Intensive Care Med

https://doi.org/10.1007/s00134-018-5211-z

SYSTEMATIC REVIEW

The use of echocardiographic indices

in defining and assessing right ventricular
systolic function in critical care research
Stephen J. Huang1*, Marek Nalos1, Louise Smith2, Arvind Rajamani1 and Anthony S. McLean1

© 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM

Abstract 
Purpose:  Many echocardiographic indices (or methods) for assessing right ventricular (RV) function are available, but
each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted
a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent
pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was
defined in each study.
Methods:  Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997
to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary
studies were excluded. These studies’ characteristics and RV indices reported were summarized.
Results:  Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There
has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in
ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the
combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite
indices, many did not explain their choices.
Conclusions:  TAPSE seemed to be the most popular index in the last 2–3 years. Many studies used combinations of
indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV
dysfunction amongst these studies.
Keywords:  Echocardiography, Right ventricular function, Critical care, Intensive care, Emergency, Anaesthetics

Introduction been reported as a predictor for mortality and morbidity

Acute right ventricular (RV) dysfunction is common in
the critically ill population, especially where RV after-
load is increased such as in patients with massive pulmo-
nary embolism and acute respiratory distress syndrome
(ARDS). Other common causes of acute RV dysfunction
are RV myocardial infarction and post-operative RV fail-
ure. RV dysfunction, including acute cor pulmonale, has
*Correspondence: Stephen.huang@sydney.edu.au
1
Department of Intensive Care Medicine, Nepean Hospital, Sydney
Medical School, The University of Sydney, Sydney, NSW, Australia
Full author information is available at the end of the article
in critically ill patients [1, 2].
Assessment of RV function is part of patient care in
the critical care setting. Traditionally, RV function has
been assessed by invasive right-heart catheterisation.
However, the procedure of right-heart catheterisation is
cumbersome and risky [3], and RV function can only be
inferred from intracardiac pressures and cardiac output
information [4]. Direct quantification of RV function is
impossible with this method. In the last 20  years, right-
heart catheterisation has been gradually supplanted by
non-invasive transthoracic echocardiography (TTE), or
minimally invasive transoesophageal echocardiography
(TEE). Echocardiography offers many advantages in RV
function assessment, including the ability to estimate
intracardiac or pulmonary artery pressures, the quantifi-
cation of RV function, the measurement of cardiac out-
put and the ability to be performed at the bedside quickly
and non-invasively. As such, critical care echocardiogra-
phy has become an essential part of patient care in the
critical care setting.
Echocardiographic assessment of RV function is not
without challenges. First, the geometry of the RV is com-
plex; hence unlike the left ventricle (LV), assessment such
as ejection fraction cannot be based on a symmetrical
conical shape [5]. Second, over the years many echocar-
diographic RV function indices have been introduced
as surrogates of RV function (Table  1). Some of these
indices measure the longitudinal (regional) function
of the RV (e.g. tricuspid annular plane systolic excur-
sion or TAPSE) while others measure the global func-
tion (e.g. fractional area change or FAC). Each index has
pros and cons (Table 1), but may not necessary yield the
same information. Third, the quality of images and tech-
nical limitations may preclude operators from obtaining

Table 1  Summary of common objective echocardiographic indices for RV function

Index Description Advantages Disadvantages (limitations)

