What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension?

BACKGROUND: Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions. OBJECTIVE: This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation. DISCUSSION: The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic). CONCLUSIONS: Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.

Long-term Prognostic Significance of Admission Tricuspid Regurgitation Pressure Gradient in Hospitalized Patients With Heart Failure With Preserved Ejection Fraction: A Report From the Japanese Real-World Multicenter Registry.

BACKGROUND: Doppler-estimated peak systolic tricuspid regurgitation pressure gradient (TRPG) is a representative noninvasive parameter for evaluating pulmonary artery systolic pressure, which can be a determinant of adverse outcomes in chronic heart failure with preserved ejection fraction (HFpEF). However, the prognostic implications of TRPG at admission for hospitalized patients with HFpEF are undetermined. METHODS AND RESULTS: We examined 469 consecutive hospitalized patients with decompensated HFpEF (left ventricular ejection fraction ≥ 50%) who underwent TRPG measurement at admission in our HFpEF multicenter registry. The primary outcome of interest was all-cause death. Admission TRPG was significantly correlated with estimated pulmonary capillary wedge pressure and left atrial dimension (r = 0.24, P < 0.001 and r = 0.21, P < 0.001, respectively). During a median follow-up period of 748 (IQR 540-820) days, 83 patients died. Higher TRPG was significantly associated with higher mortality compared to lower TRPG (log-rank; P = 0.007). Multivariable analysis revealed that elevated TRPG was an independent determinant of mortality (HR 1.02, 95% CI 1.01-1.04, P = 0.008) after adjustment for prespecified confounders and renal function. CONCLUSIONS: Elevated TRPG at admission was an independent determinant of mortality in hospitalized patients with HFpEF, indicating that TRPG at admission could be a useful marker for risk stratification in these patients.

Risk classification of pulmonary arterial hypertension by echocardiographic combined assessment of pulmonary vascular resistance and right ventricular function.

Which combination of clinical parameters improves the prediction of prognosis in patients with pulmonary arterial hypertension (PAH) remains unclear. We examined whether combined assessment of pulmonary vascular resistance and right ventricular function by echocardiography is useful for classifying risks in PAH. In 41 consecutive patients with PAH (mean age of 48.9 ± 17.3 years, 31 females), a 6-min walk test, pulmonary function test, and echocardiography were performed at baseline and during PAH-specific therapies. The study endpoint was defined as a composite of cardiovascular death and hospitalization for PAH and/or right ventricular failure. During a follow-up period of 9.2 ± 8.7 months, 18 patients reached the endpoint. Multivariate regression analysis showed that the ratio of tricuspid regurgitation pressure gradient to the time-velocity integral of the right ventricular outflow tract (TRPG/TVI) and tricuspid annular plane systolic excursion (TAPSE) during PAH-specific treatment were independent prognostic predictors of the endpoint. Using cutoff values indicated by receiver operating characteristic analysis, the patients were divided into four subsets. Multivariate analyses by Cox's proportional hazards model adjusted for age, sex and body mass index indicated that subset 4 (TRPG/TVI ≥ 3.89 and TAPSE ≤ 18.9 mm) had a significantly higher event risk than did subset 1 (TRPG/TVI < 3.89 and TAPSE > 18.9 mm): HR = 25.49, 95% CI 4.70-476.97, p < 0.0001. Combined assessment of TRPG/TVI and TAPSE during adequate PAH-specific therapies enables classification of risks for death and/or progressive right heart failure in PAH.

Detection of Pulmonary Hypertension with Systolic Pressure Estimated by Doppler Echocardiography.

Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure (PAP) ≥ 25 mmHg at rest as assessed by right heart catheterization (RHC), and Doppler-derived systolic PAP (sPAPECHO) or tricuspid regurgitation pressure gradient (TRPG) is widely used to screen for PH. However, the cutoff value of sPAPECHO or TRPG for detecting a mean PAP ≥ 25 mmHg that was determined invasively has not been well defined.We studied 189 patients who underwent RHC. Echocardiography was performed within 24 hours of invasive evaluation, and sPAPECHO was defined as the TRPG with right atrial pressure estimated on the basis of the current guideline.From the receiver operating characteristic (ROC) curve analysis, the optimal sPAPECHO, and TRPG cutoffs for detecting PH were 41 mmHg (sensitivity, 92%; specificity, 91%; area under the curve = 0.95) and 36 mmHg (sensitivity, 90%; specificity, 93%; area under the curve = 0.95), respectively. The area under the TRPG ROC curve was similar to the area under the sPAPECHO ROC curve.Given that Doppler echocardiography is required to accurately detect PH rather than to accurately estimate systolic PAP, our results provide useful information with regard to screening patients for PH and recommending further investigations on PH.

A subclinical high tricuspid regurgitation pressure gradient independent of the mean pulmonary artery pressure is a risk factor for the survival after living donor liver transplantation.

BACKGROUND: Portopulmonary hypertension (POPH) is characterized by pulmonary vasoconstriction, while hepatopulmonary syndrome (HPS) is characterized by vasodilation. Definite POPH is a risk factor for the survival after orthotopic liver transplantation (OLT), as the congestive pressure affects the grafted liver, while subclinical pulmonary hypertension (PH) has been acknowledged as a non-risk factor for deceased donor OLT. Given that PH measurement requires cardiac catheterization, the tricuspid regurgitation pressure gradient (TRPG) measured by echocardiography is used to screen for PH and congestive pressure to the liver. We investigated the impact of a subclinical high TRPG on the survival of small grafted living donor liver transplantation (LDLT). METHODS: We retrospectively analyzed 84 LDLT candidates. Patients exhibiting a TRPG ≥25 mmHg on echocardiography were categorized as potentially having liver congestion (subclinical high TRPG; n = 34). The mean pulmonary artery pressure (mPAP) measured after general anesthesia with FIO20.6 (mPAP-FIO20.6) was also assessed. Patients exhibiting pO2 < 80 mmHg and an alveolar-arterial oxygen gradient (AaDO2) ≥ 15 mmHg were categorized as potentially having HPS (subclinical HPS; n = 29). The clinical course after LDLT was investigated according to subclinical high TRPG. RESULTS: A subclinical high TRPG (p = 0.012) and older donor age (p = 0.008) were correlated with a poor 40-month survival. Although a higher mPAP-FIO20.6 was expected to correlate with a worse survival, a high mPAP-FIO20.6 with a low TRPG was associated with high frequency complicating subclinical HPS and a good survival, suggesting a reduction in the PH pressure via pulmonary shunt. CONCLUSION: In cirrhosis patients, mPAP-FIO20.6 may not accurately reflect the congestive pressure to the liver, as the pressure might escape via pulmonary shunt. A subclinical high TRPG is an important marker for predicting a worse survival after LDLT, possibly reflecting congestive pressure to the grafted small liver.

Risk factors for portopulmonary hypertension in patients with cirrhosis: a prospective, multicenter study.

BACKGROUND: Tricuspid regurgitation pressure gradient (TRPG) measurement by echocardiography is recommended as the most objective examination to detect portopulmonary hypertension (PoPH). This study aimed to identify factors associated with a high TRPG in patients with cirrhosis and develop a scoring model for identifying patients who are most likely to benefit from echocardiography investigations. RESULTS: A total of 486 patients who underwent echocardiography were randomly allocated to the derivation and validation sets at a ratio of 2:1. Of the patients, 51 (10.5%) had TRPG ≥ 35 mmHg. The median brain natriuretic peptide (BNP) was 39.5 pg/mL. Shortness of breath (SOB) was reported by 91 (18.7%) patients. In the derivation set, multivariate analysis identified female gender, shortness of breath, and BNP ≥ 48.9 pg/mL as independent factors for TRPG ≥ 35 mmHg. The risk score for predicting TRPG ≥ 35 mmHg was calculated as follows: - 3.596 + 1.250 × gender (female: 1, male: 0) + 1.093 × SOB (presence: 1, absence: 0) + 0.953 × BNP (≥ 48.9 pg/mL: 1, < 48.9 pg/mL: 0). The risk score yielded sensitivity of 66.7%, specificity of 75.3%, positive predictive value of 25.5%, negative predict value of 94.3%, and predictive accuracy of 74.4% for predicting TRPG ≥ 35 mmHg. These results were almost similar in the validation set, indicating the reproducibility and validity of the risk score. CONCLUSIONS: This study clarified the characteristics of patients with suspected PoPH and developed a scoring model for identifying patients at high risk of PoPH, which may be used in selecting patients that may benefit from echocardiography.

