Echocardiographic assessment of right ventricular function: how to account for tricuspid regurgitation and pulmonary hypertension

Echocardiography is the usual initial test in dyspneic patients, but its application to right ventricular (RV) analysis is challenging. RV evaluation involves 3 steps, starting with quantification of afterload and pre-load. RV afterload is assessed by measurement of pulmonary artery systolic pressure (PASP) from tricuspid regurgitation (TR) velocity and right atrial pressure; pulmonary regurgitation velocity can also be used to assess pulmonary artery (PA) diastolic and mean PA pressure. Estimation of pulmonary vascular resistance (PVR) is useful if RV function is impaired. The second step is to assess the mechanism and severity of TR. For quantification of RV performance, we usually use 1 conventional (tricuspid annular plane systolic excursion [TAPSE], fractional area change [FAC], or right ventricular index of myocardial performance [RIMP]) and 1 novel method (pulsed wave or color Doppler tissue imaging systolic velocity [s'], or strain imaging). RV volumes may be measured using 3-dimensional echocardiography (Fig. 1, Table 1).