Tricuspid Regurgitation Signal Research Articles

Echocardiographic estimation of pulmonary vascular resistance in advanced lung disease.

Noninvasive assessment of pulmonary hemodynamics is often performed by echocardiographic estimation of the pulmonary artery systolic pressure (ePASP), despite limitations in the advanced lung disease population. Other noninvasive hemodynamic variables, such as echocardiographic pulmonary vascular resistance (ePVR), have not been studied in this population. We performed a retrospective analysis of 147 advanced lung disease patients who received both echocardiography and right heart catheterization for lung transplant evaluation. The ePVR was estimated by four previously described equations. Noninvasive and invasive hemodynamic parameters were compared in terms of correlation, agreement, and accuracy. The ePVR models strongly correlated with invasively determined PVR and had good accuracy with biases of <1 Wood units (WU), although with moderate precision and wide 95% limits of agreement varying from 5.9 to 7.8 Wood units. The ePVR models were accurate to within 1.9 WU in over 75% of patients. In comparison to the ePASP, ePVR models performed similarly in terms of correlation, accuracy, and precision when estimating invasive hemodynamics. In screening for pulmonary hypertension, ePVR models had equivalent testing characteristics to the ePASP. Mid-systolic notching of the right ventricular outflow tract Doppler signal identified a subgroup of 11 patients (7%) with significantly elevated PVR and mean pulmonary artery pressures without relying on the acquisition of a tricuspid regurgitation signal. Analysis of ePVR and determination of the notching pattern of the right ventricular outflow tract Doppler flow velocity envelope provide reliable insights into hemodynamics in advanced lung disease patients, although limitations in precision exist.

The accuracy and influencing factors of Doppler echocardiography in estimating pulmonary artery systolic pressure: comparison with right heart catheterization: a retrospective cross-sectional study

BackgroundNoninvasive assessment of pulmonary artery systolic pressure by Doppler echocardiography (sPAPECHO) has been widely adopted to screen for pulmonary hypertension (PH), but there is still a high proportion of overestimation or underestimation of sPAPECHO. We therefore aimed to explore the accuracy and influencing factors of sPAPECHO with right heart catheterization (RHC) as a reference.MethodsA total of 218 highly suspected PH patients who underwent RHC and echocardiography within 7 days were included. The correlation and consistency between tricuspid regurgitation (TR)-related methods and RHC results were tested by Pearson and Bland–Altman methods. TR-related methods included peak velocity of TR (TR Vmax), TR pressure gradient (TR-PG), TR mean pressure gradient (TR-mPG), estimated mean pulmonary artery pressure (mPAPECHO), and sPAPECHO. With mPAP ≥ 25 mm Hg measured by RHC as the standard diagnostic criterion of PH, the ROC curve was used to compare the diagnostic efficacy of sPAPECHO with other TR-derived parameters. The ratio (sPAPECHO–sPAPRHC)/sPAPRHC was calculated and divided into three groups as follows: patients with an estimation error between − 10% and + 10% were defined as the accurate group; patients with an estimated difference greater than + 10% were classified as the overestimated group; and patients with an estimation error greater than − 10% were classified as the underestimated group. The influencing factors of sPAPECHO were analyzed by ordinal regression analysis.ResultssPAPECHO had the highest correlation coefficient (r = 0.781, P < 0.001), best diagnostic efficiency (AUC = 0.98), and lowest bias (mean bias = 0.07 mm Hg; 95% limits of agreement, − 32.08 to + 32.22 mm Hg) compared with other TR-related methods. Ordinal regression analysis showed that TR signal quality, sPAPRHC level, and pulmonary artery wedge pressure (PAWP) affected the accuracy of sPAPECHO (P < 0.05). Relative to the good signal quality, the OR values of medium and poor signal quality were 0.26 (95% CI: 0.14, 0.48) and 0.23 (95% CI: 0.07, 0.73), respectively. Compared with high sPAPRHC level, the OR values of low and medium sPAPRHC levels were 21.56 (95% CI: 9.57, 48.55) and 5.13 (95% CI: 2.55, 10.32), respectively. The OR value of PAWP was 0.94 (95% CI: 0.89, 0.99). TR severity and right ventricular systolic function had no significant effect on the accuracy of sPAPECHO.ConclusionsIn this study, we found that all TR-related methods, including sPAPECHO, had comparable and good efficiency in PH screening. To make the assessment of sPAPECHO more accurate, attention should be paid to TR signal quality, sPAPRHC level, and PAWP.

