In cases with mild RVH, there may be no symptoms whereas the clinical picture in patients with severe hypertrophy is that of heart failure. For example, they experience dyspnea, chest pain, dizziness, peripheral edema, and possibly loss of consciousness. These individuals may also exhibit tachycardia and palpitations.

Physical exam
The clinician should perform a complete exam that consists of cardiac auscultation, palpation of the pulses, and other relevant aspects. Moreover, cardiac auscultation will reveal rate, rhythm, and any existing murmurs that can collectively provide details about the underlying etiology of the RVH.

• Swelling

  If you have any symptoms of a heart problem, including chest pain, shortness of breath, or swelling in your legs, contact your doctor as soon as possible. [healthline.com]

  Diagnosis and Treatment Swelling of the right ventricle can be seen in an electrocardiogram or echocardiogram, Dr. Bott-Silverman says. But magnetic resonance imaging (MRI) is the most reliable, she adds. [heart-advisor.com]

  RVH is identified and diagnosed when patients develop symptoms of cardiac failure which include shortness of breath, chest pain, swelling of the lower extremities, and episodes of loss of consciousness. [symptoma.com]

  A middle-aged, obese, non English speaking man presented as a walk-in with SOB and leg swelling. His O2 saturations were 59% on room air. Systolic BP was in the 170's. [hqmeded-ecg.blogspot.com]

  Another manifestation of right ventricular hypertrophy is edema or swelling of the ankles, feet and legs. Diagnosis includes the use of an electrocardiogram (ECG) in order to monitor the activities of the heart. [wisegeek.com]

• Pulmonary Valve Stenosis

  RVH is typically seen in the setting of pulmonary valve stenosis or Tetralogy of Fallot. A rare cause of isolated RVH is premature closure of the patent ductus arteriosus (PDA) in utero that results in pulmonary hypertension. [ncbi.nlm.nih.gov]

  Pulmonary valve stenosis is the narrowing of the membrane or valve that connects the right ventricle with the pulmonary artery, the blood vessel going to the lungs. [wisegeek.com]

  The third cause is pulmonary valve stenosis. Pulmonary valve stenosis causes abnormality in the flow of the blood from the right ventricle going into the pulmonic valve. The end result is a reduced amount of blood going to the lungs. [chdbabies.com]

  Causes of right ventricular hypertrophy Lung disease, congenital heart disease (transposition of the great arteries, pulmonary valve stenosis, atrial septal defect, ventricular septal defect), tricuspid valve regurgitation are the most common causes. [ecgwaves.com]

• Congestive Heart Failure

  Congestive Heart Failure Related Articles Facts and Definition of Congestive Heart Failure Heart failure sounds frightening because it sounds like the heart just stops working. Do not be discouraged by the term heart failure. [emedicinehealth.com]

  If left untreated, right ventricular hypertrophy can increase your risk of congestive heart failure. If you do have right ventricular hypertrophy, make sure to closely follow the treatment plan recommended by your doctor. [healthline.com]

  Furthermore, LVH increases patient risk of other cardiovascular diseases including myocardial infarction, congestive heart failure, stroke, arrhythmia and sudden death. [meds.queensu.ca]

  Congestive Heart Failure This is a common feature of all late stage cardiomyopathies when the muscles of the heart become too weak to pump enough blood to the body for normal function. [childrenscardiomyopathy.org]

• Asymptomatic

  Children with a small ventricular septal defect are typically asymptomatic and grow and develop normally. [merckmanuals.com]

  Methods 214 asymptomatic, elite athletes underwent ECG and transthoracic echocardiography. [heart.bmj.com]

  Mild RVH is usually asymptomatic, but severe cases will produce features of heart failure such as dyspnea, angina, and peripheral edema. [symptoma.com]

  Screening asymptomatic adults for coronary heart disease with resting or exercise electrocardiography: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation. [onlinejacc.org]

• Coarctation of the Aorta

  […] of the aorta, congenital heart disease, cor pulmonale, Eisenmenger's syndrome, hypoplastic left heart syndrome, left ventricular hypertrophy or dilation, mitral stenosis, obstructive sleep apnea, primary pulmonary hypertension, pulmonary embolism, pulmonary [wikidoc.org]

  Other types of congenital heart defects Coarctation of the aorta : This defect happens when the aorta narrows and prevents blood from flowing freely to the lower part of the body. [my.clevelandclinic.org]

