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Challenges and opportunities in assessing right ventricular structure and function: a Roadmap for standardization, clinical implementation and research

Nature Reviews Cardiology volume 23, pages 60–77 (2026)Cite this article

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Abstract

Given its crucial role in determining patient symptoms and outcomes in various cardiopulmonary diseases, the thorough and accurate assessment of right ventricular function is essential for both diagnosis and ongoing patient monitoring. In the era of precision medicine, a more detailed characterization of patients with cardiopulmonary diseases is needed, especially with the emergence of novel pharmacological and device-based therapies, such as transcatheter tricuspid valve intervention, gene therapy in patients with cardiomyopathy and anti-obesity interventions for patients with heart failure. Precise and reproducible quantification of right ventricular morphology and function are crucial for risk stratification, the selection of different therapies for the appropriate patients and the evaluation of treatment outcomes. As our understanding of right ventricular pathophysiology expands, the need for sensitive markers of functional deterioration, reliable prognostic indicators and more precise surrogates for clinical trials becomes increasingly important. In this Roadmap, we address current challenges in the standardization of image acquisition, analysis and interpretation across different modalities. We explore the factors limiting the clinical adoption of more advanced approaches and provide expert recommendations to overcome these barriers. Additionally, we outline potential next steps for incorporating parameters of right ventricular function as surrogate end points in multicentre clinical trials of new drugs or devices, and highlight new research opportunities, including the integration of artificial intelligence technologies. Finally, we issue a call for international collaboration on selected priority areas.

Key points

  • Right ventricular (RV) function is crucial for determining symptoms and outcomes in cardiopulmonary diseases, making its accurate assessment vital for effective diagnosis and patient monitoring.

  • Despite substantial research on RV imaging and the prognostic value of RV systolic dysfunction, RV parameters remain underutilized in guiding patient management within clinical practice guidelines.

  • Substantial challenges persist in standardizing image acquisition, analysis and reporting, even among widely used modalities such as transthoracic and transoesophageal echocardiography and cardiac magnetic resonance.

  • Defining the minimal clinically meaningful change in RV parameters is necessary to integrate these measures into clinical trials.

  • Artificial intelligence has the potential to transform RV assessment by enhancing image acquisition, analysis, data interpretation and decision support.

  • The RVNet(Work) initiative aims to lead efforts in standardizing and improving RV morphology and functional assessment through collaborative partnerships.

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Fig. 1: Assessment of RV structure and function: a roadmap for standardization, clinical implementation and research.

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Acknowledgements

This Roadmap article is written on behalf of the RVNet(Work) Group. The authors thank M. Tokodi (Semmelweis University, Hungary) for his valuable insights on the artificial intelligence aspects of this article. A.K. has received grant support from the National Research, Development, and Innovation Office (NKFIH) of Hungary (FK 142573) and 2024-1.2.3-HU-RIZONT-2024-00057 (implemented with support provided by the Ministry of Culture and Innovation of Hungary from the National Research, Development, and Innovation Fund, financed under the 2024-1.2.3-HU-RIZONT funding scheme), and is supported by the János Bolyai Research Scholarship of the Hungarian Academy of Sciences. The authors used ChatGPT from OpenAI for language editing of the initial draft manuscript.

Author information

Authors and Affiliations

  1. Department of Experimental Cardiology and Surgical Techniques, Heart and Vascular Center, Semmelweis University, Budapest, Hungary

    Attila Kovács

  2. Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University of Tübingen, Tübingen, Germany

    Harry Magunia & Marius Keller

  3. Department of Anaesthesiology, Duke University, Durham, NC, USA

    Alina Nicoara

  4. Research Institute of Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, UK

    David Oxborough & Dick Thijssen

  5. Liverpool Centre for Cardiovascular Science, Liverpool, UK

    David Oxborough

  6. Nagold Medical Center, Academic Teaching Hospital of Eberhard Karls University of Tübingen, Nagold, Germany

    Marius Keller

  7. Royal United Hospitals Bath & University of Bath, Bath, UK

    Daniel X. Augustine

  8. Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, Netherlands

    Dick Thijssen

  9. Academic Center for Congenital Heart Disease, Radboud University Medical Center, Nijmegen, Netherlands

    Arie van Dijk

  10. Department of Anaesthesiology, Montréal Heart Institute, Université de Montréal, Montréal, Canada

    Andre Denault

  11. Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA

    Francois Haddad

  12. Research and Early Clinical Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK

    Elena Surkova

  13. Royal Brompton and Harefield Hospitals, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK

    Elena Surkova

  14. National Heart and Lung Institute, Imperial College London, London, UK

    Elena Surkova

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  1. Attila Kovács
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Contributions

A.K., H.M., A.N., D.O., M.K., F.H. and E.S. researched data for the article. All authors contributed substantially to discussion of the content. A.K., H.M., M.K., D.X.A., F.H. and E.S. wrote the article. A.N., D.O., D.X.A., D.T., A.v.D. and A.D. reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Attila Kovács.

