Pulmonary Hypertension: Echo Assessment

Neonates, infants and children: signs, normal values by age, cut-offs and risk tables, with the adult approach for comparison

Show values for

Signs and pressure estimates

Group	What to look for	Source
Neonate	Echo indicators of PH: right-to-left shunt at duct, atrium or ventricle · continuous left-to-right PDA flow, Vmax <2.0 m/s · TR >2.8 m/s and/or systolic PAP >half systemic · early-diastolic PR >2.3 m/s · septal flattening, raised eccentricity index · short PAAT · RV hypertrophy · RA enlargement	WSPH 2024, Table 9
All ages	RVSP = 4 × TR Vmax² + RA pressure (assume 5 mmHg in neonates; 5–10 in children). PA diastolic = 4 × end-diastolic PR² + RA. Right-to-left duct (≥30% of the cycle): systolic PAP = 4 × duct Vmax² + systolic BP; direction is more reliable than the number.	ASE 2024 TNE; Koestenberger 2016; de Boode 2018
All ages	LV shape, end-systole: round = RV pressure <50% of LV · D-shaped 50–100% · crescent ≥100%	de Boode 2018, Table 4
BPD infants	Severity by RVSP as a fraction of systemic: none <1/3 · mild 1/3–1/2 · moderate 1/2–2/3 · severe >2/3 (with septal position, RV hypertrophy and function)	Krishnan 2017, Table III

LV eccentricity index and RV/LV ratio

Group	Values (end-systole)	Source
Healthy, by age	Eccentricity index median (2.5th–97.5th centile): 1 week 1.18 (0.99–1.37); 1 month 1.16 (0.97–1.34); 6 months 1.03 (0.89–1.17); 1 year 0.98 (0.87–1.09); 2–18 y about 1.00, upper 1.04–1.08. RV/LV ratio: 1 week 0.83 (0.58–1.08); 6 months 0.61 (0.37–0.84); 1 year 0.52 (0.31–0.74); 2–18 y medians 0.51–0.57, upper 0.66–0.74	Schweintzger 2022, Suppl. Tables S3A, S4A
Preterm infants, 36–38 wk PMA	Eccentricity index ≥1.15: septal flattening (sensitivity 93%, specificity 96%); ≥1.3: RV pressure >half systemic (60% / 91.5%)	Abraham 2016, Table I
Child >1 y	Eccentricity index ≥1.06 and RV/LV ≥0.67 separated established PH from healthy children (sensitivity 100%; specificity 96.6% and 94.6%). RV/LV >1: more adverse events.	Schweintzger 2022, Table 2; Jone 2014
Adult	Eccentricity index >1.1 in systole and/or diastole and RV/LV basal ratio >1.0 are signs of PH.	ESC/ERS 2022, Table 10

How to measure

Parasternal short axis at the mid-papillary level, end-systole (last frame of LV free-wall contraction). Eccentricity index = LV diameter parallel to the septum ÷ diameter perpendicular to it; about 1.0 when round.
RV/LV ratio: RV and LV minor-axis diameters on the same line. Not valid when a shunt or PR volume-loads the RV.
Methods differ (endocardium vs compact myocardium; end-systolic vs maximal index): do not mix scales. Burkett 2020 found an end-systolic index of 1.16 best for mPAP >25 (AUC 0.81) and says it needs validation.

PA acceleration time (PAAT)

Group	Values (ms)	Source
Preterm <29 wk	Day 1 44 ± 3, PAAT/RVET 0.25; days 5–7 49 ± 6; 1 year corrected 78 (median). At 32 weeks PMA, <47 ms with PAAT/RVET <0.28 predicted PH at 36 weeks (sensitivity 91%, specificity 95%)	Patel 2019, Table 2
Neonate	PAAT/RVET normal ≥0.25 (RVET/PAAT ≤4)	ASE 2024 TNE, Table 3
Healthy, by age	Mean (−2 SD), girls / boys: 1st month 80.2 (54.5) / 78.2 (52.5); 2nd year 95.5 (69.2) / 93.4 (67.2); 6th year 113.9 (86.3) / 111.9 (84.2); 11th year 129.9 (100.6) / 127.9 (98.6); 18th year 148.1 (116.3) / 146.0 (114.3). Below −2 SD: sensitivity 70%, specificity 99% for PH.	Koestenberger 2017, Table 3
Child 1–18 y	<90 ms detected PH (sensitivity 97%, specificity 95%); PAAT/RVET <0.31 (87% / 89%). <40 ms with ratio <0.23: PVRi >10 WU·m², mPAP >45	Levy 2016 (mPAP >25)
Adult	RVOT acceleration time <105 ms and/or mid-systolic notching is a sign of PH. Healthy children average below 105 ms until about 3–4 years (Koestenberger 2017, Table 3).	ESC/ERS 2022, Table 10

How to measure

Pulsed Doppler at the pulmonary valve, parasternal short axis: onset of ejection to peak velocity; average 3–5 beats. With a rounded peak, measure to its earliest part.
Heart rate, RV function and large left-to-right shunts all change PAAT. A mid-systolic notch suggests raised PVR; normal values come from unnotched signals.