• Loss of Appetite

  Deep chest pains Shortness of breath Mild, moderate, or severe pressure on the chest Heart beats very rapidly or forcefully Heart palpitations Heart skips beats or add beats Dizziness Loss of appetite Lightheadedz Loss of consciousness Swelling in legs [belmarrahealth.com]

• Hypertension

  For example, pulmonary hypertension is managed with phosphodiesterase 5 (PDE5A) inhibitors to open the pulmonary arteries while essential hypertension is treated with standard antihypertensives. [symptoma.com]

  A total of 330 untreated and treated uncomplicated essential hypertensives consecutively attending a hospital out-patient hypertension clinic were considered for the analysis. [doi.org]

  The disorders that induce pulmonary hypertension and secondary right ventricular hypertrophy include the following (Table 1): Pulmonary arterial hypertension (PAH) Pulmonary hypertension owing to left heart disease Pulmonary hypertension from lung disease [ncbi.nlm.nih.gov]

• Heart Disease

  RVH is much rarer than left ventricular hypertrophy (LVH) and is encountered, in its extensive form, in several congenital heart diseases. [link.springer.com]

  BACKGROUND: The outcome of the surgical repair in congenital heart disease correlates with the degree of myocardial damage. [ncbi.nlm.nih.gov]

  Three were reported from that hospital in 1942. 2 Ordinarily when a patient with heart disease of obscure origin is encountered an attempt is made to fit him into one of the well recognized etiologic categories of heart disease, but there is a large group [annals.org]

• Palpitations

  Hi Dan, While your heart function may be OK, (right ventricular hypertrophy) RVH and any recent change in your heart rhythm such as increased palpitations are not and your doctors should look further for an explanation. [cardiachealth.org]

  Symptoms that may be consequent to arrhythmia (such as palpitation, dizziness, and syncope) were not reported by the study population. Twelve-lead electrography was performed to measure the heart rate, QTc intervals, and QTc dispersion values. [ncbi.nlm.nih.gov]

  There are many different causes within these categories including: Heart palpitations, shortness of breath, and chest pain may be symptoms of RVH. [medicalnewstoday.com]

  Symptoms:          Shortness of breath Chest pain palpitations Dizziness Fainting Rapid exhaustion with physical activity Fatigue Syncope Some time patient shows no symptoms 8. [slideshare.net]

  These individuals may also exhibit tachycardia and palpitations. Physical examThe clinician should perform a complete exam that consists of cardiac auscultation, palpation of the pulses, and other relevant aspects. [symptoma.com]

• Tachycardia

  Value of the 12-lead electrocardiogram in discriminating atrioventricular nodal reciprocating tachycardia from circus movement atrioventricular tachycardia utilizing a retrograde accessory pathway. Am J Cardiol 1987:59:296. ‎ [books.google.de]

  Abstract Uncontrolled/untreated maternal hyperthyroidism has been associated with fetal tachycardia. We report a case of right-ventricular (RV) hypertrophy with pericardial effusion related to untreated maternal Graves' disease. [ncbi.nlm.nih.gov]

  A middle aged female came to our CCU with acute dyspnea with tachycardia. Echo revealed a dilated RA and RV. She had mild TR and moderate to severe PAH (The TR jet measured 3.8m/sec) The MPA showed a hazy shadow suspicious of thrombus. [drsvenkatesan.com]

• Family History of Heart Disease

  Getting a full medical history from the patient can also be very helpful since some heart problems can be inherited. If there is a family history of heart disease, it can put a person at a higher risk of developing RVH. [belmarrahealth.com]

  Diagnosis A careful history is essential, with particular emphasis on family history. A family tree should be constructed to ascertain whether a pedigree exists that is consistent with familial cardiomyopathy. [clevelandclinicmeded.com]

• Seizure

  The EKG has nothing to do with the seizures. [medhelp.org]

All patients with any heart condition or presentation suggestive of cardiac disease should be evaluated thoroughly. The clinician should assess the clinical picture, personal and family history, and existing risk factors. Additionally, the workup includes a physical examination and laboratory tests.

