Visual Right Ventricular Assessment in ICU: A Multicenter International Study

Objectives: Right ventricular (RV) dysfunction frequently contributes to circulatory failure in critical care, making its diagnosis essential. Although visual assessment is commonly used, its reliability remains debated. This study evaluated the concordance between visual grading of RV systolic function, size, and interventricular septal motion and standard quantitative echocardiographic parameters. Design: This was a multicenter international prospective study. Setting: Raters with different levels of echocardiography expertise reviewed transthoracic echocardiography recordings from 115 critically ill patients. Patients: The raters visually assessed RV systolic function (normal, moderate, or severe dysfunction), RV size (dilated/nondilated), and septal motion (paradoxical/nonparadoxical). Quantitative parameters, blinded to raters, included fractional area of change (FAC), tricuspid annular plane systolic excursion (TAPSE), S’ wave, and RV-free wall longitudinal strain (RVFWLS), according the most recent (2025) guideline-recommended thresholds for abnormality and severity. Interventions: None. Measurements and Main Results: Seventy-three raters from five countries participated. Agreement between visual grading and FAC was strong for experts (κ = 0.73) and intermediates (κ = 0.64), but only moderate for novices (κ = 0.55). Overall visual assessment showed moderate agreement with RVFWLS (κ = 0.45), TAPSE (κ = 0.44), and S’ wave (κ = 0.43). Agreement for RV size was moderate using RV basal diameter (κ = 0.43) and RV/left ventricle (LV) area ratio (κ = 0.47), but low for the RV/LV basal diameter ratio (κ = 0.25). Concordance for septal motion was low (κ = 0.28). Conclusions: Visual assessment of RV function by experienced raters shows satisfactory concordance with guideline-based FAC, supporting its integration into a multiparametric evaluation and structured educational programs.