TAPSE

Group	Values (cm)	Source
First 48 h, by GA	Predicted mean (±2 SD) by week of gestation (26th week = 25+0 to 25+6): 26th week 0.45 (0.32–0.58); 30th 0.59 (0.46–0.72); 34th 0.74 (0.61–0.87); 38th 0.88 (0.75–1.01); 41st 0.99 (0.86–1.12)	Koestenberger 2011, Table 1
Newborn–18 y	Mean (−2 SD): 0–30 days 0.91 (0.68); 1–3 months 1.14 (0.85); 7–12 months 1.44 (1.13); 2 y 1.65 (1.36); 5 y 1.87 (1.60); 10 y 2.05 (1.79); 14 y 2.26 (1.87); 18 y 2.47 (2.05)	Koestenberger 2009, Table 1
Adult	Normal >1.7; TAPSE/systolic PAP <0.55 mm/mmHg is a sign of PH	ASE 2025 right heart; ESC/ERS 2022

Risk in established PH

Group	Higher-risk echo findings	Source
Pediatric PAH	TAPSE <12 mm · RV FAC <25% · RV free-wall strain >−17% · RV global strain >−14% · eccentricity index systole >1.89, diastole >1.55 · RV/LV (diastolic) >1 · RA area >18 cm² · pericardial effusion	WSPH 2024, Table 4
Pediatric PH	Lower vs higher risk: RV/LV end-systolic <1 vs >1.5 · TAPSE z >−2 vs <−3 · TR systolic/diastolic duration <1.0 vs >1.4 · PAAT >100 vs <70 ms (>1 y) · effusion = higher risk	EPPVDN 2019, Figure 2

Screening and follow-up

Class	Recommendation	LOE
I	Preterm: echo if still ventilated at day 7, and at BPD diagnosis (36 weeks PMA) (PPHNet 2017: day 7 I, C; 36 weeks I, B. AHA/ATS: established BPD I, B)	B–C
I	BPD with PH: echo weekly at first, then 1–2 per month (EPPVDN)	C
I	Established PH: serial echo every 3–6 months, sooner if unstable or after a therapy change (EPPVDN, Table 3)	B

More screening detail, other conditions

ASE 2024 TNE: screening TNE for infants born <29 weeks still needing oxygen or ventilation at 8 postnatal weeks or 36 weeks PMA, whichever is sooner.
EPPVDN: preterm infants at risk may be screened as early as day 7 (IIb, B); echo for all infants with BPD or on supplemental oxygen at 34–36 weeks corrected and before discharge (I, C).
PPHNet: also screen severe early hypoxemic respiratory failure (I, B) and sustained need for support at any age (I, B); once PH is found, repeat every 1–2 weeks at first.
Every BPD-PH study should check all pulmonary veins for stenosis: velocity >1.0 m/s (ASE 2024 TNE) or non-phasic flow (PPHNet).
AHA/ATS 2015: echo for PH in chronic lung disease, severe obstructive sleep apnea, and liver disease before transplant listing (I, B). Sickle cell disease: screen by 8 years (IIa, C); TR ≥2.5 m/s abnormal, ≥3.0 m/s suggests moderate–severe PH, though TR velocity tracks PVR poorly in these children.

Adult probability (for comparison)

Group	Values	Source
Adult	Peak TR ≤2.8 m/s or unmeasurable: low probability, intermediate if other signs. 2.9–3.4: intermediate, high if other signs. >3.4: high. "Other signs" need two categories: ventricles, pulmonary artery, IVC/RA.	ESC/ERS 2022, Figure 5, Table 10

Key points

Echo screens; catheterization confirms before targeted therapy, except in PPHN, BPD-associated PH or when it is too risky (EPPVDN, class I).
Never rely on one parameter. No TR jet does not mean normal pressure.
PH is now mPAP >20 mmHg after 3 months of age; many pediatric echo cut-offs were derived against mPAP ≥25, others against echo alone.
Neonates differ: healthy newborns have a flatter septum (higher eccentricity index; 97.5th centile 1.37 at 1 week) and a larger RV/LV ratio. Child and adult cut-offs do not transfer.
Index to age: PAAT and TAPSE grow with the child; use the tables below.