Longitudinal function index

  TAPSE A single dimensional measurement of
the longitudinal motion of the tricuspid
annular plane
Measured at lateral free wall
  St A single dimensional measurement of the
peak longitudinal systolic velocity of the
tricuspid annulus
Measured at lateral free wall
  RVS A single dimensional measurement of
the percentage change in longitudinal
length
Measured at lateral free wall
Global function index
  FAC A two dimensional measurement of the
change in RV area
Usually measured in the longitudinal view
but some use the cross-sectional view
Similar to and correlates with ejection
fraction
  Tei A Doppler (or tissue Doppler) measurement
­indexa of the ratio of sum of isovolumic times to
ejection time
Reflects both systolic and diastolic function
(combined)
  EDA A two dimensional measurement of the
ratio ratio of RV end-diastolic to LV end-
diastolic ratio
A measure of how severe the RV is dilated
compared to LV
Severely dilated RV usually connotes RV
dysfunction
Usually used in conjunction with paradoxi-
cal septal motion in defining cor pulmo-
nale
TAPSE tricuspid annular plane systolic excursion, St tissue Doppler of the tricuspid annular systolic velocity, RVS right ventricular strain, FAC fractional area change, EDA
ratio RV end-diastolic area to LV end-diastolic area ratio
a
  Also known as RV index of myocardial performance (RVIMP)
Easy to perform
Quick
Minimal training required
Less dependent on image quality
Averaging is easy to perform
Good intra- and interoperator reproduc-
ibility
Easy to perform
Quick
Less subject to 2D image quality
Less dependent on image quality
Averaging is easy to perform
Good intra- and interoperator reproduc-
ibility
Not angle-dependent
Yields regional wall motion information
Not subject to translational artefact
Not angle-dependent
Not subject to regional wall motion infor-
mation
Not subject to translational artefact
Fair interoperator reproducibility
Not subject to regional wall motion
abnormality
Not subject to translational artefact
Sensitive to loading conditions
Less subject to image quality
Not angle-dependent
Not subject to regional wall motion infor-
mation
Not subject to translational artefact
Sensitive to loading conditions
Good intra- and interoperator variabilities
Angle-dependent
Maybe misleading if regional wall motion
abnormalities are present
Subject to LV motion and translational
artefact
Angle-dependent
Maybe misleading if regional wall motion
abnormalities are present
Subject to LV motion and translational
artefact
Requires good image quality
Relatively time-consuming
Requires off-line analysis
Requires extra and expensive software
Special training required
Poor interoperator variabilities
Requires good image quality
Relatively time-consuming
Some training required
RVOT not included in assessment
Does not necessarily correlate with PASP
Angle-dependent
Depends on good Doppler signal
Not recommended in irregular heart beats
Moderate intra- and interoperator variabilities
A mild increase does not imply RV dysfunc-
tion
Requires good image quality
Relatively time-consuming
Some training required
certain RV function indices in the critical care setting.
Because of these challenges, we were curious to find out
how RV function was assessed and defined echocardio-
graphically in critical care research. As there is no sys-
tematic review available on this topic, we conducted a
narrative (descriptive) systematic review to summarize
the echocardiographic assessments of RV function in
critical care research (PROSPERO Registration Number:
CRD42018092716).
Methods
Eligibility criteria
All studies must have utilized echocardiography, either
transthoracic or transoesophageal, to assess RV systolic
function and been conducted in a critical care setting:
anaesthetic departments (AD), emergency departments
(ED) or intensive care units (ICU). Both observational
studies and clinical trials were eligible. Non-adult studies,
case studies/series, reviews and secondary studies were
not eligible.
Search strategy and databases
In order to capture most of the primary studies, we
employed a high sensitivity (broadened) strategy by
searching the following text words: {[“right ventri*” OR
“cor pulmonale” (Title and Abstract)] AND [“echocar-
diogr*” (Title and Abstract)] AND [“critical care” OR
“intensive care” OR “emergency” OR “anesth*” OR
“anaesth*” (All field)]}. To study the evolution of different
echocardiography measurements of RV function, pub-
lications dating back 20  years (from 1997 to June 2017)
were searched (the search was performed in August
2017). Three databases, PubMed and EMBASE (with
Medline via Ovid), were used. The following filters were
applied: human, adult, English language, and journal
articles.
function indices. The following terms were accepted as an
alternative to “RV systolic function” in the articles: “RV
function” (except diastolic function), “RV dysfunction” or
“cor pulmonale”. Studies types were classified objectively
on the basis of how the investigators conducted the study,
analysed the data and what was reported. Descriptive and
summary statistics were provided where appropriate. All
statistics and graphics were performed and produced
using the open statistical software R (version 3.4.3) (The
R Foundation for Statistical Computing, Austria, http://
www.R-proje​ct.org/).
Results
Number of studies included
The searches returned 592 studies, of which 97 studies
were duplicated in more than one databases. A total of
414 studies were excluded for not meeting one or more
of the criteria and 78 studies met all inclusion criteria
(Fig.  1). Three studies of the authors’ own works were
also included [6–8]. Altogether, a total of 81 relevant
studies were included in this systematic review (Table 2).
Jan 1997 - June 2017:
PubMed 319
Embase + Medline 270
Other sources 3
Total 592
Excluded 97 duplicates
PubMed 316
Embase + Medline 176
Other sources 3
Total 495

Excluded 414 from PubMed and Embase:

Studies selection
Two investigators (SJH and MN) manually screened all PubMed Embase
Case studies 132 68
the abstracts independently according to the predeter- Reviews 2 2
mined eligibility criteria (see above). Case studies, com- Guidelines 1 0
Non-critical care 62 10
mentaries, reviews and secondary studies were excluded. Non-echo 13 5
Full text articles were downloaded for screening if the No RV data 45 49
Non-adult 3 3
information provided in the abstract was not obvious. Study protocol 1 0
Any disagreements were resolved through discussion Irrelevant studies 0 1
Non-English 10 7
with a third independent investigator (ASM). Total 269 145

Data extraction and statistics

PubMed 47
The full text articles of all eligible studies were obtained, Embase + Medline 31
and the following information was extracted: study design Other sources 3
Total 81
and type of study, year of publication, setting, types and
number of subjects (patients), definition of RV function Fig. 1  Flow diagram showing the number of excluded and eligible
or dysfunction, and all reported echocardiography RV studies
Table 2  Details of included studies
No. First authors Patient ­typea Setting/country Sample Study ­typeb RV function surro- Basis for definition
size gates ­measuredc of RV dysfunction