Electrocardiography

The diagnosis of RVH requires an evaluation of the ECG, which provides key findings. The most common observation is a right axis deviation greater than 100 degrees. As with LVH, the deviation occurs because of the electrical activity that is produced by the depolarization of the myocardial cells. This axis shift should be present before considering RVH.

Further ECG evidence of this disease may include:

• QRS abnormalities due to the increased voltage in leads V1, V5, and V6
• P wave abnormalities (as reflected by P pulmonale and peaked T-waves inferiorly)
• ST depression and T wave inversion in leads V2 through V6. These changes commonly occur in advanced RVH diseases such as pulmonary hypertension and pulmonary stenosis

Note the greater the number of features, the higher the sensitivity for RVH. Other specific findings include:

• Right axis deviation >100 degrees
• The R wave in V1 > 7mm
• Presence of an rSR' pattern in V1; R' > 10mm
• The sum of R in V1 and S in V5 or V6 > 10.5mm
• Presence of qR complex in V1
• ST- T wave abnormalities secondary to hypertrophy

Newer studies such as tissue Doppler imaging (TDI) and speckle tracking may be helpful. TDI can assess the peak systolic strain of the RV free wall, which is decreased in those with pulmonary hypertension [11].

Other

More tests may be warranted during the evaluation of underlying causes or coexisting diseases. For example, chronic hypertension is often a component of the disease, which should be considered in these patients. Moreover, individuals with lung disease may require pulmonary function tests while those with congenital diseases will need a detailed assessment.

• Right Axis Deviation

  Example 4 Right ventricular hypertrophy in a patient with arrhythmogenic right ventricular cardiomyopathy (ARVC): Right axis deviation. [lifeinthefastlane.com]

  The ECG shows tall P waves in lead II indicating right atrial abnormality. Right axis deviation is also seen. Chest leads are recorded at a calibration of 5 mm/mV. [metealpaslan.com]

  The most common observation is a right axis deviation greater than 100 degrees. As with LVH, the deviation occurs because of the electrical activity that is produced by the depolarization of the myocardial cells. [symptoma.com]

• Left Axis Deviation

  Left axis deviation 2 points QRS duration 0.09 sec 1 point Delayed intrinsicoid deflection in V5 or V6 (>0.05 sec) 1 point CORNELL Voltage Criteria for LVH (sensitivity = 22%, specificity = 95%) S in V3 + R in aVL > 24 mm (men) S in V3 + R in aVL > 20 [ecg.utah.edu]

  If you see one of these, you may have left ventricular hypertrophy. You may also see left axis deviation, but it is not needed for diagnosis. However, right axis deviation is needed for diagnosing right ventricular hypertrophy. [unm.edu]

• Right Bundle Branch Block

  In contrast, when an incomplete right bundle branch block exists, the rSR' pattern is a relatively sensitive but nonspecific predictor of RVH. [ncbi.nlm.nih.gov]

  Hence, the QRS duration is slightly prolonged (but it does not reach 120 milliseconds, unless there is concomitant bundle branch block). rSR’ pattern is occasionally seen in V1–V2. This resembles, but is not, right bundle branch block (RBBB). [ecgwaves.com]

  Other causes of an R/S ratio of greater than 1 in lead V1: Posterior wall myocardial infarction (also causes ST segment depression in V1-V3, but T waves are symmetrically inverted, and the patient would be presenting with chest pains) Right bundle branch [healio.com]

• Incomplete Right Bundle Branch Block

  In contrast, when an incomplete right bundle branch block exists, the rSR' pattern is a relatively sensitive but nonspecific predictor of RVH. [ncbi.nlm.nih.gov]

  (septal fascicular block) Duchennes Muscular Dystrophy Normal variant V4r may be a more useful and reliable than lead V1 in that it often reveals an r>s while v1 remains normal An incomplete right bundle branch block in the right precordial chest leads [wikidoc.org]

• P Pulmonale

  P pulmonale is very common. Figure 2. Two ECGs showing left and right ventricular hypertrophy. [ecgwaves.com]

  Example 2 Right axis deviation (+150 degrees) P pulmonale (P wave in lead II > 2.5 mm) Incomplete RBBB Right ventricular strain pattern with T-wave inversion and ST depression in the right precordial (V1-3) and inferior (II, III, aVF) leads. [lifeinthefastlane.com]

