Accuracy of Doppler-derived estimation of pulmonary vascular resistance in congenital heart disease: an index of operability

A prediction model of simple echocardiographic variables to screen for potentially correctable shunts in adult patients with pulmonary arterial hypertension associated with atrial septal defects: a cross-sectional study

During the routine follow-up of adult patients with pulmonary arterial hypertension associated with atrial septal defects (ASD-PAH), the suitability of shunt closure depends on the invasive right heart catheterization (RHC). It is difficult to grasp the timing of RHC shunt closure for moderate-severe PAH. This retrospective cross-sectional study was designed to investigate which echocardiographic variables are related to pulmonary vascular resistance (PVR) in adult ASD-PAH patients and propose a method using echocardiographic variables to screen for patients where shunt closure is suitable. A total of 139 adult ASD-PAH patients with a PASP ≥ 60 mmHg measured by transthoracic echocardiogram (TTE) were included in this study. All RHCs were performed within a week after TTE. The Correctable shunt was defined as PVR ≤ 4.6 wood units (WU). Multivariate regressions were performed with echocardiographic variables. The nomogram of prediction model was constructed by the predictors of PVR ≤ 4.6 WU by multivariate logistic regression analysis. Multivariate linear regression revealed that TAPSE (tricuspid annular plane systolic excursion)/pulmonary artery systolic pressure (PASP) measured by TTE was negatively associated with PVR (β per SD: - 1.84, 95%CI - 2.62, - 1.06). Multivariate logistic regression showed that TAPSE/PASP and pulmonary valve (PV) peak velocity were positively associated with a potentially correctable shunt (PVR ≤ 4.6 WU) (OR per SD: 2.38, 95%CI 1.34, 4.25, and OR per SD: 2.67, 95%CI 1.26, 5.64, respectively). In receiver operating characteristic analysis, the TAPSE/PASP + PV peak velocity combined model achieved the best performance (AUC: 0.8584, sensitivity: 83.33%, specificity: 72.16%). Internal verification showed stable performance (AUC: 0.8591, sensitivity: 88.10%, specificity: 68.04%). The net benefit of this model was greater than other models when it came to a wide range probability threshold in decision curve analysis. TAPSE/PASP + PV the peak velocity model may have great value in predicting adult ASD-PAH patients with operability potential, which could help clinicians make the treatment decision for follow-up patients.

Assessing pulmonary circulation in severe bronchopulmonary dysplasia using functional echocardiography

Pulmonary hypertension (PH) is common in infants with severe bronchopulmonary dysplasia (BPD) and increases the risk of death. The objectives of this preliminary study were to compare responses of pulmonary circulation parameters to 100% oxygen (O₂) and inhaled nitric oxide (iNO) in infants with BPD and PH using echocardiography. Responses between fetal growth restriction (FGR) and appropriate for gestational age infants were compared. Ten infants <28 weeks GA at birth were assessed at ≥36 weeks corrected gestation. Baseline echocardiography1 was performed which was repeated (echocardiography2) after 30 minutes of O₂. After a gap of 2–3 hours, iNO was administered for 15 minutes and echocardiography3 was performed, followed by iNO weaning. The gestation and birthweight of the cohort were 25.9 ± 1.6 weeks and 612 ± 175 g. Assessments were performed at 38.7 ± 1.4 weeks corrected gestational age. Baseline time to peak velocity: right ventricular ejection time (TPV/RVETc) increased from 0.24 ± 0.02 to 0.27 ± 0.02 (O₂, p = .01) and 0.31 ± 0.03 (iNO, p < .001), indicating a decrease in pulmonary vascular resistance [PVR]. Baseline tricuspid annular plane systolic excursion (TAPSE) increased from 8.1 ± 0.6 mm to 9.3 ± 0.7 mm (O₂, p = .01) and 10.5 ± 1.1 mm (iNO, p = .0004), indicating improved ventricular systolic performance. Percentage change for all parameters was greater with iNO. Significant correlations between cardiac performance and PVR were noted. FGR infants noted higher baseline PVR (TPV/RVETc, 0.21 ± 0.02 vs. 0.25 ± 0.01, p = .002), lower ventricular performance (TAPSE, 7 ± 1.2 mm vs. 8.6 ± 6 mm, p = .003), and lower percentage change with O₂ and iNO. A reactive component of pulmonary circulation provides real‐time physiological information, which could rationalize treatment decisions.

Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young

While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.

Analysis of Biphasic Right Ventricular Outflow Doppler Waveform in Patients with Pulmonary Hypertension

Pulmonary hypertension (PH) with pulmonary vascular disease (PVD) is a progressive and debilitating disease associated with increased pulmonary vascular resistance (PVR). Biphasic right ventricular outflow tract (RVOT) Doppler flow is frequently seen in severe PH patients with PVD. In association with hemodynamics, the precise analysis of biphasic RVOT Doppler flow (RVDF) has not been fully elucidated. Therefore, the purpose of the present study is to analyze the relation between the hemodynamics and indices of biphasic RVDF in PH patients with PVD.Seventy PH patients with biphasic RVDF were analyzed. All patients underwent transthoracic echocardiography and right heart catheterization. For the analysis of biphasic RVDF, the early waveform was determined as P₁ while the late waveform was determined as P₂. For each P₁ and P₂, the duration (D, seconds) and peak flow velocity (PFV, in m/second) were measured.P₁D and P₂PFV were significantly correlated with PVR (P₁D: r = -0.542, P < 0.0001, P₂PFV: r = -0.513, P < 0.0001). Therefore, we propose a novel RVDF formula for estimation of PVR, as follows. PVR = 26 - 77 × P₁D - 14 × P₂PFV. The PVR could be estimated by this proposed formula (r = 0.649, P < 0.0001), which is derived from one Doppler image only unlike previously used PVR prediction formula.P₁D and P₂PFV were associated with PVR. Moreover, this simple RVDF formula proposed herein can estimate PVR in PH patients with PVD.

Noninvasive Echocardiographic Measures of Pulmonary Vascular Resistance in Children and Young Adults with Cardiomyopathy

BACKGROUND

Patients with cardiomyopathy (CM) are at increased risk for pulmonary hypertension (PH). Data are lacking on the use of noninvasive PH measures by echocardiography in patients with CM. The aim of this study was to evaluate the correlation between Doppler-derived echocardiographic indices and catheterization-based measurement of pulmonary vascular resistance (PVR) in children and young adults with CM.

METHODS

Imaging studies were retrospectively reviewed from pediatric patients with CM who underwent both echocardiography and cardiac catheterization within a 72-hour period. The ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, the S/D ratio, and right ventricular myocardial performance index were correlated with invasive PVR. Receiver operating characteristic curves were developed to determine cutoffs for detecting PVR ≥ 6 indexed Wood units, a value associated with higher heart transplantation risk.

RESULTS

Twenty-three patients with CM (median age, 11.7 years; range, 0.5-21 years) met the criteria for analysis, the majority (n = 17 [74%]) of whom had dilated CM. Linear regression showed significant correlations between echocardiography-based ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral, S/D ratio, and right ventricular myocardial performance index versus invasive PVR (r = 0.84, r = 0.72, and r = 0.72, respectively, P < .001). All echocardiographic measures showed high sensitivity, specificity, and predictive values to detect PVR ≥ 6 indexed Wood units, with ratio of peak tricuspid regurgitation velocity to right ventricular outflow tract velocity-time integral demonstrating the highest area under the curve (0.958; 95% CI, 0.866-1).

CONCLUSIONS

Right-sided Doppler-derived echocardiographic indices correlate with PVR measured by cardiac catheterization in children and young adults with CM. These parameters may serve as useful adjuncts in serial assessment of right ventricular hemodynamics in this population.

Bronchopulmonary dysplasia-associated pulmonary hypertension: clues from placental pathology

OBJECTIVES

Bronchopulmonary dysplasia (BPD) and the associated complication of pulmonary hypertension (PH) leads to increased mortality and a longer length of stay among survivors. Placental histopathology may give early clues of subsequent events. The objective was to evaluate the relationship of maternal vascular underperfusion (MVU) changes on placental histopathology with subsequent development of BPD-associated PH in a cohort of extremely premature infants.