A novel semi-automated method to improve estimation of right ventricular systolic pressure by Doppler ultrasound

Accurate measurements of maximal tricuspid regurgitation (TR) velocity is central for noninvasive estimation of right ventricular systolic pressure (RVSP). A better understanding of TR waveform shape may improve confidence in RVSP estimation. Our aim was to develop a semi-automated analysis of TR waveform shape and to model TR Vmax. We created an automated method to extract TR signals from the doppler image. We used Spearman correlation to study features of TR waveforms in relation to RV metrics. We then used a multi linear regression to develop a model to predict RVSP. From a cohort of 115 patients with pulmonary hypertension, we randomly defined a derivation (67%) and a validation data set (33%). We achieved good extraction of the waveform from the doppler (Pmax and VTI extracted vs. Pmax and VTI measured, r 2 = 0.991 and 0.929). Curve characteristics such as Pmax, skewness, defined as time to Pmax/RR, dP/dt max and min are strongly associated with RV longitudinal strain ( Table 1 ). The multivariate analysis using dP/dt min and max, pressure at dp/dt min and max time points, heart rate and time of TR duration normalized by RR predicted RVSP in our training data set (r 2 = 0.908). The model enabled prediction of RVSP in the validation data set (r 2 = 0.949, Fig. 1 ). We have developed an automated model to analyze TR waveforms and showed that interpolation of TR waveform features is possible and can provide additional support for accurate estimation of RVSP.

Abstract 10657: Automated Tracing of Tricuspid Regurgitation Doppler Waveforms

Introduction: The definition of pulmonary hypertension relies on the invasive measurement of increased pulmonary arterial pressures (PAPs). The systolic PAP can be non-invasively estimated from the maximal velocity (Vmax) of tricuspid regurgitation (TR) Doppler signals. However, the accuracy of this method is conditioned by the quality of the TR signal. It is also subject to high interobserver variability. To address these issues, we developed an automated, machine-learning framework to analyze TR signals. We hypothesize our method can accurately predict Vmax and velocity time integral (VTI) for any TR signal. Methods: We analyzed 306 TR Doppler signals consisting of high and intermediate signal qualities from 65 patients (median 50 [21, 86] years old). Our method combines a U-Net convolutional neural network with OpenCV, an image processing tool. The U-Net performs semantic image segmentation on an input TR Doppler signal. OpenCV then deduces the Vmax and VTI of the curve. We compared our predictions against expert assessments of the TR signal, Vmax, and VTI. We used 230/56 signals for training/validation to determine the optimal parameters in our U-Net and 20 signals for testing to obtain an unbiased measure of performance. Results: As shown in the figure, our framework accurately predicts Vmax with a bias of 0.06 m/s and 95% limits of agreement of [-0.50, 0.63] m/s, and VTI with a bias of 0.01 m and 95% limits of agreement of [-0.22, 0.23] m. Two signals proved difficult to trace due to noisy images. Our framework takes about 5 seconds to predict Vmax and VTI for each TR signal. Conclusions: The accuracy of the predicted Vmax and VTI is heavily influenced by the quality of the input TR signal. We can solve this issue by training our U-Net on a larger dataset and leveraging other computer-vision techniques or flagging these signals for user intervention. Automation of signal analysis opens the door for more detailed curve analysis on larger clinical cohorts.

Abstract 14250: Semi-automated Analysis of Tricuspid Regurgitation Doppler Profile for Detection and Evaluation of Pulmonary Hypertension

Introduction: Non-invasive detection of pulmonary hypertension relies on the tricuspid regurgitant (TR) Doppler maximal velocity (Vmax). When the TR signal is incomplete, Vmax must be estimated by extrapolation, which is prone to error. Automatic extrapolation could improve robustness but requires an in-depth understanding of complete TR shape. Semi-automated analysis was used to test the hypothesis that all waveforms can be expressed with a small set of curve parameters. Methods: We retrospectively analyzed complete continuous Doppler TR signals from 76 patients (median 50 [39, 56] years-old, 77% female) with pulmonary arterial hypertension in whom echocardiography and invasive hemodynamics were available within 3 months. Semi-automated analysis divided Doppler images into heartbeats (three signals per patient) using the ECG and recognized segmented waveforms for shape analysis. Multiple linear regression modeling assessed the independent association between waveform features (Vmax, velocity-time integral, curve width, skewness (t1,t2), kurtosis and time scale) and age, sex, pulmonary vascular resistance (PVR), TR severity, right ventricular (RV) end-diastolic area index (size), RV strain (function) and right atrial volume index. Results: TR waveforms were non-Gaussian with varying skewness, width and kurtosis. Figure summarizes the covariates associated with TR waveform features. Vmax was directly related to PVR and RV strain, but not to TR severity. The RR-normalized width was correlated to heart rate, TR severity, RV strain and size (all p&lt;0.0001). Kurtosis was not only associated with heart rate but also with PVR, TR severity, RV strain and size (all p&lt;0.01). Conclusions: The non-Gaussian TR Doppler curve shape is influenced by TR severity, RV function and size. The high variability in shape limits the ability to extrapolate signals in the presence of an incomplete envelope. Machine learning algorithms may be valuable to address this issue.

