Annual Scientific Meeting-Korean Circulation Society

Echo Estimation of Pulmonary Arterial Pressure

: Tips and Pitfalls

Chonnam National University Hospital

Kye Hun Kim, MD, PhD
 Case: Lee O O (57/M)

CC DOE (D: several years)

PI DOE on hard working or climbing for several years

Recent aggravation of dyspnea from 2 months ago

PE Jugular venous distention (+)

Soft delayed P2
Systolic ejection murmur (IV/VI) on LUSB

Lab NT-proBNP 803.3 pg/ml

Lee O O (57/M): Electrocardiography
Lee O O (57/M): Chest X-ray
Lee O O (57/M): Echocardiography
Lee O O (57/M): Echocardiography
 Case: Lee O O (57/M)

. ?

TR maximal velocity 3.95 m/s .

Doppler 62mmHg .

TR .

Eccentricity index 1.0 .

Lee O O (57/M): Echocardiography
Lee O O (57/M): CT RV and Pulmonary Angiography
 Pulmonary Artery Pressure: Clinical Implications

Pulmonary hemodynamics
: Influenced by many of cardiac or non-cardiac diseases
: An independent predictor of prognosis of cardiac diseases

Estimation of pulmonary artery pressure (PAP)

: Important in the diagnosis of certain primary disease of
pulmonary vascular beds or systemic disease
: Important in the estimation of cardiac hemodynamic status
 Evaluation of Pulmonary Artery Pressure

Right heart catheterization (RHC)

: Invasive, but gold standard for evaluating PAP
: Still be a important tool in idiopathic or associated PAH

Echocardiography with Doppler

: Non-invasive, useful method
: Has been replaced the role of RHC for evaluating PAP
: A number of methods are available for estimatiing PAP
Normal Hemodynamic Parameters
Normal Hemodynamic Parameters
 Estimation of Systolic PAP: TR Velocity

In the absence of PS or RVOT obstruction

: RV systolic pressure (RVSP) = Systolic PAP

P between RV and RA = RVSP - RA pressure

: RVSP = P between RV and RA + RA pressure

In the presence of TR
: P between RV and RA = 4 x (TR peak velocity)2
: RVSP = 4 x (TR peak velocity)2 + RA pressure
Estimation of Systolic PAP

PH Severity Values

Severity SPAP(mmHg)
Normal 18-25
Mild 30-40
Moderate 40-70
Severe > 70
 Tips for Measuring PAP: TR Velocity

Use multiple views including sub-costal view

: To obtain best curve and the maximal velocity
: Best alignment between TR flow and Doppler signal
AF (+)
: Mean of multiple measurements of TR velocity
Use color Doppler
: Correct continuous Doppler gain, baseline, scale, and
velocity to maximize curve view
Use contrast with air-saline or air-blood-saline to enhance
inadequate TR signals
Milan A et al. JASE 2010;23:225-39
 Estimation of RA Pressure using IVC Diameter

Normal Intermediate High

Variable
(0-5 mmHg) (5-10 mmHg) (15 mmHg)

IVC diameter 2.1 cm 2.1 cm >2.1 cm >2.1 cm

Collapse with sniff >50% <50% >50% <50%

Restrictive filling
Tricuspid E/E >6
Diastolic flow
Secondary indices of
predominance in
elevated RA pressure
hepatic veins
(systolic filling
fraction < 55%)

2010 JASE Guideline for RV Quantification

 RA Pressure using IVC Diameter: Technical Tips

Optimize the subcostal view to obtain a clear view of the

right atrium and IVC displayed in its long axis

Measure IVC diameter at end-diastole and end-expiration or

after deep inspiration of sniff maneuver

Measurement can be made in 2D image view approximately

2 cm before right atrium or using M-mode on subcostal
short-axis view
RA Pressure Measurements

Milan A et al. JASE 2010;23:225-39

 Tips for Measuring PAP: Tricuspid DTI

Optimize the apical 4-chamber view to obtain a clear view of

the tricuspid annulus
Reduce the sector to increase frame rate
Try to make the RV free wall as parallel as possible with the
Doppler cursor using, if necessary, off axis view
Place the sample volume (size, 3-8 mm) on the lateral
tricuspid annulus
Correct tissue Doppler gain, baseline, scale, and velocity to
optimize the signal
 Tips for Measuring PAP: Hepatic Venous Flow

