Assessing the accuracy of echocardiographic estimation of pulmonary pressures: Insights from a 5-grade tricuspid regurgitation classification

BACKGROUND: The accuracy of echocardiographic right ventricular systolic pressure (eRVSP) estimation may be compromised in the context of severe tricuspid regurgitation (TR). This study assessed the agreement between eRVSP and invasive RVSP (iRVSP) using the five-grade TR severity classification. METHODS: 742 patients who underwent same-day transthoracic echocardiography (TTE) and right heart catheterization (RHC) we retrospectively screened. TR severity was graded from 1 to 5; all patients with TR grades 3-5 were referred for TEE-R screening. RESULTS: The final cohort included 454 patients. eRVSP and iRVSP demonstrated strong correlations in TR grades 1-4 (R = 0.70-0.87; all p < 0.001) whereas in TR-5 the association was moderate (R = 0.57). Limits of agreement were wide across all grades. The difference in right atrial pressure (ΔRAP) emerged as the sole independent predictor of Δ(e-iRVSP). An eRVSP threshold of 35 mmHg yielded high sensitivity (80-90 %) for pulmonary hypertension (pH) detection in TR grades 1-4, but sensitivity was reduced in TR-5 (54 %), improving to 71 % with a lower threshold of 30 mmHg. Within the TR 3-5 screening subgroup, eRVSP demonstrated high diagnostic accuracy for identifying iRVSP >60 mmHg (AUC = 0.93). CONCLUSION: eRVSP provides reliable rule-out information for PH across TR grades 1-4. In torrential TR, the low sensitivity might be improved by applying a lower threshold may improve sensitivity. Importantly, eRVSP effectively identifies PH at thresholds relevant for excluding TEE-R eligibility.