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Original Research: Pulmonary Vascular Disease |

Echocardiography of the Pulmonary Circulation and Right Ventricular FunctionEchocardiography and Pulmonary Circulation: Exploring the Physiologic Spectrum in 1,480 Normal Subjects FREE TO VIEW

Antonello D’Andrea, MD; Robert Naeije, MD; Ekkehard Grünig, MD; Pio Caso, MD; Michele D’Alto, MD; Enza Di Palma, MD; Luigi Nunziata, MD; Lucia Riegler, MD; Raffaella Scarafile, MD; Rosangela Cocchia, MD; Olga Vriz, MD; Rodolfo Citro, MD; Raffaele Calabrò, MD; Maria Giovanna Russo, MD; Eduardo Bossone, MD, PhD, FCCP
Author and Funding Information

From the Department of Cardiology (Drs D’Andrea, Caso, D’Alto, Di Palma, Nunziata, Riegler, Scarafile, and Cocchia and Profs Calabrò and Russo), Monaldi Hospital, Second University of Naples, Naples, Italy; the Cardiology Clinic (Dr Naeije), Erasme Academic Hospital, Free University of Brussels, Brussels, Belgium; the Centre of Pulmonary Hypertension (Dr Grünig), Thoraxclinic, University Hospital Heidelberg, Heidelberg, Germany; the Department of Cardiology (Dr Vriz), S. Antonio Hospital, San Daniele del Friuli, Udine, Italy; the Department of Cardiology (Dr Citro), University Hospital, San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy; and the Department of Cardiac Surgery (Prof Bossone), IRCCS Policlinico San Donato, Milan, Italy.

Correspondence to: Eduardo Bossone, MD, PhD, FCCP, Department of Cardiac Surgery, IRCCS Policlinico San Donato, Via Pr. Amedeo, 36-83023 Lauro (AV), Italy; e-mail: ebossone@hotmail.com


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):1071-1078. doi:10.1378/chest.12-3079
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Background:  Although transthoracic echocardiography (TTE) is an excellent noninvasive screening test for pulmonary hypertension, the physiologic range of Doppler echocardiography-derived pulmonary pressures remains not completely investigated. The aim of the present study was, therefore, to explore the full spectrum of pulmonary pressures and right ventricular (RV) functional indexes by TTE in healthy subjects and to investigate clinical and echocardiographic correlates.

Methods:  A random sample of 1,480 healthy individuals (mean age, 36.1 ± 15.5 years; range, 20-80 years; 905 men) underwent a comprehensive TTE. Pulmonary artery systolic pressure (PASP), mean pressure, and pulmonary vascular resistance were estimated by standard Doppler echocardiography formulas. In addition, RV diastolic (Doppler transtricuspid inflow measurements) and systolic indexes (RV fractional area change, RV tissue Doppler peak systolic velocity, tricuspid annular plane systolic excursion) were calculated.

Results:  PASP and mean pulmonary artery pressure values were significantly higher in subjects aged > 50 years and in those with a BMI > 30 kg/m2. In particular, a PASP > 40 mm Hg was found in 118 subjects (8%) of those aged > 50 years and in 103 (7%) of those with a BMI > 30 kg/m2. No differences by age were registered in RV systolic indexes and in pulmonary vascular resistances. On multivariate analysis, in the overall study population, age, BMI, mitral E/e′ ratio, and left ventricular stroke volume were the only independent predictors of PASP.

Conclusions:  This study delineates an estimate of pulmonary hemodynamics in a wide age range cohort of healthy subjects. Pulmonary pressures increased with age and BMI, as expected.

Figures in this Article

Pulmonary hypertension (PH) and related right-sided heart function represent key prognostic determinants of several cardiorespiratory conditions, such as left-sided heart disease.1 Given the nonspecific symptoms and subtle physical signs, particularly in early stages, a high clinical index of suspicion is necessary to detect the disease before irreversible pathophysiologic changes occur.2 In this regard, transthoracic Doppler echocardiography (TTE), by providing direct and/or indirect signs of elevated pulmonary pressures, is an excellent noninvasive screening test for patients with symptoms, risk factors, or both for PH.35

However, the physiologic range of Doppler echocardiography-derived pulmonary pressures and right ventricular (RV) functional parameters remains not completely investigated. The aim of this study is to explore the full spectrum of pulmonary pressures and RV functional indexes by TTE in healthy subjects and to investigate clinical and echocardiographic correlates.