  Right atrial overload and right ventricular hypertrophy Right atrial overload and right ventricular hypertrophy Right atrial overload (P pulmonale) and right ventricular hypertrophy. [cardiophile.org]

  pulmonale or Right atrial enlargement or P congenitale S1 S2 S3 pattern in children Tall R wave in V1 or qR in V1 R wave greater than S wave in V1 R wave progression reversal Inverted T wave in the anterior precordial leads Differential Diagnosis of R [wikidoc.org]

• Ventricular Hypertrophy

  Keywords Left Ventricular Hypertrophy Ventricular Hypertrophy Right Ventricle Left Ventricular Mass Mitral Stenosis These keywords were added by machine and not by the authors. [link.springer.com]

  Right ventricular hypertrophy (RVH) was estimated by the maximal right ventricular wall thickness (max RVWT), and the ratio of the maximal and minimal thickness (max RVWT/min RVWT) was calculated to evaluate asymmetrical hypertrophy (AH) of the right [ncbi.nlm.nih.gov]

  ECG changes seen in left ventricular hypertrophy (LVH) and right ventricular hypertrophy (RVH). [ecgwaves.com]

  Your doctor might use a combination of these tests to confirm whether or not you have right ventricular hypertrophy. The treatment of right ventricular hypertrophy depends on the underlying cause. [healthline.com]

• Right Ventricular Hypertrophy on ECG

  […] block Wolff-Parkinson-White Type A Lead misplacement (if V1 is placed too high) Isolated posterior wall hypertrophy (occurs in Duchenne ’ s muscular dystrophy) ECG Examples: Right Ventricular Hypertrophy (RVH) ECG Right Ventricular Hypertrophy (RVH) [healio.com]

  Topics for study: Introduction Left Ventricular Hypertrophy (LVH) Right Ventricular Hypertrophy (RVH) Biventricular Hypertrophy Introductory Information: The ECG criteria for diagnosing right or left ventricular hypertrophy are very insensitive (i.e., [ecg.utah.edu]

• Electrocardiogram Change

  There was no relationship between electrocardiogram changes and Doppler tricuspid regurgitation gradient. [ncbi.nlm.nih.gov]

  There was no relationship between electrocardiogram changes and Doppler tricuspid regurgitation gradient. CONCLUSION. [pediatrics.aappublications.org]

  AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy. [link.springer.com]

• Abnormal ECG

  Furthermore, the echocardiographic technique was useful in evaluating RVH in 18 patients with an abnormal ECG due to right or left bundle branch block or myocardial infarction. We conclude that echocardiography is reliable in diagnosing RVH. [ncbi.nlm.nih.gov]

The therapeutic approach targets the underlying diseases that are contributing to RVH. Patients with pulmonary hypertension may benefit from the use of vasodilators including epoprostenol. Furthermore, PDE5A inhibitors used for erectile dysfunction can be effective in dilating the pulmonary vasculature. Sildenafil and tadalafil are examples of this drug class.

In cases with systemic hypertension, the treatment regimen consists of antihypertensives such as ACE inhibitors, beta blockers, and others as well. Additionally, smoking cessation, lifestyle modifications, and weight loss are very advantageous in cardiac patients.

If the culprit of the hypertrophy is an underlying pulmonary valve abnormality or complex congenital anomalies, surgical intervention may be warranted.

Patients with obstructive sleep apnea (OSA) are encouraged to lose weight in addition to the standard treatment of this disorder.

The prognosis of RVH is dependent on its etiology and resultant pathology. As a predominant cause of RVH, pulmonary hypertension is linked to morbidity and mortality. Likewise, RVH sequela such as heart failure leads to poor outcomes.

Additionally, patients with biventricular hypertrophy are at high risk of developing serious events. Hence, cardiovascular diseases should be carefully managed and monitored as a means of improving the survival rates and quality of life in these patients.

RVH develops from numerous etiologies. This structural change may occur secondary to diseases such as pulmonary valve stenosis and pulmonic regurgitation. Additionally, lung pathologies including pulmonary hypertension and chronic obstructive pulmonary disease (COPD) and congenital diseases such as ventricular septal defect (VSD) and tetralogy of Fallot result in hypertrophy of the right ventricle. Further causes are obstructive sleep apnea (OSA), cardiac fibrosis, and exposure to high altitude.