Focused Cardiac Ultrasound to Detect Pre-capillary Pulmonary Hypertension.

Background: Early recognition of pre-capillary (PC) pulmonary hypertension (PH) benefits dogs, allowing earlier treatment and improving prognosis. The value of focused cardiac ultrasound (FCU) to diagnose PH and assess its severity has not been investigated yet. Hypothesis: A subjective 10-point FCU pulmonary hypertension score (PHS) allows diagnosis and assessment of severity of PCPH. Animals: This study involved fifty client-owned dogs. Methods: Dogs, recruited between September 2017 and February 2020, were classified into four categories (no, mild, moderate, and severe PH; C1 to C4, respectively). C1 and C2, and C3 and C4 were regrouped as group 1 and group 2, respectively. A blinded general practitioner assessed four FCU cineloops. Five echocardiographic parameters were subjectively scored, resulting in a total score of 0-10. Non-parametric tests compared global scores between categories and groups. A receiver operating characteristic (ROC) curve determined the cutoff value to differentiate group 1 and group 2. A gray zone approach allowed diagnosing or excluding moderate to severe PH with 90% certitude. Results: Global scores were significantly higher for C4 than for C1, C2, and C3. Global scores of G2 were significantly higher than G1. The ROC curve indicated a cutoff value of 5, discriminating group 1 from group 2 with a sensitivity of 77% and a specificity of 100%. A score of ≥5/10 allowed diagnosing moderate to severe PH with ≥90% certainty while a score of ≤2/10 excluded PH with ≥90% certainty. Conclusions and Clinical Significance: Moderate to severe PCPH can be accurately detected by non-cardiologists using a 10-point FCU PHS score.

Clinical and Predictive Value of Computed Tomography Angiography in High-Altitude Pulmonary Hypertension.

Background: High-altitude pulmonary hypertension (HAPH), as the group 3 pulmonary hypertension, has been less studied so far. The limited medical conditions in the high-altitude plateau are responsible for the delay of the clinical management of HAPH. Objectives: This study aims to identify the imaging characteristics of HAPH and explore noninvasive assessment of mean pulmonary arterial pressure (mPAP) based on computed tomography angiography (CTA). Methods: Twenty-five patients with suspected HAPH were enrolled. Right heart catheterization (RHC) and pulmonary angiography were performed. Echocardiography and CTA image data were collected for analysis. A multivariable linear regression model was fit to estimate mPAP (mPAPpredicted). A Bland-Altman plot and pathological analysis were performed to assess the diagnostic accuracy of this model. Results: Patients with HAPH showed slow blood flow and coral signs in lower lobe pulmonary artery in pulmonary arteriography, and presented trend for dilated pulmonary vessels, enlarged right atrium, and compressed left atrium in CTA (P for trend <0.05). The left lower pulmonary artery-bronchus ratio (odds ratio: 1.13) and the ratio of right to left atrial diameter (odds ratio: 1.09) were significantly associated with HAPH, and showed strong correlation with mPAPRHC, respectively (r = 0.821 and r = 0.649, respectively; all P < 0.0001). The mPAPpredicted model using left lower artery-bronchus ratio and ratio of right to left atrial diameter as covariates showed high correlation with mPAPRHC (r = 0.907; P < 0.0001). Patients with predicted HAPH also had the typical pathological changes of pulmonary hypertension. Conclusions: Noninvasive mPAP estimation model based on CTA image data can accurately fit mPAPRHC and is beneficial for the early diagnosis of HAPH.