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Competing interests

A.K. serves as the chief medical officer at Argus Cognitive, a company involved in the development of software medical devices, for which he receives financial compensation. This relationship had no influence on the scientific content or conclusions of this article. D.X.A. reports a research grant from Janssen. A.D. reports consultancy at Elevate Healthcare and a research grant from Edwards. F.H. reports research support from Johnson & Johnson on the assessment of deep learning methods in pulmonary hypertension. E.S. is an employee and a shareholder of AstraZeneca. The other authors declare no competing interests.

Peer review

Peer review information

Nature Reviews Cardiology thanks Julia Grapsa, Nina Ajmone Marsan and Alex Pui-Wai Lee for their contribution to the peer review of this work.

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Related links

RVNet(Work): www.rvwork.net

Supplementary information

Glossary

Arrhythmogenic RV cardiomyopathy

A genetic heart disorder in which heart muscle tissue is replaced by fat and scar tissue, primarily affecting the right ventricle and increasing the risk of arrhythmia.

Artificial intelligence

Technology that simulates human intelligence, performing tasks such as image analysis, data interpretation and decision-making in various fields, including health care.

Body surface area

The total surface area of the human body, often used in medical settings to calculate drug dosages and assess physiological parameters.

Cardiac implantable electronic device

Medical device that is implanted in the body to monitor and regulate heart functions, primarily used in patients with arrhythmias or heart failure.

Cardiac magnetic resonance

An imaging technique using magnetic fields and radio waves to create detailed heart images, often used for cardiac function assessment.

Contractility

The capacity of heart muscle to contract with force, influencing how effectively the heart pumps blood; is a key indicator of cardiac function.

Ebstein anomaly

A rare congenital heart defect in which the tricuspid valve is abnormally positioned and malformed, affecting blood flow and often leading to heart enlargement and arrhythmias.

Federated learning

A machine learning approach where multiple institutions collaboratively train a model on decentralized data, ensuring data privacy by keeping information stored locally instead of sharing it centrally.

Fractional area change

A measure of right ventricular function calculated by the change in chamber area between the contraction and relaxation phases.

Implantable cardioverter–defibrillator

A device implanted in the chest to detect and correct abnormal heart rhythms by delivering electrical shocks, to prevent sudden cardiac arrest.

Kansas City Cardiomyopathy Questionnaire

A patient-reported questionnaire to assess symptoms, physical limitations and quality of life in individuals with heart failure, used to gauge disease impact and treatment outcomes.

Longitudinal strain

A measure of heart muscle deformation along its length during contraction, used to assess ventricular function and detect early signs of cardiac dysfunction.

Mechanical circulatory support

Devices that assist or replace heart function to maintain blood flow in patients with severe heart failure, including options such as ventricular assist devices.

Minimal clinically meaningful change

The smallest improvement (or decline) in a clinical measure that signifies a noticeable benefit (or harm) to the patient; often used to assess treatment effectiveness (or harm).

Phosphocreatine-to-ATP ratio

A measure of cardiac energy efficiency, indicating the balance between energy supply and demand in heart muscle cells.

Pressure–volume analysis

A method for evaluating heart function by measuring the relationship between pressure and volume in the heart chambers during the cardiac cycle, offering insights into cardiac performance.

Pulmonary artery systolic pressure

The pressure in the pulmonary artery during contraction of the right ventricle, commonly measured to assess pulmonary hypertension and right-sided heart function.

Pulmonary hypertension

High blood pressure in the arteries of the lungs, which can strain the heart and cause symptoms such as shortness of breath, dizziness and fatigue.

RV ejection fraction

The percentage of blood pumped out of the right ventricle with each heartbeat; an indicator of heart function.

RV–PA coupling

The relationship between right ventricular function and pulmonary artery pressure, reflecting how efficiently the right ventricle adapts to load changes in pulmonary circulation.

Speckle tracking

An echocardiographic technique that tracks natural markers, or ‘speckles’, in the heart muscle on ultrasonography images to assess heart muscle movement and function.

Systemic right ventricle

A right ventricle functioning as the main pumping chamber to the body, seen in some congenital heart conditions, often leading to unique challenges over time.

Tetralogy of Fallot

A congenital heart defect with four abnormalities that affect blood flow through the heart, causing low oxygen levels and symptoms such as cyanosis.

Tissue Doppler imaging

An ultrasonography technique that measures the velocity of heart muscle movements, providing insights into heart function.

Transcatheter tricuspid valve interventions

Minimally invasive procedures to repair or replace the tricuspid valve via catheter-based techniques, often used for patients with severe tricuspid valve insufficiency.

Transoesophageal echocardiography

Imaging technique, in which an ultrasonography probe is placed in the oesophagus to capture detailed heart images.

Transthoracic echocardiography

A common heart ultrasonography procedure performed through the chest wall to assess heart structure and function.

Tricuspid annular plane systolic excursion

A measure of right ventricular function based on the movement of the tricuspid valve during contraction.

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Kovács, A., Magunia, H., Nicoara, A. et al. Challenges and opportunities in assessing right ventricular structure and function: a Roadmap for standardization, clinical implementation and research. Nat Rev Cardiol 23, 60–77 (2026). https://doi.org/10.1038/s41569-025-01180-9

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