PH Echo Estimator Experimental

RV systolic pressure from the TR jet

RV-RA gradient [mmHg] = 4 x V^2          V = peak TR velocity in m/s (simplified Bernoulli)
RVSP [mmHg]           = 4 x V^2 + RA pressure
RVSP / systolic BP    = shown as a fraction of systemic pressure (no category assigned)

Yock & Popp 1984: TR jets were recordable in 54 of 62 patients with clinically elevated right-sided pressures; 4V² plus mean RA pressure (estimated clinically from the jugular veins) correlated with catheter RVSP, r = 0.93, SEE 8 mmHg. RVSP equals PA systolic pressure only without RV outflow or pulmonary valve obstruction. Burkett 2020 reported TR not measurable in 21.8% of pediatric PH studies; Levy 2016 notes clinically relevant discrepancies between Doppler and catheter pressures in children.

PA acceleration time (Levy 2016)

sPAP [mmHg]      = 64 - 0.39 x PAAT [ms]
mPAP [mmHg]      = 48 - 0.28 x PAAT
PVR  [WU]        = 12 - 0.10 x PAAT
PVRi [WU x m2]   =  9 - 0.07 x PAAT
Cut-offs for PH (PVRi >3 WU.m2 and mPAP >25 mmHg): PAAT <90 ms (sens 97%, spec 95%); PAAT/RVET <0.31 (sens 87%, spec 89%)
PAAT <40 ms: regressions unpredictable; detected PVRi >10, mPAP >45, sPAP >65 (sens 93%, spec 92%)

• Derivation: 75 children aged 1–18 years (median 5.3) with wide-ranging hemodynamics at Saint Louis Children’s; validation: 50 children. Excluded: single ventricle, mechanical tricuspid valve, RV outflow obstruction, left heart disease, arrhythmias, pulmonary insufficiency, pulmonary vasodilators. Validated at heart rates 55–150 bpm. Overall cohort ranges: mPAP 12–60 mmHg, PVR 2–10.4 WU, PVRi 2–18 WU·m²; estimates below these ranges are flagged as extrapolation and zero or negative estimates are not shown. Equations from the PMC author manuscript (PMC5408579).
• Not validated in infants under 1 year, including preterm infants; this page withholds the estimates there.
• Age-specific normal values for PAAT: Koestenberger 2017 (756 healthy children, 1 day to 18 years; neonates median 81 ms, range 53–104; 18th year median 151 ms, range 107–187). This page computes the z-score:

mean [ms] = 77.38 + 0.72 x age + 13.88 x sqrt(age), minus 2.02 for boys   (age in years)
SD   [ms] = 12.87 + 0.17 x age
z         = (PAAT - mean) / SD
z <-2: PH detected with sensitivity 70%, specificity 99%; best cut-off z -1.565 (92% / 96%)

• The paper's printed formula adds 2.02 ms for girls instead; its Table 3, worked example and text all fit girls with no sex term and boys with −2.02 ms, so Table 3 is followed here (the two differ by about 0.15 z).
• The −2 cut-off missed many children with PH under 10 years, especially infants, so a z-score within ±2 SD does not exclude PH there. Performance was tested in 54 children with PH aged 3 months to 18 years (catheter-defined, mPAP ≥25 mmHg and PVR ≥3 WU·m², except 11 with BPD-associated PH defined by echo). The authors advise against using PAAT to predict PH when heart rate is above +2 SD for age. The healthy newborns weighed 2.4 kg or more; their gestational age is not reported. The z-score is withheld for single ventricle and RV outflow obstruction (the healthy reference had structurally normal hearts).

LV eccentricity index

EI = LV minor-axis diameter parallel to the septum / diameter perpendicular to (bisecting) the septum

• Ryan 1985: normal EI essentially 1.0 at end-systole and end-diastole; RV pressure overload raised end-systolic EI (1.44 ± 0.16 in adults with PA systolic >40 mmHg).
• Burkett 2020 (78 pediatric PH patients with simultaneous cath, 78 controls; diameters from compact myocardium): control end-systolic EI 0.99 [0.97–1.04]; end-systolic EI 1.16 best identified PH (mPAP >25 mmHg, AUC 0.807); maximal EI 1.42 and 1.94 best identified half-systemic and systemic PH. The authors state these values “must be validated before clinical use”.
• Abraham & Weismann 2016 (216 infants: 207 preterm at 36–38 weeks PMA screened for BPD-PH, 9 with PPHN; reference was echo only, no catheterization): EIs ≥1.15 had the best accuracy against all three echo definitions (septal flattening 93% / 96.2%; TR gradient >36 mmHg 94.4% / 74.4%; RVSP >half systemic 93.3% / 81.5%); EIs ≥1.3 marked more than half-systemic RV pressure (60% / 91.5%). Healthy neonates have a median end-systolic EI of 1.16–1.18 in the first month (Schweintzger 2022, Table S4A), so ≥1.15 overlaps normal then; Abraham’s cohort had only 9 term infants (PPHN).
• Averin 2016 (29 children, 46 studies, echo within 30 days of cath): LVEI >1.24 (sens 88%, spec 83%) and >1.48 (sens 76%, spec 100%) for RV/aortic systolic pressure >0.5.
• Simpkin 2026: after complete AVSD repair EI is higher than in healthy children even without PAH; end-systolic EI >1.28 best predicted elevated RVSP and PVRi.