1 Ochiai et al. [9] Cardiac surgery ICU/Japan 14 Association (PO) PA loops (Ees), FAC FAC
2 Ochiai et al. [10] Cardiac surgery ICU/Japan 11 Association (PO) PA loops (Ees), FAC FAC
3 Vieillard-Baron et al. ARDS ICU/France 75 Prognosis (PO) EDA ratio, PSM, FAC Conjunctive Cidx (EDA
[11] ratio + PSM)
4 Jackson et al. [12] PE ED/USA 124 Diagnosis (PO) RV contractility, PSM, Not defined
RV dilatation, PASP
5 Vieillard-Baron et al. PE ICU/France 98 Descriptive (RO) EDA ratio, PSM, FAC Conjunctive Cidx (EDA
[13] ratio + PSM)
6 Maslow et al. [14] Cardiac Anaesth/USA 41 Prognosis (RO) FAC, RVWM FAC
7 McLean et al. [6] Mixed ICU/Australia 84 Diagnosis (PO) TAPSE TAPSE
8 McLean et al. [7] Mixed ICU/Australia 121 Association (PO) TAPSE TAPSE
9 Catena et al. [15] Cardiac ICU/Italy 8 Descriptive (PO) FAC FAC
10 Mansencal et al. [16] PE ED/France 46 Diagnosis (PO) EDA ratio EDA ratio
11 Bal et al. [17] Shock ICU/France 41 Diagnosis (PO) EDA ratio EDA ratio
12 Lamia et al. [18] Mixed ICU/France 86 Association (PO) TAPSE, EDA ratio, FAC Not defined
13 Mokart et al. [19] Sepsis ICU/France 51 Prognosis (PO) RV dilatation, PSM, Permuted Cidx [EDA
PASP ratio + (PSM or
PASP)]
14 Gallotta et al. [20] PE ED/Italy 90 Prognosis (PO) RV dilatation, PSM, Compensatory Cidx
TAPSE
15 Aksay et al. [21] PE ED/Turkey 77 Prognosis (RO) RV dilatation, RVWM, Compensatory Cidx
PSM
16 Kline et al. [22] PE ED/USA 161 Prognosis (PO) RVWM Subjective RVWM
17 Sade et al. [23] Mixed ICU/Turkey 89 Agreement (PO) FAC, St FAC
18 Vieillard-Baron et al. ARDS ICU/France 42 Association (PO) EDA ratio, PSM Conjunctive Cidx
[24]
19 McLean and Huang Sepsis ICU/Australia 40 Prognosis (PO) St St
[8]
20 Kline et al. [25] PE ED/USA 152 Prognosis (PO) RVWM Subjective RVWM
21 Tousignant et al. [26] Cardiac Anaesth/Canada 24 Agreement (PO) St, RVS, RVSR, IVA Not defined
22 Palmieri et al. [27] PE ED/Italy 89 Association (PO) EDA ratio, PSM, TAPSE Conjunctive Cidx
23 Dessap et al. [28] ARDS ICU/France 11 Association (PO) EDA ratio, eccentricity Conjunctive Cidx
ratio
24 Tousignant et al. [29] Cardiac Anaesth/Canada 24 Descriptive (PO) TAPSE, St Not defined
25 Mahjoub et al. [30] Shock ICU/France 35 Diagnosis (PO) TAPSE, St Not defined
26 Gernoth et al. [31] ARDS ICU/Italy 12 Association (PO) Tei Tei
27 Ricci et al. [32] Cardiac ICU/USA 53 Prognosis (RO) FAC FAC
28 Matyal et al. [33] Lung surgery Anaest/USA 59 Prognosis (PO) Tei, St Tei
29 Karakilic et al. [34] AHF ED/Turkey 34 Association (PO) St, RVS St
30 Gackowski et al. [35] Cardiac surgery ICU/Poland 40 Prognosis (PO) TAPSE TAPSE
31 Rendina et al. [36] PE ED/Italy 211 Association (RO) PSM, RV dilatation, Compensatory Cidx
RVWM, PASP
32 Papaioannou et al. APO ICU/Greece 32 Prognosis (PO) FAC, TAPSE, St Not defined
[37]
33 Dessap et al. [38] ARDS ICU/France 203 Prevalence & progno- EDA ratio, PSM Conjunctive Cidx
sis (PO)
34 Fougéres et al. [39] ARDS ICU/France 21 Association (PO) EDA ratio, PSM Conjunctive Cidx
35 Haas et al. [40] Surgical Anaesth/Germany 10 Descriptive (PO) TAPSE, FAC, St, EDA Not defined
ratio
36 Albers et al. [41] Cardiac surgery ICU/Germany 73 Association (PO) St, RVS, RVSR Not defined
37 Park et al. [42] Respiratory ED/Korea 52 Diagnosis (PO) FAC, Tei, RVS Not defined
38 Golpe et al. [43] PE ED/Spain 103 Association (PO) RV dilatation, RVWM Compensatory Cidx
Table 2  continued
No. First authors Patient ­typea Setting/country Sample Study ­typeb RV function surro- Basis for definition
size gates ­measuredc of RV dysfunction
39 Brown et al. [44] Sepsis ICU/USA 23 Prevalence (PO) FAC, TAPSE Compensatory Cidx
40 Park et al. [42] PE ICU/Korea 24 Diagnosis (PO) FAC, Tei, RVS, St Not defined
41 Guervilly et al. [45] ARDS ICU/France 16 Interventional (PT) EDA ratio, PSM Conjunctive Cidx
42 Schuuring et al. [46] Cardiac surgery ICU/Netherlands 86 Descriptive (PO) TAPSE, St, Tei Compensatory Cidx
43 Furian et al. [47] Sepsis ICU/Brazil 45 Descriptive (PO) St St
44 Corciova et al. [48] Cardiac surgery ICU/Romania 171 Prognosis (RO) TAPSE TAPSE
45 Fichet et al. [49] ARDS ICU/France 50 Feasibility (PO) FAC, TAPSE, St, EDA Permuted Cidx
ratio, PSM
46 Harmankaya [50] Sepsis ICU/Turkey 55 Prognosis (PO) St, Tei Not defined
47 Fagnoul et al. [51] Sepsis ICU/Belgium 46 Descriptive (PO) St, EDA ratio EDA ratio
48 Franchi et al. [52] Mixed ICU/Italy 20 Association (PO) TAPSE, RVS RVS
