How to assess the right ventricle using handheld ECHO

26th Nov 2020

Assessing right ventricle systolic function in patients with COVID-19

Disseminated microthrombosis has been found in patients infected with SARS-CoV-2. When these microclots occur in the pulmonary vasculature, they can result in pulmonary emboli. 

Acute pressure overload due to pulmonary emboli is poorly tolerated by the right ventricle, thus causing dilatation and strain. 

Focused right ventricular (RV) assessment of a patient with COVID-19 will typically demonstrate right ventricular dilatation and signs of right ventricular strain. This results from an increased RV afterload and increased pulmonary vascular resistance.

Echocardiograms showing right ventricle (RV) dilatation and strain in patients with COVID-19. Apical four-chamber and RV-focused views.

Figure 1. In patients with COVID-19, focused right ventricular assessments have shown signs of right ventricle (RV) dilatation and strain—the result of increased afterload and pulmonary vascular resistance due to pulmonary emboli caused by disseminated microthrombosis. 

Check out this short video clip from our COVID Mini: Handheld ECHO Course that highlights right ventricular dilatation and strain that can be seen in patients with COVID-19 and disseminated microthrombosis:


Right ventricular systolic function paired with the characteristic interventricular septal motion and inferior vena cava (IVC) dilatation are features to assess in a patient with COVID-19. Medmastery note.


Assessing interventricular septal motion in patients with COVID-19

Increased right ventricular pressure overload can be qualitatively assessed by examining the motion of the interventricular septum, which may exhibit paradoxical septal motion. 

Since the interventricular septum is a shared structure, the left ventricle may show signs of underfilling as the heart contracts in the confined space. Thus, underfilling of the left ventricle may result in the left atrium and left ventricle chambers appearing smaller. 

Echocardiograms highlighting the interventricular septum. Apical four-chamber and short-axis views.

Figure 2. In patients with COVID-19, increased right ventricular pressure overload can be identified by assessing the interventricular septum for paradoxical septal motion. As a result of the right heart overload, the left heart chambers may also appear smaller. PSAX, parasternal short-axis view.

Check out this short video clip from our COVID Mini: Handheld ECHO Course that highlights the paradoxical septal motion of the interventricular septum (and resulting decrease in size of left heart chambers) that can be seen in patients with COVID-19 and increased right ventricular pressure overload:


Clickable call to action, "Start learning for free", with direct link to sign up for a free Medmastery trial account.


Assessing right ventricular afterload in patients with COVID-19

Conversely, increased right ventricular afterload will cause right atrial pressure to increase. This leads to tricuspid regurgitation and a dilated, non-collapsing inferior vena cava (IVC).

Echocardiograms showing right ventricular afterload causing tricuspid regurgitation and dilated, non-collapsing inferior vena cava (IVC) in patients with COVID-19.

Figure 3. In patients with COVID-19, increased right ventricular afterload causes right atrial pressure to increase which leads to tricuspid regurgitation and a dilated, non-collapsing inferior vena cava (IVC). 

Check out this short video clip from our COVID Mini: Handheld ECHO Course that highlights the tricuspid regurgitation and non-collapsing, or dilated, IVC that can be seen in patients with COVID-19 and increased right ventricular afterload:


That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

  • Chamsi-Pasha, MA, Sengupta, PP, and Zoghbi, WA. 2017. Handheld echocardiography: Current state and future perspectives. Circulation136: 2178–2188. PMID: 29180495
  • Clerkin, KJ, Fried, JA, Raikhelkar, J, et al. 2020. COVID-19 and cardiovascular disease. Circulation141: 1648–1655. PMID: 32200663
  • Doyen, D, Moceri, P, Ducreux, D, et al. 2020. Myocarditis in a patient with COVID-19: A cause of raised troponin and ECG changes. Lancet395: 1516. PMID: 32334650
  • Drake, DH, De Bonis, M, Covella, M, et al. 2020. Echocardiography in pandemic: Front-line perspective, expanding role of ultrasound and ethics of resource allocation. J Am Soc Echocardiogr33: 683–689. PMID: 32503707
  • Fukuhara, S, Rosati, CM, and El-Dalati, S. 2020. Acute type A aortic dissection during the COVID-19 outbreak. Ann Thorac Surg. 110: e405–e407. PMID: 32333849
  • Haji, K, Wong, C, Neil, C, et al. 2019. Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE). Echo Res Pract6: 91–96. PMID: 31516721
  • Hua, A, O’Gallagher, K, Sado, D, et al. 2020. Life-threatening cardiac tamponade complicating myo-pericarditis in COVID-19. Eur Heart J41: 2130. PMID: 32227076
  • Johri, AM, Galen, B, Kirkpatrick, JN, et al. 2020. ASE statement on point-of-care ultrasound during the 2019 novel coronavirus pandemic. J Am Soc Echocardiogr33: 670–673. PMID: 32503704
  • Meyer, P, Degrauwe, S, Van Delden, C, et al. 2020. Typical takotsubo syndrome triggered by SARS-CoV-2 infection. Eur Heart J41: 1860. PMID: 32285915
  • Neskovic, AN, Hagendorff, A, Lancellotti, P, et al. 2013. Emergency echocardiography: The European association of cardiovascular imaging recommendations. Eur Heart J Cardiovasc Imaging14: 1–11. PMID: 23239795
  • Nguyen, VTQ, Ho, JE, Ho, CY, et al. 2008. Handheld echocardiography offers rapid assessment of clinical volume status. Am Heart J156: 537–542. PMID: 18760138
  • Poissy, J, Goutay, J, Caplan, M, et al. 2020. Pulmonary embolism in patients with COVID-19: Awareness of an increased prevalence. Circulation142: 184–186. PMID: 32330083
  • Shi, S, Qin, M, Shen, B, et al. 2020. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol5: 802–810. PMID: 32211816
  • The American Society of Echocardiography. ASE statement on protection of patients and echocardiography service providers during the 2019 novel coronavirus outbreak. 2020.  
  • The American Society of Echocardiography. Cleaning recommendations from ultrasound manufacturers. 2020.
  • The Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England. COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0. 2020. 
  • Zeng, JH, Liu, YX, Yuan, J, et al. 2020. First case of COVID-19 complicated with fulminant myocarditis: A case report and insights. Infection48: 773–777. PMID: 32277408