The Right Ventricle, Part 2: Function and Congestion

After a straightforward valve operation, TAPSE is twelve millimetres — well under the transthoracic normal. But the fractional area change is 40 per cent, the 3D ejection fraction is 48 per cent, and the lactate is falling. Which number is lying? This is part two of two on the right ventricle on transoesophageal echo, following the right ventricle chapter of the fourth edition of Practical Perioperative Transoesophageal Echocardiography. It's about measurement: which numbers to trust, when, and why bypass changes the way the right ventricle contracts — longitudinal shortening falls and circumferential contraction rises, for up to a year. We go through each systolic measure: TAPSE and the TOE alignment problem (and anatomical M-mode), S-prime and why transthoracic cut-offs don't transfer, fractional area change, 3D ejection fraction, speckle-tracking strain, and the myocardial performance index — with normal values and pitfalls for each. Then diastolic function — E, A, E-prime and deceleration time — and how E over E-prime unmasks pseudonormal filling. Finally, congestion beyond the heart: the A, S, V and D waves of hepatic vein flow and how they change as the right ventricle fails, portal vein pulsatility, intrarenal venous flow and the resistive index, and why IVC collapse doesn't translate to TOE. We finish with Calum sorting every measure into traffic lights: trust it, use with caution, or leave it. Chapters (00:00) Cold open — TAPSE says failing, FAC says fine (01:05) Geometric and non-geometric measures (01:25) TAPSE on TOE (02:40) Tissue Doppler S-prime (03:15) Fractional area change (03:55) 3D ejection fraction (04:50) Strain and speckle tracking (05:45) Myocardial performance index (06:35) What to trust after bypass (06:55) Diastolic function (07:55) Relaxation, pseudonormal and restrictive filling (08:45) Congestion beyond the heart (09:05) Hepatic vein Doppler (10:05) Portal vein pulsatility (10:30) Renal venous flow (10:55) The IVC on TOE (11:10) Traffic lights Key takeaways After bypass, RV longitudinal function falls and circumferential contraction rises for up to a year — interpret TAPSE and S′ with caution and lean on global measures TAPSE (normal >16 mm on TTE) is underestimated in the ME four-chamber view unless anatomical M-mode or the deep transgastric RV inflow view is used S′ (TTE normal ≥9.5 cm/s pulsed-wave, ≥6.0 cm/s colour TDI) has not been validated in TOE views FAC = (RVEDA − RVESA) ÷ RVEDA; below 35% is abnormal; angle-independent, includes trabeculations, inflow portion only 3D RVEF above 45% is normal; needs ≥25 Hz, often multi-beat ECG-gated acquisition; may underestimate volumes RV free wall strain more negative than −20% is normal; speckle tracking needs good images and frame rates above ~40/s MPI = (IVCT + IVRT) ÷ ET; normal <0.43 (PW) or <0.54 (TDI); unreliable with arrhythmia or high RAP Diastology: E/A 0.8–2.1, E′ 0.08–0.20 m/s, E/E′ 2–6, deceleration time 120–200 ms; E/E′ >6 with a normal E/A suggests pseudonormalisation Restrictive RV filling: E/A >2.1 with a deceleration time <120 ms Hepatic vein flow as the RV fails: exaggerated A-wave, blunted then reversed S-wave, relatively larger D-wave Portal flow becomes pulsatile with congestion (pulsatility index normally <0.5); intrarenal venous flow becomes pulsatile and the resistive index rises (normal <0.7) IVC size and collapsibility are not validated with TOE or positive-pressure ventilation References / further reading The right ventricle (Chapter 14). In: Lambert AS, Allen SJ, Sidhu S, eds. Practical Perioperative Transoesophageal Echocardiography, 4th edn. Oxford: Oxford University Press, 2025. ISBN 9780198873686 Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2010; 23: 685–713 Silverton NA, Gebhardt BR, Maslow A. The intraoperative assessment of right ventricular function during cardiac surgery. J Cardiothorac Vasc Anesth 2022; 36: 3904–15 Denault AY, Haddad F, Jacobsohn E, Deschamps A. Perioperative right ventricular dysfunction. Curr Opin Anaesthesiol 2013; 26: 71–81 Rola P, Miralles-Aguiar F, Argaiz E, et al. Clinical applications of the venous excess ultrasound (VExUS) score: conceptual review and case series. Ultrasound J 2021; 13: 32 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice.