The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature.
Main:
RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy.
Conclusion:
The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.
HurfordWEZapolWM. The right ventricle and critical illness: a review of anatomy, physiology, and clinical evaluation of its function. Intensive Care Med. 1988;14(Suppl 2):448–457.
2.
VoelkelNFQuaifeRALeinwandLA, et al.Right ventricular function and failure: report of a National Heart, Lung, and Blood Institute working group on cellular and molecular mechanisms of right heart failure. Circulation. 2006;114(17):1883–1891.
3.
LahmTDouglasISArcherSL, et al.Assessment of right ventricular function in the research setting: knowledge gaps and pathways forward. An official American Thoracic Society research statement. Am J Respir Crit Care Med. 2018;198(4):e15–e43.
4.
CampbellSJBecharaRIslamS. Point-of-care ultrasound in the intensive care unit. Clin Chest Med. 2018;39(1):79–97.
5.
VillavicencioCLeacheJMarinJ, et al.Basic critical care echocardiography training of intensivists allows reproducible and reliable measurements of cardiac output. Ultrasound J. 2019;11(1):5.
6.
OrdeSSlamaMYastrebovK, et al.Subjective right ventricle assessment by echo qualified intensive care specialists: assessing agreement with objective measures. Crit Care. 2019;23(1):70. doi:10.1186/s13054-019-2375-z
7.
GrünigEHennPD’AndreaA, et al.Reference values for and determinants of right atrial area in healthy adults by 2-dimensional echocardiography. Circ Cardiovasc Imaging. 2013;6(1):117–124. doi:10.1161/circimaging.112.978031
8.
PartingtonSLKilnerPJ. How to image the dilated right ventricle. Circ Cardiovasc Imaging. 2017;10(5):e004688. doi:10.1161/CIRCIMAGING.116.004688
9.
RudskiLGLaiWWAfilaloJ, et al.Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of echocardiography. J Am Soc Echocardiogr. 2010;23(7):685–713. doi:10.1016/j.echo.2010.05.010
10.
RydingA.Essential Echocardiography—E-Book: Expert Consult—Online & Print. Elsevier Health Sciences; 2013.
11.
OmmenSRNishimuraRAHurrellDGKlarichKW. Assessment of right atrial pressure with 2-dimensional and Doppler echocardiography: a simultaneous catheterization and echocardiographic study. Mayo Clin Proc. 2000;75(1):24–29.
12.
CiozdaWKedanIKehlDWZimmerRKhandwallaRKimchiA. The efficacy of sonographic measurement of inferior vena cava diameter as an estimate of central venous pressure. Cardiovasc Ultrasound. 2016;14(1):33.
13.
TigheDAAurigemmaGP. Right-to-left shunts and saline contrast echocardiography. Chest. 2010;138(2):246–248.
14.
MitchellCRahkoPSBlauwetLA, et al.Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2019;32(1):1–64.
15.
SilvestryFECohenMSArmsbyLB, et al.Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen Ovale: from the American Society of Echocardiography and society for cardiac angiography and interventions. J Am Soc Echocardiogr. 2015;28(8):910–958.
16.
PradaGVieillard-BaronAMartinAK, et al.Echocardiographic applications of m-mode ultrasonography in anesthesiology and critical care. J Cardiothorac Vasc Anesth. 2019;33(6):1559–1583.
17.
BrownSBRainaAKatzDSzerlipMWiegersSEForfiaPR. Longitudinal shortening accounts for the majority of right ventricular contraction and improves after pulmonary vasodilator therapy in normal subjects and patients with pulmonary arterial hypertension. Chest. 2011;140(1):27–33.
18.
KaulSTeiCHopkinsJMShahPM. Assessment of right ventricular function using two-dimensional echocardiography. Am Heart J. 1984;107(3):526–531.
19.
KopecnaDBriongosSCastilloH, et al.Interobserver reliability of echocardiography for prognostication of normotensive patients with pulmonary embolism. Cardiovasc Ultrasound. 2014;12:29.
20.
López-CandalesADohiKRajagopalanNEdelmanKGulyasyBBazazR. Defining normal variables of right ventricular size and function in pulmonary hypertension: an echocardiographic study. Postgrad Med J. 2008;84(987):40–45.
21.
MillerDFarahMGLinerAFoxKSchluchterMHoitBD. The relation between quantitative right ventricular ejection fraction and indices of tricuspid annular motion and myocardial performance. J Am Soc Echocardiogr. 2004;17(5):443–447.
22.
BarthélémyRRoyXJavanainenTMebazaaAChoustermanBG. Comparison of echocardiographic indices of right ventricular systolic function and ejection fraction obtained with continuous thermodilution in critically ill patients. Crit Care. 2019;23(1):1–10.
23.
Díaz-GómezJLAlvarezABDanarajJJ, et al.A novel semiquantitative assessment of right ventricular systolic function with a modified subcostal echocardiographic view. Echocardiography. 2017;34(1):44–52.
24.
