Investigating the value of right heart echocardiographic metrics for detection of pulmonary hypertension in patients with advanced lung disease

  • Myriam Amsallem
  • David Boulate
  • Zoe Kooreman
  • Roham T. Zamanian
  • Guillaume Fadel
  • Ingela Schnittger
  • Elie Fadel
  • Michael V. McConnell
  • Gundeep Dhillon
  • Olaf Mercier
  • François Haddad
Original Paper


This study determined whether novel right heart echocardiography metrics help to detect pulmonary hypertension (PH) in patients with advanced lung disease (ALD). We reviewed echocardiography and catheterization data of 192 patients from the Stanford ALD registry and echocardiograms of 50 healthy controls. Accuracy of echocardiographic right heart metrics to detect PH was assessed using logistic regression and area under the ROC curves (AUC) analysis. Patients were divided into a derivation (n = 92) and validation cohort (n = 100). Experimental validation was assessed in a piglet model of mild PH followed longitudinally. Tricuspid regurgitation (TR) was not interpretable in 52% of patients. In the derivation cohort, right atrial maximal volume index (RAVI), ventricular end-systolic area index (RVESAI), free-wall longitudinal strain and tricuspid annular plane systolic excursion (TAPSE) differentiated patients with and without PH; 20% of patients without PH had moderate to severe RV enlargement by RVESAI. On multivariate analysis, RAVI and TAPSE were independently associated with PH (AUC = 0.77, p < 0.001), which was confirmed in the validation cohort (0.78, p < 0.001). Presence of right heart metrics abnormalities did not improve detection of PH in patients with interpretable TR (p > 0.05) and provided moderate detection value in patients without TR. Only two patients with more severe PH (mean pulmonary pressure 35 and 36 mmHg) were missed. The animal model confirmed that right heart enlargement discriminated best pigs with PH from shams. This study highlights the frequency of right heart enlargement and dysfunction in ALD irrespectively from presence of PH, therefore limiting their use for detection of PH.


Echocardiography Lung disease Pulmonary hypertension Right heart failure Strain 



The authors would like to thank the Stanford Cardiovascular Institute and Vera Moulton Wall Center of Pulmonary Hypertension at Stanford for their support.


This study was funded by the Stanford Cardiovascular Institute, the Vera Moulton Wall Center of Pulmonary Hypertension at Stanford and the French National Reseach Agency (ANR-15-RHUS-0002).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest. MA received a Young Investigator Seed Grant from the Vera Moulton Wall Center. MVM previously received cardiac MRI research support from GE Healthcare and is currently on partial leave of absence while at Verily. FH received funds from Pai Chan Lee Research fund.

Ethical approval

All applicable international, national, and/or institutional guidelines for the care and use of animals were followed (Institutional Animal Care Committee of Marie Lannelongue Hospital, Paris-Sud University, France). All procedures performed in studies involving human participants were approved by Stanford University Institutional Review Board in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Supplementary material

10554_2017_1069_MOESM1_ESM.pdf (898 kb)
Supplementary material 1 (PDF 897 KB)
10554_2017_1069_MOESM2_ESM.pdf (79 kb)
Supplementary material 2 (PDF 79 KB)
10554_2017_1069_MOESM3_ESM.pdf (313 kb)
Supplementary material 3 (PDF 313 KB)


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Copyright information

© Springer Science+Business Media Dordrecht 2017

Authors and Affiliations

  • Myriam Amsallem
    • 1
    • 5
  • David Boulate
    • 2
  • Zoe Kooreman
    • 1
  • Roham T. Zamanian
    • 3
    • 4
  • Guillaume Fadel
    • 1
  • Ingela Schnittger
    • 1
  • Elie Fadel
    • 2
  • Michael V. McConnell
    • 1
  • Gundeep Dhillon
    • 3
  • Olaf Mercier
    • 2
  • François Haddad
    • 1
  1. 1.Division of Cardiovascular MedicineStanford University School of MedicineStanfordUSA
  2. 2.Laboratoire de Recherche Chirurgicale, Marie Lannelongue HospitalUniversity of Paris SudLe Plessis RobinsonFrance
  3. 3.Division of Pulmonary and Critical Care MedicineStanford University School of MedicineStanfordUSA
  4. 4.Vera Moulton Wall Center for Pulmonary Vascular DiseaseStanford University School of MedicineStanfordUSA
  5. 5.Stanford Cardiovascular InstituteStanfordUSA

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