a) List four assessments of the RIGHT ventricle that can be made on transthoracic echocardiography. (20% marks)
b) List four clinical signs of right heart failure. (20% marks)
c) Classify the causes of pulmonary hypertension with examples. (60% marks)
RV size: LV size on apical 4-chamber view RV diameter
RV wall thickness
Tricuspid annular plane systolic excursion (TAPSE) or S-PRIME on apical 4-chamber view
Right ventricular systolic pressure gradient to right atrium using tricuspid regurgitation (TR) jet. Ventricular septal motion (D-shaped septum) that can indicate pressure or volume overload
Tissue Doppler and E/E’ ratios
Elevated Jugular venous pressure
Right ventricular heave
Right ventricular third heart sound
Peripheral oedema Enlarged liver edge Ascites
1. Pulmonary arterial hypertension (PAH)
Idiopathic PAH, Heritable-genetic disease, Drugs and toxins induced: appetite suppressants e.g. fenfluramine, Associated with systemic disease: Connective tissue diseases e.g. scleroderma, HIV infection, Porto-pulmonary hypertension
2. Pulmonary hypertension due to left heart disease
Systolic dysfunction, Diastolic dysfunction, Valvular disease: Mitral stenosis, Mitral Regurgitation, Congenital abnormalities
3. Pulmonary hypertension due to lung diseases and/or hypoxia
Chronic obstructive pulmonary disease, Interstitial lung disease, Sleep-disordered breathing, Alveolar hypoventilation disorders, Chronic exposure to high altitude
4. Chronic thromboembolic pulmonary hypertension
5. PH with unclear and/or multifactorial mechanisms
Hematological disorders: myeloproliferative disorders, Systemic disorders: sarcoidosis, vasculitis, Metabolic disorders: glycogen storage disease, Others: tumour obstruction, fibrosing mediastinitis, chronic renal failure on dialysis
Additional Examiners’ Comments:
Some candidates provided more than four answers for parts a) and b) and it should be noted that only the first four answers are considered. Part c) in general was poorly answered and many candidates confused acute elevations in pulmonary pressure with the disease entity of pulmonary hypertension.
a) For the RV parameters detectable with TTE, I went to the 2010 ASE Guidelines for the echocardiographic assessment of the right heart in adults.
In brief, the assessable parameters are:
- RV dimensions
- RA dimensions
- RVOT dimensions
- RV wall thickness
- IVC dimensions
- RV systolic function
- Several parameters: RIMP, TAPSE, 2D RV FAC, 2D RV ejection fraction (EF), three-dimensional (3D) RV EF, tissue Doppler–derived tricuspid lateral annular systolic velocity (S'), and longitudinal strain and strain rate.
- RV diastolic function
- Various parameters: E/A ratio, deceleration time, the E/e' ratio, and RA size
- Pulmonary systolic pressure/RSVP
b) Clinical signs of right heart failure are difficult to find in any one single resource.
- Features attributable to pulmonary hypertension
- Loud P2(may be palpable)
- Narrowly split S2
- Tricuspid murmur
- Diastolic murmur of pulmonary regurgitation
- Features attributable to RV hypertrophy
- Prominent a wave in the JVP
- Right-sided fourth heart sound (augmented by inspiration)
- Left parasternal heave
- Downward subxiphoid thrust.
- Features attributable to RV dilatation and decompensated failure
- Prominent v wave in the significantly raised JVP
- Right-sided third heart sound (augmented by inspiration)
- Peripheral oedema
- Hepatomegaly (which may be pulsatile)
- Signs of LV failure, eg. pulmonary oedema (due to out-bowing of the intraventricular septum, and LV diastolic failure resulting from this)
The list used by the college answer is the updated 2013 Dana Point classification, which can be found in the Siomonneau article in Table 1.
Pulmonary Arterial Hypertension
|Left heart disease||
|Lung disease or hypoxia||
|Pulmonary hypertension due to unclear or multifactorial aetiologies||
Simonneau, Gérald, et al. "Updated clinical classification of pulmonary hypertension." Journal of the American College of Cardiology 54.1s1 (2009): S43-S54.
Rudski, Lawrence G., et al. "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography: endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography." Journal of the American Society of Echocardiography 23.7 (2010): 685-713.