For a better estimation of pulmonary pressures by echocardiography: Need for quality improvement

Echocardiography provides controversial accuracy in estimations of systolic pulmonary pressures (sPAP). The objective of this study was to determine the factor influencing the accuracy using echocardiography in patients with history of heart failure with preserved ejection fraction or pulmonary arterial hypertension. Between January 2014 and January 2018, 184 patients with suspected pulmonary hypertension, underwent right heart catheterization (RHC) and transthoracic echocardiography within 5 days in our referral centre. Right ventricular systolic pressure was estimated according to tricuspid regurgitation (TR) signal and compared to hemodynamic sPAP. Twelve parameters were studied to determine the reasons of lack of accuracy in the echocardiographic sPAP result, namely: the cause of the pulmonary hypertension, the heart rate, the presence of atrial fibrillation, the right atrial size, the operator's experience (young or experienced), the severity of the TR, the TR signal quality, the number of incidences recorded of TR images, the inferior vena cava size, the difference between echo and hemodynamic right atrial pressure measurement, the cardiac index and the mean PAP. A difference of 10 mmHg between echo and hemodynamic sPAP measurement was considered as significant. Seventy-nine patients (50%) had a very good TR signal quality. Twenty-seven patients (15%) had no signal or very poor TR signal quality. Seventy-eight patients (50%) had a difference > 10 mmHg between echo and Hemodynamic sPAP estimation. The parameters associated with a difference of 10 mmHg or more between both measurements were a higher mean PAP (43 ± 10 vs. 39 ± 8 mmHg; P = 0.001), the experience of the operator ( P = 0.008), and the number of acquisition of the TR signal ≥ 3 ( P = 0.017). Echocardiography reliably estimates sPAP when attention is given to quality metrics, the experience of the reader, and the mean PAP.

What influences echocardiography reliability in estimation of pulmonary pressure?

If echocardiography provides reliable estimations of pulmonary pressures remain controversial. The objective of this study was to determine the accuracy of estimating right ventricular systolic pressure (RVSP) and the factor influencing this accuracy using echocardiography in patients with history of heart failure with preserved ejection fraction (HFpEF) or pulmonary arterial hypertension. Between January 2014 and December 2015, 118 patients with suspected pulmonary hypertension (PH), underwent right heart catheterization (RHC) and transthoracic echocardiography within 5 days in our referral center. The correlation in estimating RVSP according to tricuspid regurgitation (TR) signal quality and reader expertise were retrospectively determined. TR signal quality using continuous-wave Doppler were classified subjectively in three groups: good (type 1), moderate (type 2) and poor (type 3). We compared measurements from the echocardiography laboratory clinical report assessed by level 3–trained cardiologists certified in echocardiography, with offline reassessment by a level 1–young cardiologist blinded to RHC values. In total, 86 patients (72%) had a good or moderate TR signal quality. The comparison between clinical reports and young cardiologist reassessment gave a linear regression line having the equation y = −0, 1549 + 1, 0286 x. Correlation coefficient between RVSP estimation from RHC and echocardiography were respectively 0,69 (P < 0,001) from the clinical report and 0,62 (P < 0,001) from level 1 reader. When TR signal quality was good and moderate, correlation coefficient was respectively 0,75 (P < 0,001) from the clinical report and 0,72 (P < 0,001) from the level 1 reader. In 50 patients with type 1 TR quality signal, the correlation coefficient were respectively 0,83 (P < 0,001) and 0,78 (P < 001). Echocardiography reliably estimates RVSP when attention is given to quality metrics and the level of the reader.

Improving the echocardiographic assessment of pulmonary pressure using the tricuspid regurgitant signal-The "chin" vs the "beard".

