Right heart strain

Last revised by Yuranga Weerakkody on 30 Nov 2021

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).

Patients with right heart strain may have elevated levels of 4:

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

Described features include:

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 >4.2 cm, a mid-cavity diameter >3.5 cm, and a length exceeding 8.6 cm
      • ideally measured in the RV focused apical 4 chamber view
    • right ventricle/ left ventricle end diastolic basal diameter ratio >1
    • 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 view
    • 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
  • 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
  • paradoxical septal motion
    • an abrupt rise in pulmonary arterial pressures prolong right ventricular contraction
    • persistence of elevated RV pressures as the LV begins to relax results in reversal of the normal interventricular septal curvature
  • right atrial enlargement
    • leftward bowing of the interatrial septum may be seen, as with the interventricular septum
  • right ventricular hypertrophy
    • free wall thickness >5 mm
    • excess trabeculation of the myocardium
  • right ventricular systolic dysfunction
    • a pattern of right ventricular free wall hypokinesis with apical sparing is often found, referred to as the McConnell's sign
  • right ventricular hypokinesia
  • elevated right ventricular pressures
    • right ventricular systolic pressure > 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 <60 ms, and a tricuspid regurgitation jet >30 but <60 mmHg
  • plethoric inferior vena cava
    • diameter >2.1 cm as measured in the subcostal long axis view
    • with loss of its usual phasic variation throughout the respiratory cycle
  • tricuspid regurgitation
    • often secondary to annular dilation resulting in valvular incompetence​

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Cases and figures

  • 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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  • Case 7
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  • Case 8
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  • Case 9: due to saddle pulmonary embolism
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