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How to assess RV function on echo
The right ventricle wraps around the LV and contracts mostly longitudinally, pulling the tricuspid annulus toward the apex. No single number describes it, so combine a longitudinal measure (TAPSE or S′) with an area-based one (FAC) and your visual impression of the free wall.
Look at two directions of motion
- Longitudinal: the tricuspid annulus descends toward the apex in systole. This is most of the RV's stroke volume and what TAPSE and S′ measure.
- Radial: the free wall moves in toward the septum (the "bellows" motion). FAC captures it together with the longitudinal motion.
They can come apart. After cardiac surgery the annulus barely moves while the free wall still contracts: longitudinal function is reduced but radial and overall function are preserved. In acute pulmonary embolism the opposite region-by-region pattern appears: the mid free wall stops while the apex keeps contracting (McConnell's sign).
Which view
Use the RV-focused apical 4-chamber view: the transducer is moved laterally from the standard apical 4-chamber so that the LV apex stays at the top of the sector and the whole RV free wall, including the apex, is seen at its largest. Foreshortened or LV-centred views underestimate RV size and make FAC unreliable.
The measurements
| Measure | How | Abnormal (adults) |
|---|---|---|
| TAPSE | M-mode through the lateral tricuspid annulus: distance it travels from end-diastole to peak systole | <17 mm |
| FAC | (RV end-diastolic area − end-systolic area) ÷ end-diastolic area × 100, tracing the endocardium under the trabeculations | <30% (men), <35% (women) |
| S′ | Pulsed tissue Doppler peak systolic velocity of the lateral annulus | <9 cm/s |
| Free-wall strain | Speckle-tracking longitudinal strain of the RV free wall | no single cut-off across vendors; −23% as a tentative limit |
| 3D RV EF | Full-volume 3D dataset | <45% |
| RIMP | RV index of myocardial performance (isovolumic times ÷ ejection time) | >0.43 (pulsed Doppler), >0.54 (tissue Doppler) |
Normal limits follow the British Society of Echocardiography 2020 right heart guideline; check the values your laboratory uses.
Pitfalls
- TAPSE and S′ are angle-dependent and regional: they describe the basal free wall only. Align the M-mode cursor with the annular motion.
- After cardiac surgery TAPSE and S′ are commonly reduced even when overall RV function is preserved; FAC and 3D EF are more representative.
- Loading conditions: severe tricuspid regurgitation and volume overload can keep TAPSE and FAC normal or high while the RV is failing.
- Translation: a heart that swings with each beat inflates TAPSE.
Grading
BSE gives no mild, moderate or severe grades for RV systolic dysfunction: at minimum, say whether function is normal or abnormal. The simulator asks exactly that, separately for overall, radial and longitudinal function: overall from FAC, longitudinal from TAPSE, radial from the free wall's inward motion.
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