1. Correct Answer: C. C

Rationale: The diameter of the IVC should be measured in the subcostal long-axis view with the patient in the supine position at 1.0 to 2.0 cm from the junction with the right atrium. For accuracy, this measurement should be made perpendicular to the IVC long axis. The diameter of the IVC decreases in response to inspiration when negative intrathoracic pressure leads to an increase in RV filling from the systemic veins. The diameter of the IVC and the percentage decrease in the diameter during inspiration correlate with RAP.

1. Ommen SR, Nishimura RA, Hurrell DG, Klarich KW. Assessment of right atrial pressure with 2-dimensional and Doppler echocardiography: a simultaneous catheterization and echocardiographic study. Mayo Clin Proc. 2000;75:24-29.

2. 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.

3. Weyman A. Cross-Sectional Echocardiography. Lea & Febiger; 1981.

2. Correct Answer: A. Normal RAP

Rationale: In Figure 51.2, the hepatic vein pattern is dominant in systole, which indicates a normal RAP. In ventilated patients, the IVC pattern might be useful to estimate the RAP. In the normal hepatic vein waveform, the S wave is larger than or equal to the D wave. This is expected, considering that the powerful systolic movement of the tricuspid annulus toward the cardiac apex causes a large antegrade rush of blood into the heart.

1. 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.

2. Scheinfeld MH, Bilali A, Koenigsberg M. Understanding the spectral Doppler waveform of the hepatic veins in health and disease. RadioGraphics. 2009;29:2081-2098.

3. Correct Answer: D. Hepatic vein systolic filling fraction

Rationale: Among echocardiographic and Doppler parameters of RA and RV function, hepatic venous flow dynamics relate best to mean RAP. This information can be used clinically to estimate mean RAP. The higher the RAP, the lower the pressure gradient between the hepatic veins and the right atrium and thus the lower the forward systolic flow. This observation was described previously in patients with restrictive heart disease and elevated filling pressures. The hepatic vein systolic filling fraction is the ratio Vs/(Vs+Vd) and a value <55% was found to be the most sensitive and specific sign of elevated RAP. Particularly systolic filling fraction, derived with either time-velocity integrals or maximal velocities, had the best relation to mean RAP and allowed a good estimation of atrial pressure in patients with a variety of underlying clinical conditions.

1. Nagueh SF, Kopelen HA, Zoghbi WA. Relation of mean right atrial pressure to echocardiographic and Doppler parameters of right atrial and right ventricular function. Circulation. 1996;93:1160-1169.

4. Correct Answer: C. 50 to 59 mm Hg

Rationale: The pulmonary artery systolic pressure is given by 4V² + RAP. The RAP is estimated by the diameter and change in diameter of the IVC with inspiration. IVC diameter ≤2.1 cm that collapses >50% with a sniff suggests a normal RAP of 3 mm Hg (range, 0-5 mm Hg), whereas an IVC diameter >2.1 cm that collapses <50% with a sniff suggests a high right trial pressure of 15 mm Hg (range, 10-20 mm Hg). In indeterminate cases in which the IVC diameter and collapse do not fit this paradigm, an intermediate value of 8 mm Hg (range, 5-10 mm Hg) may be used or, preferably, secondary indices of elevated RAP should be integrated.

In this case, 4(3.2)² +15 = 55.9 mm Hg.

1. Aduen JF, Castello R, Lozano MM, et al. An alternative echocardiographic method to estimate mean pulmonary artery pressure: diagnostic and clinical implications. J Am Soc Echocardiogr. 2009;22(7):814-819.

2. 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.

5. Correct Answer: A. A

Rationale: RV basal linear dimension is easily obtained on an apical four-chamber view at end diastole. RV end-diastolic basal diameter has been shown to be a predictor of survival in patients with chronic pulmonary artery disease. The basal diameter is generally defined as the maximal short-axis dimension in the basal one-third of the right ventricle seen on the four-chamber view. The upper reference limit for the RV basal dimension is 4.2 cm. Respiration influences the size of the right ventricle. During inspiration, it is slightly larger. It is important to take the patient’s body surface area into account.

1. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440-1463.

2. 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.

6. Correct Answer: B. Pulmonary arterial hypertension

Rationale: In this case, the diagnosis is pulmonary arterial hypertension since it is most consistent with the clinical presentation of right heart failure with elevation of RAP. The degree of immobility of the free RV wall, the wall thickness observed, and the size of the RA make the process more likely to be chronic than acute. This makes carcinoid heart disease, acute pulmonary embolism, and RV infarction very less likely.

1. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440-1463.

2. 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.

7. Correct Answer: C. C

Rationale: The systolic movement of the base of the RV free wall provides one of the most visibly obvious movements on normal echocardiography. TAPSE is a method to measure the distance of systolic excursion of the RV annular segment along its longitudinal plane, from a standard apical four-chamber window at the level of lateral tricuspid valve annulus. TAPSE represents longitudinal function of the right ventricle in the same way as mitral annular plane systolic excursion by Doppler tissue imaging does with the left ventricle. It is inferred that the greater the descent of the base in systole, the better the RV systolic function. TAPSE is simple, less dependent on optimal image quality, and reproducible, and it does not require sophisticated equipment or prolonged image analysis. A TAPSE cutoff value <17 mm has high specificity, though low sensitivity to distinguish abnormal from normal subjects.

1. 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.