49 Schuuring et al. [53] Cardiac surgery ICU/Netherlands 412 Association (RO) TAPSE, St Conjunctive Cidx
50 Lhéritier et al. [54] ARDS ICU/France 201 Prevalence & progno- EDA ratio, eccentricity Conjunctive Cidx
sis (PO) index, PSM
51 Boissier et al. [55] ARDS ICU/France 226 Prevalence & progno- EDA ratio, PSM Conjunctive Cidx
sis (PO)
52 Hyllen et al. [56] Cardiac surgery ICU/Sweden 40 Association (PO) FAC, TAPSE, St, Tei, Subjective
RVSP, RVS
53 Kusunose et al. [57] Lung surgery ICU/USA 89 Prognosis (RO) FAC, TAPSE, RVS Compensatory Cidx
54 Madhaven et al. [58] Respiratory Anaesth/India 20 Descriptive (PO) FAC, TAPSE, Tei, St Not defined
55 Yildirim et al. [59] Sepsis ED/Turkey 211 Association (PO) TAPSE TAPSE
56 Ramjee et al. [60] Cardiac ED/USA 291 Prognosis (RO) Subjective RV size and Subjective
RV systolic function
score
57 Bloomer et al. [61] PE ED/Netherlands 31 Descriptive (PO) Subjective RV systolic Subjective
function score
58 Denault et al. [62] Cardiac surgery ICU/Canada 120 Interventional (PT) FAC, TAPSE, St Compensatory Cidx
59 Guinot et al. [63] Cardiac surgery ICU/France 99 Prognosis (PO) St, TAPSE, RVEF, RV Permuted Cidx (any
dilatation two)
60 Denault et al. [64] Cardiac surgery Anaesth/Canada 110 Association (post hoc) TAPSE, FAC TAPSE
61 Imada et al. [65] Cardiac surgery Anaesth/Japan 54 Agreement (RO) FAC, RVEF Not defined
62 Khemasuwan et al. PE ICU/USA 211 Prognosis (RO) RV dilatation, PASP, Not defined
[66] TAPSE, RVS, RVSR
63 Azari et al. [67] PE ICU/Iran 30 Descriptive (PO) TAPSE Not defined
64 Perez-Teran et al. [68] Lung surgery ICU/Spain 120 Prognosis (RO) FAC, TAPSE, St, RVS Not defined
65 Russell et al. [69] Dyspnoea ED/USA 198 Descriptive (post hoc) RVWM Subjective RVWM
66 Legras et al. [70] ARDS ICU/France 195 Prevalence (PO) TAPSE, EDA ratio, FAC, Conjunctive Cidx (EDA
PSM, PASP ratio + PSM)
67 Dahhan et al. [71] PE ED/USA 69 Prognosis (RO) TAPSE, Tei, FAC, RVS Not defined
68 Nadziakiewicz et al. Cardiac ICU/Poland 23 Association (RO) TAPSE, FAC, RV dilata- Conjunctive Cidx
[72] tion, EDA ratio
69 Dessap et al. [2] ARDS ICU/France 752 Prevalence (PO) EDA ratio, PSM Conjunctive Cidx
70 Tuzovic et al. [73] PE ED/US 82 Association (RO) RVWM, RVS, FAC, Subjective (RVWM)
TAPSE
71 Biteker et al. [74] Sepsis ED/Turkey 111 Association (PO) TAPSE TAPSE
72 Lazzeri et al. [75] ARDS ICU/Italy 42 Prognosis (PO) TAPSE, EDA ratio TAPSE
73 Mishra et al. [76] Cardiac surgery ICU/India 40 Interventional (PT) TAPSE, St, Tei Permuted Cidx (any
combination)
74 Abtahi et al. [77] Cardiac ED/Iran 60 Association (PO) TAPSE, St, Tei Tei
75 Lazzeri et al. [78] ARDS ICU/Italy 74 Prognosis (PO) TAPSE TAPSE
Table 2  continued
No. First authors Patient ­typea Setting/country Sample Study ­typeb RV function surro- Basis for definition
size gates ­measuredc of RV dysfunction
76 Lazzeri et al. [79] ARDS ICU/France 46 Prognosis (PO) RV dilatation, PSM, Permuted Cidx (any
PASP, TAPSE one or combina-
tion of RV dilata-
tion + PSM)
77 Cecchini et al. [80] ARDS in sicklers ICU/France 362 Prevalence & progno- EDA ratio, PSM Conjunctive Cidx
sis (RO)
78 Dudzinski et al. [81] PE ED/USA 298 Diagnosis (PO) RVWM, RV dilatation, Compensatory Cidx
PSM
79 Jia et al. [82] PE ED/China 113 Diagnosis (RO) RVWM, EDA ratio, Permuted Cidx (any
PASP, TAPSE, RV combination)
dilatation
80 Diaz-Gomez et al. [83] Cardiac ICU/USA 45 Agreement (PO) TAPSE, SEATAK TAPSE
81 Weekes et al. [84] PE ED/USA 123 Prognosis (post hoc) TAPSE TAPSE
a
  AHF acute heart failure, APO acute pulmonary oedema, ARDS acute respiratory distress syndrome, PE pulmonary embolism
b
  Post hoc post hoc analysis of previous trial or observational study, PO prospective observational study, PT prospective trial, RO retrospective observational study
c
  Cidx composite index, EDA ratio RV end-diastolic area to LV end-diastolic area ratio, FAC fractional area change, IVA isovolumic acceleration, PA loop (Ees) pressure–
area loop (end-systolic elastance), PASP pulmonary artery systolic pressure, PSM paradoxical septal motion, RVS RV strain, RVSR RV strain rate, RVWM RV wall motion,
SEATAK subcostal echocardiographic assessment of tricuspid annular kick, St tricuspid annular systolic velocity, TAPSE tricuspid annular plane systolic excursion, Tei Tei
(myocardial performance) index

