Right Heart Strain

Dr. Kothari and Dr. Heron bring this week’s image of the week to us. The images are the bedside echo of a patient with right heart strain. The parasternal short view shows a classic “D” sign, where the bottom chamber (muscular left ventricle) is forced inward by the pressure built up in the top chamber (the right ventricle). 

The parasternal long axis and apical four-chamber view both show septal bowing with the intra-ventricular septum begin pushed over into the left ventricle. 

These images are form a patient with chronic right heart strain, which can be confirmed by history, medical record (previous echo) and possibly measuring the right ventricular free wall thickness in a sub-costal view (in this view chronic wall thickining is >0.4cm).  IV-Septum is the "inter-ventricular septum."

Given the appropriate concern (based on patient’s history and physical) for acute right heart strain from PE, the following ultrasonographic signs MAY help to elucidate the diagnosis of sub-massive pulmonary embolism. The following findings may suggest the diagnosis of hemodynamically significant PE:

1) “D” sign as noted above
2) A RV/LV ratio of > 0.6/1
3) A right free ventricular wall <0.4cm in diameter
4) A McConnell's sign- right ventricular strain with normal apical right ventricular function (See article below for sensitivity and specificity.)

Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism.

McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT.

Am J Cardiol. 1996 Aug 15;78(4):469-73.

PMID:8752195