Multimodality imaging of the right heart: Translating quantitative assessment into therapeutic strategy

The right heart is a crucial determinant of prognosis across a broad spectrum of cardiovascular diseases, including pulmonary hypertension, tricuspid regurgitation, and heart failure. In the contemporary era of transcatheter device-based therapies, accurate assessment of right ventricular (RV) and right atrial anatomical and functional remodeling is critical for clinical decision-making. Although echocardiography remains the cornerstone of right heart evaluation, its interpretation is often limited by complex geometry of the RV and the load dependency of some parameters. Recent advances in multimodality imaging have enabled more robust and quantitative characterization of right heart structure and function. Three-dimensional echocardiography and RV strain provide improved functional assessment beyond conventional parameters of RV function. Cardiac magnetic resonance offers reference-standard quantification of RV volumes and mass, enhancing reproducibility and risk stratification. Computed tomography contributes complementary anatomical, functional and volumetric information, particularly relevant in structural heart interventions and evaluation of systemic venous congestion. Importantly, imaging biomarkers reflecting RV-pulmonary arterial coupling, atrial remodeling, and systemic venous congestion have demonstrated incremental prognostic value. Integration of these quantitative metrics into clinical practice may refine risk stratification, optimize timing of intervention, and identify patients unlikely to benefit from invasive therapies. This review summarizes contemporary advances in right heart imaging and proposes a practical framework for integrating echocardiography, Cardiac magnetic resonance, and computed tomography into therapeutic strategy in patients with right heart disease.