Assessment of Pulmonary

Pressures and Right Heart

Function

Jeffrey B. Geske, M.D.

Geske.Jeffrey@mayo.edu

©2018 MFMER | 3664386-1

Assessment of Pulmonary Pressures

and Right Heart Function

Jeffrey B. Geske, MD

©2018 MFMER | 3664386-2

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 Disclosure
• No disclosures

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Learning Objectives
• Simplify echocardiographic assessment of pulmonary
hemodynamics
• Review quantitation of right ventricular size and function
• Discuss echocardiographic prognostic findings in pulmonary
hypertension
• Clarify mechanistic differentiation of PH by
echocardiography

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 Pulmonary Hypertension – Outline
Echo Evaluation

Disease
Severity

PH? / Mechanism
Pressures

Echo
in PH

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28 y/o Female Presents with Dyspnea,

Syncope and Lower Extremity Edema

RV
LV

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 28 y/o Female Presents with Dyspnea,
Syncope and Lower Extremity Edema

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Hemodynamics

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 25
Pressure (mm Hg)

20 Pulmonary
artery
15 pressure
Right
10 ventricular
Right atrial pressure
5
pressure
0 +
0.0 0.2 0.4 0.6 0.8 1.0
+ + +
Seconds

RVSP = 4 (VTR)2 + RAP

RV systolic pressure = PA systolic pressure
(in the absence of pulmonary stenosis)

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Overestimating RV Systolic Pressure

Rich Imagination and Overgained Signals

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 Overestimating RV Systolic Pressure
Don’t measure the fuzz!

2.9 vs. 3.6 i.e. 34 mmHg vs. 52 mmHg 3.5 vs. 4.8 i.e. 49 mmHg vs. 92 mmHg

TR Tips:
Avoid overgained, fuzzy signals
Use contrast if needed
Modal signal

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RA Pressure
• Don’t base estimate on an arbitrary value
• Base on 2D and Doppler imaging of the IVC and hepatic veins

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 IVC Measurement

Rudski LG et al: J Am Soc Echocardiogr: 23;685, 2010

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Assessment of Right Atrial Pressure

Based on IVC and Hepatic Vein Imaging

HV PW Doppler
• normal IVC dimension (≤21 mm)
5 mmHg • normal (>50%) collapse with sniff/inspiration

10 mmHg • normal IVC with reduced collapse

15 mmHg • Dilated IVC with normal collapse

• Severely dilated IVC & hepatic veins

20 mmHg • Little or no collapse with sniff/inspiration

Mayo Clinic
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 Assessment of Right Atrial Pressure
Based on IVC and Hepatic Vein Imaging

HV PW Doppler
• normal IVC dimension (≤21 mm)
3 mmHg • normal (>50%) collapse with sniff/inspiration

• normal IVC with reduced collapse

8 mmHg
• Dilated IVC with normal collapse

• Severely dilated IVC & hepatic veins

15 mmHg • Little or no collapse with sniff/inspiration

Simplified version recommended by ASE. Guidelines, 2010

Rudski LG et al: J Am Soc Echocardiogr: 23;685, 2010
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Estimated RVSP with Wide-Open TR

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 Estimated RVSP with Wide-Open TR
• TR velocity is typically low
as little pressure gradient
between RA and RV
• Ventricularization of RA
pressures
• Proximal velocity no
longer <<< distal velocity

RVSP = 4 (VTR)2 + RAP

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Estimated RVSP with Wide-Open TR

RA pressure typically very high

Hard to accurately predict

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 Pulmonary Hypertension Definition
PH = mean pulmonary artery pressure
≥25 mm Hg

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Relationship of PA Systolic and PA Mean Pressure

100 0.67 * PASP +0.5 Mean PAP ≈ 2/3rds systolic PAP

PA mean pressure, mmHg

90 r= 0.96, p<0.0001
80 n=534
70
(by cath)

60
50
40
30
20
10
0
0 25 50 75 100 125 150
PA systolic pressure, mmHg (by cath)
Courtesy of Dr. G Kane
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 Mean Pulmonary Artery Pressure
The most reproducible method
to calculate mean PA pressure
is based on the mean Doppler
gradient of the tricuspid
regurgitant (TR) signal

PAPm = TRmn gr + RAP

Adeun JF et al: J Am Soc Echocardiogr: 22;814, 2009

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Pulmonary Artery Diastolic Pressure

25 Pulmonary
Pressure (mm Hg)

artery
20 Diastole pressure

15
Right
10 ventricular
pressure
5

0
0.6 0.8 1.0 0.2 0.4 0.6 0.8 1.0
Seconds

PADP = 4 (VePR)2 + RAP

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 Mean PA Pressure
Peak PR velocitymax = 3 m/s