Tricuspid regurgitation pressure gradient identifies prognostically relevant worsening renal function in acute heart failure.

AIMS: Not all worsening renal function (WRF) during heart failure treatment is associated with a poor prognosis. However, a metric capable providing a prognosis of relevant WRF has not been developed. Our aim was to evaluate if a change in tricuspid regurgitation pressure gradient (TRPG) could discriminate prognostically relevant and not relevant WRF in patients with acute heart failure (AHF). METHODS AND RESULTS: We examined 809 consecutive hospitalized patients with heart failure (78 ± 12 years, 54% male). WRF was defined as an increase in creatinine >0.3 mg and ≥25% from admission to discharge. TRPG was measured at admission and before discharge using echocardiography. The primary outcome was all-cause death within 1-year after discharge. Patients were classified as follows for analysis: no WRF and no TRPG increase (n = 523); no WRF and TRPG increase (no WRF with iTRPG, n = 170); WRF and no TRPG increase (WRF without iTRPG, n = 90); and WRF and TRPG increase (WRF with iTRPG, n = 26). A change in TRPG weakly but significantly correlated to a change in haemoglobin and haematocrit, a percent decrease in brain natriuretic peptide, and body weight reduction during the index period of hospitalization. All-cause mortality within 1 year was higher in patients with WRF and iTRPG, compared to the other three groups (P = 0.026). On Cox regression analysis, only WRF with iTRPG was associated with higher mortality (hazard ratio 4.24, P = 0.001), even after adjustment for other confounders. CONCLUSION: An increase in TRPG may provide a marker to identify prognostically relevant WRF in patients with AHF.

A decrease in tricuspid regurgitation pressure gradient associates with favorable outcome in patients with heart failure.

AIMS: Although the prognostic impact of the high tricuspid regurgitation pressure gradient (TRPG) has been investigated, the association of the decrease in TRPG during follow-up with clinical outcomes in heart failure (HF) has not been previously studied. The aim of this study was to investigate the association of a decrease in TRPG between hospitalization and 6 month visit with subsequent clinical outcomes in patients with acute decompensated HF (ADHF). METHODS AND RESULTS: Among 721 patients with available TRPG data both during hospitalization and a subsequent 6 month visit, the study population was divided into two groups: a decrease in TRPG group (>10 mmHg decrease at 6 month visit) (N = 179) and no decrease in TRPG group (N = 542). The primary outcome measure was a composite of all-cause death or HF hospitalization. The cumulative 6 month incidence of primary outcome measure was significantly lower in the decrease in TRPG group than in the no decrease in TRPG group (12.2% vs. 18.7%, P = 0.02). After adjusting for confounders, there was a significantly lower risk in decrease in TRPG group than in the no decrease in TRPG group for the measured primary outcome (hazard ratio: 0.56, 95% confidence interval 0.32-0.93, P = 0.02). The lower risk in decrease in TRPG group was not different among the basal TRPG values. CONCLUSIONS: Heart failure patients with a decrease in TRPG at 6 months after discharge from ADHF hospitalization had lower subsequent risk of all-cause death and HF hospitalization than those without a decrease in TRPG, regardless of TRPG values.

The utility of point-of-care ultrasound right-sided cardiac markers as a screening test for moderate to severe pulmonary hypertension in dogs.

