Right heart strain

Right heart strain (or more precisely right ventricular strain) is a term given to denote the presence of right ventricular dysfunction usually in the absence of an underlying cardiomyopathy. It can manifest as an acute right heart syndrome.

Right heart strain can often occur as a result of pulmonary arterial hypertension (and its underlying causes such as massive pulmonary emboli).

May have elevated levels of 4:

  • troponin
  • B-type natriuretic peptide (BNP)

The reported sensitivity and specificity of CT in demonstrating right heart dysfunction are around 81% and 47% respectively 5.

Described features include:

  • abnormal position of the interventricular septum 1
    • flattening of the interventricular septum
    • paradoxical interventricular septal bowing, i.e. towards the left ventricle
  • right ventricular enlargement (right ventricle bigger than the left ventricle)
  • pulmonary trunk enlargement (bigger than the aorta)
  • features of right heart failure
    • inferior vena caval contrast reflux 1
    • dilated azygous venous system
    • dilated hepatic veins +/- with contrast reflux

The reported sensitivity and specificity of echocardiography in demonstrating right heart dysfunction are around 56% and 42% respectively 5.

Described features include: 9

  • dilatation of the right ventricle
    • quantified as a basal diameter > 4.2cm, a mid-cavity diameter >3.5cm, and a length exceeding 8.6 cm, as measured in the RV focused apical 4 chamber view
    • the right ventricular outflow tract is considered enlarged when the measured diameter in the parasternal long axis exceeds 3.3 cm, or when the measured diameter exceeds 2.7 cm in the distal RVOT, as measured in the basal parasternal short axis
    • qualitative features include diffuse rounding and loss of the typical triangular to crescentic morphology
    • the right ventricle may occupy a portion of the apex, which is in health composed solely of the left ventricle
  • right ventricle/ left ventricle end diastolic basal diameter ratio > 1
    • as measured in the apical 4 chamber view across the plane of the atrioventricular valve annulus
    • the "RV-focused" apical 4 chamber is a suggested alternative
    • comparative end diastolic area may also be calculated in a similar manner and compared between ventricles
    • an eccentricity index may be calculated in the parasternal short axis, which is supportive of right heart strain when > 1.1
  • interventricular septal flattening
    • commonly referred to as the "D" sign, a reference to the short axis appearance of the left ventricle in the presence of septal flattening
    • classically accompanied by paradoxical septal motion, in which the concavity of the septum with respect to the left ventricle is lost, in the presence of higher end-systolic right sided pressures
  • right ventricular hypertrophy
    • when present, implies some degree of chronicity to the inciting hemodynamic insult
      • defined as a free wall thickness, as measured at end diastole in the subcostal 4 chamber view, exceeding 5mm
    • excess trabeculation of the myocardium is also indicative of a chronic process
  • right ventricular hypokinesia
    • typically quantified as a tricuspid annular plane systolic excursion, as measured by M-mode from the apical 4 chamber view, < 1.6cm
    • other accepted parameters for assessing systolic function include right ventricular fractional area change, which is abnormal when < 35%
  • elevated right ventricular pressures
    • right ventricular systolic pressure, derived from the simlified bernoulli equation, exceeding 35 mmHg is consistent
    •  the "60/60 sign" has gained recent attention, putatively indicating an acute cause of elevated right ventricular pressures, with a pulmonary valve acceleration time <60ms, and a tricuspid regurgitation jet > 30 but < 60 mmHg
  • plethoric inferior vena cava
    • as measured in the subcostal long axis view, plethora supported by a diameter > 2.1 cm
    • indicative of elevated central venous pressure; further supported by a lack of respirophasic diameter variation
    • other related features congruent with elevated right-sided pressures include right atrial enlargement, with an area as measured in the apical 4 chamber view exceeding 18cm2 and severe tricuspid regurgitation
      • features supportive of quantifying tricuspid regurgitation as severe include a vena contracta width > 7mm, hepatic venous pulsatility with prominence of the v wave and loss of the normal S/D wave relationship, hepatic venous retrograde a-S-v complexes , and a proximal isovolumetric surface area >10 cm2
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Article information

rID: 31600
System: Cardiac, Chest
Section: Gamuts
Synonyms or Alternate Spellings:
  • Right ventricular strain
  • RV strain

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Cases and figures

  • Massive bilateral...
    Case 1: in the setting of pulmonary emboli
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  • Case 2: in the setting of saddle pulmonary emboli
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  • Case 3: massive PE
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  • Case 4: from cocaine toxicity
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  • Case 5
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  • Case 6
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