Echocardiographic Evaluation of Pulmonary Pressures and Right Ventricular Function after Pediatric Cardiac Surgery: A Simple Approach for the Intensivist

Abstract

Pulmonary hypertension (PH) is diagnosed using cardiac catheterization and is defined as an elevation of mean pulmonary artery pressure (PAP) greater than 25 mmHg. Although invasive hemodynamics remains the gold standard and is mandatory for disease confirmation, transthoracic echocardiography (TTE) is an extremely useful non-invasive and widely available tool that allows for screening and follow-up, in particular, in the acute setting. TTE may be a valuable alternative, allowing for direct measurement and/or indirect assessment of PAP. Because of the complex geometric shape and pattern of contraction of the right ventricle (RV), as well as the inherent complexity of cardiac repair, no single view or measurement can provide definite information on RV function and PAP and/or pulmonary vascular resistance. In addition, specific training and expertise may be necessary to obtain the views and measurements required. Some simple measurements may be of help when rapid evaluation is mandatory and potentially life saving: the assessment of tricuspid and/or pulmonary valve regurgitant jet and the use of the Bernoulli equation allow for measurement of PAP. Measurements such as the analysis of the pulmonary Doppler wave flow, the septal curvature, or the eccentricity index, assessing ventricular interdependence, are useful for indirect assessment. A four-chamber view of the RV gives information on its size, hypertrophy, function (fractional area change), and tricuspid annular plane systolic excursion as an evaluation of the longitudinal function. Based on these simple measurements, TTE can provide detection of PH, measurement or estimation of PAP, and assessment of cardiac function. TTE is also of importance in follow up of PH as well as providing an assessment of therapeutic strategies in the postoperative setting of cardiac surgery. However, PAP may be misleading as it is dependent on cardiac output and requires accurate measurements. In the presence of residual lesions, analyses of some Doppler measurements may be misleading and not reflect real PAP. Should the TTE evaluation reveal non-conclusive, invasive hemodynamics remains the gold standard.

Commentary: Echocardiographic Evaluation of Pulmonary Pressures and Right Ventricular Function after Pediatric Cardiac Surgery: A Simple Approach for the Intensivist

“…If properly performed, echocardiography may make cardiac catheterization expandable in the immediate postoperative period ( 7 ), taking into account the critical condition of these patients and potential complications ( 8 ).However, cardiac catheterization still remains the gold standard for the diagnosis of a PAH ( 8 ). In addition we agree with the notice of Beghetti ( 2 ) that more data of treatment strategies for pediatric PAH, although partially existing ( 9 , 10 ), are highly recommended.…”

“…To date, in our intensive care unit (ICU) we use calculation of the TR jet, the PR jet, the pulmonary artery acceleration time (PAAT), the tricuspid annular peak systolic velocity (TDI), and the tricuspid annular plane systolic excursion (TAPSE) measurements to quickly investigate RV function and pressure in postoperative patients. We completely agree with the author ( 2 ) that pulmonary vascular resistance (PVR) is too complex to measure in critical care medicine when a quick evaluation is needed and furthermore that more detailed/complex measurements such as TEI index, strain measurements, and 3D measurements are way too time consuming in this specific setting.…”

“…The article “Echocardiographic Evaluation of Pulmonary Pressures and Right Ventricular Function after Pediatric Cardiac Surgery: A Simple Approach for the Intensivist” by Beghetti ( 2 ) describes an extremely useful overview how to use an echocardiography approach to quickly evaluate pulmonary arterial pressure (PAP) and right ventricular (RV) function in children in regard of PAH in the intensive care unit setting. The author elaborates that in this population there is a clear need for a thoroughly evaluation of children with an “RV under pressure,” using the first line investigation echocardiography ( 2 ). Children with PAH still are challenging in regard of evaluation and treatment ( 3 ).…”

“…We want to thank the author for addressing the need for quick, simple, and reproducible measurements in children with suspected PAH and/or RV dysfunction for the intensivist and want to highlight his article, which now provides essential tools to acquire this target ( 2 ). It would be of benefit for the audience of Frontiers in Pediatrics if doctor Beghetti would be willing to provide a simple Table/Figure with the few variables to quickly measure RV function and PAH estimation—as a short survey for intensivists all over the world.…”

Echocardiographic Evaluation of Ventricular Function—For the Neonatologist and Pediatric Intensivist

“…For the specific condition, readers are advised to refer to the relevant TINEC research articles published under the same theme in Frontiers in Pediatrics ; such as echocardiographic evaluation of patent ductus arteriosus, echocardiographic evaluation of hemodynamics, and echocardiographic evaluation of pulmonary hypertension, readers are advised to refer to the relevant TINEC research articles published under the same theme in Frontiers in Pediatrics ( 46 – 48 ).…”