Dogs with respiratory disease can develop pulmonary hypertension (PH), a comorbid condition that can impact therapy and prognosis. Without confirmation using the criterion standard of echocardiography, this complication may be missed. Point-of-care ultrasound (POCUS) is a simple, non-invasive screening test that may suggest PH. It was hypothesized that in dogs POCUS right-sided cardiac markers (R-SCM) at the subxiphoid view would predict moderate to severe PH confirmed by echocardiography. Forty-three client-owned dogs that underwent respiratory evaluation with POCUS and echocardiography were included. POCUS R-SCM evaluated in the subxiphoid view included subjective caudal vena cava distention (CVCsx), CVCsx >1cm, gallbladder wall edema and ascites. PH was defined by tricuspid regurgitation pressure gradient (TRPG) as mild (30-49.9mmHg), moderate (50-74.9mmHg) or severe (>75mmHg). POCUS subxiphoid views were blindly evaluated post hoc and compared to echocardiography. Chi square test and one-way ANOVA were used to evaluate correlations between POCUS R-SCM and echocardiographic diagnosis of moderate to severe PH. Twenty-six dogs with PH, and 17 dogs without PH, were enrolled. There was no significant difference in the presence or absence of any R-SCM between dogs with and without PH. When dogs with no PH and mild PH were grouped and compared to dogs with moderate to severe PH (i.e., dogs for which treatment for PH would be recommended), no significant differences in R-SCM were noted. POCUS R-SCM using the CVCsx view was not a sensitive screening test to identify dogs with PH in this study population.

Tricuspid Regurgitation Pressure Gradient as a Useful Predictor of Adverse Cardiovascular Events and All-Cause Mortality in Patients With Atrial Fibrillation.

BACKGROUND: Tricuspid regurgitation pressure gradient (TRPG) is reportedly a predictor of cardiovascular (CV) mortality in patients without atrial fibrillation (AF); its relationship with cardiac outcomes in patients with AF has never been evaluated. This study aimed to examine the ability of TRPG to predict CV events and all-cause mortality in patients with AF. MATERIALS AND METHODS: Comprehensive echocardiography was performed in 155 patients with persistent AF. Combined CV events were defined as CV mortality, stroke and hospitalization for heart failure. RESULTS: During an average follow-up period of 27 months, 57 CV events and 31 all-cause deaths occurred. According to multivariate analysis, predictors of CV events included diuretic use, decreased left ventricular ejection fraction (LVEF), increased ratio of transmitral E velocity (E) to early diastolic mitral annular velocity (E') and TRPG. Predictors of all-cause mortality included old age, decreased LVEF, increased E/E' and TRPG. Notably, the addition of TRPG to a model containing clinical significant parameters, LVEF and E/E' significantly improved the values in predicting adverse CV events and all-cause mortality. CONCLUSIONS: The TRPG is not only a useful predictor of adverse CV events and all-cause mortality in patients with AF, it may also provide additional prognostic values for CV outcome and all-cause mortality over conventional parameters in such patients.

Assessment of functional tricuspid regurgitation using 320-detector-row multislice computed tomography: risk factor analysis for recurrent regurgitation after tricuspid annuloplasty.

OBJECTIVE: Functional tricuspid regurgitation (TR) often develops secondary to left heart disease. Tricuspid annuloplasty (TAP) is usually the treatment of choice for significant TRs, but recurrence of TR after surgery can occur. Previous studies have not clearly demonstrated the cause of the recurrent TR after TAP. By using an electrocardiogram-gated 320-detector-row multislice computed tomography (CT), we sought to delineate the morphologic cause of the incompetent tricuspid valve and identify the risk factors for recurrent TR. METHODS: From August 2010 to September 2011, 35 patients underwent preoperative CT of the tricuspid valve. The distance between each commissure, the tethering angle of each leaflet, and the tethering height were measured. TAP using a rigid annuloplasty ring was performed in 22 patients. Risk factors for recurrent TR were determined by multivariate analyses. RESULTS: End-diastolic and end-systolic tricuspid valve annular diameters (TVAD) correlated significantly with preoperative TR severity (R(2), 0.2734-0.4287; P < .05). However, compared with TVAD, tethering angles and height showed stronger correlation with preoperative TR severity (R(2): tethering angles, 0.5769-0.6810; tethering height, 0.6854). Multivariate analysis revealed that tethering height was an independent risk factor of postoperative recurrent TR (P = .0069). CONCLUSIONS: TVAD, tethering angles, and tethering height correlated significantly with preoperative TR severity. The tethering height of the tricuspid valve showed significant correlation with recurrent TR.