Transthoracic echocardiography (TTE) is a fundamental investigation for the noninvasive assessment of pulmonary hemodynamics and right heart function. The aim of this study was to assess the correlation and agreement of Doppler calculation of right ventricular systolic pressure (RVSP) and pulmonary vascular resistance (PVR) using "chin" and "beard" measurements of tricuspid regurgitant velocity (TRVmax ), with invasive pulmonary artery systolic pressure (PASP) and PVR. One hundred patients undergoing right heart catheterisation (RHC) and near simultaneous transthoracic echocardiography were studied. TRVmax was recorded for "chin" measurement (distinct peak TRVmax signal) and where available (63 patients), "beard" measurement (higher indistinct peak TRVmax signal). Measurable TRV signal was obtained in 96 patients. Mean RVSPchin 54.7±22.7mmHg and RVSPbeard 68.6=23±26.3mmHg (P<.001). There was strong correlation between both RVSPchin and RVSPbeard with invasive PASP (Pearson's r=.9, R2 =0.82, P<.001 - r=.88, R=.78, P<.001, respectively.). Bland-Altman analysis for RVSPchin and RVSPbeard showed a mean bias of -0.5mmHg (95% limits of agreement -21.4 to 20.5mmHg) and -10.7 (95% LOA -35.5 to 14.2mmHg), respectively. Receiver operator characteristics of TRVmax "chin" and "beard" for diagnosis of pulmonary hypertension was assessed with optimal cut-offs being 2.8m/s (sensitivity 93%, specificity 87%) and 3.2m/s (sensitivity 91%, specificity 82%), respectively. There was similar correlation between PVRchin and PVRbeard (r=.87, R2 =0.75, P<.001 and r=.86, R2 =0.74, P<.001, respectively). At higher PVR, there was overestimation of calculated PVR using PVRbeard . The accuracy of noninvasive measurement of right heart pressures is increased using the "chin" in estimation of both RVSP and PVR.

Contrast microsphere enhancement of the tricuspid regurgitant spectral Doppler signal - Is it still necessary with contemporary scanners?

BackgroundAccurate evaluation of the tricuspid regurgitant (TR) spectral Doppler signal is important during transthoracic echocardiographic (TTE) evaluation for pulmonary hypertension (PHT). Contrast enhancement improves Doppler backscatter. However, its incremental benefit with contemporary scanners is less well established. The aim of this study was to assess whether the TR spectral Doppler signal using contemporary scanners was improved using a second generation contrast agent, Definity® (CE), compared to unenhanced TTE (UE). MethodsAnalysis of patients who underwent UE then CE TR interrogation was performed. TR signal was evaluated by an experienced reader and graded 1 (clear-high level of confidence of interpretation and complete spectral Doppler envelope), 2 (suboptimal with medium-low level of confidence of interpretation and incomplete envelope), 3 (poor-absent and no measurable spectral Doppler signal). Maximal TR velocity (TRV) was defined as peak velocity that could be clearly identified. An inexperienced sonographer read 30 randomly selected studies. Results176 TTE were performed in 173 patients (mean age 57±14.8years). Wilcoxon signed rank test demonstrated significant improvement (p<0.0001) in TR spectral Doppler signal quality with CE TTE. Mean score CE TTE vs. TTE=2.32±0.85 vs. 2.56±0.75 respectively (p<0.0001). Mean maximal TRV CE TTE vs. UE TTE=2.61±0.44m/s vs. 2.54±0.49m/s respectively (p<0.0001). The inexperienced reader had a greater improvement in scoring CE TTE signals vs. UE TTE (p<0.0001). ConclusionIn the era of contemporary scanners, CE improved the ability to detect and measure TRV, except in those with clear unenhanced TR spectral Doppler signals or greater than mild tricuspid regurgitation.

Severe right ventricular and tricuspid valve dysfunction after pericardiocentesis

Pericardiocentesis is performed to treat cardiac tamponade or diagnose the cause of pericardial effusion. Cardiogenic shock with right ventricular (RV) dysfunction is a rare complication after pericardiocentesis. We report a case of an 82-year-old man who suddenly suffered cardiopulmonary arrest 12h after pericardiocentesis. A transthoracic echocardiogram showed remarkable RV dysfunction and tricuspid valve dysfunction. Tricuspid valve closure was severely impaired, and the tricuspid regurgitation signal showed laminar flow with an early peak. However, after treatment with high-dose inotropic drugs, hemodynamic parameters gradually recovered. A transthoracic echocardiogram performed 24h later showed improved motion of the RV and the tricuspid valve, resulting in a reduction in tricuspid regurgitation. RV and tricuspid valve dysfunction after pericardiocentesis needs to be recognized as a critical complication. Physicians also need to pay attention to not only the amount of drainage but also underlying RV dysfunction.

