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Echocardiographic assessment of the right heart

Jonathan Afilalo, MD, MSc, FACC, FRCPC(C)
Lawrence Rudski, MD, FRCPC(C), FACC, FASE
Section Editor
Jeroen J Bax, MD, PhD
Deputy Editor
Susan B Yeon, MD, JD, FACC


The right ventricle (RV) has historically received less attention than its counterpart of the left side of the heart, yet there is a substantial body of evidence showing that RV size and function are perhaps equally important in predicting adverse outcomes in cardiovascular disease. RV dysfunction is associated with excess morbidity and mortality in patients with chronic left-sided heart failure, acute myocardial infarction (with or without RV involvement), pulmonary embolism, pulmonary arterial hypertension, and congenital heart disease [1-3]. Advances in noninvasive imaging of the RV, particularly with echocardiography, have yielded insights into the pathophysiology of this complex and once elusive chamber.

In an attempt to standardize the echocardiographic evaluation of the right heart, the American Society of Echocardiography published guidelines on measures and normal reference values to identify right ventricular pathology [4] and the American Society of Echocardiography and European Association of Cardiovascular Imaging (ASE/EACVI) subsequently updated some of these reference values [5]. This topic will review the echocardiographic assessment of the right heart, specifically the right atrium (RA) and RV. The echocardiographic assessment of right-sided heart valves is presented separately. (See "Echocardiographic evaluation of the tricuspid valve" and "Echocardiographic evaluation of the pulmonic valve and pulmonary artery".)


The right atrium (RA) transmits and pumps blood across the tricuspid valve into the right ventricle (RV), which then ejects the stroke volume through the pulmonic valve and into the main pulmonary artery. In the absence of shunt, forward stroke volume of the right heart is obligately equal to that of the left.

The right heart differs from the left in terms of anatomy and physiology. The RV loosely resembles a pyramid and is composed of three portions: the inlet, the body, and the outflow tract. Contraction is generated by a deep layer of longitudinal fibers that result in longitudinal (base to apex) shortening, and a superficial layer of circumferential fibers that result in inward thickening (movie 1) [6]. The RV lacks a third layer of spiral fibers as seen in the left ventricle.

The RV end-diastolic volume is slightly larger than that of the left ventricle, and as a result has a slightly lower ejection fraction. RV ejection is accomplished with a mass that is approximately one-fifth that of the left ventricle. Accordingly, the RV is well suited as a volume pump, but is prone to failure when faced with an acute pressure challenge.

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Literature review current through: Nov 2017. | This topic last updated: Jun 30, 2016.
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