The total number of relevant publications per year
is shown in Fig.  2a. The earliest studies that reported
echocardiographic indices for RV function were found
in 1998 and 1999 (n = 2) [9, 10]. There had been a sud-
den increase in the number of studies from 2007, and
then another surge in 2015. The number of studies
found in the first 6  months of 2017 was 4. Most studies
(63.0%) were conducted in ICU (n = 51), followed by ED
(n = 22 or 27.1%) and the rest were in AD (n = 8 or 9.9%)
(Fig. 2b).
Characteristics of studies
Sixty-one studies (75.3%) were prospective in design
and 17 (21.0%) were retrospective observational stud-
ies. Three of the 61 prospective studies were clinical tri-
als [45, 62, 76], the rest were observational studies. Three
were post hoc analysis of previously conducted studies
[64, 69, 84].
Types of studies
Most employed TTE (n = 54), 19 studies used TEE and
8 used both. Most studies were either prognosis (n = 23
or 28.4%) or association (n = 22 or 27.2%) studies. Twelve
(14.8%) were descriptive and 9 (11.1%) were diagnos-
tic studies. Few were interventional (n = 3), agreements
between two or more methods (n = 4) or prevalence stud-
ies (n = 3). Five studies had both prevalence and progno-
sis characteristics (Supplementary Material Fig. S1). The
distributions of the types of studies in different settings
were also slightly different (Supplementary Table  S1).
While the predominant type of studies in AD setting was
descriptive in nature (37.5%), approximately two-thirds
of the studies in ED and ICU were of prognosis and asso-
ciation types. Diagnostic studies were also common in
ED (22.7%). ICU had more variety of studies.
Cohorts and sample size
The study populations were from a wide range of
patients, and most were patients with pulmonary embo-
lism (PE), acute respiratory distress syndrome (ARDS),
cardiac surgery, cardiac dysfunction or sepsis (Fig.  3a).
The distribution of patient types was also setting specific
(Fig. 3b): studies in AD were mostly surgical patients or
patients with underlying cardiac problems, studies in ED
were mostly with PE (n = 15), and ICU studies displayed
a wide spectrum of patients comprising both surgical and
medical patients but mostly ARDS patients.
Supplementary Figure S2 shows the study sample sizes
over the last 20  years. The minimum sample size was 8
and the maximum was 752. Half of the studies had sam-
ple sizes of 60 or less. There has been a trend of increas-
ing sample size in the last 10 years, in particular ICU and
ED studies. The median sample sizes for ICU and ED
studies were 50 and 107, respectively. Sample sizes in AD
studies were smaller (median = 32).
Feasibility, intra‑ and interobserver agreements
Twenty-four studies reported feasibility as the number
of patients that the investigators  were unable to obtain
echocardiograms. The average proportion of patients
reported to have poor acoustic views or images was 7.9%,
ranging from 0% to 27%. Two studies which used TTE
 a b
12
10
Total number of publications
8
6
4 15
2
0 0
1995 2000 2005 2010
Year
Fig. 2  Characteristics of included studies. a Total number of relevant publications per year. b Total number of publications in each setting. *Up to
June 2017. ED emergency department, ICU intensive care unit
reported more than 25% of patients with poor acoustic
windows [65, 72]. Thirteen and sixteen studies reported
intra- and interobserver agreements, respectively.
Another two studies did not report the agreements in
the studies but quoted the authors’ previous reports on
agreements. Agreements were reported as variabilities,
Pearson correlations, kappa correlations or intraclass
correlations.
RV function indices
Number of  indices measured per  study  Figure  4 shows
the distribution of the number of RV indices measured per
study. Three AD studies used subjective scoring of RV sys-
tolic function, details of which were not available. Eighteen
studies reported one RV function index. Sixty reported mul-
tiple (> 1) indices, amongst which six reported five or more.
Definitions of RV dysfunction  RV dysfunction or similar
terms (see “Methods”) was clearly defined in 64 of the 81
studies (79.0%) (Fig. 5). Seventeen studies (21.0%) did not
define RV dysfunction and 16 of these measured more
50
45
40
Total number of publications
35
30
25
20
*
10
5
2015 Anesthetic ED ICU
Setting
than one indices for RV function. Among those which had
clear definitions, 31 studies (50%) defined RV dysfunc-
tion based on a single index, including EDA ratio, FAC,
RV strain (RVS), tissue Doppler tricuspid annular systolic
velocity (St), TAPSE, Tei index, as well as subjective score
of RV free wall motion (RVWM) (Fig. 5). TAPSE was the
most common index used singly in defining RV dysfunc-
tion, followed by FAC and EDA ratio.
The use of more than one index, or composite indices
(Cidx), to define RV dysfunction was also common among
studies (n = 33). The number of RV function indices meas-
ured and the number used in defining RV dysfunction
are shown in Table  3. The table shows that the number
measured might not necessarily be the same as the num-
ber used in defining RV dysfunction. Three types of Cidx
were reported: (1) compensatory Cidx (the “OR” rule),
i.e. the diagnosis of RV dysfunction was based on any one
of the surrogates that was reported as abnormal (n = 11);
(2) conjunctive Cidx (the “AND” rule), i.e. the diagno-
sis of RV dysfunction required all surrogates reported as
abnormal (n = 14); and (3) permuted Cidx which used any
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0 5 10 15 0 5 10 15 0 5 10 15
Total number of publications
Fig. 3  a Breakdown of study cohorts for all studies. b Breakdown of cohort for each setting. ARDS acute respiratory distress syndrome, PE pulmo-
nary embolism

