Cardiac Exam for RV Function

Clinical question	Is the right ventricular function preserved, mildly/moderately/reduced, or hyperdynamic in this patient?
Patient positioning	Left lateral decubitus is ideal
Supine works for most POCUS situations
Head elevated to improve apical views if needed
Supplies needed	No special supplies required
Probe	Phased array (cardiac probe)
Normal findings	RV smaller than LV (RV:LV ratio <0.6)
RV free wall with normal thickening and inward motion
Tricuspid annulus moves ≥16 mm toward apex during systole (TAPSE)
No septal flattening or paradoxical septal motion
Sensitivity & specificity	Qualitative visual estimation: ~85–90% congruence with formal echo for “significant RV dysfunction”
TAPSE (Tricuspid Annular Plane Systolic Excursion)
Sensitivity ~80–85% for RV dysfunction
Specificity >90%
Useful screening tool in critically ill or PE patients
Contraindications	None to ultrasound
Limited acoustic windows in COPD, obesity, or after thoracic surgery
Alternate diagnostic modalities	Formal echocardiogram: Gold standard for RV function, pressure estimates
TEE: Invasive but better views if TTE limited
Cardiac MRI: Best imaging of RV volumes and function (not bedside)
CT PA: If evaluating PE as cause of RV strain

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The RV is often referred to as the “silent ventricle” because we often forget to think about it in the setting of patient decompensation. Always keep it in your differential for lower extremity swelling, abdominal distention, hepatic congestion, fatigue, SOB, chest pain, palpitations, and/or plethoric jugular veins.

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TAPSE should not be used to definitively rule in or rule out PE, but is a useful clinical tool in an acutely decompensating patient that is too unstable to scan.

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How to perform this exam

1. Prepare your supplies:

Obtain an ultrasound machine with a cardiac probe, ultrasound gel, and a chuck or towel.

2. Explain the purpose of the exam (if patient is conscious)

Position your patient for comfort
Left lateral decubitus if they can tolerate this position; otherwise, supine with head elevated.

3. Apply copious ultrasound gel to the probe.

4. Obtain an Apical 4-Chamber (A4C) view

Probe at apex with marker toward patient’s left
Visualize both RV and LV side-by-side
Assess:
- RV size compared to LV
- Free wall contractility
- Septal position and motion
- Qualitative RV Assessment
Qualitative RV Assessment
- Normal: RV < LV; strong free wall motion
- Mild: Slight dilation, mildly reduced free wall thickening
- Moderate: RV ≈ LV, sluggish motion
- Severe: RV > LV; free wall akinetic or hypokinetic

5. Apply quantitative measure of RV function

One such measure that is easy to obtain is TAPSE (Tricuspid Annular Plane Systolic Excursion.
Steps:
- From A4C view, place M-mode cursor over lateral tricuspid annulus
- Freeze during normal respiratory cycle
- Measure distance between annulus at end-diastole and peak systole
Interpretation:
- TAPSE ≥17 mm = Normal
- TAPSE <17 mm = Suggests RV systolic dysfunction
- TAPSE <10 mm = Severe RV dysfunction

Tip: For accuracy, angle M-mode beam as close to vertical as possible (parallel to annular motion)