Study Population

From April 2009 to July 2011 a sample of 1,587 consecutive healthy individuals was enrolled and referred to our echocardiographic laboratory of Monaldi Hospital in Naples (Italy) for the purpose of the present study. Volunteer control subjects were all recruited in Naples (Italy), selected from our department of cardiology among subjects investigated for work eligibility. Fifty of the initial subjects investigated refused to be included in the echocardiographic protocol. None of the selected control subjects included into the study had cardiovascular structural or functional abnormalities or received any medication.

All subjects underwent a detailed history, physical examination, ECG, chest radiography, and comprehensive TTE, including Doppler studies. Exclusion criteria were coronary artery disease, arterial hypertension, valvular or congenital heart disease, bicuspid aortic valve, congestive heart failure, cardiomyopathies, diabetes mellitus, sinus tachycardia, use of illicit drugs, and inadequate echocardiographic image quality. According to these criteria, 57 subjects were excluded: eight for coronary artery disease, 12 for arterial hypertension, 19 for significant valvular insufficiency (nine for mitral and 10 for tricuspid valve regurgitation more than mild), four for bicuspid aortic valve, two for hypertrophic cardiomyopathy, two for dilated cardiomyopathy, five for use of illicit drugs, and five for inadequate echocardiographic image quality.

Our final study population, therefore, consisted of 1,480 healthy individuals (mean age, 36.1 ± 15.5 years; range, 20-80 years; 905 men). All the subjects enrolled in the study protocol provided a written informed consent.

Imaging Protocol

Standardized transthoracic echocardiography and Doppler examinations were performed with commercially available equipment in all the subjects (Vivid 7 or Vivid E9; General Electric Company). Specific views included the parasternal long- and short-axis views (at the mitral valve and papillary muscle level); apical 4-, 2-, and 3-chamber views; and subcostal views including respiratory motion of the inferior vena cava. Pulsed and continuous-wave Doppler interrogation was performed on all four cardiac valves. All studies were reviewed and analyzed off-line by two independent observers blinded to the clinical characteristics of the study population. Specific measurements were made by the average of three to five cardiac cycles.

M- and B-Mode Measurements:

Left ventricular (LV) diastolic and systolic diameters, interventricular septum, and posterior wall thickness measurements were performed in parasternal long-axis view with the patient in the left lateral position. LV mass was calculated by the Penn convention6 and indexed for height (left ventricular mass index)2.7 (Cornell adjustment).7 Relative diastolic wall thickness was determined as the ratio between twice the posterior wall thickness and LV end-diastolic diameter.8

LV ejection fraction was calculated by the biplane Simpson’s rule in the apical four- and two-chamber views. Left atrial maximal volume was measured at the point of mitral valve opening, using the biplane area-length method and corrected for body surface area.9 The percentage RV fractional area change was calculated as: (RV end-diastolic area − RV end-systolic area)/RV end-diastolic area × 100. Tricuspid annular plane systolic excursion (TAPSE) was calculated as index of RV longitudinal systolic function, by placing a M-mode cursor through the tricuspid annulus in a standard apical four-chamber window and measuring the difference between end-diastolic and end-systolic amount of longitudinal motion of the annulus (in mm)10 (Fig 1).

Figure Jump LinkFigure 1. Echocardiographic evaluation of RV functional parameters. A, TAPSE calculated by placing an M-mode cursor through the tricuspid annulus in a standard apical four-chamber window. B, RV TD peak Sm assessed from the apical four-chamber view by placing the sample volume at the tricuspid annulus. C and D, RV end-diastolic and end-systolic areas assessed by planimetry from the apical four-chamber view. FAC = fractional area change; HR = heart rate; RV = right ventricular; Sm = systolic velocity; TAPSE = tricuspid annular plane systolic excursion; TD = tissue Doppler.Grahic Jump Location
Color Doppler Analysis:

Valvular regurgitation was quantified from color Doppler imaging and categorized as absent, minimal (within normal limits), mild, moderate, or severe. Intermediate vena contracta values (3-7 mm) were confirmed by the proximal isovelocity surface area method.11

Doppler-derived LV diastolic inflow was recorded in apical four-chamber view by placing the sample volume at the tips level. The following LV diastolic measurements were measured: E and A peak velocities (m/s) and their ratio, E-wave deceleration time (milliseconds), and isovolumic relaxation time (milliseconds, as the time interval occurring between the end of systolic output flow and the transmitral E-wave onset by placing pulsed Doppler sample volume between outflow tract and mitral valve).8 By tissue Doppler (TD), the early (e′) diastolic velocities were measured at the septal and lateral corner of the mitral annulus, and the mean between the two values was calculated. Mitral E velocity, corrected for the influence of relaxation (ie, the E/mean e′ ratio), was assessed to estimate LV filling pressures.12 LV stroke volume was calculated as the product of LV outflow tract area and outflow tract time-velocity integral.13

