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Pulmonary hypertension echo
1. Pulmonary hypertension is defined as a mean pulmonary artery pressure greater than 25 mm Hg at rest as measured by right heart catheterization. Severity is classified as mild, moderate, or severe based on pressure readings. 2. Echocardiography can be used to estimate pulmonary artery pressures and assess right heart structures for signs of pulmonary hypertension. Measurements like tricuspid regurgitation velocity, pulmonary regurgitation pressure gradient, and inferior vena cava size correlate with pulmonary artery pressures. 3. Additional findings on echo that indicate pulmonary hypertension include right ventricular dilation, septal flattening, reduced right atrial emptying, and pulmonary artery acceleration time. Together, echo findings can establish the diagnosis
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Introduction to pulmonary hypertension and ECHO diagnostics by Dr. Sayee Venkatesh.
Definition of pulmonary hypertension, mean pulmonary artery pressures, and classification based on severity.
Calculation of PVR values, normal ranges, and significance in pulmonary hypertension.
Details of M-mode ECHO patterns, significance of waveform features in pulmonary hypertension diagnosis.
D-shape left ventricle during systole/diastole indicating right ventricular pressure overload.
Measurement of right ventricular hypertrophy as an indicator of pulmonary hypertension.
Calculation of RVSP and RAP using echocardiographic methods per ASE guidelines.
Estimation of mean PAP and grading severity of pulmonary hypertension through specific formulas.
Protocols for measuring peak pressure gradients, mean PAP, and end diastolic values.
Methods for measuring RVOT acceleration time and implications for diagnosing significant pulmonary hypertension.
Calculation of PVR values indicating normal or elevated resistance in pulmonary vascular changes.
Criteria for dilated right atrium and ventricles as indicative of pulmonary hypertension.
Identification of poor prognostic signs in pulmonary hypertension, such as RA area and pericardial effusion.
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Pulmonary hypertension echo
- 1. PULMONARY HYPERTENSION ECHO Dr sayeevenkatesh Post graduate- dept of cardiology Stanley medical college
- 2. DEFINITION BRAUNWALD : Normal meanpulmonary artery pressure is 14 +- 3 mm Hg Mean PAP greater than 25 mm Hg at rest or > 30 mmHg during exercise and pulmonary vascular resistance > 3 wood units. When PCWP is < 15 mm Hg – precapillary PHT PCWP >15 mm Hg – post capillary PHT. ESC 2015 : Mean PAP greater than 25 mm Hg at rest measured by right heart catheterisation. Latest : mpap greater than 21 mm Hg at rest . grade MPAP MILD 25 – 40 mm Hg MODERATE 41-55 SEVERE > 55
- 3. PVR = meanPAP – PCWP / Cardiac output. When this value is multiplied by 80 , value will be in mmHg / litre / min or dynes /sec/ cm5 or wood units. Normal value of PVR in adults is ( 67 +- 23 )or 1 wood unit.
- 4. M- mode ofpulmonary valve a – atrial systole b – onset of ventricular systole c d – ventricular systole e – completion of systole. ef – diastole
- 5. • Normal valueof a is 3 – 7 mm during quiet respiration. • In pulmonary hypertension amplitude of a decreases. • When a < 2 mm mPAP 20 – 40 mmHg. absent a wave mPAP - > 40 mm Hg. Normal ef slope is 6 – 115 mm / sec . Reduction in ef slope is a feature of PHT. Ef slope is posterior in direction. If anterior in direction it is called as negative ef slope Negative ef slope is significant of pulmonary hypertension. Mid systolic notching of cd wave is significant of pulmonary HTN. Amplitude of bc has no significance. FLUTTERING OF POSTERIOR PULMONARY CUSP IN SYSTOLE – PHT. The valve seen in m mode is left cusp of pulmonary valve. REAPPEARENCE OF “a “ WAVE INDICATES ONSET OF RV FAILURE. ( M mode echo by alagesan )
- 11. Shape of leftventricle • Normally the shape of left ventricle will be circular both during systole and diastole. • Increase in RV pressure causes the flattening of IVS towards LV, which gives a D shape of LV. • D shape LV during diastole – RV Volume overload. • D shaped LV during systole – RV pressure overload . • D shape during both – combined overload of RV
- 13. • When thefree wall of RV is > 5 mm also indicates RV hypertrophy which is a feature of pulmonary hypertension.
