The role of echocardiography in the diagnosis and management of patients with pulmonary hypertension

Abstract

Pulmonary hypertension (PH) is defined as an increased mean pulmonary artery pressure (P(pa)) >25 mmHg at rest as assessed by right heart catheterisation (RHC). However, this technique is invasive and noninvasive alternatives are desirable for early diagnosis of PH. Although estimation of systolic pulmonary arterial pressure is easily obtained using Doppler echocardiography, cases of under- and over-estimations are not rare and direct measurement of P(pa) is not possible using this method. Therefore, echocardiography should be considered as a tool for assessment of the likelihood rather than the definite presence or absence of PH. Transthoracic echocardiography may be useful for noninvasive screening of patients at risk of PH. On the basis of an echocardiographic assessment, patients showing signs suggestive of PH can be referred for a confirmatory RHC. A number of variables measured during echocardiography reflect the morphological and functional consequences of PH and have prognostic value. The presence of pericardial effusion, reduced tricuspid annular plane excursion and right atrial enlargement are associated with a poorer prognosis. Echocardiography is also an important procedure for monitoring the response of patients to therapy, and is recommended 3-4 months after initiation of, or a change in, therapy. Echocardiographic assessment as part of a goal-oriented approach to therapy is essential for the effective management of PH patients.

Conflict of interest statement

Statement of Interest

A. Torbicki has served as a consultant for Actelion, Eli Lilly, GlaxoSmithKline and mondoBIOTECH; received honoraria from Bayer Schering, Eli Lilly and Sanofi Aventis; and conducted research supported by Actelion, Bayer Schering, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, mondoBIOTECH and Pfizer.

Figures

Figure 1.

Typical echocardiographic features in a patient with severe pulmonary arterial hypertension. Dilatation of the right cavities, compression of the left cavities, presence of a pericardial effusion (arrow). RV: right ventricle; LV: left ventricle; RA: right atrium; LA: left atrium.

Figure 2.

Measurement of a) the right atrial area and b) dimensions in an apical four-chamber view. RV: right ventricle; LV: left ventricle; RA: right atrium; N: normal value.

Figure 3.

Measurement of the eccentricity index. RV: right ventricle; LV: left ventricle. Reproduced from [57] with permission from the publisher.

Figure 4.

Left heart consequences of pulmonary hypertension. a) Abnormal left ventricular filling by pulsed-wave Doppler. b and c) Measurement of cardiac output using Doppler echocardiography. LV: left ventricle; LA: left atrium; AO: aorta; D: aortic annulus diameter; TVI: time velocity integral.

Figure 5.

Assessment of the right ventricle global performance by the Tei index. a) Method of measurement of Tei index. Right ventricle myocardial performance index (RVMPI) ([a−b]/b) is calculated by measuring two intervals: 1) a is interval between cessation and onset of tricuspid inflow; and 2) b is ejection time (ET) of right ventricular outflow. ICT: isovolumetric contraction time; IRT: isovolumetric relaxation time; TRT: tricuspid regurgitation time. Reproduced from [62] with permission from the publisher. b) Prognostic value of Tei index. Reproduced from [63] with permission from the publisher.

Figure 6.

Measurement of the tricuspid annulus plane systolic excursion (TAPSE). a) Method of measurement of TAPSE by M-mode echocardiography. b) Prognostic value of TAPSE. Reproduced from [65] with permission from the publisher.

Figure 7.

Tissue Doppler imaging (TDI) of the basal part of the right ventricle free wall allows the measurements on a single cardiac cycle of several parameters of right ventricular function, including systolic (S) and diastolic (E and A) velocities, isovolumic contraction phase parameters, and TDI Tei index. IVV: isovolumic contraction velocity.

Figure 8.

Reverse remodelling of left and right cavities under specific therapy in a patient with severe idiopathic pulmonary arterial hypertension. a) Before specific therapy: severe dilatation of the right ventricle (RV) with left ventricle (LV) compression, in two dimensional (a) and M-mode (b) echocardiography. After 4 months of combination therapy: partial regression of RV dilatation and LV compression (c and d).