and infiltra-
regarding RV function can be generated with the tive processes such as cardiac sarcoidosis (Figs.
use of tissue tracking and MRI strain techniques, 15 and 16). Assessment of RV diffuse fibrosis
which are now beginning to be used for clinical and extracellular volume can be performed using
practice.34 Phase velocity encoding sequences a T1 mapping technique. T1 values have been
can be used to quantitate flow rates. When placed shown to correlate with RV dysfunction, provided
at the level of the main pulmonary artery, this can that care is taken to ensure the region of interest
be used to determine RV stroke volume and car- is maintained on the thin RV free wall.35 Like with
diac output, pulmonic regurgitant fraction, and echo, evaluation of the left heart, valves, pericar-
flow velocities through the pulmonic valve. dium, and congenital lesions (such as septal
Tricuspid regurgitant fraction can also be calcu- defect and anomalous pulmonary veins or coro-
lated from the difference between the RV stroke nary arteries) remains important as potential con-
volume on volumetric analysis and pulmonic valve tributors to RV dysfunction.12,30 Limitations of
forward flow.2,33 Evaluation for an intracardiac MRI can include cost, availability, prolonged scan-
shunt can also be performed by the ratio of the ning time, need for gadolinium-based contrast
RV to LV stroke volumes on volumetric analysis administration and breath-hold requirements.
or the pulmonic and aortic forward flow on quanti- Although most new-generation cardiac pacing
tative flow (Qp:Qs). A Qp:Qs of greater than 1.2 and implantable defibrillator devices are now
suggests a clinically meaningful left-to-right intra- CMR compatible, artifact from the generator or
cardiac shunt. RV lead may limit diagnostic imaging quality.
Cine imaging in CMR is useful to identify RV CMR remains contraindicated in some older,
regional dysfunction, in a similar way to that noncompatible devices. The use of CMR for
described previously using echo. However, addi- assessment of the right heart is increasing, espe-
tional information can be gleaned about the etiol- cially for those with suboptimal echo acoustic win-
ogy of RV dysfunction with the use of tissue dows or when accurate assessment of RVEF is
characterization. Edema weighted imaging with desired.
sequences such as T2 short tau inversion recovery
can provide information regarding RV myocardial CARDIAC COMPUTED TOMOGRAPHY
inflammation; however, sensitivity is suboptimal.
Delayed gadolinium enhancement (DGE) provides Additional imaging of the right heart can be per-
more reliable tissue characterization, with contrast formed using cardiac computed tomography

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214 Wang & Jellis

Fig. 14. Cardiac MRI short axis stack, steady-state free precession sequence, with the RV endocardium (yellow), LV
endocardium (red), and LV epicardium (green) contoured at end-diastole. Endocardial contours are also per-
formed at end-systole to establish ventricular volumes, which are then used to calculate biventricular ejection
fractions.

(CT). Single phase-contrast imaging provides echocardiography.36,37 The main limitation of this
structural information about the heart and extrac- retrospective technique is increased radiation
ardiac structures, along with some myocardial tis- dose, so appropriate patient selection and dose
sue characterization using density measures. For minimization techniques are important
subjects in whom CMR is contraindicated, image considerations.
acquisition throughout the cardiac cycle can be CT is now the main noninvasive imaging modal-
performed using spiral retrospective imaging with ity for evaluation of coronary artery disease.38
electrocardiographic gating. This can then be Another advantage of CT over CMR is the ability
played as a cine image or contoured for RV vol- to assess extracardiac structures for abnormalities
umes in similar way to CMR, thereby allowing such as pulmonary arterial thromboembolism or
qualitative evaluation of RV function and calcula- lung parenchymal disease.39 CT also may be valu-
tion of RVEF with good spatial resolution compa- able to define thoracic anatomy before cardiac
rable to MRI and superior to transthoracic surgery or to assess vascular access before

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 Imaging in Right Heart Failure 215

Fig. 15. Cardiac MRI demonstrates aneurysmal deformation (arrow) of the RV free wall on cine steady-state free
precession imaging (A), along with fibro-fatty infiltration on delayed enhancement imaging (arrow) in arrhyth-
mogenic RV cardiomyopathy (B).

percutaneous structural interventions.40 The short learning.41 Like CMR, cardiac CT is sensitive to
scan time of CT is also an advantage over CMR for abnormal heart rhythms and inability for breath-
critically ill patients. Disadvantages include the use hold. Currently for the purpose of RV assessment,
of ionizing radiation, need for nephrotoxic CT is generally used only when MRI is unavailable
contrast, and more limited ability to assess cardiac or contraindicated.
hemodynamics. Further recent advances in CT
include faster gantry rotation time and double NUCLEAR MEDICINE
gantry design of some scanners enabling
improved temporal resolution and coverage, avail- There is a limited utility for nuclear medicine in the
ability of dual-energy scanners at 2 different en- specific evaluation of RV function. Nuclear stress
ergy levels associated with less radiation, artifact imaging can provide some qualitative data
and contrast use, and new software incorporating regarding RV function and size with stress
plaque and tissue characterization and machine compared with rest. RV involvement can some-
times be evident with cardiac PET in the setting
of cardiac sarcoidosis, where focal inflammation
in the free wall is evidenced by increased fluoro-
deoxyglucose uptake.42

SUMMARY
Accurate evaluation of the right heart and associ-
ated structures is critical in the setting of RV fail-
ure. Although echocardiography remains the
mainstay in this arena, multimodality imaging can
be useful to get a more comprehensive and quan-
titative assessment of RV dysfunction and associ-
ated cardiac and extracardiac conditions.
Typically this additional imaging is best provided
with CMR imaging techniques, although CT and
nuclear imaging can be useful for specific indica-
tions. Hopefully, improved accuracy in the nonin-
vasive assessment of RV failure with
multimodality imaging will ultimately translate to
Fig. 16. Involvement of the RV in cardiac sarcoidosis, better management to improve outcomes for pa-
seen by DGE within the RVOT (white arrow) and LV tients with RV involvement in a variety of cardio-
(black arrows). vascular diseases.

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216 Wang & Jellis

ACKNOWLEDGMENTS 11. Hahn RT, Abraham T, Adams MS, et al. Guidelines

for performing a comprehensive transesophageal
Dr Wang is supported by the National Heart Foun- echocardiographic examination: recommenda-
dation of New Zealand Overseas Clinical and tions from the American Society of Echocardiogra-
Research Fellowship, grant number 1775. phy and the Society of Cardiovascular
Anesthesiologists. J Am Soc Echocardiogr 2013;
DISCLOSURE 26(9):921–64.
12. Lang RM, Badano LP, Mor-Avi V, et al. Recommen-
The authors have nothing to disclose. dations for cardiac chamber quantification by echo-
cardiography in adults: an update from the
American Society of Echocardiography and the Eu-
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