Non-invasive assessment of pulmonary hypertension: Doppler–echocardiography

doi:10.1016/j.pupt.2006.03.008

Pulmonary Pharmacology & Therapeutics

Volume 20, Issue 2, April 2007, Pages 135-140

https://doi.org/10.1016/j.pupt.2006.03.008 Get rights and content

Abstract

Pulmonary hypertension (PH) is a clinical condition characterised by elevated pulmonary artery pressure (PAP) and vascular resistances. At the onset of the disease, symptoms are frequently atypical so that PH diagnosis is usually made when the disease is advanced, which often is too late for efficacious treatment. As a consequence the prognosis is poor. Echo–Doppler evaluation allows: (a) an early identification of patients with PH, (b) to establish a patient's prognosis and (c) to evaluate a proper patient's follow-up. In patients with PH echocardiography provides information about right heart dimensions, pulmonary artery pressures, right ventricle systolic and diastolic function and left and right ventricle interdependence. Most importantly Echo–Doppler evaluation has became a major diagnostic tool for PH allowing evaluation of changes with time and with different treatments which are aimed at reducing pulmonary artery pressure and right heart dimensions and at improving right heart function.

Introduction

Pulmonary hypertension (PH) is a clinical condition characterised by elevated pulmonary artery pressure (PAP) and vascular resistance. PH is defined as mean pulmonary artery pressure (MPAP) exceeding 25 mm Hg at rest, or 30 mm Hg during exercise.

Echo–Doppler assessment of PH includes three different issues: detection of elevated PAP values, functional evaluation of the right ventricle, and differential diagnosis to detect underlying conditions such as congenital heart disease or left heart disease. The present review highlights the scientific status of echocardiography in the first two issues.

Section snippets

Detection of pulmonary hypertension

The sensitivity and specificity of Echo–Doppler evaluation in diagnosing PH are strongly dependent on the threshold value used as a cut-off point for establishing the presence of PH and PH grades of severity. Unfortunately, several conditions limit the capability to detect and measure the velocity of the tricuspid regurgitant jet, such as air trapping, expansion of the thoracic cage and alterations in the position of the heart. Moreover, both the positive and the negative predictive values of

Right atrial pressure estimation

Elevated RAP is a manifestation of right ventricular failure usually due to high right ventricular diastolic pressure. RAP has been demonstrated as a strong predictor of survival in both baseline conditions and during follow-up therapy of patients with PH. Nevertheless, despite several attempts made to obtain an accurate estimation of RAP, attention has been focused mainly on patients with chronic heart failure (CHF) due to both ischaemic and idiopathic cardiomyopathy. Thus, application of

Normal values and clinical implications

Cardiac catheterisation is currently used as the gold standard technique to firmly establish haemodynamic status, although there is no clear consensus as to what value of PAP is needed for PH diagnosis [3], [4], [10], [11], [12], [13].

The Third World Symposium on Pulmonary Hypertension held in Venice in 2003 defined mild PH as a resting Doppler-estimated PASP between 36 and 50 mm Hg, which corresponds to a tricuspid regurgitant velocity of 2.8–3.4 m/s, assuming a fixed 5 mm Hg RAP [14].

Doppler

Morphological evaluation of right side chambers

Morphological description comprises evaluation of right side chambers dimensions, including determination of pulmonary artery dimension, detection of right ventricular hypertrophy, and description of pericardial effusion. Right ventricular hypertrophy is mostly the consequence of a chronically increased afterload and it is generally assessed by measuring the end-diastolic thickness of the free wall; a value above 5 mm is strongly associated with a chronic increased afterload [20], [21], [22].

Functional evaluation of the right ventricle

The pulmonary circulation is a low pressure and low resistance highly compliant system, able to accommodate flow rates ranging from resting conditions to strenuous exercise, with minimal increases in pulmonary pressures. This is possible because of the favourable reserve characteristic of the pulmonary circulation, reflecting passive distension of the vascular bed and recruitment of additional vessels. The primary function of the right ventricle is to provide sustained low-pressure perfusion

Conclusion

Evaluation of right ventricle performance in PH patients is difficult and, as a consequence, needs to be done by an experienced cardiologist and cannot be carried out by sonographers without specific experience.

