Chest
ReviewsPulmonary Arterial Hypertension: The Key Role of Echocardiography
Section snippets
2D-echo
Because of chronic RV pressure overload, most patients present with enlarged right-side chambers, RV hypertrophy, and reduced global RV systolic function.9 This is accompanied by a systolic flattening of the interventricular septum (IVS), with increased thickness and an abnormal IVS/posterior left ventricular (LV) wall ratio (> 1) in response to pressure overload. The LV appears D-shaped with reduced diastolic and systolic volumes, but preserved global systolic function9 (Fig 1, top).
Prognostic Implications
The prognosis of PAH is relatively poor and directly related to the severity of right-heart dysfunction.12272829303132333435363738394041424344 Together with a number of hemodynamic and noninvasive parameters, the echocardiographic indicators of right-heart impairment (Table 4), which include indexed right atrial area, the degree of septal shift in diastole, a high Doppler RV performance index, and the severity of PE, have been associated with unfavorable outcomes (death or lung transplantation).
Ex-echo
Ex-echo is a reliable means of monitoring PAP during exercise and thus differentiating physiologic and pathologic pulmonary PAP responses.762636465 It can be used to assess the pulmonary vascular response to increasing blood flow and may help identify patients with ExPH. In healthy subjects, moderate exercise leads to an increase in stroke volume and a relatively small increase in PAP. Pulmonary vascular resistance falls with exercise as a physiologic response that allows the thin-walled RV to
Future Directions
The extensive application of new echocardiographic methods (pulsed-wave tissue Doppler imaging, contrast, tridimensional, and intracardiac echocardiography) may open up new horizons in the noninvasive assessment of RV function and structure in patients with PAH. Systolic and diastolic tissue Doppler imaging-derived velocity profiles of RV free wall and the lateral tricuspid annulus have been related to right chamber hemodynamic and function, and may be useful in detecting RV dysfunction early,
Conclusions
Echocardiography is an essential component of the diagnostic algorithm of PAH insofar as it makes it possible to confirm the diagnosis. It may also help to exclude PH related to congenital systemic-to-pulmonary shunts or secondary to pulmonary venous hypertension, thromboembolic disease or obstructed pulmonary vessels, predict the prognosis, monitor the efficacy of specific therapeutic interventions, and detect the preclinical stage of the disease.
References (102)
- et al.
The prognostic role of the ECG in primary pulmonary hypertension
Chest
(2002) - et al.
Echocardiographic features of primary pulmonary hypertension
J Am Soc Echocardiogr
(1999) - et al.
Effects of beraprost sodium, an oral prostacyclin analogue, in patients with pulmonary arterial hypertension: a randomized double-blind, placebo-controlled trial
J Am Coll Cardiol
(2002) - et al.
Effects of the oral endothelin-receptor antagonist bosentan on echocardiographic and Doppler measures in patients with pulmonary arterial hypertension
J Am Coll Cardiol
(2003) - et al.
Echocardiographic features of primary pulmonary hypertension
Am J Cardiol
(1974) - et al.
Echocardiographic evidence of pericardial effusion in severe chronic pulmonary hypertension
Am J Cardiol
(1989) - et al.
Continuous wave Doppler determinant of right ventricular pressure: a simultaneous Doppler catheterization study in 126 patients
J Am Coll Cardiol
(1985) - et al.
Evaluation of pulmonary artery pressure and resistance by pulsed Doppler echocardiography
Am J Cardiol
(1987) - et al.
Comparison of three Doppler ultrasound methods in the prediction of pulmonary artery pressure
J Am Coll Cardiol
(1987) - et al.
