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Combined RV pressure and volume overload on echo: D-shape in systole and diastole

D-shape in systole and diastole: the septum stays flattened throughout the cycle (eccentricity index > 1 at both end-diastole and end-systole). The RV is very large, hypertrophied and usually hypokinetic, for example pulmonary hypertension with severe TR.

Watch it in the simulator →Practise random cases

Where to look

PSAX at papillary level at end-diastole AND end-systole (D-shape in both); apical 4-chamber for a very large, thick, hypokinetic RV and dilated RA.

Typical wall-motion pattern

Example: Combined RV pressure and volume overload (e.g. pulmonary hypertension with severe TR) — D-shape in systole and diastole

All 17 segments thicken normally.

EF in this example: 65% (Normal (≥55%)).

1 Normal2 Hypokinetic3 Akinetic4 Dyskinetic5 Aneurysmal

Ejection fraction

Across 24 simulated cases of this pattern the true EF ranged from 62% to 69% (median 65%, Normal (≥55%)). Every case in the simulator is different, so practise until your visual estimate lands in the right 5% range.

Teaching points

Combined pressure and volume overload: the septum is flattened in BOTH systole and diastole (eccentricity index > 1 at end-diastole and at end-systole). The RV is very large, hypertrophied and hypokinetic.
Apical 4-chamber: very large, thick-walled, hypokinetic RV with a dilated RA; the septum is shifted toward the LV throughout the cycle.
Timing is the key: compare the PSAX septum at end-diastole (just after the QRS) with end-systole (just before mitral valve opening).
Ventricular ectopics: the premature beat is weak and dyssynchronous and the beat after the pause is stronger. Judge EF and wall motion on normal sinus beats only.

Common pitfalls

Do not call it pure pressure overload because the systolic D-shape is obvious: check end-diastole too. If the septum is flat in both phases, both pressure and volume are raised.

Try it now: open the Combined RV pressure and volume overload (D-shape in systole and diastole) example with the segment overlay, then test yourself in Practice where cases are random and graded against the exact answer.