The Right Ventricle in Focus: State-of-the-Art CMR Imaging - Challenges, Standards, and Innovations

The right ventricle (RV) is recognized as a critical contributor to cardiovascular outcomes. Cardiovascular magnetic resonance (CMR) has emerged as the reference standard for comprehensive RV assessment, enabling precise evaluation of ventricular volumes, function, flow, and tissue characterization. In this review, we provide a state-of-the-art overview of RV imaging using CMR. We first outline the anatomical and physiological features that distinguish the RV from the left ventricle. Next, we highlight the key technical challenges in imaging the RV, notably its complex geometry, prominent trabeculation, and thin myocardial wall. We then summarize current clinical CMR approaches, including cine imaging for volumetric assessment, phase-contrast techniques for flow quantification, and methods for tissue characterization such as late gadolinium enhancement. Additionally, we discuss advanced and emerging CMR techniques aimed at overcoming current RV imaging limitations, including high-resolution three-dimensional cine imaging, four-dimensional flow imaging, parametric mapping, and novel reconstruction strategies. These innovations hold promise for improving accuracy, reproducibility, and mechanistic insight into RV structure and function. Finally, we review the clinical role of CMR in major RV pathologies, including congenital heart disease, pulmonary hypertension, arrhythmogenic right ventricular cardiomyopathy, and tricuspid regurgitation. Across these conditions, CMR provides vital diagnostic and prognostic information, with growing evidence supporting its role in guiding clinical management. As technical advancements continue and standardization improves, CMR is poised to transform RV evaluation from a historically challenging endeavor into a precise and impactful component of cardiovascular care.