combination of  at least two indices (n = 5). As a result of Discussion

the nature of pathophysiology, the use of Cidx was common
amongst studies involving ARDS or pulmonary embolism
(Table  2). The most common combination was the use of
EDA ratio and paradoxical septal motion (PSM) in defin-
ing cor pulmonale (n = 15). A significant number of stud-
ies (n = 16) did not define RV dysfunction clearly, although
objective indices were measured.
Evolution of echocardiographic indices for RV function
Supplementary Figure S3 shows the evolution of the usage
of common RV function indices in the last 20  years. The
indices shown in the figure were those measured in the
studies and were used in isolation or in combination with
other indices in defining RV function. The figure shows the
frequency of each index being reported in published stud-
ies per year. Several features are noticeable in the figure.
First, there was a trend of increasing use of objective indices,
such as EDA ratio, FAC, TAPSE, St and Tei index. Subjective
RV wall motion (RVWM) assessment was seldom used in
research. Second, there was also a rise in the use of FAC and
TAPSE in recent years. The use of TAPSE started in 2003
and there has been a dramatic increase in the last 2–3 years.
Our systematic review evaluated 81 eligible studies over
the last 20  years and noticed an increased in interest in
echocardiographic assessments of RV in research, espe-
cially since late 2000. These studies could be categorized
according to settings, study design as well as patient
types. Large differences were seen in the number of
echocardiographic indices used and how RV dysfunction
was defined. While some studies used a single index to
define RV dysfunction, many used Cidx or did not define
RV dysfunction based on the indices they measured. The
emerging trend was the use of TAPSE.
Study characteristics
Studies involving echocardiography in the critical care
setting were sparse prior to 2000 as echocardiography
was rarely available before 2000, and continued to be
very small in number in early 2000s (1–2 publications per
year) [85]. Among the three main areas of critical care,
intensive care was the earliest to report the use of echo-
cardiography in research [86, 87]. One of the earliest RV
studies using TTE was in 1987 [86], and the first TEE
assessment of RV was reported in 1992 [88]. The number
 30
25
Total number of publications
20
15
10
0 1
Number of different RV function indices reported
Fig. 4  Number of different RV function indices measured or reported per study
increased in the late 2000s, which might reflect the surge
in interest in RV function, coupled with the increasing
availability of ultrasound machines and training in the
critical care setting.
Our review also showed that the intensive care setting
has been the most active in the use of echocardiography
in RV assessment in research. This might be because ICU
patients requiring echocardiography are more diverse
than those in AD and ED settings. Apart from ARDS,
which is the most common type of study population, the
ICU cohorts also comprised shock, post-surgical, sepsis
or other patients reflecting a multipurpose and versatile
role of echocardiography in ICU, more so than in ED and
AD. Echocardiography is commonly used for diagnosis,
monitoring and management, and for prognosis in ICU.
These led to more diverse research topics which was
reflected in the types of studies found.
There was a high prevalence (or interest) of ARDS
studies in ICU. This is consistent with the cause of RV
dysfunction which is most often related to acute respira-
tory failure and high RV afterload due to positive-pres-
sure ventilation. On the other hand, PE studies were the
most common in ED, suggesting that echocardiography
was commonly used as a screening tool in selected high-
risk patients.
2 3 4 5 6
The ability to obtain echocardiographic images in criti-
cally ill patients was crucial for both clinical practice and
research. About one-third of the studies reported the
feasibility of performing echocardiography. Fortunately,
most studies were able to obtain optimal echocardio-
grams for most patients. As expected, those studies uti-
lizing TTE had the highest failure rates (some as high as
27%). The position of the patients, co-morbidities (e.g.
COPD), mechanical ventilation, wounds and/or experi-
ence of the operators might contribute to the high failure
rates in TTE. The failure to obtain optimal studies might
have encouraged the use of compensatory or permuted
Cidx (see below). Unfortunately, the proportions of miss-
ing data for various indices were not reported in most
studies. Intra- and interobserver agreements are impor-
tant to understand the reliability and reproducibility of
specific echocardiographic measurements. We found that
only about 15–20% of the studies reported intra- and/or
interobserver agreements. However, there seemed to be a
lack of a standard way of reporting observer agreements.
On the basis of the small sample size and variable eval-
uation criteria, it may be safe to conclude that many of
the studies were of low to moderate quality. Over the
years, there was a gradual increase in sample size, per-
haps due to better research training in recent years and/
 20

18

16
Total number of publications

14

12

10

ati
o C S
tive
) St SE Te
i x idx idx ve ed
Ar FA RV P Cid C dC cti fin
jec TA tor
y
tive bje de
ED (su
b
sa nc ute Su No
t
en nju rm
W M
mp Co Pe
RV Co
Definitions of RV dysfunction
Fig. 5  Number of studies using the index/indices shown in defining RV dysfunction. White column: RV dysfunction was defined on the basis of a
single index. Grey column: definition was based on more than one indices or on subjective index. Black column: definition not stated. EDA ratio RV
end-diastolic area to LV end-diastolic area ratio, FAC fractional area change, RVS RV strain, RVWM RV wall motion, St tissue Doppler tricuspid annular
systolic velocity, TAPSE tricuspid annular plane systolic excursion, Tei Tei index, Cidx composite indices