Pulsed Doppler evaluation of RV diastolic indexes was performed in the apical four-chamber view by placing the sample volume at the tips of tricuspid valve. The following measurements of global RV filling were obtained: E and A peak velocities (m/s), E/A ratio, and E-wave deceleration time.9

To obtain a measure of RV myocardial function by TD, RV peak systolic velocity (RV s′) was assessed from the apical four-chamber view by placing the sample volume at the tricuspid annulus. Because this technique uses Doppler, special care is required to ensure optimal image orientation and avoid underestimation of velocities.9

Noninvasive Pulmonary Artery Systolic Pressure and Vascular Resistance:

Peak tricuspid regurgitation velocity (TRV) was measured from the spectral profile of the tricuspid regurgitation jet in the RV inflow projection of the parasternal long-axis view, the parasternal short-axis view, or the apical four-chamber view. The highest transvalvular velocity was used for calculation of RV systolic pressure. American Society of Echocardiography-recommended estimations were used to estimate right atrial pressure (RAP) by inferior vena cava respiratory index.9 Pulmonary artery systolic pressure (PASP) was then calculated by adding the value of RAP to the systolic transtricuspid gradient (PASP = 4V2 + RAP, where V = maximal velocity of tricuspid regurgitation jet). PASP was assumed to equate the RV systolic pressure in the absence of pulmonic stenosis and/or RV outflow tract obstruction.14,15 To enhance the Doppler signal, an IV contrast agent was used if needed (SonoVue; Bracco Imaging SpA). Mean pulmonary artery pressure was calculated as 0.6 × PASP + 2 mm Hg.16 The RV outflow tract time-velocity integral (RVOTTVI) (cm) was obtained by placing a 1- to 2-mm pulsed-wave Doppler sample volume in the proximal RV outflow tract, just within the pulmonary valve, when imaged from the parasternal short-axis view. The sample volume was placed so that the closing but not opening click of the pulmonary valve was visualized. The TRV/RVOTTVI ratio was then calculated as correlate of pulmonary vascular resistance14,15 (Fig 2) by use of the following formula: pulmonary vascular resistance = TRV/RVOTTVI × 10 + 0.16.

Figure Jump LinkFigure 2. Echocardiographic noninvasive evaluation of pulmonary artery pressures and vascular resistance. A, Mild tricuspid regurgitation by color Doppler analysis from the apical four-chamber view. B, TRV by Doppler analysis, with calculation of PASP and mean pressure. C, The RVOTTVI obtained by placing a 1- to 2-mm pulsed-wave Doppler sample volume in the proximal right ventricular outflow tract. D, IVC diameter, measured perpendicular to the long axis of the IVC at end-expiration, proximal to the junction of the hepatic veins. Env.TI = ejection time interval; IVC = inferior vena cava; P = pressure; PASP = pulmonary artery systolic pressure; PVR = pulmonary vascular resistance; RAP = right atrial pressure; RVOTTVI = right ventricular outflow tract time-velocity integral; TRV = tricuspid regurgitation velocity; V = velocity; VTI = velocity time.Grahic Jump Location
Statistical Methods

All the analyses were performed by SPSS for Windows, release 16.0 (IBM). Variables are presented as mean ± SD. Analyses of variance by Newman-Keuls post hoc test for multiple comparisons were performed to estimate differences between groups. Linear regression analyses and partial correlation test by Pearson method were done to assess univariate relations. To identify significant independent determinants of PASP measurement in healthy subjects, their individual association with clinical relevant and echocardiographic variables was assessed by multivariable linear regression analysis. The following variables were included into the analysis: clinical data (age, sex, BMI, BP, pulse pressure) and standard echocardiographic indexes (LV volumes, LV mass index, LV stroke volume, LV ejection fraction, left atrial volume index, Doppler transmitral and transtricuspid inflow measurements, RV dimensions). These variables were selected according to their clinical relevance and potential impact on pulmonary artery pressures, as shown by earlier studies. Variable selection was performed in the multivariable linear regression as an interactive stepwise backward elimination method, each time excluding the one variable with the highest P value, according to Wald statistics. To decrease the inflation of the type 1 error rate due to multiple testing, the statistical significance was defined as two-sided P value < .01.

