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Right Ventricular Size and Function Evaluation
Normal RV function:
RV wall thinner than LV wall
RV chamber should be no more than two thirds the size of the LV chamber
RV normally has a crescent shape when viewed from the PSAX or triangular when viewed from a four-chamber view
Signs of RV pressure overload:
RV appears greater than two thirds the size of the LV (A4C)
Interventricular Septal Bowing/D-sign (PSAX)
RVOT violates rule of thirds (PLAX) - diameter of RV is bigger than LVOT and/or left atrium
Paradoxical septal motion (septum bulges into LV in diastole)
RV diastolic thickness >5 mm suggests hypertrophy from chronic process, while thickness <5 mm suggests an acute process, such as pulmonary embolus (PE)
McConnell's sign: RV free wall hypokinesis with apical sparing is seen in both acute and chronic RV failure. In other words, the apex is the only area of the RV that appears to be moving.
RV Enlargement/Pressure Overload(Apical 4 Chamber):
RV is bigger than LV on this A4C (suggesting at least moderate enlargement), and there is paradoxical septal movement. The RA is very dilated, and there is also a pericardial effusion present.
RV Enlargement/Pressure Overload(PSAX):
There is interventricular septal flattening (D-sign) and paradoxical septal motion noted in this PSAX view, along with RV dilation. There is also a pericardial effusion present.
Evaluation of Pericardial Effusions, Signs of Cardiac Tamponade
Pericardial effusions: can be seen in all of the main cardiac views
In the PLAX view, can differentiate pericardial effusions from pleural effusions by identifying the fluid pocket in relation to the descending aorta. Specfically, if the effusion tracks in front of the descending aorta (proximal to the probe(top of screen)) it is pericardial, if behind descending aorta, pleural.
Tamponade physiology: you can see RVOT collapse and a large effusion
Look for signs of tamponade physiology
IVC plethora, <50% collapse (most sensitive) [above]
RV diastolic collapse (most specific)
RA diastolic collapse (intermediate sensitivity and specificity)
MV or TV inflow velocity variation (an advanced technique)
Inferior Vena Cava (IVC) Interpretation
The ability of the IVC to predict volume responsiveness is limited except at the extremes which are:
A collapsed [<10 mm] IVC
A very plethoric [>2.5 cm and unchanging] IVC)
The most common serious error in IVC assessment is failure to identify a slit-like IVC and substituting the aorta.
If only one vessel is seen in the transverse plane, then it is likely the aorta and the IVC is probably critically underfilled.
In spontaneously breathing patients, the IVC will collapse with inspiration(negative pressure in thoracic cavity), while in patients on positive pressure ventilation, the IVC will distend with inspiration.
In ventilated patients the diagnostic performance is controversial and depends on tidal volume, respiratory effort, and abdominal pressure.
Plethoric IVC in a hypervolemic patient (e.g. ADHF)
Slit like IVC in a hypovolemic patient
Images / information from: https://www.pocus101.com/cardiac-ultrasound-echocardiography-made-easy-step-by-step-guide/ ; https://www.echocardiographer.org/tte-plax ; https://nephropocus.com/2019/12/07/pericardial-versus-pleural-effusion-on-plax-view/
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