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RV pressure overload on echo: systolic D-shaped septum

Systolic D-shape: in PSAX the septum flattens toward the LV during systole, maximal at end-systole, while the LV is relatively round at end-diastole (eccentricity index > 1 at end-systole). Look for RV free-wall hypertrophy (> 5 mm) and, when the RV fails, dilatation with reduced TAPSE. The LV myocardium itself thickens normally.

Watch it in the simulator →Practise random cases

Where to look

PSAX at papillary level frozen at end-systole (D-shape) and end-diastole (relatively round); apical 4-chamber or subcostal for RV wall thickness, size and TAPSE.

Typical wall-motion pattern

Example: RV pressure overload (e.g. pulmonary hypertension) — systolic D-shape

All 17 segments thicken normally.

EF in this example: 70% (Normal (≥55%)).

1 Normal2 Hypokinetic3 Akinetic4 Dyskinetic5 Aneurysmal

Ejection fraction

Across 24 simulated cases of this pattern the true EF ranged from 67% to 73% (median 70%, Normal (≥55%)). Every case in the simulator is different, so practise until your visual estimate lands in the right 5% range.

Teaching points

Pressure overload: the septum flattens in SYSTOLE, maximal at end-systole (systolic D-shape, eccentricity index > 1 at end-systole). At end-diastole the LV is relatively round. RV free-wall hypertrophy (> 5 mm) is typical; this RV is also dilated and failing (reduced TAPSE), as in advanced pulmonary hypertension.
Apical 4-chamber: dilated, thick-walled, hypokinetic RV; the septum bows into the LV mainly in systole.
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

Judge the shape at end-systole AND end-diastole, not mid-cycle: a systolic-only D-shape is pressure overload. RV hypertrophy can be present with preserved function (e.g. pulmonary stenosis); acute pressure overload (e.g. PE) dilates the RV without hypertrophy. The septum still thickens, so it is not an LV RWMA.

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