Pulmonary hypertension echocardiography or ultrasound

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Richard Channick, M.D.; Assistant Editor(s)-in-Chief: Ralph Matar; José Eduardo Riceto Loyola Junior, M.D.[2]

Overview

Echocardiography may demonstrate right ventricular or atrial enlargement with a thickened interventricular septum in patients with pulmonary hypertension, decreased right ventricular function, or hypertrophy. Pulmonary artery systolic pressure can also be estimated using echocardiography. Right ventricular afterload may be suggested by a leftward septal displacement during systole. Pericardial effusions and diminished left ventricular cavity typically portend a dismal prognosis.

Echocardiography

Once pulmonary hypertension is suspected in a patient, a transthoracic echocardiogram should be done to assess right heart functions including:

• Pulmonary arterial pressure
• Tricuspid regurgitation
• Increased velocity of pulmonary valve regurgitation and short acceleration time of right ventricle ejection into the pulmonary artery
• Enlarged right heart chambers
• Abnormal shape and function (displacement) of interventricular septum
• Right ventricular wall hypertrophy
• Dilated main pulmonary artery
• Pericardial effusion
• Doppler echocardiographic index (Tei index or myocardial performance index) which is the sum of both isovolumetric contraction and relaxation intervals, divided by the ejection time

Echocardiographic assessment

• The most important initial parameter for evaluation using echocardiography is the pulmonary artery systolic pressure (PASP), which can be estimated using echocardiography.
• Its evaluation is limited when an accurate tricuspid regurgitation envelope can't be measured.
• Signs of right ventricular or atrial enlargement, decreased right ventricular function or hypertrophy are more important than PASP because they indicate a more severe disease with cardiac compromise.
• Leftward deviation of the interventricular septum, the "D sign" is correlated with poorer prognosis.

Shown below is a table summarizing the criteria to estimate the likelihood of the presence of PH based on echocardiography findings.

Likelihood of the Presence of PH	Criteria	Class, Level of Evidence
Unlikely	Tricuspid regurgitation velocity ≤2.8 m/s AND Pulmonary artery systolic pressure ≤36 mmHg AND Absence of other echocardiography findings suggestive of PH	Class I, Level of Evidence B
Possible	Tricuspid regurgitation velocity ≤2.8 m/s AND Pulmonary artery systolic pressure 37-50 mmHg AND Presence of other echocardiography findings suggestive of PH	Class IIa, Level of evidence C
Possible	Tricuspid regurgitation velocity 2.9-3,4 m/s AND Pulmonary artery systolic pressure ≤36 mmHg AND Presence or absence of other echocardiography findings suggestive of PH	Class IIa, Level of Evidence C
Likely	Tricuspid regurgitation velocity >3.4 m/s AND Pulmonary artery systolic pressure >50 mmHg AND Presence or absence of other echocardiography findings suggestive of PH	Class I, Level of evidence B

Echocardiography plays a pivotal role in the diagnosis of PH due to left heart failure. Echocardiographic findings characteristic of left ventricular diastolic dysfunction are:

• Left atrial enlargement
• Concentric remodeling of the left ventricle
• Left ventricular hypertrophy
• Findings suggestive of increased left ventricular filling pressure

Video showing Top 10 echocardiographic findings in moderate to severe pulmonary hypertension

Disclaimer: Adapted from Billy Cathey RDCS:Pulmonary hypertension 2D findings: {{#ev:youtube|3yOdNyTH07g}} Abbreviations:

• RVE: Right ventricular enlargement
• RVH: Right ventricular hypertrophy
• RAE: Right atrial enlargement
• TR: Tricuspid regurgitation
• PFO: Patent foramen ovale
• RVSP: Right ventricular systolic pressure
• SPAP: Systolic pulmonary artery pressure
• RVOT: Right ventricular outflow tract
• IVC: Inferior vena cava