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Cited by (43)

Comparative accuracy of non-invasive imaging versus right heart catheterization for the diagnosis of pulmonary hypertension: A systematic review and meta-analysis
2020, IJC Heart and Vasculature
Right heart catheterization (RHC) is the gold-standard in the diagnosis of pulmonary hypertension (PH) but at the cost of procedure-related complications. We sought to determine the comparative accuracy of RHC versus non-invasive imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and transthoracic echocardiography (TTE).
Pulmonary hypertension was defined as a mean pulmonary artery pressure (mPAP) of>20 mmHg. Multiple databases were queried for relevant articles. Raw data were pooled using a bivariate model to calculate the measures of diagnostic accuracy and to estimate Hierarchical Summary Receiver Operating Characteristic (HSROC) on Stata 13.
A total of 51 studies with a total patient population of 3947 were selected. The pooled sensitivity and specificity of MRI for diagnosing PH was 0.92(95% confidence interval (CI) 0.88–0.96) and 0.86 (95% CI, 0.77–0.95), respectively. The net sensitivities for CT scan and TTE were 0.79 (95% CI 0.72–0.89) and 0.85 (95% CI 0.83–0.91), respectively. The overall specificity was 0.82 (0.76–0.92) for the CT scan and 0.71 (95% CI 0.61–0.84) for TTE. The diagnostic odds ratio (DOR) for MRI was 124 (95% CI 36–433) compared to 30 (95% CI 11–78) and 24 (95% 11–38) for CT scan and TTE, respectively. Chi-squared (x2) test showed moderate heterogeneity on the test for equality of sensitivities and specificities.
MRI has the highest sensitivity and specificity compared to CT and TTE. MRI can potentially serve as a surrogate technique to RHC for the diagnosis of PH.
Reliability of Echocardiographic Indicators of Pulmonary Vascular Disease in Preterm Infants at Risk for Bronchopulmonary Dysplasia
2017, Journal of Pediatrics
To determine the assessment and inter-rater reliability of echocardiographic evaluations of pulmonary vascular disease (PVD) in preterm infants at risk for bronchopulmonary dysplasia.
We prospectively studied echocardiograms from preterm infants (birthweights 500-1250 g) at 7 days of age and 36 weeks postmenstrual age (PMA). Echocardiograms were assessed by both a cardiologist on clinical service and a single research cardiologist. Interpretations were reviewed for inclusion of determinants of PVD and assessed for inter-rater reliability using the Prevalence Adjusted Bias Adjusted Kappa Score (PABAK).
One hundred eighty and 188 matching research and clinical echocardiogram reports were available for the 7-day and 36-week PMA studies. At least one of the specific qualitative measures of PVD was missing from 54% of the clinical reports. PVD was diagnosed at 7 days in 31% and 20% of research and clinical interpretations, respectively (PABAK score of 0.54). At 36 weeks, PH was diagnosed in 15.6% and 17.8% of research and clinical interpretations, respectively (PABAK score of 0.80).
Although all qualitative variables of PVD are not consistently provided in echocardiogram reports, the inter-rater reliability of cardiologists evaluating measures of PVD revealed strong agreement, especially at 36 weeks PMA. We speculate that establishment of a protocol for echocardiographic evaluation may improve the identification of PVD in preterm infants.
Percutaneous CT guided lung biopsy in patients with pulmonary hypertension: Assessment of complications
2016, European Journal of Radiology
Citation Excerpt :
Second, all patients included in our study had cardiac ultrasound within 6 months, which estimated pulmonary arterial pressures using tricuspid regurgitate jet method [21]. Although there still might be an on-going debate in the scientific community regarding the accuracy of cardiac ultrasound in diagnosing PHTN, echocardiography has been accepted as a non-invasive and readily available modality for identification of patients with PHTN [13,21]. Some of patients in our study underwent an additional right cardiac angiography prior to PTNAB, which confirmed the diagnosis of PHTN.
To assess the complications of CT-guided percutaneous transthoracic needle aspiration and/or core biopsy (PTNAB) of lung nodules in patients with pulmonary arterial hypertension (PHTN).