Although systemic hypertension is a well-known cause of left ventricular hypertrophy (LVH), it may contribute to RVH as well. One study, in particular, examined the effects of systemic hypertension on the right ventricle. The findings demonstrated that this chamber undergoes similar changes as the left ventricle regarding wall dimensions and other measurements as well [1].

RVH, which frequently occurs in patients with systemic hypertension, is accompanied by LVH in almost 20% of patients observed in a specialist clinic. Furthermore, the presence of biventricular hypertrophy indicates an elevated cardiovascular risk.

Chronic pressure overload

In patients with longstanding pressure overload, the response of the heart consists of gradual structural changes. As described by Laplace's Law, the elevated pressure results in increased stress in the walls. Consequently, the right ventricle undergoes hypertrophy as a compensatory mechanism. The pathological changes responsible for the enlargement are the proliferation of sarcomeres and the resultant growth of the myocytes [2]. Further alterations include the expansion of the extracellular matrix and fibrosis.

Eventually, the heart struggles to manage the pressure overload and undergoes dilation. The ensuing systolic and diastolic dysfunction result in RV failure.

Cellular changes in RVH

While the events leading to right ventricular failure are not clear, the cellular mechanisms have been elucidated. Specifically, there is enhanced myocyte apoptosis, which may account for the progressive decline in RV function [2]. Moreover, the α-subtype myosin heavy chain is observed to be reduced in comparison to the b-subtype myosin heavy chain in systolic dysfunction [3] [4].

Other cellular changes include certain modifications to the β-adrenoreceptor and the angiotensin type 1 receptor. The latter may be implicated in the overactivation of the renin-angiotensin system that occurs in right ventricular dysfunction.

Also, hypertrophy and dysfunction of the right ventricle may develop as a response to the ischemia observed in pulmonary artery hypertension (PAH) [5].

Further findings associated with RVH is the upregulation of mitochondrial nitric oxide synthase (mtNOS), which is reversed with the PDE5A inhibitor, sildenafil [6]. These observations have been previously reported in PAH studies that showed the hypertrophied tissue exhibited an increase in 1) PDE5 expression [7], 2) membrane potential in the mitochondria [8], and 3) glucose uptake [9].

All of these observations may provide insight regarding the treatment of these patients [10].

RVH is identified and diagnosed when patients develop symptoms of cardiac failure which include shortness of breath, chest pain, swelling of the lower extremities, and episodes of loss of consciousness. Once a patient experiences these, he or she should seek medical attention.

A healthy lifestyle can prevent or slow down the progression of systemic hypertension, which may contribute to the development of biventricular hypertrophy and cardiac failure. Cessation of smoking, modifying the diet, increasing physical activity, and weight control are beneficial strategies for the overall health of the patient, especially the cardiovascular aspect.

Also, good respiratory health is paramount in the protection of the right ventricular function. Smoking cessation and abstinence from alcohol should be a priority for all individuals.

OSA is likely a risk factor for RVH, especially in obese individuals. Patients that are snoring and experiencing nocturnal dyspnea should undergo evaluation for this condition.

Right ventricular hypertrophy (RVH) occurs as a response to the increased stress on the walls of the right ventricle. Among the numerous etiologies of RVH are pulmonary hypertension and diseases associated with right ventricular outflow obstruction. Furthermore, the enlargement of this ventricle is based on the hemodynamic and structural changes that occur as a consequence of the stressed right ventricle. Over time, the progression of the underlying diseases and the resultant weakened heart can lead to a decline in the cardiac function.

Mild RVH is usually asymptomatic, but severe cases will produce features of heart failure such as dyspnea, angina, and peripheral edema.

The diagnosis is achieved through a detailed personal and family history, a physical exam with a focus on the cardiovascular system, and tests such as the electrocardiogram (ECG). The latter study may reveal crucial findings such as right axis deviation and other abnormalities. Additionally, an echocardiogram will demonstrate the size of the chambers and overall performance of the heart.

The treatment is directed at the underlying conditions of hypertrophied ventricle. For example, pulmonary hypertension is managed with phosphodiesterase 5 (PDE5A) inhibitors to open the pulmonary arteries while essential hypertension is treated with standard antihypertensives. Furthermore, congenital heart anomalies may require surgical intervention.

Maintaining good general health and modification of lifestyle may prevent or slow the progression of diseases that cause RVH and heart failure.

What is right ventricular hypertrophy (RVH)?