Noninvasive estimation of atrial pressure from the inspiratory collapse of the inferior vena cava
Am J Cardiol
(1990)
Frequency and severity of tricuspid regurgitation determined by Doppler echocardiography in primary pulmonary hypertension
Am J Cardiol
Doppler echocardiographic assessment of impaired left ventricular filling in patients with right ventricular pressure overload due to primary pulmonary hypertension
J Am Coll Cardiol
Echocardiographic predictors of an adverse response to a nifedipine trial in primary pulmonary hypertension: diminished left ventricular size and leftward ventricular septal bowing
Chest
Effect of diagnosis on survival benefit of lung transplantation for end-stage lung disease
Lancet
Effect of orally active prostacyclin analogue on survival of outpatients with primary pulmonary hypertension
J Am Coll Cardiol
A comparison of the acute hemodynamic effects of inhaled nitric oxide and aerosolized iloprost in primary pulmonary hypertension: German PPH study group
J Am Coll Cardiol
Comparison of survival in patients with pulmonary hypertension associated with fenfluramine to patients with primary pulmonary hypertension
Am J Cardiol
Assessment of right ventricular function two-dimensional echocardiography
Am Heart J
An echocardiographic index for separation of right ventricular volume and pressure overload
J Am Coll Cardiol
Quantification of tricuspid regurgitation by Doppler color flow mapping after cardiac transplantation
Am J Cardiol
Quantitative assessment of pulmonary hypertension in patients with tricuspid regurgitation using continuous wave Doppler ultrasound
J Am Coll Cardiol
Doppler echocardiographic index for assessment of global right ventricular function
J Am Soc Echocardiogr
Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension
Am J Cardiol
Frequency and prognostic significance of pericardial effusion in primary pulmonary hypertension: PPH Study Group
Am J Cardiol
Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension
J Am Coll Cardiol
Hemodynamics and survival in patients with pulmonary arterial hypertension related to systemic sclerosis
Chest
Noninvasive evaluation of pulmonary artery systolic pressures during dynamic exercise by saline-enhanced Doppler echocardiography
Am Heart J
Contrast-enhanced Doppler ultrasound for noninvasive assessment of pulmonary artery pressure during exercise in patients with chronic congestive heart failure
Am J Cardiol
Left ventricular filling pressures during exercise. a cardiological blind spot?
Chest
Range of tricuspid regurgitation velocity at rest and during exercise in normal adult men: implications for the diagnosis of pulmonary hypertension
J Am Coll Cardiol
Pulsed Doppler echocardiography in the diagnosis of pulmonary hypertension in COPD
Chest
Evaluation of right ventricular systolic pressure during incremental exercise by Doppler echocardiography in adults with atrial septal defect
Chest
Effects of the dual endothelin-receptor antagonist bosentan in patients with pulmonary hypertension: a randomised placebo-controlled study
Lancet
Estimation of left and right ventricular filling pressures after heart transplantation by tissue Doppler imaging
Am J Cardiol
Association between myocardial right ventricular relaxation time and pulmonary arterial pressure in chronic obstructive lung disease: analysis by pulsed Doppler tissue imaging
J Am Soc Echocardiogr
Detection of early right ventricular dysfunction in Chagas's disease using Doppler tissue imaging
J Am Soc Echocardiogr
Pulsed Doppler tissue imaging in dystrophinopathic cardiomyopathy
J Am Soc Echocardiogr
Transpulmonary passage of Albunex as a marker of intracardiac hemodynamics and outcome in chronic congestive heart failure
Am Heart J
Ventricular interdependence: significant left ventricular contributions to right ventricular systolic function
Prog Cardiovasc Dis
Hand-carried ultrasound (HCU) device: recommendations regarding new technologies; a report from the Echocardiography Task Force on New Technology of the Nomenclature and Standards Committee of the American Society of echocardiography
J Am Soc Echocardiogr
ACCP consensus statement: primary pulmonary hypertension
Chest
Electrocardiogram in primary pulmonary hypertension
Eur J Cardiol
Radiologic features in primary pulmonary hypertension [abstract]
Chest
The electrocardiogram in the diagnostic algorithm for primary pulmonary hypertension: the need for clinical correlation [abstract]
Chest
Echocardiographic assessment of overt or latent unexplained pulmonary hypertension
Can J Cardiol
Effects of long-term infusion of prostacyclin (epoprostenol) on echocardiographic measures of right ventricular structure and function in primary pulmonary hypertension
Circulation
Non-invasive estimation of pulmonary artery systolic pressure with Doppler ultrasound
Br Heart J
Estimation of pulmonary artery pressure by pulsed Doppler echocardiography [abstract]
Circulation
Non invasive evaluation of pulmonary hypertension by a pulsed Doppler technique
Circulation
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