STUDY DESIGN

In a cohort of preterm infants '⩽28 weeks' gestational age (GA) and with 'severe' BPD, this retrospective study evaluated specific placental histopathological changes and assessed the relationship with subsequent development of PH. 'Severe' BPD was defined as the need for ⩾30% oxygen and/or positive pressure ventilation at 36 weeks postmenstrual age. Placental and echocardiographic assessments were done by investigators masked to the grouping and clinical outcomes.

RESULTS

Fifty six infants with severe BPD formed the cohort; PH was noted in 22 (39.3%) infants. The GA of the infants with and without PH was comparable (25.8±1.6 vs 25.8±1.3 weeks, P=0.9). On placental histopathological examination, 13 (23%) had features of MVU. On univariate logistic regression, the presence of changes consistent with MVU increased the relative risk of subsequent BPD-associated PH by 2.75 (95% confidence interval 1.56 to 4.85, P=0.004). The significance persisted after adjustment for GA. Stratification by the presence or absence of fetal growth restriction, yielded nonsignificant associations (P=0.17).

CONCLUSION

Based on the results of the present study, specific placental histopathological changes may give early clues to the subsequent development of BPD-associated PH.

Pulmonary hypertension associated with bronchopulmonary dysplasia in preterm infants

Bronchopulmonary dysplasia (BPD) and BPD-associated pulmonary hypertension (BPD-PH) are chronic inflammatory cardiopulmonary diseases with devastating short- and long-term consequences for infants born prematurely. The immature lungs of preterm infants are ill-prepared to achieve sufficient gas exchange, thus usually necessitating immediate commencement of respiratory support and oxygen supplementation. These therapies are life-saving, but they exacerbate the tissue damage that is inevitably inflicted on a preterm lung forced to perform gas exchange. Together, air-breathing and necessary therapeutic interventions disrupt normal lung development by aggravating pulmonary inflammation and vascular remodelling, thus frequently precipitating BPD and PH via an incompletely understood pathogenic cascade. BPD and BPD-PH share common risk factors, such as low gestational age at birth, fetal growth restriction and perinatal maternal inflammation; however, these risk factors are not unique to BPD or BPD-PH. Occurring in 17-24% of BPD patients, BPD-PH substantially worsens the morbidity and mortality attributable to BPD alone, thus darkening their outlook; for example, BPD-PH entails a mortality of up to 50%. The absence of a safe and effective therapy for BPD and BPD-PH renders neonatal cardiopulmonary disease an area of urgent unmet medical need. Besides the need to develop new therapeutic strategies, a major challenge for clinicians is the lack of a reliable method for identifying babies at risk of developing BPD and BPD-PH. In addition to discussing current knowledge on pathophysiology, diagnosis and treatment of BPD-PH, we highlight emerging biomarkers that could enable clinicians to predict disease-risk and also optimise treatment of BPD-PH in our tiniest patients.

Right Ventricular Outflow Tract (RVOT) Changes in Children with an Atrial Septal Defect: Focus on RVOT Velocity Time Integral, RVOT Diameter, and RVOT Systolic Excursion

OBJECTIVE

Aim of the study was to determine the influence of right heart volume overload in children with atrial septal defect (ASD) on right ventricular outflow tract (RVOT) variables.

METHODS

A prospective study was conducted in 115 children (age range: 2 days-18.1 years) with a moderate to large ASD. We determined effects of age, body length (BL), body weight (BW), and body surface area (BSA) on the variables RVOT diameter, RVOT velocity time integral (VTI), and RVOT systolic excursion (SE), and tested the predictive value of published normal values for age, BW, BL, and BSA in our ASD patients.

RESULTS

In our pediatric ASD patients, the age-specific RVOT diameter (z-score: +2.2, 95% CI: 2.0-2.4, P < 0.001) was significantly increased compared to normal values with 54% of our ASD patients having a z-score >2.0. The age-specific RVOT VTI z-score (z-score: +3.6, 95% CI: 3.2-3.9, P < 0.001) was significantly increased compared to normal values with 81% of our ASD patients having a z-score >2.0. The age-specific RVOT SE z-score was not increased but slightly lower compared to normal values (z-score: -0.5, 95% CI: -0.7 to -0.3, P < 0.001) with 3% of our ASD patients having a z-score >2.0 while 12% of the patients had a z-score <-2.