Addressing the Controversy of Estimating Pulmonary Arterial Pressure by Echocardiography

There is currently controversy over whether echocardiography provides reliable estimations of pulmonary pressures. The objective of this study was to determine the factors influencing the accuracy and reliability of estimating right ventricular systolic pressure (RVSP) using echocardiography in patients with advanced lung disease or pulmonary arterial hypertension. Between January 2001 and December 2012, 667 patients with advanced lung disease or pulmonary arterial hypertension underwent right heart catheterization and transthoracic echocardiography. Of those, 307 had both studies within 5days of each other. The correlation and bias in estimating RVSP according to tricuspid regurgitation (TR) signal quality and reader expertise were retrospectively determined. Reasons for under- and overestimation were analyzed. The diagnostic performance of estimated RVSP, relative right ventricular size, eccentricity index, and tricuspid annular plane systolic excursion was compared for classifying patients with pulmonary hypertension (mean pulmonary artery pressure≥25mmHg). Invasive mean and systolic pulmonary artery pressures were strongly correlated (R(2)=0.95, P<.001), with mean pulmonary artery pressure=0.60×systolic pulmonary artery pressure+2.1mmHg. Among patients undergoing right heart catheterization and transthoracic echocardiography within 5days, level 3 readers considered only 61% of TR signals interpretable, compared with 72% in clinical reports. Overestimation in the clinical report was related mainly to not assigning peak TR velocity at the modal frequency and underestimation to overreading of uninterpretable signals. When the TR signal was interpretable, the areas under the curve for classifying pulmonary hypertension were 0.97 for RVSP and 0.98 for RVSP and eccentricity index (P>.05). When TR signals were uninterpretable, eccentricity index and right ventricular size were independently associated with pulmonary hypertension (area under the curve, 0.77). Echocardiography reliably estimates RVSP when attention is given to simple quality metrics.

Pulmonary artery diameter to predict pulmonary hypertension in pulmonary sarcoidosis

Pulmonary hypertension (PH) is a known complication of pulmonary sarcoidosis with a prevalence ranging from 5% to 74% [1]. The aetiology of PH in sarcoidosis is not fully understood. Usually, it is attributed to the destruction of the distal capillary bed by lung fibrosis and/or chronic hypoxaemia. However, the severity of PH does not correlate consistently with the degree of pulmonary fibrosis, and PH exists in sarcoidosis patients without fibrosis, suggesting a multifactorial mechanism. The presence of PH is associated with a poor prognosis, and early diagnosis and treatment might improve outcome [1]. Echocardiography should always be performed when PH is suspected [2]. However, the accuracy of echocardiography in patients with interstitial lung diseases is often limited due to poor image quality and unreliable tricuspid regurgitation signal to measure the right ventricular systolic pressure (RVSP) [3]. Further invasive investigation with the gold standard, right heart catheterisation (RHC), is often required. In order to optimise the noninvasive diagnostic approach, there is a need for more accurate predictors of PH. Computed tomography (CT) may raise suspicion of PH in symptomatic patients or those examined for unrelated indications by showing an increased pulmonary artery (PA) diameter (≥29 mm) and PA diameter/ascending aorta diameter (AAD) ratio (≥1.0) [2]. Similarly, PA diameter indexed to body surface area (BSA) has been suggested as possible predictor of PH. However, these parameters have never been investigated in pulmonary sarcoidosis specifically. Pulmonary artery indexed for body surface area is the most accurate predictor for PH on CT in pulmonary sarcoidosis

Echo Doppler Estimation of Pulmonary Capillary Wedge Pressure in Patients with Severe Aortic Stenosis.