Why

Definitions: WSPH 2024 Table 1 (mPAP >20 mmHg, pre-capillary with PAWP ≤15 and PVRI >3 WU·m²); applied beyond the first months of life. Cut-offs from Levy 2016, Burkett 2020, Jone 2014 and Koestenberger 2017 used mPAP ≥25 (or >25).
TR is often absent or incomplete: measurable in only 9–17% of preterm infants at routine scans (Patel 2019); with RV dysfunction the TR-derived pressure can be falsely low.
EPPVDN 2019: expert echo is multiparametric (class I, C); TTE cannot establish the definite diagnosis or WHO group (I, C).

Sources and how this page was checked

Guidance (full text read)

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. 7th World Symposium pediatric task force.
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;38:879-901. doi:10.1016/j.healun.2019.06.022.
Abman SH, Hansmann G, Archer SL, et al. Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society. Circulation 2015;132:2037-2099. doi:10.1161/CIR.0000000000000329.
Krishnan U, Feinstein JA, Adatia I, et al. Evaluation and management of pulmonary hypertension in children with bronchopulmonary dysplasia. J Pediatr 2017;188:24-34.e1. doi:10.1016/j.jpeds.2017.05.029.
Hansmann G, Sallmon H, Roehr CC, Kourembanas S, et al. Pulmonary hypertension in bronchopulmonary dysplasia. Pediatr Res 2021;89:446-455. doi:10.1038/s41390-020-0993-4.
McNamara PJ, Jain A, El-Khuffash A, et al. Guidelines and recommendations for targeted neonatal echocardiography and cardiac point-of-care ultrasound in the NICU: an update from the ASE. J Am Soc Echocardiogr 2024;37:171-215. doi:10.1016/j.echo.2023.11.016 (corrected version).
de Boode WP, Singh Y, Molnar Z, et al. Application of neonatologist performed echocardiography in the assessment and management of persistent pulmonary hypertension of the newborn. Pediatr Res 2018;84(Suppl 1):68-77. doi:10.1038/s41390-018-0082-0.
Koestenberger M, Friedberg MK, Nestaas E, Michel-Behnke I, Hansmann G. Transthoracic echocardiography in the evaluation of pediatric pulmonary hypertension and ventricular dysfunction. Pulm Circ 2016;6:15-29. doi:10.1086/685051.
Adult. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022;43:3618-3731. doi:10.1093/eurheartj/ehac237.
Adult. Mukherjee M, Rudski LG, Addetia K, et al. Guidelines for the echocardiographic assessment of the right heart in adults and special considerations in pulmonary hypertension. J Am Soc Echocardiogr 2025;38:141-186. doi:10.1016/j.echo.2025.01.006.

Studies (full text read)

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 (with supplement).
Abraham S, Weismann CG. Left ventricular end-systolic eccentricity index for assessment of pulmonary hypertension in infants. Echocardiography 2016;33:910-915. doi:10.1111/echo.13171.
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:e009825. doi:10.1161/CIRCIMAGING.119.009825.
Jone PN, Hinzman J, Wagner BD, Ivy DD, Younoszai A. Right ventricular to left ventricular diameter ratio at end-systole in evaluating outcomes in children with pulmonary hypertension. J Am Soc Echocardiogr 2014;27:172-178. doi:10.1016/j.echo.2013.10.014.
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:e005336. doi:10.1161/CIRCIMAGING.116.005336.
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;29:1056-1065. doi:10.1016/j.echo.2016.08.013.
Patel MD, Breatnach CR, James AT, et al. Echocardiographic assessment of right ventricular afterload in preterm infants: maturational patterns of pulmonary artery acceleration time over the first year of age and implications for pulmonary hypertension. J Am Soc Echocardiogr 2019;32:884-894.e4. doi:10.1016/j.echo.2019.03.015.
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;22:715-719. doi:10.1016/j.echo.2009.03.026.
Koestenberger M, Nagel B, Ravekes W, et al. Systolic right ventricular function in preterm and term neonates: reference values of the tricuspid annular plane systolic excursion (TAPSE) in 258 patients and calculation of z-score values. Neonatology 2011;100:85-92. doi:10.1159/000322006.

How it was checked

Sources were read in full text (October 2026), not their online supplements (except Schweintzger 2022). Numbers are as printed in the table or results named in each row. Adult values are labelled Adult.
Where sources disagree, the page says so or shows the table: Koestenberger 2017's printed PAAT z formula gives values 2.02 ms above its own Table 3, which the paper's examples follow; the PPHNet flowchart and severity table group pressure differently; the neonatal TNE guideline gives a normal eccentricity index of ≤1.3 while healthy-newborn centiles reach 1.37.
Not reproduced: heart-rate-indexed PAAT (no formula in the sources read), pediatric end-diastolic PR normal values (none found) and TAPSE norms for preterm infants beyond 48 h.