CONCLUSION

In our study population, we show the RVOT VTI and diameter to be relevant predictors in identifying an enlarged RVOT size and flow in children with moderate to large ASD.

Right Ventricular Outflow Tract Velocity Time Integral Determination in 570 Healthy Children and in 52 Pediatric Atrial Septal Defect Patients

Determination of the right ventricular outflow tract velocity time integral (RVOT VTI) is an important part of the noninvasive investigation of pulmonary blood flow in adults; however, age-related pediatric reference data are lacking. We examined growth-related changes of RVOT VTI values in children and the predictive value of RVOT VTI values in identifying enhanced pulmonary blood flow in children with secundum type atrial septal defect (ASD). A prospective study was conducted in a group of 570 healthy children and 52 children with a moderate-sized to large ASD. We determined the effects of age, body length (BL), body weight (BW), and body surface area (BSA) on RVOT VTI values. The predictive value of normal values stratified for age, BW, BL, and BSA was tested in our 52 ASD children. RVOT VTI values ranged from mean 9.7 ± 1.2 cm in neonates to 23.3 ± 2.7 cm in children with 18 years of age and showed a positive correlation with age, BL, BSA, and BW. In our population, RVOT VTI z-scores showed a high specificity for detecting ASD patients (>97 %) with sensitivity up to 71 %. We provide normal ranges and calculated z-scores of pediatric RVOT VTI values. Normal RVOT VTI z-scores might be additional predictors in identifying increased pulmonary blood flow in patients with ASD.

Can Pulmonary Vascular Resistance Predict Response to Cardiac Resynchronization Therapy in Patients with Heart Failure?

BACKGROUND

To evaluate if pulmonary vascular resistance (PVR) calculated by echocardiography can be a novel criterion to predict the response to cardiac resynchronization therapy (CRT).

METHODS

Forty-five patients with heart failure who underwent CRT were retrospectively analyzed. Based on CRT response, which was defined by a decrease of left ventricular end-systolic volume by at least 15% after 6 months, the patients were assigned to the responder or nonresponder groups. The peak tricuspid regurgitant velocity (TRV) and time velocity integral of the right ventricular outflow tract (TVIRVOT ) were obtained. The relation between TRV, PVR, and CRT response were analyzed using univariate and multivariate analyses.

RESULTS

Twenty-seven patients (60%) were responders and 18 patients (40%) were nonresponders to CRT. At baseline, responders had lower PVR (3.57±1.65 vs 2.32 ± 1.28 wood; P = 0.01), or lower PVR1 (3.26 ± 1.32 vs 1.83 ± 0.79 wood; P = 0.01) compared with nonresponders. Multivariate analysis has shown that PVR and PVR1 were independent factors for CRT response. The optimal cutoff point of PVR to predict nonresponse to CRT was 2.39 wood, with a sensitivity of 0.78 and a specificity of 0.81 (95% confidence interval [CI]: 53.4-88.2). The optimal cutoff point of PVR1 calculated by the other model was 3.55 wood, determined at a sensitivity of 0.72 and a specificity of 0.82 (95%CI: 56.7-90.7). In nonresponders, patients demonstrated higher PVR, TVIA , and TVIRVOT , and decreased TRV.

CONCLUSIONS

PVR could be used to predict response to CRT after 6 months as a novel criterion, and higher PVR may indicate nonresponse.

Repair of congenital heart disease with associated pulmonary hypertension in children: what are the minimal investigative procedures? Consensus statement from the Congenital Heart Disease and Pediatric Task Forces, Pulmonary Vascular Research Institute (PVRI)