Table 3  Number of RV function indices measured and used in defining RV dysfunction

Definition of RV dysfunction Subjective index used Number of objective RV function indices measured Total
1 2 3 4 5 6

Single index 1 17 11 1 1 0 0 31
> 1 indices 2 0 11 12 3 4 1 33
Not defined 0 1 4 4 7 1 0 17
Total 3 18 26 17 11 5 1 81

or a higher demand in research quality imposed by the
funding body or the journal.
RV function indices
Echocardiographic RV function indices can be divided
into two types: ones that measure longitudinal function
and those that measure global function (Table  1). The
former type allows fast and easy methods of assessing RV
function but are inherently limited as they do not yield
regional wall motion information. On the other hand,
global function indices are more difficult to perform but
may yield important information such as loading condi-
tion (afterload), a combination of systolic and diastolic
function as well as overall RV dysfunction due to regional
wall motion abnormalities.
Longitudinal function indices
To date, the most frequently used RV function indices
in critical care research are those which measure the
longitudinal motion of the RV. These indices are often
dichotomised to differentiate between normal and abnor-
mal, and do not provide a graded classification of RV
dysfunction (mild vs moderate vs severe). We found that
the most popular index reported in critical care research
was TAPSE probably owing to its ease of measurement,
reproducibility and less reliance on image quality. Good
correlations between TAPSE, RV ejection fraction and
FAC have been reported [89, 90]. However, TAPSE meas-
ures the longitudinal motion of the whole RV segment in
the apical view and does not yield regional wall motion
information [89]. The use of TAPSE as a measure of RV
function is recommended in the American, European
and Canadian Societies of Echocardiography joint guide-
lines [91]. Yet, the guidelines also highlight the limita-
tions of TAPSE by stating that “TAPSE assumes that the
displacement of a single segment represents the func-
tion of a complex 3D structure. Furthermore, it is angle
dependent…” [91]. TAPSE has also been reported to
have a positive correlation with LV ejection fraction and
was reduced in patients with acute myocardial infarc-
tion, heart failure or with LV dyssynchrony [92–95]. In
patients with pulmonary hypertension, TAPSE overes-
timated FAC because of an abnormal rocking motion
of the lateral LV wall at the apex (translational artefact)
[96]. This limitation was subsequently underscored in the
updated guidelines: “As a one-dimensional measurement
relative to the transducer, TAPSE may over- or underesti-
mate RV function because of cardiac translation…” [97].
Of note, a new alternative index, subcostal echocardio-
graphic assessment of tricuspid annular kick (SEATAK),
has been proposed to measure TAPSE in the subcostal
view. SEATAK displayed good correlation with TAPSE
but the feasibility of SEATAK was superior to TAPSE in
ICU patients [98].
St, also a longitudinal (lateral free wall) function index
[37], was commonly used but less so than TAPSE. St was
found to be associated with prolonged mechanical ven-
tilation [50], and was related to severity of sepsis and
mortality [99]. Surprisingly, although St was commonly
measured, it was seldom used in isolation in defining RV
dysfunction. Intervendor differences in measurement
methods and disagreement in results might account for
the lack of attraction of St both in clinical and research
uses [100]. As the measurement is akin to TAPSE, all the
limitations found in TAPSE measurements apply equally
to St.
RV longitudinal strain (RVS) and strain rate (RVSR)
are modern surrogates of RV longitudinal function [101].
RVS is mostly used as a prognostic tool, although it has
also been used for diagnostic purposes [42, 66]. Strain
measurements are time-consuming and rely on optimal
image quality. One study raised the issue of feasibility of
RVS measurement in ICU patients: in a cohort of 211
patients, 93 had suboptimal to poor echocardiographic
windows for RVS acquisition [102]. Other challenges are
reproducibility and intervendor comparability. Hence,
although strain measurement is the state-of-the-art
method, they were the least used and reported indices.
Perhaps with industrial standardization of speckle track-
ing algorithm, and with more training available, there
may be more applications of RVS in research.
Global function indices
In terms of global function indices, commonly reported
were the Tei index, EDA ratio and FAC. Tei index (also
known as RV index of myocardial performance) is
defined as the ratio of the summation of isovolumic con-
traction and relaxation times to ejection time [103]. As
the index incorporates both systolic and diastolic func-
tion, it provides a “global” functional measurement of RV
function. The Tei index has not been used extensively in
critical care research partly because of the requirement
of adequate Doppler signals, the elaborate process of
measurements and the index’s sensitivity to conduction
delay. It is not suitable to use in situations where cardiac
rhythm is irregular and where preload (right atrial pres-
sure) is high such as in PE.
Four studies used EDA ratio in isolation in defining RV
dysfunction. EDA ratio is a good indicator of RV strain
as a result of increased afterload and/or preload. An EDA
ratio > 1 is associated with a 25% mortality in ARDS [11].
However, by itself EDA is not a sensitive surrogate for RV
dysfunction, except in cases where EDA ratio > 1 [104].
When used together with paradoxical septal motion
(PSM), EDA ratio is both specific and sensitive for detect-
ing cor pulmonale [11, 54, 105]. PSM is a specific sign of
increased afterload, due to enhanced RV contractility and
prolonged duration of systole. When LV starts to relax at
end-systole or onset of diastole, the RV is still in the con-
traction phase and causes the interventricular septum to
bow towards the LV as a result of reversal of trans-septal
LV-to-RV pressure [11].
FAC, one of the reference standards often used for
comparing RV function, has been shown to correlate well
with RV ejection fraction. It has been shown in many
studies that it has a strong association with patient out-
comes. For example, reduced FAC was independently
