Assessment of Right Ventricular Function in Pulmonary Hypertension

  • Robert NaeijeEmail author
Pulmonary Hypertension (JR Klinger, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Pulmonary Hypertension


Right ventricular function is a major determinant of symptomatology and prognosis in severe pulmonary hypertension. The diagnosis of right heart failure rests on a clinical approach with invasive and noninvasive measurements. Magnetic resonance and echocardiographic imaging of the right ventricle is of prognostic relevance. The gold standard of right ventricular function is the ratio of end-systolic to arterial elastances determined from synchronized volume and pressure measurements. Pressure measurements can be obtained during a right heart catheterization and volume measurements by integration of Doppler pulmonary flow-velocity, magnetic resonance imaging, or, more recently, three-dimensional echocardiography. Imaging also informs about regional function and derived estimates of dyssynchrony and asynchrony. Modern imaging with 3D echocardiography and magnetic resonance aims at improved assessment of regional function and right ventriculo-arterial coupling to assist in the evaluation and prognostication of severe pulmonary hypertension.


Right ventricular function Right ventriculo-arterial coupling End-systolic elastance Arterial elastance Time constant Afterload Pulmonary hypertension Magnetic resonance imaging Echocardiography 


Compliance with Ethics Guidelines

Conflict of Interest Robert Naeije declares no conflict of interest.

Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.••
    Vonk-Noordegraaf A, Haddad F, et al. Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology. J Am Coll Cardiol. 2013;62(25 Suppl):D22–33. Report of the working group on the right ventricle at the world symposium on pulmonary hypertension.PubMedGoogle Scholar
  2. 2.
    Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25suppl):D45–50.Google Scholar
  3. 3.
    Hoeper MM, Barbera JA, Channink RN, et al. Diagnosis, assessment, and treatment of non-pulmonary arterial hypertension pulmonary hypertension. J Am Coll Cardiol. 2009;54(1 Suppl):S85–96.PubMedGoogle Scholar
  4. 4.
    Naeije R, D’Alto M, Forfia PR. Clinical and research measurements techniques of the pulmonary circulation. The present and the future. Progr Cardiovasc Dis 2014. doi: Scholar
  5. 5.
    Fuster V, Steele PM, Edwards WD, Gersh BJ, McGoon MD, Frye RL. Primary pulmonary hypertension: natural history and the importance of thrombosis. Circulation. 1984;70:580–7.PubMedGoogle Scholar
  6. 6.
    D’Alonzo GE, Barst RJ, Ayres SM, et al. Survival in patients with primary pulmonary hypertension. Results from a national prospective registry. Ann Intern Med. 1991;115:343–9.PubMedGoogle Scholar
  7. 7.
    Sandoval J, Bauerle O, Palomar A, et al. Survival in primary pulmonary hypertension. Validation of a prognostic equation. Circulation. 1994;89:1733–44.PubMedGoogle Scholar
  8. 8.
    McLaughlin VV, Shillington A, Rich S. Survival in primary pulmonary hypertension: the impact of epoprostenol therapy. Circulation. 2002;106(12):1477–82.PubMedGoogle Scholar
  9. 9.
    Sitbon O, Humbert M, Nunes H, et al. Long-term intravenous epoprostenol infusion in primary pulmonary hypertension: prognostic factors and survival. J Am Coll Cardiol. 2002;40:780–8.PubMedGoogle Scholar
  10. 10.
    Humbert M, Sitbon O, Chaouat A, et al. Survival in patients with idiopathic, familial, and anorexigen-associated pulmonary arterial hypertension in the modern management era. Circulation. 2010;122:156–63.PubMedGoogle Scholar
  11. 11.
    Benza RL, Miller DP, Gomberg-Maitland M, et al. Predicting survival in pulmonary arterial hypertension: Insights from the registry to evaluate early and long-term pulmonary arterial hypertension disease management (REVEAL). Circulation. 2010;122:164–72.PubMedGoogle Scholar
  12. 12.
    Raymond RJ, Hinderliter AL, Willis PW, et al. Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. J Am Coll Cardiol. 2002;39:1214–9.PubMedGoogle Scholar
  13. 13.
    Bustamante-Labarta M, Perrone S, De La Fuente RL, et al. Right atrial size and tricuspid regurgitation severity predict mortality or transplantation in primary pulmonary hypertension. J Am Soc Echocardiogr. 2002;15:1160–4.PubMedGoogle Scholar
  14. 14.
    Forfia PR, Fisher MR, Mathai SC, et al. Tricuspid annular displacement predicts survival in pulmonary hypertension. Am J Respir Crit Care Med. 2006;174:1034–41.PubMedGoogle Scholar
  15. 15.
    Utsunomiya H, Nakatani S, Nishihira M, et al. Value of estimated right ventricular filling pressure in predicting cardiac events in chronic pulmonary arterial hypertension. J Am Soc Echocardiogr. 2009;22:1368–74.PubMedGoogle Scholar
  16. 16.
    Ghio S, Klersy C, Magrini G, et al. Prognostic relevance of the echocardiographic assessment of right ventricular function in patients with idiopathic pulmonary arterial hypertension. Int J Cardiol. 2010;140:272–8.PubMedGoogle Scholar
  17. 17.
    Sachdev A, Villarraga HR, Frantz RP, et al. Right ventricular strain for prediction of survival in patients with pulmonary arterial hypertension. Chest. 2011;139:1299–309.PubMedGoogle Scholar
  18. 18.
    Brierre G, Blot-Souletie N, Degano B, et al. New echocardiographic prognostic factors for mortality in pulmonary arterial hypertension. Eur J Echocardiogr. 2010;11:516–22.PubMedGoogle Scholar
  19. 19.
    Ghio S, Pazzano AS, Klersy C, et al. Clinical and prognostic relevance of echocardiographic evaluation of right ventricular geometry in patients with idiopathic pulmonary arterial hypertension. Am J Cardiol. 2011;107:628–32.PubMedGoogle Scholar
  20. 20.
    Haeck ML, Scherptong RW, Marsan NA, et al. Prognostic value of right ventricular longitudinal peak systolic strain in patients with pulmonary hypertension. Circ Cardiovasc Imaging. 2012;5:628–36.PubMedGoogle Scholar
  21. 21.
    Fine NM, Chen L, Basztiansen PM, et al. Outcome prediction by quantitative right ventricular function assessment in 575 subjects evaluated for pulmonary hypertension. Circ Cardiovasc Imaging. 2013;6:711–21.PubMedGoogle Scholar
  22. 22.
    Ernande L, Cottin V, Leroux PY, et al. Right isovolumic contraction velocity predicts survival in pulmonary hypertension. J Am Soc Echocardiogr. 2013;26:297–306.PubMedGoogle Scholar
  23. 23.
    Ameloot K, Palmers PJ, Vandebruane A, et al. Clinical value of echocardiographic Doppler-derived right ventricular dp/dt in patients with pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging. 2014;15:1411–9.PubMedGoogle Scholar
  24. 24.