Standardization of the diagnostic routine for children with congenital heart disease associated with pulmonary arterial hypertension (PAH-CHD) is crucial, in particular since inappropriate assignment to repair of the cardiac lesions (e.g., surgical repair in patients with elevated pulmonary vascular resistance) may be detrimental and associated with poor outcomes. Thus, members of the Congenital Heart Disease and Pediatric Task Forces of the Pulmonary Vascular Research Institute decided to conduct a survey aimed at collecting expert opinion from different institutions in several countries, covering many aspects of the management of PAH-CHD, from clinical recognition to noninvasive and invasive diagnostic procedures and immediate postoperative support. In privileged communities, the vast majority of children with congenital cardiac shunts are now treated early in life, on the basis of noninvasive diagnostic evaluation, and have an uneventful postoperative course, with no residual PAH. However, a small percentage of patients (older at presentation, with extracardiac syndromes or absence of clinical features of increased pulmonary blood flow, thus suggesting elevated pulmonary vascular resistance) remain at a higher risk of complications and unfavorable outcomes. These patients need a more sophisticated diagnostic approach, including invasive procedures. The authors emphasize that decision making regarding operability is based not only on cardiac catheterization data but also on the complete diagnostic picture, which includes the clinical history, physical examination, and all aspects of noninvasive evaluation.

Non-invasive estimation of pulmonary vascular resistance in patients of pulmonary hypertension in congenital heart disease with unobstructed pulmonary flow

Context:

Pulmonary vascular resistance (PVR) is a critical and essential parameter during the assessment and selection of modality of treatment in patients with congenital heart disease accompanied by pulmonary arterial hypertension.

Aim:

The present study was planned to evaluate non-invasive echocardiographic parameters to assess pulmonary vascular resistance.

Settings and Design:

This prospective observational study included 44 patients admitted in the cardiology and pediatric cardiology ward of our institution for diagnostic or pre-operative catheter based evaluation of pulmonary arterial pressure and PVR.

Materials and Methods:

Detailed echocardiographic evaluation was carried out including tricuspid regurgitation velocity (TRV) and velocity time integral of the right-ventricular outflow tract (VTI_RVOT). These parameters were correlated with catheter-based measurements of PVR.

Results:

The TRV/VTI_RVOT ratio correlated well with PVR measured at catheterization (PVRcath) (r = 0.896, 95% confidence interval [CI] 0.816 to 0.9423, P < 0.001). Using the Bland-Altman analysis, PVR measurements derived from Doppler data showed satisfactory limits of agreement with catheterization estimated PVR. For a PVR of 6 Wood units (WU), a TRV/VTI_RVOT value of 0.14 provided a sensitivity of 96.67% and a specificity of 92.86% (area under the curve 0.963, 95% confidence interval 0.858 to 0.997) and for PVR of 8 WU a TRV/VTI_RVOT value of 0.17 provided a sensitivity of 79.17% and a specificity of 95% (area under the curve 0. 0.923, 95% confidence interval 0.801 to 0.982).

Conclusions:

Doppler-derived ratio of TRV/VTI_RVOT is a simple, non-invasive index, which can be used to estimate PVR.

Accuracy of Doppler-derived indices in predicting pulmonary vascular resistance in children with pulmonary hypertension secondary to congenital heart disease with left-to-right shunting

This study aimed to evaluate the accuracy of Doppler echocardiography-derived indices in children with pulmonary hypertension secondary to congenital heart disease with left-to-right shunting. Doppler-derived indices including the acceleration time corrected (AcTc), deceleration time corrected, deceleration index, peak velocity, heart-rate-corrected inflection time (InTc), and a new index (the acceleration slope [Acc = peak flow velocity/AcTc]) were measured from the pulmonary artery (PA) systolic flow curve before and after 100 % oxygen administration in the main, left, and right PAs of 33 children. The acquired data were compared between low and high pulmonary vascular resistance (PVR) groups and between responders and nonresponders to the vasoreactivity test. The AcTc values differed significantly between the low and high PVR groups before and after oxygen administration in the main (P = 0.032 and <0.001, respectively), right (P = 0.011 and <0.001, respectively), and left (P < 0.001 and <0.001, respectively) PAs. The AcTc cutoff point in the main PA was 3.44 before oxygen administration (81% sensitivity and 91% specificity). The InTc in the main PA and its changes differed significantly between the low and high PVR groups before and after oxygen administration and between the responders and nonresponders (P = 0.016, 0.046, and 0.021, respectively). The velocity changes of the PA in the main PA differed significantly between the responders and nonresponders to oxygen administration (P < 0.001). The Acc and its changes differed significantly between the low and high PVR groups after oxygen administration and between the responders and nonresponders to oxygen administration (P = 0.044 and 0.006, respectively). Doppler echocardiographic examination using PA systolic flow indices in addition to PA reactivity testing is a promising technique for assessing PVR in children with congenital heart disease.