Transcatheter aortic valve replacement (TAVR) has become a treatment option for patients with severe aortic stenosis (AS) and high surgical risk. Assessment of symptoms in these patients is challenging because of advanced age, comorbidities, and limited physical activity. Noninvasive quantification of pulmonary capillary wedge pressure (PCWP) in candidates for TAVR may be helpful for risk stratification. The objective of the study was to create a model for estimation of PCWP by echo Doppler in patients with severe AS. Data from 80 patients with severe AS referred for TAVR were used to develop an echo Doppler model for predicting PCWP. Its performance was evaluated in the test cohort of 33 patients who had invasive and noninvasive evaluation. No single echo Doppler parameter estimated PCWP accurately. In the retrospective analysis, the multilinear regression provided an accurate estimate of PCWP (r(2) = 0.74). The model included, in order of importance (all P < 0.05), the ratio of early transmitral velocity (E) to annular velocity (E'), the left ventricular ejection fraction, and the velocity time integral of tricuspid regurgitation signal. In the prospective cohort of patients with severe AS, the model demonstrated good predictive ability of PCWP (r = 0.77, P < 0.01). In patients with severe AS, noninvasive estimation of PCWP is possible by integration of two-dimensional, spectral, and tissue Doppler variables.

Clinical value of echocardiographic Doppler-derived right ventricular dp/dt in patients with pulmonary arterial hypertension.

Right ventricular (RV) dp/dt is the instantaneous rate of RV pressure rise during early systole and is a surrogate marker of RV contractility. The main objective of this study was to evaluate the ability of echocardiographic Doppler obtained RV dp/dt to predict long-term survival in patients with pulmonary arterial hypertension (PAH) and chronic thrombo-embolic pulmonary hypertension (CTEPH). Seventy-eight consecutive newly diagnosed untreated patients (64 ± 15 years, 71% female, 57% PAH, 43% inoperable CTEPH) were included in the study. At baseline, patients were assessed clinically [New York Heart Association (NYHA) and 6 minutes walking distance (6MWD)], by transthoracic cardiac ultrasound and by right heart catherization. RV dp/dt was assessed using spectral Doppler recordings from the tricuspid regurgitation signal at a sweep speed of 200 mm/s by measuring the time interval in which the regurgitant velocity increased from 0.5 to 2 m/s. During a mean follow-up period of 3.5 ± 1.7 years, 31 patients died and 3 received a lung transplant [study endpoint reached in 34/78 (44%) patients]. The optimal RV dp/dt cut-off was determined by receiver operating characteristic analysis at 3 years to be 410 mmHg/s (specificity 84%, positive-predictive value 55%, and negative-predictive value 83%). In univariate analysis, RV dp/dt <410 mmHg/s (hazard ratio 2.67, 95% CI 1.30-5.47, P = 0.007), tricuspid annulus plane systolic excursion (TAPSE) <15 mm, NYHA, 6MWD, and right atrial pressure were predictors of mortality. In a multivariate model with TAPSE, RV dp/dt remained an independent predictor of mortality (P = 0.01). A reduced baseline RV dp/dt is a clear indicator of poor outcome independent of TAPSE in patients with PAH/CTEPH.

Abstract 9399: Right Ventricular Dysfunction during Exercise: Potential Markers of Exercise Intolerance in Pulmonary Hypertension

Background: Development of exercise-induced pulmonary hypertension (exPH) is a clinically important; but poorly characterized hemodynamic event. Even though bicycle echocardiography (BE) has been suggested as a useful non-invasive test to estimate pulmonary artery pressures (PAP) during exercise; simple measurement of pressures appears to be an unreliable approach to detect exPH. Consequently, we queried our BE database to examine if objective parameters of right ventricular (RV) function might be useful in distinguishing abnormal responses to exercise. To accomplish this goal, we identified patients who develop mild exPH and compared them to normal controls. Methods: In this retrospective analysis, we measured RV fractional area change, tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index (RV MPI), and systolic velocity of the tricuspid annulus (TA TDI). All these measures were collected at each stage of the BE protocol from 10 control individuals, and 10 patients who developed mild exPH with estimated exercise PAP of 62 ± 9. Results: Tricuspid regurgitation signal was an unreliable measure to estimate PAP with increasing workloads; however, all objective parameters were collected in all patients at every stage. In control individuals, not only TAPSE and TA TDI increased with each stage but also baseline RV MPI was significantly lower and remained largely unchanged during exercise. In sharp contrast, TAPSE and TA TDI remained largely unchanged (Fig 1 A&amp;B) while the baseline RV MPI not only was higher but also continued to increase with exertion in the mild exPH group (Fig 1 C). Also individuals with exPH were older in age (p value&lt;0.001). Conclusion: Even though age might be an unaccountable variable in this pilot study; our data seems to suggest that objective measures of RV function during BE, might be useful for the assessment of RV response to increasing exercise workloads.

