Audience: echocardiographers and cardiology clinicians. Evidence reviewed: September 2026.
Key message
The right ventricle is geometrically complex and load dependent. Its assessment should integrate size, shape, regional motion, haemodynamic context and more than one systolic-function index.
Acquisition before measurement
Use a dedicated RV-focused apical four-chamber view rather than assuming the standard apical view is adequate. Rotate and tilt until the maximal RV long axis and cavity are displayed without foreshortening. Add parasternal long- and short-axis, RV inflow, subcostal and inferior vena cava views. Record end-expiratory images when respiration materially changes dimensions.
What to report
| Domain | Measures | Interpretive caution |
|---|---|---|
| Size | Basal, mid-cavity and longitudinal dimensions; indexed area or 3D volumes where available | Off-axis imaging can over- or underestimate size. |
| Longitudinal function | TAPSE and lateral tricuspid annular S′ | Angle and loading dependent; may overestimate function after surgery. |
| Global area change | Fractional area change (FAC) | Requires accurate endocardial tracing and excludes RV outflow contribution. |
| Deformation | RV free-wall longitudinal strain | Vendor, tracking and loading conditions affect values. |
| Volumetric function | 3D RV ejection fraction | Best when image quality and full-volume capture are adequate. |
Core measurements
TAPSE measures longitudinal displacement of the lateral tricuspid annulus by M-mode. Tissue-Doppler S′ measures peak systolic annular velocity. FAC is calculated as (end-diastolic area − end-systolic area) / end-diastolic area × 100. Free-wall strain should exclude the septum when labelled “RV free-wall strain”; specify the convention because strain is normally reported as a negative percentage.
Thresholds are aids, not diagnoses. Current guidance should be checked for laboratory-, sex- and method-specific reference limits. Discordance is common: preserved TAPSE with reduced FAC or strain may reflect regional dysfunction, altered loading or postoperative mechanics.
Context changes interpretation
- Pressure overload: look for hypertrophy, septal flattening, reduced pulmonary acceleration time and pulmonary-hypertension signs.
- Volume overload: consider significant tricuspid or pulmonary regurgitation and shunts.
- Acute RV pressure load: chamber size and regional patterns may be more informative than wall thickness.
- Post-cardiotomy or transplant: longitudinal indices may fall despite preserved global output.
- Arrhythmia: average representative beats and state the rhythm.
Common failure modes
A single normal TAPSE does not exclude RV dysfunction. A visually “normal” RV should not replace measurements when clinical decisions depend on function. Severe tricuspid regurgitation can produce apparently vigorous annular movement despite impaired effective forward performance. Poor endocardial definition should be acknowledged rather than converted into a falsely precise FAC or strain value.
Suggested report language
“The right ventricle is [normal/mildly/moderately/severely dilated]. Global systolic function is [preserved/impaired], supported by TAPSE [x] mm, lateral S′ [x] cm/s, FAC [x]% and/or free-wall strain [x]%. Interpretation is made in the context of [loading condition/rhythm/image limitation].”
Selected references
- ASE 2025 right-heart and pulmonary-hypertension guideline.
- BSE practical guideline for right-heart assessment.
- ASE/EACVI chamber quantification.
Educational material only; individual findings require clinical integration and local reference ranges.
The Cardiac Compass 