MainABBrahamRCampbellDInglisAJMcLeanAOrdeS. Subcostal TAPSE: a retrospective analysis of a novel right ventricle function assessment method from the subcostal position in patients with sepsis. Ultrasound J. 2019;11(1):19.
25.
TakahamaHMcCullyRBFrantzRPKaneGC. Unraveling the RV ejection Doppler envelope: insight into pulmonary artery hemodynamics and disease severity. JACC Cardiovasc Imaging. 2017;10(10 Pt B):1268–1277.
26.
WeymanAEDillonJCFeigenbaumHChangS. Echocardiographic patterns of pulmonic valve motion with pulmonary hypertension. Circulation. 1974;50(5):905–910.
27.
NaeijeRBadagliaccaR. The overloaded right heart and ventricular interdependence. Cardiovasc Res. 2017;113(12):1474–1485.
28.
WeymanAEWannSFeigenbaumHDillonJC. Mechanism of abnormal septal motion in patients with right ventricular volume overload: a cross-sectional echocardiographic study. Circulation. 1976;54(2):179–186.
29.
JardinFFarcotJCBoisanteLProstJFGueretPBourdariasJP. Mechanism of paradoxic pulse in bronchial asthma. Circulation. 1982;66(4):887–894.
30.
MillingtonSJArntfieldRT. Advanced point-of-care cardiac ultrasound examination: Doppler applications, valvular assessment, and advanced right heart examination. Glob Heart. 2013;8(4):305–312.
31.
VignonP.Assessment of pulmonary arterial pressure using critical care echocardiography: dealing with the yin and the yang?Crit Care Med. 2019;47(1):126–128.
32.
D’AltoMBossoneEOpotowskyARGhioSRudskiLGNaeijeR. Strengths and weaknesses of echocardiography for the diagnosis of pulmonary hypertension. Int J Cardiol. 2018;263:177–183.
33.
LafitteSPilloisXReantP, et al.Estimation of pulmonary pressures and diagnosis of pulmonary hypertension by Doppler echocardiography: a retrospective comparison of routine echocardiography and invasive hemodynamics. J Am Soc Echocardiog. 2013;26(5):457–463. doi:10.1016/j.echo.2013.02.002
34.
GalièNHumbertMVachieryJ-L, et al.2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: association for European Paediatric and congenital cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67–119.
35.
KyranisSJLatonaJPlattsD, et al.Improving the echocardiographic assessment of pulmonary pressure using the tricuspid regurgitant signal-The “chin” vs the “beard.” Echocardiography. 2018;35(8):1085–1096.
36.
MercadoPMaizelJBeylsC, et al.Reassessment of the accuracy of cardiac Doppler pulmonary artery pressure measurements in ventilated ICU patients: a simultaneous Doppler-catheterization study. Crit Care Med. 2019;47(1):41–48.
37.
ChemlaDCastelainVHumbertM, et al.New formula for predicting mean pulmonary artery pressure using systolic pulmonary artery pressure. Chest. 2004;126(4):1313–1317.
38.
AduenJFCastelloRDanielsJT, et al.Accuracy and precision of three echocardiographic methods for estimating mean pulmonary artery pressure. Chest. 2011;139(2):347–352.
39.
GeZZhangYJiXFanDDuranCM. Pulmonary artery diastolic pressure: a simultaneous Doppler echocardiography and catheterization study. Clin Cardiol. 1992;15(11):818–824.
40.
LeiMHChenJJKoYLChengJJKuanPLienWP. Reappraisal of quantitative evaluation of pulmonary regurgitation and estimation of pulmonary artery pressure by continuous wave Doppler echocardiography. Cardiology. 1995;86(3):249–256.
41.
MasuyamaTKodamaKKitabatakeASatoHNantoSInoueM. Continuous-wave Doppler echocardiographic detection of pulmonary regurgitation and its application to noninvasive estimation of pulmonary artery pressure. Circulation. 1986;74(3):484–492.
42.
SchneiderMBinderT. Echocardiographic evaluation of the right heart. Wien Klin Wochenschr. 2018;130(13-14):413–420.
43.
AugustineDXCoates-BradshawLDWillisJ, et al.Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography. Echo Res Pract. 2018;5(3):G11–G24.
44.
FisherMRForfiaPRChameraE, et al.Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. Am J Respir Crit Care Med. 2009;179(7):615–621.
45.
KitabatakeAInoueMAsaoM, et al.Noninvasive evaluation of pulmonary hypertension by a pulsed Doppler technique. Circulation. 1983;68(2):302–309.
46.
AbbasAEFortuinFDSchillerNBAppletonCPMorenoCALesterSJ. A simple method for noninvasive estimation of pulmonary vascular resistance. J Am Coll Cardiol. 2003;41(6):1021–1027.
47.
AbbasAEFraneyLMMarwickT, et al.Noninvasive assessment of pulmonary vascular resistance by Doppler echocardiography. J Am Soc Echocardiogr. 2013;26(10):1170–1177.
48.
OpotowskyARClairMAfilaloJ, et al.A simple echocardiographic method to estimate pulmonary vascular resistance. Am J Cardiol. 2013;112(6):873–882.
49.
De CastroSCavarrettaEMilanA, et al.Usefulness of tricuspid annular velocity in identifying global RV dysfunction in patients with primary pulmonary hypertension: a comparison with 3D echo-derived right ventricular ejection fraction. Echocardiography. 2008;25(3):289–293.
50.
SaxenaNRajagopalanNEdelmanKLópez-CandalesA. Tricuspid annular systolic velocity: a useful measurement in determining right ventricular systolic function regardless of pulmonary artery pressures. Echocardiography. 2006;23(9):750–755.
51.
RajagopalanNSaxenaNSimonMAEdelmanKMathierMALópez-CandalesA. Correlation of tricuspid annular velocities with invasive hemodynamics in pulmonary hypertension. Congest Heart Fail. 2007;13(4):200–204.
52.
JardinFDubourgOBourdariasJP. Echocardiographic pattern of acute cor pulmonale. Chest. 1997;111(1):209–217.
53.
HuangSJNalosMSmithLRajamaniAMcLeanAS. The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research. Intensive Care Med. 2018;44(6):868–883.
54.
KhemasuwanDYingchoncharoenTTunsuponP, et al.Right ventricular echocardiographic parameters are associated with mortality after acute pulmonary embolism. J Am Soc Echocardiogr. 2015;28(3):355–362.
55.
Vieillard-BaronAPrinSCherguiKDubourgOJardinF. Echo-Doppler demonstration of acute cor pulmonale at the bedside in the medical intensive care unit. Am J Respir Crit Care Med. 2002;166(10):1310–1319.
56.
KurzynaMTorbickiAPruszczykP, et al.Disturbed right ventricular ejection pattern as a new Doppler echocardiographic sign of acute pulmonary embolism. Am J Cardiol. 2002;90(5):507–511.
57.
McConnellMVSolomonSDRayanMEComePCGoldhaberSZLeeRT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469–473.
58.
BoissierFKatsahianSRazaziK, et al.Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome. Intensive Care Med. 2013;39(10):1725–1733.
59.
LhéritierGLegrasACailleA, et al.Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study. Intensive Care Med. 2013;39(10):1734–1742.
60.
Mekontso DessapABoissierFCharronC, et al.Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. Intensive Care Med. 2016;42(5):862–870.
61.
Vieillard-BaronASchmittJMAugardeR, et al.Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis. Crit Care Med. 2001;29(8):1551–1555.
62.
FichetJMoreauLGenéeO, et al.Feasibility of right ventricular longitudinal systolic function evaluation with transthoracic echocardiographic indices derived from tricuspid annular motion: a preliminary study in acute respiratory distress syndrome. Echocardiography. 2012;29(5):513–521.
63.
LemariéJMaigratC-HKimmounA, et al.Feasibility, reproducibility and diagnostic usefulness of right ventricular strain by 2-dimensional speckle-tracking echocardiography in ARDS patients: the ARD strain study. Ann Intensive Care. 2020;10(1):24.
64.
FurianTAguiarCPradoK, et al.Ventricular dysfunction and dilation in severe sepsis and septic shock: relation to endothelial function and mortality. J Crit Care. 2012;27(3):319. e9-e15.
65.
VallabhajosyulaSKumarMPandompatamG, et al.Prognostic impact of isolated right ventricular dysfunction in sepsis and septic shock: an 8-year historical cohort study. Ann Intensive Care. 2017;7(1):94.
66.
OrdeSRPulidoJNMasakiM, et al.Outcome prediction in sepsis: speckle tracking echocardiography based assessment of myocardial function. Crit Care. 2014;18(4):R149.
67.
DugarSPVallabhajosyulaS. Right ventricle in sepsis: clinical and research priority. Heart. 2020;106(21):1629–1630. doi:10.1136/heartjnl-2020-317381
68.
NishigamiK.Point-of-care echocardiography for aortic dissection, pulmonary embolism and acute coronary syndrome in patients with killer chest pain: EASY screening focused on the assessment of effusion, aorta, ventricular size and shape and ventricular asynergy. J Echocardiogr. 2015;13(4):141–144.
69.
RallidisLSMakavosGNihoyannopoulosP. Right ventricular involvement in coronary artery disease: role of echocardiography for diagnosis and prognosis. J Am Soc Echocardiogr. 2014;27(3):223–229.
70.
RajeshGNRajuDNandanD, et al.Echocardiographic assessment of right ventricular function in inferior wall myocardial infarction and angiographic correlation to proximal right coronary artery stenosis. Indian Heart J. 2013;65(5):522–528.
71.
D’AltoMRomeoEArgientoP, et al.Echocardiographic prediction of pre- versus postcapillary pulmonary hypertension. J Am Soc Echocardiogr. 2015;28(1):108–115.
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