Noninvasive Estimation of Diastolic Pulmonary Artery Pressure by Doppler Analysis of Tricuspid Regurgitation Velocity in Pediatric Patients

Diastolic pulmonary artery pressure (dPAP) is equal to right ventricular pressure at the time of pulmonary valve opening. We studied the accuracy of dPAP estimated from Doppler profile of tricuspid regurgitation (TR) jet in pediatric patients. Echocardiograms were prospectively performed on consecutive pediatric heart transplant recipients undergoing right-heart catheterization and endomyocardial biopsy. An estimate of dPAP was obtained by superimposing the pulmonary valve opening time, indexed to the electrocardiogram, onto the TR Doppler tracing. Echocardiographic estimates of dPAP from end-diastolic pulmonary regurgitation (PR) were obtained for comparison. Catheter-derived right atrial pressure was added to the Doppler gradient in both groups. Doppler estimates and catheter-derived measurements of dPAP were compared using Lin correlation and Bland-Altman analysis. Sixty-five catheterization studies were performed on 35 patients (20 males): median age at enrollment: 12.1 years (4 months to 18 years); median time: since transplant of 1.2 years (21 days to 16.1 years). Adequate TR signal was obtained in a significantly higher proportion of patients than an adequate PR signal (65% vs. 43%, respectively, P = .007). Median catheter-derived dPAP was 12 mm Hg (6-30 mm Hg) and right atrial pressure was 6 mm Hg (1-17 mm Hg). Median estimated dPAP from TR was 15 mm Hg (range: 7-29 mm Hg), with the Lin correlation coefficient of 0.74 (95% confidence interval [CI]: 0.6-0.87). Median estimate for dPAP from PR was 10 mm Hg (range: 2-25 mm Hg), with the Lin correlation coefficient of 0.74 (95% CI: 0.58-0.9). There was excellent interobserver agreement for dPAP from TR with the Lin correlation coefficient of 0.946 (95% CI: 0.803-0.986). Doppler estimation of dPAP from TR is a novel, reliable, noninvasive method and compares favorably with estimation from PR. Adequate TR signal for estimation of dPAP can be obtained more frequently in children than adequate PR signal, thereby increasing the proportion of patients in whom dPAP can be estimated noninvasively.

Optimización en la técnica de medida de la presión arterial pulmonar por ecocardiografía Doppler con el uso de contraste en pacientes con enfermedad pulmonar obstructiva crónica

To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs). Compare standard reference (Doppler-echocardiography) with contrast. Echocardiography department. Ambulatory chronic obstructive patient disease (COPD). Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10 mm Hg to the transtricuspid gradient, calculated from the TR peak velocity. PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10 mm Hg vs. 56±15 mm Hg (p<0.01). The use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value.

Effects of age on pulmonary artery systolic pressure at rest and during exercise in normal adults

The aim of this study was to explore the range of pulmonary artery systolic pressure (PASP) at rest and with exercise in healthy individuals of various ages, as most studies assumed PASP > 35 mmHg with exercise as the upper limits of normal. Seventy healthy volunteers, with a good continuous wave Doppler tricuspid regurgitation signal at rest, underwent quantitative Doppler echocardiographic measurements at rest and during semi-supine exercise test. Pulmonary artery systolic pressure was estimated at rest, at low level (25 W), and at peak exercise using four times tricuspid valve regurgitation velocity squared adding a right atrial pressure of 5 mmHg. During exercise, PASP increased from rest (27 +/- 4 mmHg) to peak (51 +/- 9 mmHg). None of the individuals reached a PASP > or = 60 mmHg at 25 W. Pulmonary artery systolic pressure at peak was higher in individuals > or =60 years old compared with those from 20 to 59 years old (56 +/- 9 vs. 49 +/- 7 mmHg, P = 0.02). Pulmonary artery systolic pressure at peak exercise > or =60 mmHg was found in 36% of the individuals aged from 60 to 70 and in 50% after 70. Age, LV mass, and PASP at rest were independent predictors of PASP at peak exercise. Pulmonary artery systolic pressure at peak exercise can reach values > or =60 mmHg in many healthy individuals older than 60 with good exercise capacity. However, high levels of PASP > 60 mmHg for low level of exercise should be considered abnormal.