associated with increased risk of all-cause mortality, car-
diovascular death, sudden death, heart failure and stroke
after myocardial infarction [106, 107]. Physiologically,
although FAC is sensitive to loading conditions, it also
incorporates the effects of LV function and interventricu-
lar septal motion, rendering it one of the more reliable
indices for RV function. However, RV outflow tract is not
included in the assessment and good image quality (to
define the endocardial border) required for measurement
is often not obtainable in the critically ill population.
Number of indices used in defining RV function
Only a relatively small number of studies (26.8%)
employed a single index, mostly dichotomised, to define
RV dysfunction, and many used composite (> 1) indi-
ces. Single index, especially when dichotomised, has the
benefit of simplicity where statistical analyses are made
simpler, and interpretation and presentations are made
easier. However, each index has pros and cons, and a sin-
gle index does not always portray the full picture [91].
The reasons are twofold: First, a single index used may
not fit into the context of the problem. Some are better
suited to measure certain aspects of RV function (e.g.
contractility), whilst some are better for other purposes
(e.g. assessing preload and afterload). Other confounding
factors may also be present and interfere with the inter-
pretations. Second, dichotomisation comes at some cost.
For example, dichotomisation leads to a loss of informa-
tion and inflates the false positive rate; the variability
of the data and the non-linear relationship between the
index and RV function are ignored [13].
Cidx should theoretically give a better utility tool
than by using a single index. A substantial proportion
of studies (69%) utilized Cidx in assessing RV function,
yet only a few explained the rationale behind using these
[54, 108]. The choice of combination poses many chal-
lenges. Ideally, it should be based on a sound physiologi-
cal framework. For studies that used compensatory Cidx
(the “any one” or “OR” rule), each index is assumed to
have the same weight. The advantage of compensatory
Cidx is that missing data (often seen in critical care echo-
cardiography measurements) will be compensated by the
presence of the others. Compensatory Cidx is also more
sensitive in detecting abnormality as it only requires one
out of several indices to show a positive result. Yet, this
increases the risk of type I errors resulting in a higher
(false) prevalence rate [18, 109]. The situation is similar
to multiple comparisons of outcomes in clinical trials.
On the other hand, conjunctive Cidx (the “must satisfy
all” or “AND” rule) gives a higher specificity but at the
expense of reducing sensitivity. For example, if TAPSE
and FAC are both required to be positive in defining RV
dysfunction, then in  situations where FAC is reduced
but TAPSE is within normal range because of a normal
to hyperdynamic LV (see, for example, [12]), conjunc-
tive Cidx would have misclassified (missed) the outcome
because of the requirement that BOTH indices need to
be positive. This increases the chance of type II error
rate especially in the less severe case. Another challenge
faced by the researchers (or clinicians) in using Cidx
is when some indices are on a binary scale while others
are on continuous scales. In these cases, the former case
yields a dichotomous result whilst the latter presents
the gradation of outcomes. The two are not necessar-
ily compatible. As a result of imperfect correlations and
agreements between the various indices, it is not uncom-
mon to find between-study discrepancies in conclusion.
We also found that nearly all of the studies that utilised
Cidx failed to report missing data. The failure to measure
one or more indices as a result of various reasons, such as
technical difficulties, could alter the outcomes.
Limitations
One of the commonest limitations of any systematic
review is the failure to find all the eligible studies. To min-
imize this problem, we used a “high sensitivity” approach
in our literature search, i.e. we defined our search terms
as broad as possible and searched three databases.
Despite this, we still could not guarantee that we were
able to find all eligible studies, especially for those studies
that did not report any echocardiographic RV assessment
in their abstracts. We did not critically appraise the qual-
ity of the eligible studies and hence would have included
studies of various quality in our systematic review. The
advantage of not excluding studies of lower quality was
that we were able to include more studies and to audit
different echocardiographic RV function indices used in
critical care research, which was a reflection of clinical
practice. Further, the evolution of each indices could also
be studied.
Conclusion
Right ventricular assessment is an important part of criti-
cal care cardiopulmonary and haemodynamic studies.
There are many echocardiographic RV function indices
and each has its strengths and limitations. Our system-
atic review found a plethora of study types and study
designs in critical care research. The choice of index or
indices for RV assessments and for defining RV dysfunc-
tion also varied from study to study. While some used
a single index, many used Cidx. The choice of Cidx is
complicated and should be based on clinical context
while keeping in mind potential technical difficulties in
the critical care setting. As in cor pulmonale, the choice
should also be based on a sound pathophysiological
framework.
Electronic supplementary material
The online version of this article (https​://doi.org/10.1007/s0013​4-018-5211-z)
contains supplementary material, which is available to authorized users.
Author details
1
 Department of Intensive Care Medicine, Nepean Hospital, Sydney Medical
School, The University of Sydney, Sydney, NSW, Australia. 2 Cardiovascular
Ultrasound Laboratory, Intensive Care Unit, Nepean Hospital, Sydney, NSW,
Australia.
Compliance with Ethical Standards
Conflicts of interest
The authors declare that they have no conflict of interest.
Ethics Approval
Ethics approval for systematic review is not required.
Received: 26 February 2018 Accepted: 5 May 2018
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