- 14. PA SYSTOLIC PRESSURE •In the absence of RVOT obstruction RVSP = SYSTOLIC PAP. • Calculated using the formula (4* TRV2) + RAP. • Central jet A4C view / para sternal short axis view / rv focused view. • Eccentric jet RV inflow view. • Under estimated in RV failure , poor alignment of jet , mild TR. • Over estimated anemia , with agitated saline contrast
- 15. • Right atrialpressure : ASE 2015 guidelines • Subcostal view - m mode • 0.5 – 3.0 cms from its opening into RA • Just before the junction of hepatic vein into IVC. • END EXPIRATION. IVC diameter Collapsibility RAP <21 mm > 50 % 0-5 mm Hg ( 3 ) <21 mm <50 % 5-10mm Hg ( 8 ) >21 mm >50 % 5-10 mm Hg ( 8 ) > 21 mm < 50 % 10-15 mm Hg ( 15 )
- 18. TRPG – 42.8mm HG. RAP – 8 mm Hg. RVSP = TRPG + RAP = 51 mm Hg. ( ase 2015 guidelines ) Severity of PHT ESTIMATED RVSP NORMAL < 35 mm Hg MILD 35 – 45 MODERATE 46 – 60 SEVERE > 60
- 19. • Mean PAP: 1. 4 * PRV 2 + RAP 2. 0.61 * SPAP + 2 mm Hg ( 0.61 * 42.8 ) +2 = 28 mm Hg. 3. DEBASTANI MAHAN’S equation : 90- 0.62 * rvot acc time ( heart rate < 120 msec ) 79 – 0.45 * rvot acc time ( heart rate > 120 msec ) 4. TR vti + RAP • DIASTOLIC PAP : – 4 * PRV ED 2 + RAP
- 20. PR JET MEASUREDAT END EXPIRATION SWEEP SPEED 100
- 21. • PEAK PRPRESSURE GRADIENT : 35 mm Hg. • RAP : 8 mm Hg. • MEAN PAP : 43 mm Hg. • END DIASTOLIC PR GRADIENT : 16.7 mm Hg. • RAP : 8 mm Hg. • DPAP : 24.7 mm Hg.
- 22. TR vti =21 RAP = 8 MPAP = 29 mm Hg
- 24. • RVOT ACCTIME = 74 msec. • 90 – ( 0.62 * 74 ) = 45 mm Hg = mean PAP. • For RVOT accelerated time measurement – Parasternal short axis view – End expiration – Just proximal to Pulmonary valve – Doppler beam aligned with pulmonary forward flow beam – Sweep speed 100 . Normal RVOT AT = > 130 msec PHT = RVOT AT < 100 msec
- 25. SYSTOLIC NOTCHING OFTHE RVOT VELOCITY INDICATES SIGNIFICANT PHT.
- 26. • PULMONARY VASCULARRESISTANCE: – ( TRV / RVOT VTI ) * 10 + 0.16 – WHEN VALUE >0.2 PVR > 2 WU – WHEN < 0.15 PVR NORMAL. – TRV = 3.1 – RVOT VTI 6.5cms. PVR > 0.2 PVR > 2 WOOD UNITS.
- 28. DILATED RA =WHEN RA AREA > 18 cm2 at end systole
- 29. DILATED RV ATBASE = > 41 mm at end diastole
- 30. RV dilated –at papillary level >35 mm at end diastole. Length from base to apex > 83 mm at end diastole.
- 31. RVOT above aorticvalve if > 30 mm dilated. Just proximal to pulmonary valve > 27 mm dilated
- 33. • POOR PROGNOSTICSIGNS IN PHT: • 1. RA AREA > 26 cm2 • 2. PERICARDIAL EFFUSION.