Echocardiographic evaluation of diastolic function in the setting of pulmonary hypertension

Fig. 1.. Right heart catheterization in a patient with pulmonary arterial hypertension shows normal RAP (a), elevated pulmonary pressures (b), normal PAWP at rest (c), and no change in PAWP with fluid challenge (d). The same patient on echocardiogram shows evidence of right atrial and ventricular enlargement, septal bowing, elevated tricuspid regurgitation velocity, normal mitral in-flow velocity pattern, and normal mitral annular tissue doppler velocity patterns (e).

Fig. 2.. Right heart catheterization in a patient with inducible post-capillary pulmonary hypertension shows normal RAP (a), elevated pulmonary pressures (b), and normal PAWP at rest (c). Notably, there is a marked increase in PAWP with fluid challenge (d). Echocardiogram shows evidence of a left ventricle larger than right, left atrial enlargement, normal septal shape, elevated tricuspid regurgitation velocity, abnormal mitral in-flow velocity pattern, and abnormal mitral annular tissue doppler velocity patterns (e).

Fig. 3.. Due to ventricular interdependence of the right and left ventricle, pressure and volume overload in the setting of pulmonary arterial hypertension can lead to impaired diastolic filling of the left ventricle. This results in a pressure volume relationship under normal conditions (1) that shifts to increased pressure for any given volume (2).

Fig. 4.. Determination of diastolic function and left atrial pressure estimation by echocardiogram, adapted from the American Society of Echocardiography 2016 guidelines. LAP: left atrial pressure estimate.