Transthoracic Echocardiography in the Evaluation of Pediatric Pulmonary Hypertension and Ventricular Dysfunction

Abstract

Transthoracic echocardiography (TTE) is the most accessible noninvasive diagnostic procedure for the initial assessment of pediatric pulmonary hypertension (PH). This review focuses on principles and use of TTE to determine morphologic and functional parameters that are also useful for follow-up investigations in pediatric PH patients. A basic echocardiographic study of a patient with PH commonly includes the hemodynamic calculation of the systolic pulmonary artery pressure (PAP), the mean and diastolic PAP, the pulmonary artery acceleration time, and the presence of a pericardial effusion. A more detailed TTE investigation of the right ventricle (RV) includes assessment of its size and function. RV function can be evaluated by RV longitudinal systolic performance (e.g., tricuspid annular plane systolic excursion), the tricuspid regurgitation velocity/right ventricular outflow tract velocity time integral ratio, the fractional area change, tissue Doppler imaging-derived parameters, strain measurements, the systolic-to-diastolic duration ratio, the myocardial performance (Tei) index, the RV/left ventricle (LV) diameter ratio, the LV eccentricity index, determination of an enlarged right atrium and RV size, and RV volume determination by 3-dimensional echocardiography. Here, we discuss the potential use and limitations of TTE techniques in children with PH and/or ventricular dysfunction. We suggest a protocol for TTE assessment of PH and myocardial function that helps to identify PH patients and their response to pharmacotherapy. The outlined protocol focuses on the detailed assessment of the hypertensive RV; RV-LV crosstalk must be analyzed separately in the evaluation of different pathologies that account for pediatric PH.

Right ventricular base/apex ratio in the assessment of pediatric pulmonary arterial hypertension: Results from the European Pediatric Pulmonary Vascular Disease Network

“…An accurate assessment of RV size and function is therefore critically important for guiding treatment and clinical monitoring in PAH patients of all ages . The role of echocardiography in the diagnosis and clinical follow‐up of children with PAH has evolved and expanded in recent years . In particular, echocardiographically determined RV end‐systolic and RV end‐diastolic diameters can easily be obtained and therefore may be used as noninvasive measures of RV size and geometry in children with PAH .…”

“…5,6 The role of echocardiography in the diagnosis and clinical follow-up of children with PAH has evolved and expanded in recent years. [7][8][9] In particular, echocardiographically determined RV end-systolic and RV end-diastolic diameters can easily be obtained and therefore may be used as noninvasive measures of RV size and geometry in children with PAH. 10 A novel RV end-systolic basal-apical ratio (RVES b/a ratio) recently has been demonstrated to be a simple reproducible prognostic marker in adults with PAH.…”

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

“…This underscores the need of non-invasive techniques to assess the PAP and right ventricular function such as transthoracic echocardiography (TTE). Several recent reviews describe the use and importance of TTE in the diagnosis and follow up of pediatric PH, but they mostly focus on chronic PH and are not specifically dedicated to the specific postoperative situation ( 2 – 5 ). Kaestner et al, in their review of pediatric PH in the intensive care unit, summarize some of the echocardiography measurements that are useful in this setting ( 6 ).…”

Transesophageal Echocardiographic Approach to a Patient with Suspected Pulmonary Hypertension in the Intraoperative Period

“…The another limitation of this method is in the case of severe TR in which the right atrium (RA) pressures equalize very rapidly, with the RVSP leading to reduced peak TR velocity, and in case of Gerbode shunt, in which the TR velocity may estimate the LV systolic pressure (LVSP). 16 Finally, the limitations in the measurement of RAP also should be considered. This formula holds true in the evaluation of RVSP when the above limitations are taken care of even in patients with primary TV pathology and RV dysfunction, in which case the SPAP is low because of reduced flow in the pulmonary system despite having PH defined in terms of PVR > 3 Woods unit (WU).…”