Assessment of RV Function
Assessing RV function is critical in conditions like pulmonary embolism, pulmonary hypertension, right heart failure, and shock. POCUS allows rapid bedside evaluation of RV size, function, and pressure load.
Ultrasound Setup
Probe: Phased Array (Cardiac)
Preset: Cardiac
Views: PSS, PSL, A4C
Assessment of RV Size and Function
- Obtain an A4C view with both ventricles clearly visualized
- Compare the size of the RV to the LV:
- Normal: RV is ~2/3 the size of LV (Recall rule of thirds)
- RV dilatation: RV is equal to or larger than LV
- Assess RV free wall motion—should contract inward in systole.
- Evaluate RV wall thickening (normally <5 mm; >5 mm suggests chronic pressure overload)
- Recall the "Rule of Thirds": LA, LVOT, RV should all be equal in diameter in PSL
The D Sign
This is suggestive of RV pressure overload causing septal flattening and LV compression. It is often seen in massive PE or pulmonary hypertension, though not exclusively.
- In PSAX view at mid-papillary level, observe LV shape:
- Normal: LV appears round
- D Sign: Interventricular septum flattens, making the LV look like a “D” in systole or diastole
McConnell’s Sign
This is a specific echocardiographic finding classically associated with acute massive pulmonary embolism. It refers to a distinct pattern of RV wall motion abnormality seen in the A4C view.
This pattern helps differentiate from chronic RV dysfunction where the entire RV may be globally hypokinetic.
- In A4C view, look at the RV:
- Akinesia or hypokinesis of the mid-RV free wall
- Preserved apical contractility
Assessment of RV Function
Parasternal Long Assessment
- Place cardiac probe at nipple line near the left side of the sternum. Slide on anterior chest until obtain view of the heart.
- Center image on screen, heel/rock if needed.
- Rotate = length the LV/open the LVOT.
- Sweep/fan to widen the LV.
- Assessment: Features of RV strain
- RV > LV size
- Rule of thirds: LA, LVOT, RV no longer equal in diameter.
- Poor RV free wall contractility
- Septum moving towards LV in diastole.
- Note: The video shown has no features of RV strain (see how much larger the LV is compared to the RV).
Parasternal Short Assessment
- Once a parasternal long image is obtained, heel/rock to center the LV on screen + flatten the septum
- Rotate 90 degrees with probe marker to right hip of patient
- Fan/sweep to see papillary muscles.
- Assessment: Features of RV strain
- RV > LV size
- Flat inter-ventricular septum
- D sign of left ventricle
- Septum moving towards LV in diastole.
- Note: The video shown has no features of RV strain.
Apical 4 Assessment
- Probe marker to right hip, beam towards right shoulder, place cardiac probe at apex (often near the nipple line). Slide until find the heart and center in the middle of screen.
- Heel/rock to make septum verticle.
- Sweep/fan to easily see all four chambers.
- Rotate to widen the ventricles.
- Assessment: Features of RV strain
- RV > LV size
- TAPSE of RV free wall < 2cm
- Septum moving towards LV in diastole.
- Note: The video shown has no features of RV strain.