Right Ventricle

The right ventricle should be assessed using multiple views and more than one quantitative measure. Its complex geometry makes single-view or single-parameter assessment unreliable.

Acquisition¶

Use an RV-focused apical four-chamber view for RV dimensions, fractional area change, TAPSE, tissue Doppler S′, and strain.

• Measure RV size at end diastole.
• Maximize the RV chamber without foreshortening the apex.
• Keep the RV free wall visible throughout the cardiac cycle.
• Include trabeculations and the moderator band within the cavity when tracing RV area.
• Measure RV wall thickness from the subcostal view at end diastole, excluding trabeculations and pericardial fat.

Additional views include parasternal RV inflow, parasternal RV outflow, parasternal short-axis, and subcostal views.

RV Size¶

The basal diameter is the most practical routine measurement and should be obtained immediately below and parallel to the tricuspid annulus.

RV Systolic Function¶

Do not determine RV function from a single parameter.

TAPSE¶

TAPSE measures longitudinal movement of the lateral tricuspid annulus using M-mode. It is reproducible but evaluates only basal longitudinal function.

TAPSE may be misleading with:

• Recent cardiac surgery
• Severe tricuspid regurgitation
• Regional RV dysfunction
• Altered RV geometry
• Markedly abnormal loading conditions

Tissue Doppler S′¶

Measure S′ at the lateral tricuspid annulus with the Doppler beam aligned parallel to annular motion. Like TAPSE, it primarily reflects basal longitudinal function.

Fractional area change¶

FAC reflects longitudinal shortening, radial contraction, and septal contribution but excludes the RV outflow tract.

RV strain¶

Approximate normal values:

• RV free-wall strain magnitude: >20%
• RV global longitudinal strain magnitude: >17%

Because strain is conventionally displayed as a negative value, −25% represents better deformation than −15%. Strain is vendor- and load-dependent.

Pressure Versus Volume Overload¶

Septal flattening produces a D-shaped LV in the parasternal short-axis view.

RVSP¶

When an adequate tricuspid regurgitation envelope is present:

In the absence of pulmonic stenosis or RV outflow obstruction:

Echocardiography estimates the probability and consequences of pulmonary hypertension; it does not independently establish the invasive diagnosis.

See IVC and Right Atrial Pressure.

Reporting¶

The right ventricle is normal in size with normal systolic function.

The right ventricle is mildly/moderately/severely dilated with
mildly/moderately/severely reduced systolic function.

TAPSE is ___ cm, lateral tricuspid annular S′ is ___ cm/s,
and RV fractional area change is ___%.

There is [systolic/diastolic/systolic and diastolic] septal flattening,
consistent with RV [pressure/volume] overload.

Estimated RVSP is ___ mm Hg using an estimated RAP of ___ mm Hg.

Pitfalls¶

• Measuring RV size from a nonfocused apical view
• Foreshortening the RV apex
• Calling RV function normal based only on TAPSE
• Excluding trabeculations from RV area measurements
• Ignoring loading conditions or severe TR
• Using an incomplete TR envelope to calculate RVSP
• Diagnosing pulmonary hypertension from RVSP alone
• Mistaking reduced postoperative longitudinal motion for global RV failure

Key Points¶

• Measure RV size at end diastole from an RV-focused view.
• Normal basal RV diameter is <4.1 cm.
• Normal RV wall thickness is <0.5 cm.
• Normal TAPSE is >1.7 cm.
• Normal S′ is >9.5 cm/s.
• Normal FAC is >35%.
• Use an integrated assessment rather than a single measurement.

References¶

• ASE Guidelines for Echocardiographic Assessment of the Right Heart and Pulmonary Hypertension, 2025
• ASE Guidelines for Performing a Comprehensive TTE in Adults, 2019