The initial means of detecting right ventricular (RV) dilatation is often transthoracic echocardiography (TTE), and once the presence of RV dilatation is suspected, there is the possibility of RV volume overload, RV pressure overload, RV myocardial disease, and even nonpathological RV dilatation. With respect to congenital heart disease with RV volume overload, defects or valvular abnormalities can be easily detected with TTE, with the exception of some diseases. Volumetric assessment using three-dimensional echocardiography may be useful in determining the intervention timing in these diseases. When the disease progresses in patients with pulmonary hypertension as a result of RV pressure overload, RV dilatation becomes more prominent than hypertrophy, and RV function parameters predict the prognosis at this stage of maladaptive remodeling. The differential diagnosis of cardiomyopathy or comparison with nonpathological RV dilatation may be difficult in the setting of RV myocardial disease. The characteristics of RV function parameters such as two-dimensional speckle tracking may help differentiate RV cardiomyopathy from other conditions. We review the diseases presenting with RV dilatation, their characteristics, and echocardiographic findings and parameters that are significant in assessing their status or intervention timing.

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly 70% of all HF and has become the dominant form of HF. The increased prevalence of HFpEF has contributed to a rise in the number of HF patients, known as the “heart failure pandemic”. In addition to the fact that HF is a progressive disease and a delayed diagnosis may worsen clinical outcomes, the emergence of disease-modifying treatments such as sodium-glucose transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists has made appropriate and timely identification of HFpEF even more important. However, diagnosis of HFpEF remains challenging in patients with a lower degree of congestion. In addition to normal EF, this is related to the fact that left ventricular (LV) filling pressures are often normal at rest but become abnormal during exercise. Exercise stress echocardiography can identify such exercise-induced elevations in LV filling pressures and facilitate the diagnosis of HFpEF. Exercise stress echocardiography may also be useful for risk stratification and assessment of exercise tolerance as well as cardiovascular responses to exercise. Recent attention has focused on dedicated dyspnea clinics to identify early HFpEF among patients with unexplained dyspnea and to investigate the causes of dyspnea. This review discusses the role of exercise stress echocardiography in the diagnosis and evaluation of HFpEF.

“Panic Findings: Abnormal Findings Requiring Urgent Action” in ultrasonography was published by the Japanese Society of Ultrasound in Medicine. We herein explain the key points of ultrasound panic findings in the urological region. “Urgent findings” in the urological region include fluid retention in the retroperitoneal cavity with internal echogenic spots, caused by renal trauma or rupture of renal tumor, etc. Due to the anatomical characteristics of the kidney being in the retroperitoneum and surrounded by Gerota’s fascia, the mortality rate without immediate treatment is low. By checking ultrasound findings along with vital signs, it is likely that in many cases a urological finding can be treated as a “semi-urgent finding”. There are two “semi-urgent findings” in the urological region. One is dilation of both renal pelvises (calyxes). Extrarenal dilation, where only the renal pelvis is dilated, does not need to be considered a panic finding. If one kidney is non-functioning, dilation of the contralateral renal pelvis and calyx is also a panic finding. The other “semi-urgent finding” is a mass lesion (fluid collection with internal echo) accompanied by fever or tenderness. In renal infection accompanied by fever and tenderness, along with a mass (fluid collection with internal echo), intrarenal emphysema, or renal pelvic distention with debris, is considered a “semi-urgent finding.”

When performing ultrasonography (US) on patients with acute abdomen, it is efficient and useful to rule out more urgent diseases while paying attention to the patients’ response and exacerbation in vital signs first, then screen for more frequent diseases as speculated based on abdominal symptoms, age, and sex. The “Panic Findings: Abnormal Findings Requiring Urgent Action” (panic findings) presented by the Japan Society of Ultrasonics in Medicine classifies abnormal findings in US that should be reported immediately into three groups: 1) “Urgent findings” requiring immediate action, 2) “Semi-urgent findings” requiring prompt action, and 3) “Abnormal findings” requiring early action. “Urgent findings” related to the hepatobiliary-pancreatic region include peritoneal/retroperitoneal fluid collection with debris echo, corresponding to intra-abdominal bleeding, organ damage, and rupture of tumors such as hepatocellular carcinoma. On the other hand, “semi-emergent findings” include multiple solid mass lesions or cluster signs (multiple liver metastases), liver mass lesions with fever and tenderness (liver abscess), extrahepatic bile duct dilation with fever (acute cholangitis), intrahepatic bile duct dilation (obstructive jaundice), enlarged gallbladder with fluid retention (acute cholecystitis), and enlarged pancreas with fluid retention (acute pancreatitis). These panic findings will enable rapid and reliable screening for emergency illness in patients with acute abdomen, which will prevent sudden deterioration of the patients’ condition (death) and contribute to improving the prognosis of emergency patients.

Gynecological disorders are included in the differential diagnosis of acute abdomen. In particular, gynecological disorders such as ectopic pregnancies, ovarian hemorrhage, and torsion of ovarian tumor can remain asymptomatic but can become serious if they progress, so caution is required. It is important to understand the characteristics of these diseases and the signs that should not be overlooked.

“Panic findings” are abnormal observations that may pose a life-threatening risk, requiring an appropriate response. According to the guidelines issued by the Japan Society of Ultrasonics in Medicine in November 2023, panic findings should not merely be considered abnormal observations but should function as an integral part of an emergency response system established by each facility. Ultrasound examinations are often performed by sonographers, who must remain composed when encountering abnormal findings. Echocardiographic examinations are particularly critical as they can detect life-threatening cardiac abnormalities, necessitating immediate action upon identifying a panic finding. Before the examination, it is essential to understand the request and review the latest information, such as the ECG. When a panic finding is discovered, if the patient exhibits symptoms or hemodynamic abnormalities, the sonographer should immediately contact a physician. If the patient is asymptomatic and hemodynamically stable, it is advisable to compare the current findings with previous results to determine the appropriate response. Diseases requiring immediate response/reporting include acute coronary syndrome, cardiac tamponade, acute aortic dissection, acute pulmonary embolism, intracardiac thrombus, cardiac tumors, infective endocarditis, ventricular septal rupture, pseudoaneurysm, papillary muscle or chordae tendineae rupture with acute severe mitral regurgitation, left ventricular outflow tract obstruction, and severe arrhythmias. Diseases requiring prompt reporting include prosthetic valve dysfunction, new onset or acute exacerbation of heart failure, and newly discovered severe valvular disease. In the case of cardiovascular diseases, timely intervention significantly impacts patient outcomes. The panic finding system is crucial for ensuring patient safety, and each facility must establish a system tailored to its specific circumstances.