The heart is comprised of 4 main chambers. The upper ones are called the atria, and the lower ones are referred to as the ventricles. When the wall of right sided ventricle increases in size, this is known as right ventricular hypertrophy.

A normal function of the right ventricle is necessary since it pumps blood to the lungs. Once oxygenated, the blood is then sent to the left side of the heart so that it can be pumped to the brain and the rest of the body.

Any condition that hinders or slows the pumping of the right ventricle will cause blood to back up in this chamber. Therefore, the right ventricle becomes stressed and has to grow in size to accommodate the accumulated blood.

These conditions include:

• Pulmonary stenosis: The narrowing of the valve causes less blood flow from the right ventricle to the lungs
• Ventral septal defect (VSD): This abnormality is present at birth. Depending on the severity, patients may not have symptoms until later.
• Pulmonary hypertension
• Tetralogy of Fallot: This is a complex heart abnormality that is present at birth. Infants can develop "blue baby syndrome" since there is less oxygen in the blood circulating throughout the body.

Symptoms

Patients with mild enlargement of the right ventricle may not produce symptoms. However, severe cases result in symptoms of heart failure such as shortness of breath, chest pain, dizziness, and fainting episodes. Also, they develop swelling in the legs, ankles, and feet. These patients may feel palpitations.

Diagnosis

The clinician will evaluate the patient's symptoms, personal and medical history and perform a full physical exam. The clinician may identify abnormal heart sounds and rhythms through various tests.

The main tests are the ECG and the echocardiogram. The ECG will reveal characteristic findings that are associated with an enlarged heart. Also, the echocardiogram will determine the heart size and provide details about the function of the heart.

Treatment

The doctor will determine the cause prior to treatment. Patients with high blood pressure will be treated with the standard antihypertensive therapies. Those with pulmonary hypertension can be treated with medications like sildenafil.

Also, all patients are urged to quit smoking, eat healthy, exercise regularly, maintain a healthy weight, and follow-up regularly with their doctor.

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2. Bogaard HJ, Abe K, Vonk Noordegraaf A, Voelkel NF. The right ventricle under pressure: cellular and molecular mechanisms of right-heart failure in pulmonary hypertension. Chest. 2009; 135(3):794-804.
3. Lowes BD, Minobe W, Abraham WT, et al. Changes in gene expression in the intact human heart. Downregulation of alpha-myosin heavy chain in hypertrophied, failing ventricular myocardium. J Clin Invest. 1997;100(9):2315-24.
4. Herron TJ, McDonald KS. Small amounts of alpha-myosin heavy chain isoform expression significantly increase power output of rat cardiac myocyte fragments. Circ Res. 2002; ;90(11):1150-2.
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6. Zaobornyj T, Valdez LB, Iglesias DE, Gasco M, Gonzales GF, Boveris A. Mitochondrial nitric oxide metabolism during rat heart adaptation to high altitude: effect of sildenafil, L-NAME, and L-arginine treatments.Am J Physiol Heart Circ Physiol. 2009; 296(6):H1741-7.
7. Nagendran J, Archer SL, Soliman D. Phosphodiesterase type 5 is highly expressed in the hypertrophied human right ventricle, and acute inhibition of phosphodiesterase type 5 improves contractility. Circulation. 2007;116(3):238-48.
8. Nagendran J, Gurtu V, Fu DZ, et al. A dynamic and chamber-specific mitochondrial remodeling in right ventricular hypertrophy can be therapeutically targeted. J Thorac Cardiovasc Surg. 2008;136(1):168-78, 178.e1-3.
9. Oikawa M1, Kagaya Y, Otani H, et al. Increased [18F]fluorodeoxyglucose accumulation in right ventricular free wall in patients with pulmonary hypertension and the effect of epoprostenol. J Am Coll Cardiol. 2005; 45(11):1849-55.
10. Nagendran J, Michelakis ED. Mitochondrial NOS is upregulated in the hypoxic heart: implications for the function of the hypertrophied right ventricle. Am J Physiol Heart Circ Physiol. 2009;296(6): H1723-6.
11. Rajagopalan N1, Simon MA, Mathier MA, López-Candales A. Identifying right ventricular dysfunction with tissue Doppler imaging in pulmonary hypertension.Int J Cardiol. 2008;128(3):359-63.