PAPm = 4 (Vpeak PR)2 + RAP

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Patient with Pulmonary Hypertension

Normal IVC Size with Near Complete Collapse

RVSP = 4 (VTR)2 + RAP = 4(4)2 + 3 = 67

PADP = 4 (VePR)2 + RAP = 4(2)2 + 3 = 19
PAPm = TRmn gr + RAP = 35 + 3 = 38

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 Echo Assessment of PH: 67/19/38
100
RHC: 90/28/54 RHC: 68/23/39
80

60

40

20

Room air 2L/min nasal oxygen

0
O2 Sats 87% O2 Sats 93%

 O2 sat ➔ vasoconstriction & PH

Perform the echo on oxygen
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Pulmonary Hypertension – Outline

Echo Evaluation

Disease
Severity

PH? / Mechanism
Pressures

Echo
in PH

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 In a patient with pulmonary hypertension, which of the
following factors LEAST predict outcome?
1. Pulmonary artery pressures
2. Right ventricular size
3. Right ventricular function
4. Left ventricular size
5. Presence of a pericardial effusion

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In a patient with pulmonary hypertension, which of the

following factors LEAST predict outcome?
1. Pulmonary artery pressures
2. Right ventricular size
3. Right ventricular function
4. Left ventricular size
5. Presence of a pericardial effusion

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How Do You Define Severity of PH?

• Mild PH → RVSP 40 – 55 mm Hg
• Moderate PH → RVSP 55 – 70 mm Hg
• Severe PH → RVSP > 70 mm Hg

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 PAH: A Progressive Disease
Outcome Poorly Predicted by PA Pressures
Pre-symptomatic Symptomatic Declining
Compensated decompensating Decompensated

CO

Symptom Threshold
PAP

Time

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How Do You Define Severity of PH?

• Mild PH → RVSP 40 – 55 mm Hg
• Moderate PH → RVSP 55 – 70 mm Hg
• Severe PH → RVSP > 70 mm Hg

• Don’t define severity of PH based on pressure alone

• Integrate pressure with other data including right heart function

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 Right Ventricular Afterload

PVR = (Mean PAP – PCWP) / CO

Reflects the arterial load to steady flow

• Doppler correlate:
PVR = Peak TRvel / RVOT TVI x 10
Does not incorporate LV filling pressure

The echo-derived PVR should not be used as a

substitute for an invasive PVR assessment

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Right Ventricular Afterload

Compliance / Capacitance

• Can be estimated by SV / PA pulse pressure

• May be as (more) important in PH as resistance

Stroke Volume LVOT Area X TVI

PVCAP = =
Pulse Pressure* 4 (TR Vmax2 – PRend V2)
*PA systolic – PA diastolic

Mahapatra S et al: J Am Soc Echocardiogr: 19;1045, 2006

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 “W Sign” – High RV Afterload

Normal PH
• Late onset of flow
• Early time to peak
• Mid systolic notching
• Reduced overall TVI

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Key Points About PA Pressures

• Accuracy of echo info is largely technical
• Avoid overgained TR signals
• Base RA pressure on echo data
• PA pressures important but not prognostic in PH
• Don’t look at one parameter in isolation

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 Pulmonary Arterial Hypertension
Survival in the Modern Era

100 Consecutive series

80 of PAH who died
Survival (%)

60 Non PH causes
Progressive RVF
40
Sudden death
20 (severe RV dysfxn)
Secondary cause
0 PH/RVF contributed

0 1 2 3 4 5 6 7 8
Follow-up, years

Kane GC et al: CHEST June; 139 (6), 2011

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Right Ventricular Size

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 Challenging Geometry of the RV

RV Normal
RV
Pulmonary
LV Hypertension
LV
LV LV
RV RV

RA RA
LA LA

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Appropriate RV imaging
Obtain an RV Apical 4 Chamber View
LV centric RV centric

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 Right Ventricular Size
Qualitative

Normal Mild RVE Moderate RVE Severe RVE

2/3 size of LV Similar to LV Larger than LV Very large

Shares apex D-shaped septum

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RV Size Quantitation
• Length (>83 mm* ) RV
• Mid diameter (>35 mm* )
• Basal diameter (>41 mm* ) LV
*Measures indicate dilatation
Tips
• Measure at end-diastole from an RV-focused RA
apical 4-chamber view LA
• Optimize image to have maximum diameter
without foreshortening the ventricle

