Chronic severe pulmonary hypertension. The size of right ventricle (RV) and atrium (RA) far exceeds that of left ventricle and atrium. (A) Parasternal short-axis view with displacement of ventricular septum (SE) to the left ventricle, creating the ‘D sign’ as opposed to the normal circular shape of the left ventricle in short-axis views. (B) Modified apical four-chamber view. (C) Peak tricuspid regurgitant velocity (right) is 420cm/s, which by the simplified Bernoulli equation amounts to a ventriculo-atrial pressure gradient of 71mmHg. To estimate peak systolic RV and pulmonary artery pressure, an estimate of right atrial pressure can be added to that value.