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Last reviewed: 03/19/2014

What abnormalities on echocardiography are associated with pulmonary hypertension (PH)?


Two-dimensional and Doppler echocardiography are essential to the noninvasive assessment of patients with suspected PH. Echocardiography can demonstrate cardiac structural changes such as right atrial or right ventricular enlargement, right ventricular hypertrophy, and PA enlargement. Flattening or leftward shift of the interventricular septum can also be identified. If the shift occurs during systole, it suggests ventricular pressure overload. If it occurs during diastole, it suggests volume overload. Leftward shift of the septum throughout the cardiac cycle suggests both right ventricular pressure and volume overload (Figure 30–8A, B). The left ventricle is often small and underfilled in PH, with normal systolic function (Figure 30–8B).

Echocardiography is also useful to assess the severity of tricuspid regurgitation (TR) and estimate pulmonary artery systolic pressure (PASP). PASP is estimated by entering the peak velocity of the TR jet right into the modified Bernoulli equation and adding the right atrial pressure estimated by evaluating respiratory change in the inferior vena cava diameter (PASP = 4v2 + right atrial [RA] pressure) (Figure 30–8C). Noninvasive PA pressure assessment is not only important in establishing a diagnosis of PH but also in monitoring response to therapy. Echocardiography-estimated PASP may by inaccurate when the peak velocity cannot be accurately assessed due to minimal TR, an eccentric TR jet, or severe TR. In patients with risk factors for PH and who have signs and symptoms concerning for PH, low estimated PASP may not exclude PH.

Echocardiography can also be helpful in detecting left-sided heart disease. A dilated, hypocontractile left ventricle, valvular disease, or left atrial myxoma can be identified or excluded on a routine echocardiogram. Color-flow and agitated saline injection can also be used to assess for the existence of congenital intracardiac or intrapulmonary shunts.

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  • Figure 30–8.Figure 30–8.Figure 30–8.

    Figure 30–8.Transthoracic echocardiogram of a patient with pulmonary arterial hypertension. A: This apical four-chamber view demonstrates RA and RV enlargement. There is leftward shifting (flattening) of the interventricular septum. B: This parasternal short-axis view demonstrates RV enlargement, a small LV cavity, and leftward shifting (flattening) of the interventricular septum. C: This continuous wave Doppler recording shows how the tricuspid regurgitation velocity is obtained by echocardiography and used to estimate the pulmonary artery systolic pressure (PASP = 4V2 + RAP). RV, right ventricle; IVS, interventricular septum; LV, left ventricle; RA, right atrium; LA, left atrium; RAP, right atrial pressure.
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  • Figure 18–88Figure 18–88

    Figure 18–88A. Parasternal short-axis view in severe pulmonary hypertension with marked enlargement of the right ventricle (RV). The left ventricle (LV) is small, and the interventricular septum is flattened. B. Apical four-chamber view in pulmonary hypertension. The right atrium (RA) and RV are much larger than the left-sided chambers.
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  • Figure 18–89

    Figure 18–89M-mode in severe pulmonary hypertension. The dimension of the right ventricle (RV) is larger than that of the left ventricle (LV). The interventricular septum (IVS) moves paradoxically (ie, toward the mitral valve [MV] during diastole rather than away).
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  • Figure 18–90

    Figure 18–90M-mode image of the pulmonic valve in severe pulmonary hypertension (parasternal transducer position). The A dip is absent, and a characteristic W-shaped motion of the leaflet is present during systole (the “flying W“ ), indicating partial closure of the valve during midsystole followed by reopening before diastole.
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