Reproducibility of PASP measurements was determined in all the subjects. Intraobserver and interobserver variability were examined using Pearson bivariate two-tailed correlations and Bland-Altman analysis. Correlation coefficients, 95% CIs, and percent errors were reported.

Clinical characteristics and LV Doppler echocardiography analysis in the overall population are described in Tables 1 and 2. Reference ranges according to age strata for RV functional parameters and pulmonary vascular measurements are reported in Table 3. No differences in RV systolic function (RV fractional area change, TAPSE, and RV TD peak s′) were noted. On the other hand, impairment of RV diastolic function (tricuspid peak E velocity, tricuspid peak E/A ratio) was detected in the > 50-year-old cohort (Table 3).

Table Graphic Jump Location
Table 1 —Study Population Characteristics

Data are presented as mean ± SD unless otherwise noted. BSA = body surface area; HR = heart rate.

Table Graphic Jump Location
Table 2 —LV M-Mode, B-Mode, and Doppler Analysis in the Overall Population

Data are presented as mean ± SD (range). LV = left ventricular.

Table Graphic Jump Location
Table 3 —Reference Ranges According to Age for RV Functional Parameters and Pulmonary Vascular Measurements

Data are presented as mean ± SD (range). PAP = pulmonary artery pressure; PASP = pulmonary artery systolic pressure; RV = right ventricular; TAPSE = tricuspid annular plane systolic excursion; TD = tissue Doppler; TRV/RVOTTVI = tricuspid regurgitant velocity/right ventricular outflow tract time-velocity integral.

a 

P < .001.

An adequate spectral envelope of TRV was detected in 1,450 subjects (98%). As a result, in 30 subjects, the use of an IV echocardiographic contrast agent was needed to enhance tricuspid Doppler signal.

A wide range of TRV, PASP, and mean pulmonary artery pressure values was observed, being significantly higher in subjects > 50 years old. In particular, a PASP > 40 mm Hg was found in 118 subjects (8%) of those > 50 years old and in 103 (7%) of those with a BMI > 30 kg/m2. No differences by age were registered regarding pulmonary vascular resistances. On univariate analysis, PASP was significantly associated with age (r = 0.48, P < .0001), male sex (r = 0.28, P < .05), BMI (r = 0.51, P < .0001), mitral E/E′ (r = 0.52, P < .0001), LV stroke volume (r = 0.39, P < .001), and LV mass index (r = 0.27, P < .01). On multivariate analysis, in the overall study population, age, BMI, mitral E/e′ and LV stroke volume were the only independent predictors of PASP (Table 4).

Table Graphic Jump Location
Table 4 —Significant Independent Relation of PASP in the Overall Population With Clinical Variables and Echocardiography Variables by Multivariate Analysis

NS = not significant. See Table 2 and 3 legends for expansion of other abbreviations.

The pulmonary circulation is characterized by high flow (the entire RV output) and by low pressure and low resistance (one-tenth of systemic vascular resistance).1,3,17 However, pulmonary artery pressures may be influenced by different clinical and anthropometric factors. In fact, age and BMI have been demonstrated to be major determinants of pulmonary hemodynamics.5,18 We report the full range of pulmonary pressures and of RV functional parameters in the healthy subjects and discuss clinical and echocardiographic correlates.

Previous Echocardiographic Reports on Pulmonary Hemodynamics in Healthy Subjects

Several previous echocardiographic studies on pulmonary hemodynamics enrolled patients who were referred to the hospital for cardiovascular disease or for comorbidities.5,19 McQuillan et al,5 among a subgroup of 3,790 echocardiographically normal subjects (range, 1-89 years) included in a 10-year echocardiography laboratory database of 102,818 reports, reported in a retrospective analysis a wide spectrum of PASP (28.3 ± 4.9 mm Hg; range, 15-57 mm Hg). In particular, a PASP > 40 mm Hg was found in 6% of those > 50 years old and in 5% of those with a BMI > 30 kg/m2. Furthermore, PASP was independently associated with age, BMI, male sex, LV posterior wall thickness, and LV ejection fraction.5 However, in this study PASP was the only noninvasive hemodynamic index calculated, whereas RV morphologic and functional measurements were not assessed. Moreover, PASP was calculated assuming a fixed value of 10 mm Hg for RAP, without assessing inferior vena cava respiratory index.9

