Assessing RV Adaptation Requires Multiparametric Approach

Key Takeaways:

• RV adaptation to pressure overload is described as a continuum in which single metrics are insufficient across changing loading conditions.
• Load-informed and coupling-oriented indices (e.g., TAPSE/SPAP, LAIRV) are proposed as complementary tools but require further validation.
• Multimodality assessment combining echocardiography, CMR, and invasive hemodynamics is emphasized to inform advanced clinical decision-making.

In a narrative review focused on right ventricular (RV) adaptability to pressure overload, Dandel describes RV response as a dynamic spectrum—from compensated remodeling to maladaptive dilation, rising filling pressures, and overt failure. Across this continuum, the author emphasizes that no single echocardiographic, hemodynamic, or imaging metric is sufficient across all stages and loading conditions, particularly as afterload and secondary tricuspid regurgitation evolve. Instead, the review supports an integrated, multiparametric approach to characterize RV status and to estimate the potential for reversibility after afterload reduction. This framework is discussed in the context of advanced clinical decision-making, including ventricular assist device (VAD) planning and thoracic-organ transplantation, where assessment of RV reserve is relevant.

Echocardiography is presented as the practical foundation for serial RV assessment, enabling tracking of chamber size, geometry, and function. Common longitudinal function indices such as tricuspid annular plane systolic excursion (TAPSE) and tissue Doppler S′ are described alongside two-dimensional measures such as RV fractional area change and surrogate markers of afterload (e.g., RV outflow tract acceleration time). Speckle-tracking–derived strain (global and free-wall longitudinal strain) is highlighted as a tool for detecting early dysfunction. However, the author emphasizes that these measures are load dependent and may be confounded by changes in afterload and tricuspid regurgitation, supporting interpretation within a broader physiologic context rather than as stand-alone severity markers.

To address load dependence, the review describes emerging coupling-oriented indices that relate RV function to afterload, including TAPSE/systolic pulmonary artery pressure and RV strain–based ratios. Additional composite measures, such as TAPSE×ΔPRV–RA and effective/forward RVEF (eRVEF), are presented as approaches to integrate contractility and loading conditions. The review also discusses LAIRV (VTITR×LED/AED), a proposed echocardiographic composite, noting that lower values (e.g., <15 in cited cohorts) were associated with reduced RV adaptability. These indices are presented as exploratory tools that may complement traditional measures but require prospective validation before broader clinical adoption.

For structural and functional quantification, cardiac magnetic resonance (CMR) is described as the reference standard for RV volumes and ejection fraction. Invasive hemodynamics from right-heart catheterization—including right atrial pressure, pulmonary vascular resistance, cardiac index, and transpulmonary gradient—are discussed as complementary measures. The review cites hemodynamic thresholds (e.g., mPAP >25 mmHg, PVR >2.5 Wood units) as part of decision frameworks referenced in the literature, while recognizing that definitions and thresholds may evolve over time.

Overall, the review presents RV assessment as a staged, multimodality process in which imaging and hemodynamic data are interpreted together. These integrated assessments are described as informing, rather than determining, decisions related to valve interventions, LVAD strategies (including need for RV support), and transplant pathways in advanced disease.