    Smith BC, Dobson G, Dawson D, Charalampopoulos A, Grapsa J, Nihoyannopoulos P. Three-dimensional speckle tracking of the right ventricle: toward optimal quantification of right ventricular dysfunction in pulmonary hypertension. J Am Coll Cardiol. 2014;64:41–51.PubMedGoogle Scholar
  25. 25.
    Yeo TC, Dujardin KS, Tei C, Mahoney DW, McGoon MD, Seward JB. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol. 1998;81:1157–61.PubMedGoogle Scholar
  26. 26.
    Grünig E, Tiede H, Enyimayew EO, et al. Assessment and prognostic relevance of right ventricular contractile reserve in patients with pulmonary arterial hypertension. Circulation. 2013;128:2005–15.PubMedGoogle Scholar
  27. 27.
    van Wolferen SA, Marcus JT, Boonstra A, et al. Prognostic value of right ventricular mass, volume, and function in idiopathic pulmonary arterial hypertension. Eur Heart J. 2007;28:1250–7.PubMedGoogle Scholar
  28. 28.
    Moledina S, Pandya B, Bartsota M, et al. Prognostic significance of cardiac magnetic resonance imaging in children with pulmonary hypertension. Circ Cardiovasc Imaging. 2013;6:407–14.PubMedGoogle Scholar
  29. 29.
    Yamada Y, Okuda S, Kataoka M, et al. Prognostic value of cardiac magnetic resonance imaging for idiopathic pulmonary arterial hypertension before initiating intravenous prostacyclin therapy. Circ J. 2012;76:1737–43.PubMedGoogle Scholar
  30. 30.
    van de Veerdonk MC, Kind T, et al. Progressive right ventricular dysfunction in patients with pulmonary arterial hypertension responding to therapy. J Am Coll Cardiol. 2011;58:2511–9.PubMedGoogle Scholar
  31. 31.
    Swift AJ, Rajaram S, Campbell MJ, et al. Prognostic value of cardiovascular magnetic resonance imaging measurements corrected for age and sex in idiopathic pulmonary arterial hypertension. Circ Cardiovasc Imaging. 2014;7:100–6.PubMedGoogle Scholar
  32. 32.
    Freed BH, Gomberg-Maitland M, Chandra S, et al. Late gadolinium enhancement cardiovascular magnetic resonance predicts clinical worsening in patients with pulmonary hypertension. J Cardiovasc Magn Reson. 2012;14:11.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Eysmann SB, Palevsky HI, Reichek N, Hackney K, Doughlas PS. Two-dimensional and Doppler-echocardiographic and cardiac catheterization correlates of survival in primary pulmonary hypertension. Circulation. 1989;80:353–60.PubMedGoogle Scholar
  34. 34.
    Tei C, Dujardin KS, Hodge DO, et al. Doppler echocardiographic index for assessment of global right ventricular function. J Am Soc Echocardiogr. 1996;9:838–47.PubMedGoogle Scholar
  35. 35.
    Swift AJ, Rajaram S, Capener D, et al. LGE Patterns in pulmonary hypertension do not impact overall mortality. JACC Cardiovasc Imaging. 2014;7:1209–17.PubMedGoogle Scholar
  36. 36.
    Macchia A, Monte S, Pellegrini F, et al. Depression worsens outcomes in elderly patients with heart failure: an analysis of 48,117 patients in a community setting. Eur J Heart Fail. 2008;10:714–21.PubMedGoogle Scholar
  37. 37.•
    Naeije R, Brimioulle S, Dewachter C. Biomechanics of the right ventricle. Pulm Circ. 2014;4:395–406. Updated understanding of right ventricular function.PubMedPubMedCentralGoogle Scholar
  38. 38.•
    Vonk-Noordegraaf A, Westerhof N. Describing right ventricular function. Eur Respir J. 2013;41:1419–23. Updated concise review on how to measure right ventricular function.PubMedGoogle Scholar
  39. 39.
    Saouti N, Westerhof N, Helderman F, et al. Right ventricular oscillatory power is a constant fraction of total power irrespective of pulmonary artery pressure. Am J Respir Crit Care Med. 2010;182:1315–20.PubMedGoogle Scholar
  40. 40.
    Mahapatra S, Mahapatra S, Nishimura RA, Oh JK, McGoon MD. The prognostic value of pulmonary vascular capacitance determined by Doppler echocardiography in patients with pulmonary arterial hypertension. J Am Soc Echocardiogr. 2006;19:1045–50.PubMedGoogle Scholar
  41. 41.
    Gan CT, Lankhaar JW, Westerhof N, et al. Noninvasively assessed pulmonary artery stiffness predicts mortality in pulmonary arterial hypertension. Chest. 2007;132:1906–12.PubMedGoogle Scholar
  42. 42.
    Pagnamenta A, Dewachter C, McEntee K, Fesler P, Brimioulle S, Naeije R. Early right ventriculo-arterial uncoupling in borderline pulmonary hypertension on experimental heart failure. J Appl Physiol. 2010;109:1080–5.PubMedGoogle Scholar
  43. 43.
    Pellegrini P, Rossi A, Pasotti M, et al. Prognostic relevance of pulmonary arterial compliance in patients with chronic heart failure. Chest. 2014;145:1064–74.PubMedGoogle Scholar
  44. 44.
    Ghio S, Gavazzi A, Campana C, et al. Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure. J Am Coll Cardiol. 2001;37:183–8.PubMedGoogle Scholar
  45. 45.
    Maughan WL, Shoukas AA, Sagawa K, Weisfeldt ML. Instantaneous pressure-volume relationship of the canine right ventricle. Circ Res. 1979;44:309–15.PubMedGoogle Scholar
  46. 46.
    Brimioulle S, Wauthy P, Ewalenko P, et al. Single-beat estimation of right ventricular end-systolic pressure-volume relationship. Am J Physiol Heart Circ Physiol. 2003;284:H1625–30.PubMedGoogle Scholar
  47. 47.