Furthermore, in a large cross-sectional population study by Lam et al19 (2,042 subjects followed up for a median of 9 years), the age-related increase in PASP was associated with increasing LV diastolic pressure (estimated by E/e′ ratio) and systemic vascular stiffening (assessed from the brachial artery pressure). Interestingly, PASP was also associated with higher mortality, independently of both age and presence of clinically evident cardiopulmonary disease.19

In addition, Innelli et al20 demonstrated in 298 healthy subjects (186 men, 112 women; mean age, 41.7 ± 18.0 years; range, 10-82 years) an independent impact of aging on RV myocardial diastolic and systolic indices and of noninvasively estimated RAP, obtained as E/Ea ratio by pulsed TD of tricuspid annulus. In particular, TAPSE, s′, e′, and e′/a′ ratio were progressively reduced, and e′/a′ ratio increased with the increasing age groups (all P < .0001). The e′/a′ ratio was 4.1 ± 0.9 in the age decade 11 to 20 years and 5.4 ± 1.5 in subjects > 70 years (P < .0001). This study also provided normal values of RV TD variables for age decades, which can be used as reference data to interpret appropriately the quantitative assessment of longitudinal RV function in patients with cardiac disease.20

More recently, our group reported the full range of right-sided heart measurements and PASP in a large population of 615 top-level athletes, describing the impact of different long-term intensive training on pulmonary parameters. Of note, a TRV value > 2.5 m/s was observed in 76 athletes (12.3%). By multivariable analysis, age, endurance training, duration of training, and LV stroke volume were the only independent predictors of PASP in athletes.21

Uniqueness of the Present Study

This is a large prospective study reporting an estimate of pulmonary hemodynamics and of RV functional systolic and diastolic indexes in a wide age range cohort of healthy subjects. It also describes different clinical and echocardiographic factors. Pulmonary pressures and RV diastolic dysfunction increased with age and BMI. In fact, PASP was > 40 mm Hg in subjects > 50 years of age and/or with BMI > 30 kg/m2. However, pulmonary vascular resistances did not differ significantly among decades.

Stepwise, multiple linear regression analyses also confirmed stroke volume and LV E/e′ as powerful independent determinants of PASP. This is in line with the physiologic concept that PASP is generally determined by the amount of blood flowing through the pulmonary circulation (cardiac output), the intrinsic properties of the vasculature (resistance, capacitance, and impedance), and the left atrial pressure downstream of the pulmonary circuit (LV E/e′).2224 Thus, age, body habitus, and LV diastolic and systolic function should be taken into account when interpreting Doppler-derived pulmonary hemodynamics, even in healthy subjects.

Limitations and Future Directions

The gold standard for the measurement of hemodynamic parameters is heart catheterization. Doppler echocardiography cannot measure hemodynamic parameters but only provide an estimate of them. Therefore, the main limitation of this study is the lack of true hemodynamic data.

However, invasive data would not be ethical or indicated in healthy subjects. On the other hand, TTE is considered an excellent screening test for patients with symptoms and/or risk factors for PH.25,26 In this regard, it is recommended to gather technically adequate tricuspid regurgitant signals from multiple echocardiographic views (using contrast agents if needed) and to consider PASP values and RV functional indexes in the context of the clinical scenario, searching for other “concordant clinical and echo signs” of pressure overload.9,26 The results of this study confirm previous findings.

Author contributions: Prof Bossone is the guarantor of the entire manuscript, had full access to the data, and will vouch for the integrity of the data analysis.

Dr D’Andrea: contributed to study protocol, statistical analysis, and writing and revision of the manuscript.

Dr Naeije: contributed to study protocol, statistical analysis, and writing and revision of the manuscript.

Dr Grünig: contributed to study protocol, statistical analysis, and writing and revision of the manuscript.

Dr Caso: contributed to study protocol, statistical analysis, and writing and revision of the manuscript.

Dr D’Alto: contributed to echocardiographic study and revision of the manuscript.

Dr Di Palma: contributed to echocardiographic study and revision of the manuscript.

Dr Nunziata: contributed to echocardiographic study and revision of the manuscript.

Dr Riegler: contributed to echocardiographic study and revision of the manuscript.

Dr Scarafile: contributed to echocardiographic study and revision of the manuscript.

Dr Cocchia: contributed to echocardiographic study and revision of the manuscript.

Dr Vriz: contributed to echocardiographic study and revision of the manuscript.