We analyzed PTNAB of 74 lung lesions (mean size: 3.6 ± 2.1 cm) in 74 patients (M: F 38:36; age 68 ± 15 years) with documented PHTN on cardiac ultrasound. 39 patients with lung lesions (M: F 24:15; age 65 ± 14) who underwent PTNAB in the same period with right ventricle systolic pressure (RVSP) <35 mmHg were selected as controls. Pulmonary arterial pressures were estimated on cardiac ultrasounds by using the tricuspid regurgitation jet method. Two thoracic radiologists reviewed the medical records and PTNAB images on a PACS station and documented nodule size, location, distance traversed in lung, technical success and complications.
Fine needle aspirates were obtained in all and core biopsy in 23% (17/74) of the nodules. 61% (45/74) of the nodules were in the middle and 39% (29/74) were in the outer third of lung. PHTN was mild, moderate and severe in 84% (62/74), 13% (10/74) and 3% (2/74) of the patients. Biopsy was complicated by hemorrhage in 26% (19/74), moderate hemoptysis in 1.3% (1/74), pneumothorax in 17% (12/74), chest tube in 1.3% (1/74) and hemothorax in 1.3% (1/74) of the patients. The complications rate in control group was similar, hemorrhage in 33% (19/39) (p = 0.6), moderate hemoptysis in 5% (2/39) (p = 0.3), pneumothorax in 28% (11/39) (p = 0.2), chest tube in (0/39) (p = 0.3), and hemothorax in 3% (1/39) of the patients (p = 0.7).
Percutaneous needle biopsy of lung lesions in patients with mild to moderate PHTN can be performed without significant increase in complications.
Changes in Right Ventricular Function with Exercise in Healthy Subjects: Optimal Parameters and Effects of Gender and Age
2015, Journal of the American Society of Echocardiography
Citation Excerpt :
In normal subjects, the increase in cardiac output with exercise has little effect on PAP and is likely due to the distension and recruitment of pulmonary vasculature. PAP increases with age and body mass index and is higher in men, with a percentage of older and obese subjects with PAP > 40 mm Hg (currently considered elevated PAP).37,38 Bossone et al.39 sought to investigate the upper limits of PAP change with exercise, but that study included only young active men.
Right ventricular (RV) function augments with exercise, and loss of this adaptive ability often determines symptoms. Reports on exercise-related changes in RV function in healthy subjects are sparse. In this study, healthy volunteers were prospectively recruited, and changes in RV function with exercise were examined, optimal parameters determined, and the effects of gender and age examined.
Treadmill exercise stress echocardiography with concurrent expired gas analysis was performed in 121 healthy volunteers. Parameters of RV systolic function (RV fractional area change, Doppler tissue s′ velocity, and systolic strain and strain rate) and diastolic function (peak E and A velocity, Doppler tissue e′, a′ and early and late diastolic strain rate) were evaluated at baseline and after exercise, with the difference (Δ) being systolic and diastolic reserve. Changes in pulmonary arterial pressure (PAP) was measured when accurate estimation was possible.
Most systolic functional parameters were augmented with exercise. However, systolic augmentation decreased with age (Δs′: r = −0.31, P < .01; Δ strain: r = −0.28, P = .008; Δ systolic strain rate: r = −0.31, P < .01). Similar changes were observed with diastolic function (Δe′: r = −0.33, P < .01; Δ early diastolic strain rate r = −0.20, P = .04). In the subgroup with PAP measurements, ΔPAP (r = 0.32, P < .01) increased with age. Men had greater augmentation of systolic reserve, but differences were negated when corrected for workload. S′ velocity was the most robust measure of RV systolic function.
There is a modest yet significant reduction in RV systolic and diastolic reserve with age, with an increase in PAP. S′ velocity is a robust and feasible measure that should be considered given the increasing use of stress testing to evaluate RV function.
Accuracy of Doppler echocardiographic estimates of pulmonary artery pressures in a canine model of pulmonary hypertension
2015, Journal of Veterinary Cardiology
To compare noninvasive estimates of pulmonary artery pressure (PAP) obtained via echocardiography (ECHO) to invasive measurements of PAP obtained during right heart catheterization (RHC) across a range of PAP. To examine the accuracy of estimating right atrial pressure via ECHO (RAP_ECHO) compared to RAP measured by RHC (RAP_RHC), and determine if adding RAP_ECHO improves the accuracy of noninvasive PAP estimations.
14 healthy female beagle dogs.
Comparison of ECHO and RHC measures of PAP, both at normal PAP and increased PAP generated by microbead embolization.
