Right Heart Strain
This week’s image is brought to us by Dr. Cochran and Dr. Bloom. It is a para-sternal short view of the heart and shows a clearly positive “D”sign.
This view is obtained by placing the probe in the left para-sternal position (between interspace 2-4) with the indicator to the pt’s right hip.
The ultrasound image shows the muscular left ventricle (inferior and right on screen) below the thinner walled right ventricle (upper left of screen). Normally the inter-ventricular septum is curved into the right ventricle. During right heart strain, the inter-ventricular septum flattens out and makes the view of the left ventricle look like the letter “D” instead of the letter “O”. In the right clinical setting, this can indicate acute right heart strain, ie hemodynamically significant pulmonary embolism.
Please note that this sign may also be seen in chronic right heart strain. Hypertrophy of the RV free/septal walls (free wall >4mm in subxiphoid view) and increased trabeculations are more consistent with chronic right heart strain, while a normal RV wall thickness is more suggestive of acute right heart strain. However, it can be very difficult to differentiate acute right heart strain from chronic right heart strain, and the mere presence of and enlarged RV does not confirm the diagnosis of a pulmonary emobolism.
This view is obtained by placing the probe in the left para-sternal position (between interspace 2-4) with the indicator to the pt’s right hip.
The ultrasound image shows the muscular left ventricle (inferior and right on screen) below the thinner walled right ventricle (upper left of screen). Normally the inter-ventricular septum is curved into the right ventricle. During right heart strain, the inter-ventricular septum flattens out and makes the view of the left ventricle look like the letter “D” instead of the letter “O”. In the right clinical setting, this can indicate acute right heart strain, ie hemodynamically significant pulmonary embolism.
Please note that this sign may also be seen in chronic right heart strain. Hypertrophy of the RV free/septal walls (free wall >4mm in subxiphoid view) and increased trabeculations are more consistent with chronic right heart strain, while a normal RV wall thickness is more suggestive of acute right heart strain. However, it can be very difficult to differentiate acute right heart strain from chronic right heart strain, and the mere presence of and enlarged RV does not confirm the diagnosis of a pulmonary emobolism.
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