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Pulmonary Hypertension


Protocol written by the Education Committee of the British Society of Echocardiography: David Dawson, Julia Grapsa, Petros Nihoyannopoulos (Lead Authors), Richard Steeds (Chair), Jane Allen, John Chambers, Richard Jones, Guy Lloyd, Bushra Rana, Julie Sandoval, Nicola Smith, Matthew Thomas, Gill Wharton, Richard Wheeler

Download Pulmonary Hypertension (2011)

Introduction

1. Introduction

1. 1 The BSE Education Committee has previously published a minimum dataset for a standard adult transthoracic echocardiogram, available on-line at www.bsecho.org. This document specifically states that the minimum dataset is usually only sufficient when the echocardiographic study is entirely normal. The aim of the Education Committee is to publish a series of appendices to cover specific pathologies to support this minimum dataset.

1.2 The intended benefits of such supplementary recommendations are to:

• Support cardiologists and echocardiographers to develop local protocols and quality control programs for adult transthoracic study

• Promote quality by defining a set of descriptive terms and measurements, in conjunction with a systematic approach to performing and reporting a study in specific disease-states

• Facilitate the accurate comparison of serial echocardiograms performed in patients at the same or different sites.

1.3. This document gives recommendations for the image and analysis dataset required in patients being assessed for suspected pulmonary hypertension. The views and measurements are supplementary to those outlined in the minimum dataset and are given assuming a full study will be performed in all patients.

1.4 When the condition or acoustic windows of the patient prevent the acquisition of one or more components of the supplementary Dataset, or when measurements result in misleading information (e.g. off-axis measurements) this should be stated.

1.5 This document is a guideline for echocardiography in the assessment of patients with suspected pulmonary hypertension and will be up-dated in accordance with changes directed by publications or changes in practice.

References

1. Ghio S, et al. Prognostic relevance of the echocardiographic assessment of right ventricular function in patients with idiopathic pulmonary arterial hypertension. Int J Cardiol 2008;140:272-280.

2. Forfia PR et al. Tricuspid annular displacement predicts survival in pulmonary hypertension. Am J Respir Crit Care Med 2006;174:1034-1041.

3. Brennan JM, et al. Reappraisal of the Use of Inferior Vena Cava for Estimating Right Atrial Pressure. J Am Soc Echocardiogr 2007;20:857-861.

4. McQuillan BM, et al. Clinical correlates and reference intervals for pulmonary artery systolic pressure among echocardiographically normal subjects. Circ 2001;104:2797-2802.

5. Jeon DS, et al. The Usefulness of a 10% Air-10% Blood-80% Saline Mixture for Contrast Echocardiography: Doppler Measurement of Pulmonary Artery Systolic Pressure. J Am Coll Cardiol 2002;39:124-129.

6. Kitabatake A, et al. Noninvasive evaluation of pulmonary hypertension by a pulsed doppler technique. Circ 1983;68:302-309.

7. Brechat N, et al. Usefulness of right ventricular isovolumic relaxation time in predicting systolic pulmonary artery pressure. Eur J Echocardiogr 2008;9:547-554.

8. Ryan T, et al. An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol 1985;5:918-927.

9. Raymond RJ, et al. Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. J Am Coll Cardiol 2002;39:1214-1219.

10. Melek M, et al. Tissue Doppler evaluation of tricuspid annulus for estimation of pulmonary artery pressure in patients with COPD. Lung 2006;184:121-31.

11. Yeo TC, et al. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol 1998;81:1157-1161.

  VIEW MODALITY MEASUREMENTS EXPLANATORY NOTE IMAGE

PLAX

2D

RV:LV Diastolic Ratio

Qualitative

Identify pericardial effusion as a marker of adverse prognosis

RV:LV ratio cutoff >0.5:1

• Significance: Diagnostic

• An assessment of RV enlargement

Click to enlarge

A4CH

2D

RV Minor/Major Axis Dimensions (RVd)

Quantitative

RV Diastolic and Systolic Area (RVAd/s)

Quantitative - calculate Fractional Area Change1

See BSE Guidelines: Chamber Quantification

Significance: Diagnostic

An assessment of RV size and function

Click to enlarge

A4CH

M-mode

Tricuspid Systolic Annular Plane Excursion (TAPSE)

• M-mode cursor across lateral tricuspid annulus

• Select a fast sweep speed

• Measure total excursion of the tricuspid annulus

TAPSE cutoff <1.6 cm

See BSE Guidelines: Chamber Quantification

Significance: Diagnostic

A measure of longitudinal RV systolic function2

Click to enlarge

PSAX

2D

M-mode

Inferior Vena Cava Diameter (IVC)

At end diastole and end-expiration

Perpendicular to the IVC long axis

Approx1.0 - 2.0 cm from the RA junction

Assess % reduction in diameter with sniffing

See BSE Guidelines: Chamber Quantification

Significance: Diagnostic & Prognostic

Indicator of RV filling pressure

Consider assessing hepatic vein flow to supplement accuracy3

Click to enlarge

A4C

PSAX

CW

Peak tricuspid regurgitant velocity (TR Vmax)

TR Vmax cutoff

>2.6 m/s

>2.8 m/s if obese

>2.9 m/s if >60 yrs

• Significance: Diagnostic4

• An indicator of pulmonary pressure in the absence of pulmonary stenosis

• Consider agitated saline/air/blood contrast if incomplete envelope 5

Click to enlarge

PSAX

PW

RV outflow tract acceleration time (AT)

Held end-expiration

Onset of flow to peak velocity

RVOT AT cutoff <105 ms

• Significance: Diagnostic 6

• Surrogate measure of PA pressure

Click to enlarge

A4CH

PW  TDI

Isovolumetric relaxation time (IVRT)

• Sample volume at basal lateral RV myocardium

• Held end-expiration

• Offset of S' wave to onset E' wave

RV IVRT cutoff >75 ms

• Significance: Diagnostic. A value below 40ms has a high negative predictive value for PHT 7

• A measure of RV dysfunction

Click to enlarge

PSAX

2D

Eccemticity Index (EI)

EI = D2/D1

Where: D1 = Minor axis dimension perpendicular to septum

D2 = Minor axis dimension perdendicular to D1

EI cutoff >1.0

Significance: Prognostic 8

EI end systole an expression pressure overload

EI end diastole an expression volume overload

Click to enlarge

A4CH

2D

RA Volume (RAV)

Where: RAV=0.85(A2)/L

RAVI male cutoff >33 m/m2

RAVI female cutoff >27 ml/m2

Significance: Prognostic 9

Click to enlarge

A4CH

PW  TDI

RV S' Wave Velocity

Sample volume at basal lateral RV myocardium

S' wave velocity cutoff : <12 cm/s

Significance: Diagnostic 10

Expression of RV longitudinal systolic function

Click to enlarge

A4CH

PW TDI

RV MPI MPI= a-b/b

Where:

a = A' offset to E' onset

b = S' onset to S' offset

• RV MPI cut off: >0.32

Significance: Prognostic 11

Expression of RV systolic and diastolic performance

Click to enlarge

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