Noninvasive estimates of PAP were moderately but significantly correlated (r of 0.68–0.78; p < 0.0006) with invasive measurements of PAP. Wide variance was noted for all estimations, with increased variance at higher PAP. The addition of RAP_ECHO improved correlation and bias in all cases. RAP_RHC was significantly correlated with RAP_ECHO (r = 0.38; p = 0.04) as estimated by the ellipse area method. Median RAP_RHC was significantly different between 3 subjective assessments of right atrial size (p = 0.037).
Spectral Doppler assessments of tricuspid and pulmonic regurgitation are imperfect methods for predicting PAP as measured by catheterization despite an overall moderate correlation between invasive and noninvasive values. Noninvasive measurements may be better utilized as part of a comprehensive assessment of PAP in canine patients. RAP_RHC appears best estimated based on subjective assessment of RA size. Including estimated RAP_ECHO in estimates of PAP improves the correlation and relatedness between noninvasive and invasive measures of PAP, but notable variability in accuracy of estimations persists.
Opposite behavior of plasma levels surfactant protein type B and receptor for advanced glycation end products in pulmonary sarcoidosis
2013, Respiratory Medicine
Citation Excerpt :
The tricuspidal annular plane systolic excursion (TAPSE) was measured in the M-mode by placing the cursor through the lateral tricuspid annulus in the apical four-chamber view. Pulmonary systolic artery pressure (PASP) was indirectly obtained by adding the mean right atrial pressure to the peak systolic pressure gradient of tricuspid regurgitant flow [24]. Standard echocardiographic views were analyzed by a single expert physician blind to the results of subjects' clinical characteristics, and they were obtained according to the recommendations by the American Society of Echocardiography [25].
No biological marker is currently available for evaluating pulmonary involvement and/or for monitoring the clinical course of sarcoidosis. The present pilot study focused on possible relationships between circulating plasma levels of surfactant protein type B (SP-B) and plasma receptor for advanced glycation end products (RAGE) and lung function abnormalities in patients with pulmonary sarcoidosis, since both SP-B and RAGE have been previously suggested as lung injury markers. The plasmatic levels of these two proteins were also investigated with respect to functional capacity, as assessed by a cardiopulmonary exercise test (CPET).
Thirty pulmonary sarcoidosis outpatients and fifteen volunteers (Control Group) underwent lung function tests and CPET. Resting SP-B and RAGE plasma levels were also determined. Patients were then categorized according to the severity of their pulmonary involvement, as assessed in terms of lung diffusion for carbon monoxide (DL_CO) values.
Group B showed SP-B levels higher and RAGE levels lower than Group A and Control Group (p < 0.01). Group A showed lower RAGE levels than Control Group (p < 0.01), whereas SP-B levels did not differ between these two groups. A significant univariate relationship was found between both SP-B and RAGE and several lung function data, particularly with DL_CO (SP-B Vs DL_CO: r: −0.437, p = 0.016; RAGE Vs DL_CO: r: −0.451, p = 0.012).
Circulating plasma levels of SP-B and RAGE showed an opposite behavior in patients with pulmonary sarcoidosis. SP-B values are directly related to alveolar unit damage, supporting a possible role of SP-B as a marker of disease severity in these patients. Differently, RAGE decreases in severe sarcoidosis, suggesting more complex underlying mechanisms.

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Non-invasive assessment of pulmonary hypertension: Doppler–echocardiography

Abstract

Introduction

Section snippets

Detection of pulmonary hypertension

Right atrial pressure estimation

Normal values and clinical implications

Morphological evaluation of right side chambers

Functional evaluation of the right ventricle

Conclusion

J Am Coll Cardiol

J Heart Lung Transplant

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Chest

Am Heart J

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Med

J Am Soc Echocardiogr

Am J Cardiol

Approach to patient with pulmonary hypertension

The normal pulmonary arterial pressure-flow relationships during exercise

Am J Med

Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease

Am J Respir Crit Care Med

Noninvasive estimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation

Circulation