Volume 39, Issue 4, April 2026, Pages 355-357Author links open overlay panelTasneem Z. Naqvi MD, MMMShow moreAccess through your organization

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Access through your organizationSection snippetsMechanistic Basis of Early RV Involvement

Left ventricular–RV interactions are governed by the in-series arrangement of the circulation, the shared pericardial constraint, interventricular septal mechanics, and common myocardial fiber architecture. The observation in the study by Almani et al. that RV involvement occurs early—even in grade 1 DD—and independently of pulmonary artery systolic pressure indicates that mechanisms beyond passive transmission of elevated left-sided filling pressures are operative.

The left and right ventricle

Methodologic Considerations and Caveats

Several limitations of the study warrant cautious interpretation. Patient selection was nonconsecutive and dependent on investigator availability and equipment. Subjects exhibited a wide range of LV ejection fraction (LVEF), from normal to mildly or moderately reduced, and 25% of subjects had heart failure. Thus, there perhaps was a range of subjects in the study, those with LV DD only, LV DD with preserved LVEF and heart failure, and LV systolic and DD with heart failure. However, LVEF was not

Challenges in Diastolic Function Assessment

Multiple echocardiographic variables—used alone or in combination—are employed to assess LV DD, each influenced by heart rate, blood pressure, atrial arrhythmias, LV systolic function, native mitral valve disease, and prior mitral or LA interventions. Numerous studies have demonstrated that even robust traditional parameters are load dependent and influenced by systolic function, contributing to a substantial proportion of indeterminate studies.2 The updated 2025 ASE recommendations incorporate

Right Ventricular Strain, 3D RVEF, and the Hierarchy of Sensitivity

Right ventricular global longitudinal strain has emerged as a sensitive marker of early RV dysfunction, often detecting abnormalities before conventional indices such as TAPSE and fractional area change and correlates well with magnetic resonance imaging RVEF.7 In the present study, RV free-wall strain and tissue Doppler S′ were not associated with LV DD severity, whereas RVGLS was reduced in grade 1 DD compared with normal diastolic function. One explanation may relate to methodological

Clinical Implications

The findings of this study have important clinical implications. In patients with grade 1 and 2 LV DD, RV size and function should be intentionally assessed and quantitatively reported rather than described by cursory visual estimates. Advanced but increasingly accessible and automated echocardiographic tools—particularly 3D RV volumetric analysis should be incorporated to allow detection of early RV remodeling before the development of overt pulmonary hypertension or advanced heart failure

Future Directions

Future prospective studies should focus on defining thresholds of abnormal RV strain and RV-PA coupling in grade 1 and 2 DD, incorporating exercise or stress echocardiography, and determining whether early intervention targeting LV filling pressures favorably alters the trajectory of RV remodeling.

Conclusion

Grade 1 LV DD may not always be a benign bystander.1,10 Through subtle but persistent alterations in myocardial coupling, ventricular interdependence, and filling pressures, grade 1 and grade 2 DD may initiate early right-heart remodeling and functional impairment detectable by modern echocardiography. Recognizing and reporting these changes reframes early DD as a biventricular disorder, with important implications for prognosis, phenotyping, and prevention of progression to overt heart

Conflicts of Interest

None.

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2026 by the American Society of Echocardiography.