Trends in pediatric imaging: ultrasound

For the last three decades, two-dimensional (2D) echocardiography and Doppler echocardiography have been the primary imaging modalities for the diagnosis and management of heart disease in infants, children, and adolescents. These methods are non-invasive, highly sensitive, and cost-effective, and widely available, making them very useful in clinical work. During this period, the anatomic and hemodynamic abnormalities associated with different congenital and acquired pediatric heart diseases have been well outlined by echocardiography. Recent advances in computer technology, signal processing, and transducer design have allowed the capabilities of pediatric echocardiography to be expanded beyond qualitative 2D imaging and blood flow Doppler analysis. New modalities such as three-dimensional echocardiography, tissue Doppler imaging and speckle tracking echocardiography have been used to evaluate parameters such as ventricular volume, myocardial velocity, regional strain, and strain rate, providing new insight into cardiovascular morphology and ventricular systolic and diastolic function. Accordingly, a comprehensive and sophisticated quantification of ventricular function is now part of most echocardiography protocols. Use of measurements adjusted for body size and age is common practice today. These developments have further strengthened the position of echocardiography in pediatric cardiology.

A simple echocardiographic method to estimate pulmonary vascular resistance

Pulmonary hypertension includes heterogeneous diagnoses with distinct hemodynamic pathophysiologic features. Identifying elevated pulmonary vascular resistance (PVR) is critical for appropriate treatment. We reviewed data from patients seen at referral pulmonary hypertension clinics who had undergone echocardiography and right-side cardiac catheterization within 1 year. We derived equations to estimate PVR using the ratio of estimated pulmonary artery (PA) systolic pressure (PASPDoppler) to right ventricular outflow tract velocity time integral (VTI). We validated these equations in a separate sample and compared them with a published model based on the ratio of the transtricuspid flow velocity to right ventricular outflow tract VTI (model 1, Abbas et al 2003). The derived models were as follows: PVR = 1.2 × (PASP/right ventricular outflow tract VTI) (model 2) and PVR = (PASP/right ventricular outflow tract VTI) + 3 if notch present (model 3). The cohort included 217 patients with mean PA pressure of 45.3 ± 11.9 mm Hg, PVR of 7.3 ± 5.0 WU, and PA wedge pressure of 14.8 ± 8.1 mm Hg. Just >1/3 had a PA wedge pressure >15 mm Hg (35.5%) and 82.0% had PVR >3 WU. Model 1 systematically underestimated catheterization estimated PVR, especially for those with high PVR. The derived models demonstrated no systematic bias. Model 3 correlated best with PVR (r = 0.80 vs r = 0.73 and r = 0.77 for models 1 and 2, respectively). Model 3 had superior discriminatory power for PVR >3 WU (area under the curve 0.946) and PVR >5 WU (area under the curve 0.924), although all models discriminated well. Model 3-estimated PVR >3 was 98.3% sensitive and 61.1% specific for PVR >3 WU (positive predictive value 93%; negative predictive value 88%). In conclusion, we present an equation to estimate the PVR, using the ratio of PASPDoppler to right ventricular outflow tract VTI and a constant designating presence of right ventricular outflow tract VTI midsystolic notching, which provides superior agreement with catheterization estimates of PVR across a wide range of values.

Echocardiography in pediatric pulmonary hypertension

Pediatric pulmonary hypertension is a complicated disease with multiple etiologies and high mortality. Echocardiography is at the forefront of evaluation as a noninvasive, portable imaging modality that can yield diagnostic and prognostic information regarding this disease. Echocardiography is known for its ability to give an anatomic assessment of the heart and proximal blood vessels. With the additional use of Doppler echocardiography and myocardial motion assessment, the effects of elevated pulmonary pressures on the heart can be evaluated. This can allow for estimation of pulmonary artery pressures and resistances and assessment of ventricular systolic and diastolic functions. However despite its advantages, echocardiography is still an indirect assessment of pulmonary hypertension and not a substitute for cardiac catheterization. The purpose of this review is to discuss common techniques for the assessment of pulmonary hypertension by echocardiography as well as their limitations.