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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 above 1.1 at end-diastole and end-systole). This is seen in severe pressure overload with or without an added volume load; a very large, hypertrophied, hypokinetic RV with severe TR, as in advanced pulmonary hypertension, points to combined overload.

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 > 1.1 at end-diastole and at end-systole). Severe pressure overload alone can also do this, so look for the volume cause (here severe TR). 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

Flattening in both phases does not prove a volume load: severe pressure overload also flattens the septum in diastole. Call combined overload when there is also a volume cause (severe TR or PR, a shunt).

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.