Lang RM et al: J Am Soc Echocardiogr: 28;1, 2015

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 Right Ventricular Function

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RV Function
• Patients do not die of PH, they invariably die of the
failure of the RV to compensate for the PH
• There is no gold standard measure of RV function
• CT and MRI better for RVEF
• Many echo parameters of RV function predict outcome
in patients with PH

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 RV Index of Myocardial Performance (RIMP)
Global Indicator of Systolic and Diastolic Function

TV Closure to Open time

RIMP =
(IVCT + IVRT) TVCOt – RV ET
=
RV ET RV ET

• Relatively independent of HR, preload or afterload

• Prognostic in PH
• May be falsely low if RAP high (which will ↓ IVRT)

IVCT IVRT

RVOT
ejection time

Tei C et al: J Am Soc Echocardiogr: 9;838, 1996

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Visual Assessment of Ventricular Function

LV RV

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 Predominant Longitudinal
Fiber Orientation in the RV
Unlike the LV, the RV lacks
significant endocardial and
epicardial transverse layers

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RV Function by 3D Echo

• Unlike LV, radial contractility of RV is modest

• Predominant RV motion is longitudinal (base towards apex)

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 Simple Measures of Longitudinal Shortening
TAPSE and TDI
Both prone to translational error
TAPSE (≥20mm)

ES

ED

End-diastole End-systole Systolic velocity (≥15cm/sec)

• Simple S’

• Specific, modestly sensitive

• Prognostic in PAH

Fiorfia P et al: Am J Respir Crit Care Med;174:1034, 2006

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RV Free Wall Longitudinal Peak Systolic Strain

• Sensitive and reproducible Abnormal: Less

• Angle independent Negative than -25%
• Not prone to translational motion
• Prognostic in PAH, superior to other
measures
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 RV Strain Predicts Outcomes in PH
Time Free of Cardiac Events
All-Cause Mortality or PH Medical Intervention

Time free from cardiac event or

PH medical intervention (%)
50 <-15% (severe reduction) 100
All-cause mortality (%)

-15 to -20% (moderate reduction)

40 -20 to -24% (mild reduction) 80
25% (normal)
30 60

20 40
P<0.001 P<0.001
10 20

0 0
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18
Follow-up, months Follow-up, months

Fine NM et al: Circ Cardiovasc Imag; 6:711, 2013

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Pericardial Effusion
Bad Sign in Pulmonary Hypertension
100
Mod or greater effusion
80
Mortality (%)

Mild effusion
60

40
No effusion
20

0
0 1 2 3 4 5
Follow-up, years

Mortality rates a reflection of high venous pressure rather than risk of tamponade

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 Findings Associated with Poor Prognosis in PAH
Structure RV Function Other
RV dilation RV systolic strain RA pressure
RA dilation TAPSE Pericardial effusion
Decrease in LV size Tissue Doppler Delayed relax pattern
RIMP PA capacitance
Cardiac output Severe TV regurgitation

PA pressures correlate poorly with outcome

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Pulmonary Hypertension – Outline

Echo Evaluation

Disease
Severity

PH? / Mechanism
Pressures

Echo
in PH

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 Pulmonary Hypertension
Classification

Group 1
Pulm arterial hypertension Group 2
Setting of LH Disease
• Idiopathic (primary PH)
• Familial/genetic
• Drug/toxin related Group 3
Hypoxia/Lung Disease
• Scleroderma
• Portopulmonary
• HIV Group 4
Chr Thromboembolic Disease
• Congenital sys – pulm shunts

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Pulmonary Hypertension
Classification by Echo

Pre-capillary PH Post-capillary PH

Group 1
Pulmonary Arterial Hypertension
Hemodynamics
Group 3 similar
Group 2
Hypoxia/Lung Disease Setting
FindingsofonLHEcho
Disease
and
RHC are
Group 4 indistinguishable
Chr Thromboembolic Disease

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 PH – Is It Pulmonary Venous Hypertension?
Usually easy by history, exam and echo
• Low LVEF
• Severe MR, MS, AS

PAH vs HFpEF with PH can be difficult

• Afib, LA enlargement, LVH – all suggest HFpEF
• Some echo features of ‘diastolic dysfunction’ can be
caused by a bad right heart (i.e. seen with PAH)
• Echo PVR calculations do not encompass LA pressure –
they do not distinguish PAH from PVH

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 Take Home Points
• RVSP = 4VTR2 + RAP
• Don’t overgain or measure fuzz
• Don’t use in wide open TR
• RV longitudinal motion is major contributor to systolic
function
• RV function is key for survival in PH
• Assess the left heart to determine mechanism of PH,
don’t rely on PVR by echo

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geske.jeffrey@mayo.edu

@jeffreygeske

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