Diagnostic Workup for Reduced Right Ventricular Systolic Function

Initial Evaluation

The American Heart Association recommends transthoracic echocardiography (TTE) as the first-line imaging modality to evaluate the severity of right ventricular (RV) dysfunction, determine etiology, measure sizes of right-sided chambers and inferior vena cava, assess RV systolic function, and estimate pulmonary artery systolic pressure in patients with reduced right ventricular systolic function 1
Assessment of RV systolic function is a critical component of evaluation, as impaired RV systolic function negatively impacts early functional, late functional, and survival outcomes in patients with heart failure 2

Standard echocardiographic parameters to assess RV function include tricuspid annular plane systolic excursion (TAPSE) - abnormal if <17 mm, RV fractional area change (FAC) - abnormal if <40%, and RV basal diameter - abnormal if >41 mm, as recommended by the European Society of Cardiology 3
Advanced echocardiographic parameters such as RV longitudinal strain of lateral RV free wall - abnormal if worse than -23%, RV mechanical dispersion - abnormal if >25-30 ms, and 3D RV ejection fraction - abnormal if <40% should also be considered for comprehensive assessment of RV function 3

If pulmonary hypertension is suspected based on echocardiographic findings, right heart catheterization is the gold standard for confirming the diagnosis and provides definitive information regarding pulmonary vasoreactivity testing, according to the American College of Cardiology 4
Comprehensive evaluation should include pulmonary function tests, six-minute walk test, non-contrast CT scan of the chest or CT angiogram if thromboembolic disease is suspected, as recommended by the American Heart Association 5
Ventilation/perfusion (V/Q) scan should be performed to evaluate for chronic thromboembolic pulmonary hypertension in patients with suspected pulmonary hypertension 4

Search for underlying causes of RV dysfunction, including left-sided heart disease (valvular disease, cardiomyopathy), pulmonary hypertension (pulmonary arterial hypertension, chronic thromboembolic pulmonary hypertension), pulmonary disease (COPD, interstitial lung disease), congenital heart disease with systemic-to-pulmonary shunts, sleep-disordered breathing, and autoimmune diseases, as recommended by the American College of Cardiology 6
Laboratory tests should include complete blood count, comprehensive metabolic panel, thyroid function tests, N-terminal pro B-type natriuretic peptide (NT-proBNP), and if clinically indicated: hepatitis serologies, HIV testing, hypercoagulable panel, according to the American Heart Association 5

Exercise testing should be considered for the assessment of exercise capacity in patients with severe tricuspid regurgitation with no or minimal symptoms, as recommended by the American College of Cardiology 2

Elevated right ventricular systolic pressure (RVSP) on echocardiography correlates with poor outcomes, with mortality risk increasing by approximately 40% with every 10 mmHg increase in PA systolic pressure, according to the American College of Cardiology 4

For patients with RV dysfunction due to left-sided heart failure, optimization of left ventricular function with ACE inhibitors and beta-blockers is essential, as recommended by the American College of Cardiology 7
In patients with RV dysfunction and signs of right-sided heart failure, diuretics can be useful, according to the American Heart Association 2
Medical therapies to reduce elevated pulmonary artery pressures and/or pulmonary vascular resistance might be considered in patients with severe functional tricuspid regurgitation, as recommended by the American College of Cardiology 2