How to Evaluate Pulmonary Hypertension on Echocardiography - RVSP, mPAP, RAP, PAPd Measurements

Watch the above video and try to calculate RVSP, mean PAP and Diastolic Pulmonary pressure.

Formulas:

PASP = RVSP (in the absence of RVOT Obstruction or pulmonic stenosis)

So RVSP = 4V² + RAP

Where V is the peak TR Velocity

The mean and end diastolic pressures in the pulmonary artery are directly assessed by measuring peak and end-diastolic velocities of the pulmonary regurgitant (PR) jet

• Diastolic PA pressure (PAPd) = PR end diastolic pressure gradient + RA pressure
• Mean PA pressure (PAPm) = PR peak pressure gradient + RA pressure

Estimating RA Pressure/CVP:

Easiest way to remember the specific RAP value is to understand the normal and high pressure, everything else will fall in the middle category simply!

• Normal IVC with normal collapsibility = LOW (3 mmHg)
• Abnormal IVC with abnormal collapsibility = HIGH (15 mmHg)
• Any combination of Abnormal & Normal values = INTERMEDIATE (8 mmHg)
  • Abnormal IVC, normal collapsibility
  • Abnormalcollapsibility, normal IVC
• If IVC cannot be evaluated it is ok to use RAP of 8mmHg

 

 Calculations:

Now putting Values from the video we can Calculate:

PASP = RVSP (in the absence of RVOTO or pulmonic stenosis)

RVSP = 4V² + RAP
         = 4 (4.76)² + 15
           = 105 mmHg 

Mean PAP = PR peak pressure gradient + RA pressure
    = 4(3.2)²  + Estimated RAP  
    = 41 + 15   = 56 mmHg

Diatolic PAP = PR end diastolic pressure gradient + RA pressure
    = 4(4)²   + Estimated RAP  
    = 64+ 15  = 79 mmHg
 

Reference Ranges: 

Severity of pulmonary hypertension (mPAP)

• Mild = 20-40mmHg
• Moderate = 41-55mmHg
• Severe = > 55mmHg

RVSP of more than 35mmHg is considered abnormal.

Step By Step Guide:

Measuring Right Ventricular Systolic Pressure (RVSP) and Pulmonary Artery Systolic Pressure (PASP) on echocardiography is crucial for assessing pulmonary hypertension and other cardiovascular conditions. Here's a step-by-step guide on how to measure RVSP and PASP on echo:

Measuring RVSP and PASP:

*Tricuspid Regurgitation (TR) Method*

1. *Obtain a tricuspid regurgitation (TR) jet*: Use the continuous wave (CW) Doppler mode to capture the TR jet in the right ventricular outflow tract (RVOT) or the apical four-chamber view.

2. *Measure the peak TR velocity*: Record the peak velocity of the TR jet, which corresponds to the maximum pressure gradient between the right ventricle (RV) and the right atrium (RA).

3. *Apply the Bernoulli equation*: Use the modified Bernoulli equation to estimate the RVSP: RVSP = 4 × (peak TR velocity)² + RA pressure.

4. *Estimate RA pressure*: Use the inferior vena cava (IVC) diameter and collapsibility to estimate RA pressure.

*Pulmonary Regurgitation (PR) Method*

1. *Obtain a pulmonary regurgitation (PR) jet*: Use the CW Doppler mode to capture the PR jet in the pulmonary valve or the parasternal short-axis view.

2. *Measure the peak PR velocity*: Record the peak velocity of the PR jet, which corresponds to the maximum pressure gradient between the pulmonary artery (PA) and the RV.

3. *Apply the Bernoulli equation*: Use the modified Bernoulli equation to estimate the mean PAP = 4 × (peak PR velocity)² + RAP.

*Additional Tips*

- *Use a high-quality echo machine*: Ensure that the echo machine is properly calibrated and has a good signal-to-noise ratio.

- *Optimize the Doppler settings*: Adjust the Doppler gain, frequency, and wall filter to optimize the signal.

- *Measure multiple beats*: Record and measure multiple beats to ensure accurate and reproducible results.

- *Consider using other echo parameters*: In addition to RVSP and PASP, consider using other echo parameters, such as right ventricular size and function, to provide a more comprehensive assessment.

By following these steps and tips, you can accurately measure RVSP and PASP on echocardiography and provide valuable information for diagnosing and managing cardiovascular conditions.

Thanks 

Visit Echocardiography Library to practice 100 + Echo Cases and MOCK Exams