Dr Citro: contributed to echocardiographic study and revision of the manuscript.

Prof Calabrò: contributed to study protocol, statistical analysis, and writing and revision of the manuscript.

Prof Russo: contributed to echocardiographic study and revision of the manuscript.

Prof Bossone: contributed to study protocol, statistical analysis, and writing and revision of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Grünig receives consultancy and lecture fees from Actelion Pharmaceuticals Ltd, Bayer AG, Gilead, GlaxoSmithKline, Eli Lilly and Co, Miltenyi Biotec, Novartis Corp, Pfizer Inc, Groupe PANPHARMA, and Alexion. He also participates as primary investigator in studies of Actelion Pharmaceuticals Ltd, Bayer AG, GlaxoSmithKline, Encysive Pharmaceuticals (now Pfizer Inc), Eli Lilly and Co, United Therapeutics Corp, and Pfizer Inc. Drs D’Andrea, Naeije, Caso, D’Alto, Di Palma, Nunziata, Riegler, Scarafile, Cocchia, Vriz, and Citro and Profs Calabrò, Russo, and Bossone have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We thank Ivana Santafede, Nicola Silvestri, and Paola Villani for the accurate revision of the study protocol. In accordance with Italian guidelines on clinical studies and Italian law (“Gazzetta Ufficiale” of Italian Republic, general series number 76, March 31, 2008), our echocardiographic study is considered to be an observational study. In this regard, we have provided as requested a regular description of the study protocol to the local Ethics Committee (number of protocol: H457).

LV

left ventricular

PASP

pulmonary artery systolic pressure

PH

pulmonary hypertension

RAP

right atrial pressure

RV

right ventricular

RVOTTVI

right ventricular outflow tract time-velocity integral

TAPSE

tricuspid annular plane systolic excursion

TD

tissue Doppler

TRV

tricuspid regurgitation velocity

TTE

transthoracic Doppler echocardiography

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Figures

Figure Jump LinkFigure 1. Echocardiographic evaluation of RV functional parameters. A, TAPSE calculated by placing an M-mode cursor through the tricuspid annulus in a standard apical four-chamber window. B, RV TD peak Sm assessed from the apical four-chamber view by placing the sample volume at the tricuspid annulus. C and D, RV end-diastolic and end-systolic areas assessed by planimetry from the apical four-chamber view. FAC = fractional area change; HR = heart rate; RV = right ventricular; Sm = systolic velocity; TAPSE = tricuspid annular plane systolic excursion; TD = tissue Doppler.Grahic Jump Location
Figure Jump LinkFigure 2. Echocardiographic noninvasive evaluation of pulmonary artery pressures and vascular resistance. A, Mild tricuspid regurgitation by color Doppler analysis from the apical four-chamber view. B, TRV by Doppler analysis, with calculation of PASP and mean pressure. C, The RVOTTVI obtained by placing a 1- to 2-mm pulsed-wave Doppler sample volume in the proximal right ventricular outflow tract. D, IVC diameter, measured perpendicular to the long axis of the IVC at end-expiration, proximal to the junction of the hepatic veins. Env.TI = ejection time interval; IVC = inferior vena cava; P = pressure; PASP = pulmonary artery systolic pressure; PVR = pulmonary vascular resistance; RAP = right atrial pressure; RVOTTVI = right ventricular outflow tract time-velocity integral; TRV = tricuspid regurgitation velocity; V = velocity; VTI = velocity time.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Study Population Characteristics

Data are presented as mean ± SD unless otherwise noted. BSA = body surface area; HR = heart rate.

Table Graphic Jump Location
Table 2 —LV M-Mode, B-Mode, and Doppler Analysis in the Overall Population

Data are presented as mean ± SD (range). LV = left ventricular.

Table Graphic Jump Location
Table 3 —Reference Ranges According to Age for RV Functional Parameters and Pulmonary Vascular Measurements

Data are presented as mean ± SD (range). PAP = pulmonary artery pressure; PASP = pulmonary artery systolic pressure; RV = right ventricular; TAPSE = tricuspid annular plane systolic excursion; TD = tissue Doppler; TRV/RVOTTVI = tricuspid regurgitant velocity/right ventricular outflow tract time-velocity integral.

a 

P < .001.

Table Graphic Jump Location
Table 4 —Significant Independent Relation of PASP in the Overall Population With Clinical Variables and Echocardiography Variables by Multivariate Analysis

NS = not significant. See Table 2 and 3 legends for expansion of other abbreviations.

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