Using a transesophageal probe, right-sided anatomy is more difficult to visualize than left-sided anatomy, because the right ventricle is located anteriorly (further away, structures which attenuate sound are located in between the RV and the probe) and because the shape of the RV is geometrically more complex than the LV.
Preoperative RV function is an important prognostic indicator [Maslow AD. Anesth Analg 95: 1507, 2002; FREE Full-text at Anesthesia & Analgesia]. Always assess the RV in multiple views (the anatomy is too complex for a single view).
Thickness of the RV free wall should be less than 5 mm. RV end-diastolic area is less than 60% of the LV, the RV should be triangular in shape, and the RV should not make up the cardiac apex – wall thickness > 5 mm, RVEDA is > 0.60 LVEDA, the RV is round, or the RV makes up the apex, suspect increased RV afterload.
During RV hypertrophy, the IVS flattens. When septal flattening is maximal gives one an indication of the type of dysfunction – if maximal septal distortion occurs end-systole, RV pressure is probably elevated, whereas if maximal septal distortion occurs end-diastole, RV volume is probably elevated.
Tricuspid Annular Plane Systolic Excursion (TAPSE) should be at least 20 mm. The RV free wall can be examined in the RVIFOF view, and can be seen moving inward.
Systolic reversal of hepatic vein flow is an indicator of poor RV or tricuspid valve function. To access the hepatic veins, begin at the bicaval view (IVC will be to the left), and advance the probe until the vena cava comes into view.
Rapid RV Assessment
1) RV free wall thickness (normal: less than 5 mm)
2) RV:LVEDA (normal: less than 0.60)
3) Shape (normal: triangular, does not form apex)
4) TAPSE (normal: greater than 20 mm)
5) Maximal IVS distortion (end-systole = RV pressure, end-diastole = RV volume)