8. Correct Answer: C. Severe pulmonary hypertension

Rationale: It is important to note that TR jet velocity is not related to the volume of regurgitant flow. In fact, very severe TR is often associated with a low jet velocity (2 m/s), with near equalization of RV and RA systolic pressures. A truncated, triangular jet contour with early peaking of the maximal velocity indicates elevated RAP and a prominent regurgitant pressure wave (“V wave”) in the right atrium. It should be noted that this pattern may be present in patients with milder degrees of TR and severe elevation of RAP (reduced right atrial compliance). It usually reflects a high RAP. When we get severe TR and normal RV systolic pressure, the antegrade and retrograde continuous-wave flow signals across the valve can appear qualitatively very similar with a “sine wave” appearance, corresponding to the “to-and-fro” flow across the severely incompetent valve.

1. 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.

2. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Indian Acad Echocardiogr Cardiovasc Imaging. 2020;4(1):58-121.

9. Correct Answer: C. RV pressure overload

Rationale: In Video 51.2 and Figure 51.8, the interventricular septum is flattening in systole, which is suggestive of RV pressure overload. This is a systolic D-shaped left ventricle. When it is present during systole only, it is a sign of high RV pressure. Answers A, B, and D are incorrect.

1. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16:233-271.

2. 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.

10. Correct Answer: A. Significant tricuspid valve regurgitation

Rationale: In Video 51.3 and Figure 51.9, the interventricular septal is flattening in diastole, which is suggestive of RV volume overload, like from significant tricuspid valve regurgitation or significant pulmonary valve regurgitation. This is a diastolic D-shaped left ventricle. When it is present during diastole only, it is a sign of RV volume overload, such as tricuspid valve regurgitation.

1. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16:233-271.

2. 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.

11. Correct Answer: A. 3 to 5 mm Hg

Rationale: The RAP can be estimated by looking at the dimension of the IVC diameter and its relative change in size during respiration. This method of assessing the RAP, although simple, might underestimate the true RAP, especially in cases of severe RV dysfunction or severe tricuspid valve regurgitation where the RAP can be much higher than 15 mm Hg (the maximal value obtained by this method). IVC diameter ≤2.1 cm that collapses >50% with a sniff suggests normal RAP of 3 mm Hg (range, 0-5 mm Hg), whereas IVC diameter >2.1 cm that collapses <50% with a sniff suggests high RAP of 15 mm Hg (range, 10-20 mm Hg). In scenarios in which IVC diameter and collapse do not fit this paradigm, an intermediate value of 8 mm Hg (range, 5-10 mm Hg) may be used or, preferably, other indices of RAP should be integrated to downgrade or upgrade to the normal or high values of RAP.

1. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16:233-271.

2. 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.

12. Correct Answer: C. RV pressure overload

Rationale: Prominent midsystolic notching obtained by PW Doppler through the RVOT is suggestive of high RV pressure. The decrease in RV-pulmonary artery pressure gradient and forward flow accompanied by midsystolic partial closure occurs with earlier and higher prevailing pressure, suggesting forces opposing ejection with higher pressure. In pulmonary arterial hypertension (PAH), the notched profile of RVOT Doppler flow velocity envelope appears to integrate indicators of pulmonary vascular load and RV function and serves as a marker for adverse outcomes. Answers A, B, and D are incorrect.

1. Tahara M, Tanaka H, Nakao S, et al. Hemodynamic determinants of pulmonary valve motion during systole in experimental pulmonary hypertension. Circulation. 1981;64:1249-1255.

2. Takahama H, McCully RB, Frantz RP, Kane GC. Unraveling the RV ejection Doppler envelope. Insight into pulmonary artery hemodynamics and disease severity. JACC Cardiovasc Imaging. 2017;10:1268-1277.

3. Weyman AE, Dillon JC, Feigenbaum H, Chang S. Echocardiographic patterns of pulmonic valve motion with pulmonary hypertension. Circulation. 1974;50:905-910.

13. Correct Answer: C. 43.6 mm Hg

Rationale: The diagnosis of pulmonary artery hypertension is made based on a mean PAP, as determined by right heart catheterization. There are several methods of estimating mean PAP by echo, several of them with excellent correlation with right heart catheterization. Estimation of mean PAP obtained through measurement of TR velocity is a technique similar to that used to obtain the mean gradient across the aortic valve. The complete TR jet envelope can be traced, giving TR TVI and yielding a mean RV-RA pressure gradient. Adding an estimated RAP as described yields an estimated mean PAP. This method has the attraction of being most physiologically sound. Estimation of mean PAP can be obtained through measurement of peak PR velocity: mPAP = 4 × Peak PR velocity² + RAP.

1. Aduen JF, Castello R, Lozano MM, et al. An alternative echocardiographic method to estimate mean pulmonary artery pressure: diagnostic and clinical implications. J Am Soc Echocardiogr. 2009;22(7):814-819.

2. 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.

14. Correct Answer: D. TAPSE >1.9 cm

Rationale: The systolic movement of the base of the RV free wall provides one of the most visibly obvious movements on normal echocardiography. TAPSE is a method to measure the distance of systolic excursion of the RV annular segment along its longitudinal plane, from a standard apical four-chamber window. It is inferred that the greater the descent of the base in systole, the better the RV systolic function. TAPSE is simple, less dependent on optimal image quality, and reproducible, and it does not require sophisticated equipment or prolonged image analysis. In a study of 750 patients with a variety of cardiac conditions, compared with 150 age-matched normal controls, a TAPSE cutoff value <17 mm yielded high specificity, though low sensitivity to distinguish abnormal from normal subjects. Answers A, B, and C are incorrect.

1. 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.