**2. Prognostic value of the echocardiographic data in PH**

According to the clinical, biochemical, echocardiographic, or other imaging data, patients with PH can be classified as low, intermediate, and high risk of clinical worsening or death [1]. Patients categorized as low risk have estimated 1-year mortality of <5%, those categorized as intermediate risk have estimated 1-year mortality of 5–10%, and those in the high-risk category >10% [1].

The ESC guidelines on pulmonary hypertension propose an echocardiographic risk assessment in PH according to the right atrial area (area over 26 cm2 ) (**Figure 1**) and the presence of pericardial effusion (**Figure 2**) [1]. However, many studies demonstrated the usefulness of other echocardiographic parameters as prognostic factors in PH. Patients, with PH and EI above 1.7 (**Figure 2**) combined with TAPSE below 15 mm, have a higher death rate than patients with normal values. The diastolic

dysfunction of the RV, expressed by the changes in tricuspid flow E/A ratio and RV relaxation abnormalities by TDI, is associated with a poor prognosis. The systolic dysfunction of the RV is related to a poor prognosis of the PH: TAPSE less than 18 mm, tricuspid S<sup>0</sup> < 9.5 cm/s assessed by TDI, 3D - RVEF below 45%, RVFAC less than 35%, dP/dt below 400 mmHg/s on the TR flow, reduced strain of the RV using speckle tracking echocardiography (**Figure 5**).

Many studies support the prognostic role of classical echocardiographic data in PH.


#### **Figure 5.**

*Example of measurement of free wall right ventricular strain (FWS). Strain-based TAPSE is an approximated M-mode TAPSE, by calculation of the excursion relative to the image apex.*

*Echocardiographic Prognostic Factors in Pulmonary Hypertension DOI: http://dx.doi.org/10.5772/intechopen.107420*


prolonged slope of minute ventilation/CO2 production, and elevated plasma brain natriuretic peptide level.


Speckle tracking echocardiography applied to the RV has demonstrated its utility in the prognostic stratification of patients with PH:



*TAPSE = tricuspid annular plane systolic excursion; S´ = right ventricle free wall tissue Doppler systolic velocity during ejection period (Lateral tricuspid annulus peak systolic velocity); RVFAC = right ventricle fractional area changes PA = pulmonary artery; LV = left ventricle; and TDI = tissue Doppler imaging.*

#### **Table 2.**

*Echocardiographic parameters recommended in clinical practice for the assessment of PH prognosis.*

mid-basal RV free wall segments. Pattern 1 was characterized by a prompt return of strain-time curves to baseline after peak systolic negativity, like in normal control subjects, and corresponded to mild PH. Pattern 2 was characterized by persisting negativity of strain-time curves well into diastole before an enddiastolic returning to baseline and corresponded to more advanced PH with preserved RV function. Pattern 3 was characterized by a slow return of straintime curves to baseline during diastole corresponded to PH with end-stage RV failure. 60% and respectively 33% of patients with Pattern 3 had a fasterworsening disease assessed at 1 and 2 years

