Advanced Imaging of the Right Heart and Pulmonary Circulation: The Role of Echocardiography and Cardiovascular Magnetic Resonance

Echocardiography and cardiovascular magnetic resonance (CMR) have substantially advanced the non-invasive evaluation of the right heart and pulmonary circulation. This review provides a comprehensive overview of contemporary and emerging applications of these modalities across nine selected, clinically relevant right-heart and pulmonary vascular disorders including pulmonary arterial hypertension, pulmonary embolism, and more. We summarize established diagnostic criteria and prognostic parameters derived from both modalities, highlighting the complementary roles of echocardiography—as the first-line, real-time assessment tool—and CMR, which provides the reference standard for right ventricular volumetry, tissue characterization via late gadolinium enhancement (LGE) and parametric mapping, and quantitative flow assessment. Emerging techniques, including speckle-tracking and feature-tracking strain imaging, four-dimensional flow CMR, exercise CMR, and hybrid PET/MRI, are discussed with respect to their current evidence base and potential for integration into clinical practice. The potential of artificial intelligence-assisted image analysis to enhance diagnostic efficiency is also addressed. A multimodality imaging strategy, tailored to the clinical context, represents the current standard of care in right heart disease.