The usefulness of contrast during exercise echocardiography for the assessment of systolic pulmonary pressure

BackgroundThe systolic pulmonary artery pressure (PAPs) can be accurately estimated, non-invasively, using continuous-wave Doppler (CWD) ultrasound measurement of the peak velocity of a tricuspid regurgitant (TR) jet.However, it is often difficult to obtain adequate tricuspid regurgitation signals for measurement of PAPs, what could lead to its underestimation. Therefore, utilization of air-blood-saline contrast has been implemented for the improvement of Doppler signal in several clinical contexts.It is now recommended in the evaluation of patients with pulmonary hypertension. Physical activity is severely restricted in patients with PAH, being exertional dypnea the most typical symptom. Exercise stress echo-Doppler imaging allows assessment of the response to exercise. It is an excellent screening test for patients with suspected PAH. Our purpose was to evaluate the value and accuracy of agitated saline with blood contrast echocardiography, in the improvement of the Doppler signal, to quantify PAPs during treadmill exercise-echocardiography.PurposeTo evaluate the value of contrast echocardiography, using agitated saline with blood, in the improvement of the Doppler signal used to quantify the pulmonary artery systolic pressure during exercise.MethodsFrom a total of 41 patients (pts), we studied 38 pts (93%), 35 women, aged 54 ± 12 years-old. 27 with the diagnosis of systemic sclerosis, 10 with history of pulmonary embolism and one patient with a suspected idiopathic PAH, who were referred to the Unity of Heart Failure and Pulmonary Hypertension for screening of PAH. According to the Unity protocol, a transthoracic echocardiogram was made, in left decubitus (LD), with evaluation of right ventricle-right atria gradient (RV/RAg). A peripheral venous access was obtained, with a 3-way stopcock and the patients were placed in orthostatism (O), with a new evaluation of RV/RAg. Exercise echocardiography (EE) was begun, with evaluation of RV/RAg at peak exercise (P) and afterwards agitated saline (8 cc with 1 cc of air and 1 cc of blood) was injected, followed by a new evaluation of RV/RAg (PC) and then the interruption of the EE. Pulmonary Hypertension was diagnosed when RV/RAg at the end of the exercise was superior to 40 mmHg.ResultsThe quality of Doppler signal was deteriorated in 5 pts, maintained in 6 pts and improved in 26 pts, with the use of contrast. In one patient, an interventricular septal defect was diagnosed. In 6 pts, a Doppler signal was only obtained with the use of contrast. In 15 pts, a RV/RAg superior to 40 mmHg was only obtained with the use of contrast. Of these, 9 have already been submitted to right heart cathetherism, that confirmed the diagnosis of pulmonary hypertension in 5 of them (56%). RV/RAg (P) was 44 ± 11 mmHg and RV/RAg (PC) was 54 ± 11 mmHg, p < 0,001.Conclusion1. The method is applicable in a large number of patients. 2. RV/RA gradients obtained at peak exercise are higher with the use of contrast, and the clinical meaning of this difference should be evaluated in a larger number of pts submitted to right heart cathetherism. The high number of false positives should lead to a higher diagnostic threshold. 3. This method seems to have relevant clinical value in the diagnosis of pulmonary arterial hypertension.

Tricuspid Valve Disease

The normal tricuspid valve anatomy and function have several dissimilarities to the corresponding mitral valve in the left heart, in part, based on lower pressures in the right heart chambers. The functional abnormalities resulting from tricuspid valve disease are classified as primary and secondary. Primary valve disease is any associated intrinsic valve pathology. The list of responsible conditions includes congenital, rheumatic, infective endocarditis, carcinoid heart disease, toxic effects of chemicals, tumors, blunt trauma, and myxomatous degeneration. The secondary tricuspid valve disease does not involve intrinsic anatomic abnormalities of the valve apparatus, aside from tricuspid annular dilation secondary to right ventricular dilation and dysfunction. The most common cause of tricuspid valve disease is secondary to left heart disease, either myocardial, valvular, or mixed. Although bedside diagnosis of advanced tricuspid valve disease is feasible, echocardiography provides valuable clues to the presence and severity of tricuspid valve stenosis and/or regurgitation with considerable accuracy. The tricuspid regurgitation signal using Doppler techniques is utilized for estimation of right ventricular systolic pressure, which, in the absence of right ventricular outflow obstruction, corresponds to pulmonary arterial systolic pressure. This is clinically useful since nearly 80 to 90% of patients exhibit some degree of tricuspid regurgitation. The treatment of tricuspid valve disease is guided by underlying etiology and pathology. Tricuspid valve repair is increasingly advocated for patients with advanced tricuspid regurgitation, especially when combined with surgery on the left heart pathology. Primary tricuspid valve disease is often treated by surgical approach specific to the underlying pathology.