    Kerbaul F, Brimioulle S, Rondelet B, Dewachter C, Hubloue I, Naeije R. How prostacyclin improves cardiac output in right heart failure in conjunction with pulmonary hypertension. Am J Respir Crit Care Med. 2007;175:846–50.PubMedGoogle Scholar
  48. 48.
    De Man FS, Handoko ML, van Ballegoij LL, et al. Bisoprolol delays progression towards right heart failure in experimental pulmonary hypertension. Circ Heart Fail. 2012;5:97–105.PubMedGoogle Scholar
  49. 49.•
    Kuehne T, Yilmaz S, Steendijk P, et al. Magnetic resonance imaging analysis of right ventricular pressure-volume loops: in vivo validation and clinical application in patients with pulmonary hypertension. Circulation. 2004;110:2010–6. First report on gold standard measurements of right ventricular function by the pressure-volume approach in sevee pulmonary hypertension.PubMedGoogle Scholar
  50. 50.
    Tedford RJ, Mudd JO, Girgis RE, et al. Right ventricular dysfunction in systemic sclerosis associated pulmonary arterial hypertension. Circ Heart Fail. 2013;6:953–63.PubMedGoogle Scholar
  51. 51.
    Overbeek MJ, Lankhaar JW, Westerhof N, et al. Right ventricular contractility in systemic sclerosis-associated and idiopathic pulmonary arterial hypertension. Eur Respir J. 2008;31:1160–6.PubMedGoogle Scholar
  52. 52.
    Wauthy P, Naeije R, Brimioulle S. Left and right ventriculo-arterial coupling in a patient with congenitally corrected transposition. Cardiol Young. 2005;15:647–9.PubMedGoogle Scholar
  53. 53.
    McCabe C, White PA, Hoole SP, et al. Right ventricular dysfunction in chronic thromboembolic obstruction of the pulmonary artery: a pressure-volume study using the conductance catheter. J Appl Physiol. 2014;116:355–63.PubMedGoogle Scholar
  54. 54.
    Sanz J, García-Alvarez A, Fernández-Friera L, et al. Right ventriculo-arterial coupling in pulmonary hypertension: a magnetic resonance study. Heart. 2012;98:238–43.PubMedGoogle Scholar
  55. 55.
    Trip P, Kind T, van de Veerdonk MC, et al. Accurate assessment of load-independent right ventricular systolic function in patients with pulmonary hypertension. J Heart Lung Transplant. 2013;32:50–5.PubMedGoogle Scholar
  56. 56.
    Vanderpool RR, Pinsky MR, Naeije R, et al. Right ventricular-pulmonary arterial coupling predicts outcome in patients referred for pulmonary hypertension. Heart. 2015;101:37–43. First report on prognostic impact of comprehensive measurements of right ventriculo-arterial coupling in severe pulmonary hypertension.PubMedGoogle Scholar
  57. 57.
    Rain S, Handoko ML, Trip P, et al. Right ventricular diastolic impairment in patients with pulmonary arterial hypertension. Circulation. 2013;128:2016–25.PubMedGoogle Scholar
  58. 58.
    D’Alto M, Romeo E, Argiento P, et al. Echocardiographic prediction of pre- versus postcapillary pulmonary hypertension. J Am Soc Echocardiogr. 2015;28:108–15.PubMedGoogle Scholar
  59. 59.
    Opotowsky AR, Ojeda J, Rogers F, et al. A simple echocardiographic prediction rule for hemodynamics in pulmonary hypertension. Circ Cardiovasc Imaging. 2012;5:765–75.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Lopez-Candales A, Dohi K, Rajagopalan N, et al. Right ventricular dyssynchrony in patients with pulmonary hypertension is associated with disease severity and functional class. Cardiovasc Ultrasound. 2005;3:23.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Meris A, Faletra F, Conca C, et al. Timing and magnitude of regional right ventricular function: a speckle tracking derived strain study of normal subjects and patients with right ventricular dysfunction. J Am Soc Echocardiogr. 2010;23:823–31.PubMedGoogle Scholar
  62. 62.
    Marcus JT, Gan CT, Zwanenburg JJ, et al. Interventricular mechanical asynchrony in pulmonary arterial hypertension: left-to-right delay in peak shortening is related to right ventricular overload and left ventricular underfilling. J Am Coll Cardiol. 2008;51:750–7.PubMedGoogle Scholar
  63. 63.
    Guazzi M, Bandera F, Pelissero G, et al. A tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis. Am J Physiol Heart Circ Physiol. 2013;305:H1373–81.PubMedGoogle Scholar
  64. 64.
    Vogel M, Schmidt MR, Christiansen SB, et al. Validation of myocardial acceleration during isovolumic contraction as a novel non-invasive index of right ventricular contractility. Circulation. 2002;105:1693–9.PubMedGoogle Scholar
  65. 65.
    Sharma T, Lau EM, Choudhary P, et al. Dobutamine stress for evaluation of right ventricular reserve in pulmonary arterial hypertension. Eur Respir J. 2014; 45(3):700–708PubMedGoogle Scholar
  66. 66.
    Guihaire J, Haddad F, Noly PE, et al. Right ventricular reserve in a piglet model of chronic pulmonary hypertension. Eur Respir J. 2014; 45(3):709–717PubMedGoogle Scholar
  67. 67.•
    Naeije R. The 6-min walk distance in pulmonary arterial hypertension: “Je t’aime, moi non plus”. Chest. 2010;137:1258–60. Brief review on the physiologic meaning of exercise tests in severe pulmonary hypertension.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of CardiologyErasme University HospitalBrusselsBelgium

Personalised recommendations