TAPSE

• Koestenberger 2009 (640 healthy children, 1 day to 18 years, no sex difference), Table 1: mean, ±2 SD and ±3 SD for each age group, from 0.91 cm (−2 SD 0.68) at 0–30 days to 2.47 cm (−2 SD 2.05) at 18 years. The paper prints no regression, so this page places a TAPSE in a band of its age group rather than giving a z-score. The year groups (“1 y” to “18 y”) are read as completed years; the paper does not define them further.
• EPPVDN 2019 (Figure 2, level of evidence C): TAPSE z >−2 is a lower-risk and z <−3 a higher-risk determinant in pediatric PH. WSPH 2024 lists an absolute TAPSE <12 mm as a higher-risk finding in pediatric PAH (Ivy 2024, Table 4); healthy infants can be below 12 mm (Koestenberger 2009: mean 0.91 cm at 0–30 days; −2 SD 1.13 cm at 7–12 months).

What this page does not do

It does not combine markers into a points score: no validated pediatric PH echo score exists. Each marker is reported against the cut-off of the study that derived it, with that study’s population.

References

• Abman SH, Hansmann G, Archer SL, et al. Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Circulation 2015;132(21):2037-2099. doi:10.1161/CIR.0000000000000329
• Ivy D, Rosenzweig EB, Abman SH, et al. Embracing the challenges of neonatal and paediatric pulmonary hypertension. Eur Respir J 2024;64(4):2401345. doi:10.1183/13993003.01345-2024
• Schweintzger S, Kurath-Koller S, Burmas A, et al. Normal echocardiographic reference values of the right ventricular to left ventricular endsystolic diameter ratio and the left ventricular endsystolic eccentricity index in healthy children and in children with pulmonary hypertension. Front Cardiovasc Med 2022;9:950765. doi:10.3389/fcvm.2022.950765
• Yock PG, Popp RL. Noninvasive estimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation. Circulation 1984;70(4):657-662. doi:10.1161/01.cir.70.4.657
• Levy PT, Patel MD, Groh G, et al. Pulmonary Artery Acceleration Time Provides a Reliable Estimate of Invasive Pulmonary Hemodynamics in Children. J Am Soc Echocardiogr 2016;29(11):1056-1065. doi:10.1016/j.echo.2016.08.013
• Koestenberger M, Grangl G, Avian A, et al. Normal Reference Values and z Scores of the Pulmonary Artery Acceleration Time in Children and Its Importance for the Assessment of Pulmonary Hypertension. Circ Cardiovasc Imaging 2017;10(1):e005336. doi:10.1161/CIRCIMAGING.116.005336
• Ryan T, Petrovic O, Dillon JC, et al. An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol 1985;5(4):918-927. doi:10.1016/s0735-1097(85)80433-2
• Burkett DA, Patel SS, Mertens L, Friedberg MK, Ivy DD. Relationship Between Left Ventricular Geometry and Invasive Hemodynamics in Pediatric Pulmonary Hypertension. Circ Cardiovasc Imaging 2020;13(5):e009825. doi:10.1161/CIRCIMAGING.119.009825
• Abraham S, Weismann CG. Left Ventricular End-Systolic Eccentricity Index for Assessment of Pulmonary Hypertension in Infants. Echocardiography 2016;33(6):910-915. doi:10.1111/echo.13171
• Averin K, Michelfelder E, Sticka J, Cash M, Hirsch R. Changes in Ventricular Geometry Predict Severity of Right Ventricular Hypertension. Pediatr Cardiol 2016;37(3):575-581. doi:10.1007/s00246-015-1317-z
• Simpkin CT, DeLima M, MacBeth M, et al. Eccentricity Index Is Associated With Pulmonary Arterial Hypertension in Children After Repair of Complete Atrioventricular Septal Defects. Echocardiography 2026;43(4):e70451. doi:10.1111/echo.70451
• Hansmann G, Koestenberger M, Alastalo TP, et al. 2019 updated consensus statement on the diagnosis and treatment of pediatric pulmonary hypertension: the European Pediatric Pulmonary Vascular Disease Network (EPPVDN). J Heart Lung Transplant 2019;38(9):879-901. doi:10.1016/j.healun.2019.06.022
• Koestenberger M, Ravekes W, Everett AD, et al. Right ventricular function in infants, children and adolescents: reference values of the tricuspid annular plane systolic excursion (TAPSE) in 640 healthy patients and calculation of z score values. J Am Soc Echocardiogr 2009;22(6):715-719. doi:10.1016/j.echo.2009.03.026