Optimize the sub-costal view to obtain a clear view of the IVC

displayed in its long axis
Use color Doppler to identify and maximize hepatic vein view
Align the cursor as parallel as possible to the hepatic vein
Use pulsed Doppler
: Place the sample volume (size, 5-7 mm) 1-2 cm into the HV
: Correct Doppler gain, baseline, scale, and velocity to
maximize curve view
 Estimation of Systolic PAP: Pulmonary Flow

Pulmonary flow acceleration time (AcT)

: Pulse wave Doppler of pulmonary

forward flow

: Qualitative, not quantitative

: < 93ms in elevated SPAP

: Sensitivity 71%, specificity 56%

 Tips for Measuring PAP: Pulmonary Forward Flow

Sample in parasternal long-axis view modified for the RV out

flow tract and in short-axis view looking for the best curve and
maximal velocity
Use color flow Doppler and, when necessary, off-axis view to
obtain the best alignment between pulmonary forward flow
and Doppler signal
Use pulsed Doppler
: Sample volume (size, 5-7 mm) in RVOT just proximal to the PV
: Correct Doppler gain, baseline, scale, and velocity to maximize
curve view
Milan A et al. JASE 2010;23:225-39
Estimation of Systolic PAP

Milan A et al. JASE 2010;23:225-39

Estimation of Mean PAP: Peak PR Velocity
 Estimation of Mean PAP: Peak PR Velocity

Continuous wave Doppler of pulmonary regurgitation

: Mean PAP = 4 x (peak PR velocity)2 + RA pressure
Technical tips for measuring PR velocity
: Measure in parasternal long-axis view modified for RVOT and in
short-axis view looking for the best curve and maximal velocity
: Use color flow Doppler and, when necessary, off-axis view to
obtain the best alignment between PR flow and Doppler signal
: Correct Doppler gain, baseline, scale, and velocity to maximize
curve view
: Pay attention to avoid aliasing
 Estimation of Mean PAP

Mahan`s equation
: Use acceleration of pulmonary forward flow on PW Doppler
: Mean PAP = 79 - (0.45 x AcT of pulmonary forward flow)

Mean PAP by Mahans equation

= 79-(0.45 x AcT)= 79- (0.45 x 78)
= 79-35 = 44 mmHg
Estimation of Mean PAP

Milan A et al. JASE 2010;23:225-39

 Estimation of Diastolic PAP

End-diastolic PR velocity
: CW or PW Doppler of pulmonary regurgitation
: Diastolic PAP = 4 x (end-diastolic PR velocity)2 + RA pressure
: High correlation with invasively measured diastolic PAP
(Masuyama T et al. Circulation 1986;74:484-92)

RV pressure assessment at the time of pulmonary valve opening

: Diastolic PAP = 4 x (TR velocity at PV opening)2 + RA pressure
: High correlation with invasively measured diastolic PAP
(Stephen B et al. Chest 1999;116:73-7)
 Estimation of Diastolic PAP

PR end-diastolic velocity

RV systolic velocity at PV opening Milan A et al. JASE 2010;23:225-39

Estimation of PAP in VSD

SPAP = RVSP = LVSP - 4V2 = SBP 4V2

Estimation of PAP in patients with PDA

SPAP = SBP - 4V2

 Pitfall in echo-estimation of PAP

Although the application of echo technique to estimate SPAP

has been widely validated, its precision is debatable

Validation studies between echo and RHC measurements

: Mean difference ranged from 3 to 38 mmHg
: SPAP was underestimated with the echocardiographic
method by >20 mm Hg in 31% of all patients studied
: Pressure underestimation was greater than overestimation

Should not be used to decide when to treat patients or to

monitor therapy efficacy
Pitfall in echo-estimation of PAP
 Pitfall in Echo Estimation of PAP

Technical caveat of measuring TR velocity

: Not clearly evaluated in about 15% of patients
: Varies with respiration (lower with inspiration)
Obtaining with patients in in-held expiration
: Aortic stenosis or mitral regurgitation mimic the TR
AS: short flow duraton
MR: Vpeak > 4 m/s
: Overestimation with too high Doppler gain
Oh JK. The ECHO manual 3rd Ed
Thanks for your attention