Right Ventricular Hypertrophy: Pathophysiology, Multimodality Imaging, and Clinical Implications

Right ventricular (RV) hypertrophy is the principal adaptive response to increased afterload. This response can be appropriate, preserving RV systolic function and RV-pulmonary artery coupling, or maladaptive, leading to RV dilatation and failure. While pure pressure overload typically induces adaptive hypertrophy, concomitant myocardial injury and ischemia often drive maladaptive changes. Multimodality imaging plays a crucial role in distinguishing these states by characterizing the relationship between RV mass, volume, and function. Cardiac magnetic resonance imaging, in particular, provides the reference standard for quantifying these parameters and offers unique insights through myocardial tissue characterization. This narrative review outlines the pathophysiology of RV hypertrophy and the application of cardiovascular imaging for its clinical assessment. We conclude by highlighting the critical clinical utility of evaluating RV hypertrophy for screening for pulmonary hypertension, risk stratification, and as a potential therapeutic target.