Echocardiographic PH Probability Assessment
Select TR peak velocity range, then check signs present from at least 2 of the 3 categories (A, B, C) to determine PH probability.
Step 1
Peak TR Velocity
Step 2 — Category A: Ventricles
A — Ventricular Signs (formal guideline criteria)
Supportive / Prognostic (not formal probability criteria)
B — Pulmonary Artery Signs (formal guideline criteria)
Supportive (not in formal probability criteria)
C — IVC and RA Signs (formal guideline criteria)
Result
PH Probability
Select TR velocity to begin
—
Probability Matrix
| Peak TRV | Other Signs | Probability |
|---|---|---|
| <2.8 m/s or N/M | None | Low |
| <2.8 m/s or N/M | Present (≥2 categories) | Intermediate |
| 2.8 m/s | Present (≥2 categories) | Intermediate |
| 2.9–3.4 m/s | None | Intermediate |
| 2.9–3.4 m/s | Present (≥2 categories) | High |
| >3.4 m/s | Any | High |
PH Definition (2025)
PH (any) — invasivemPAP >20 mm Hg
Pre-capillary PHmPAP >20 + PCWP ≤15 + PVR >2 WU
Isolated post-capillarymPAP >20 + PCWP >15 + PVR ≤2 WU
Combined pre+post-capillarymPAP >20 + PCWP >15 + PVR >2 WU
⚠️ Echo assigns probability only. Definitive PH diagnosis requires invasive right heart catheterization.
Hemodynamic Calculators
Based on 2025 ASE-recommended formulas. All values are estimates — invasive measurement is the gold standard.
Calculator
RVSP / PASP
RVSP = 4 × (TR Vmax)² + RAP
PASP ≈ RVSP (if no PS or RVOT obstruction)
PASP ≈ RVSP (if no PS or RVOT obstruction)
m/s
RVSP / PASP
⚠️ Average ≥3 beats in sinus rhythm; ≥5–10 beats in AF. Use densest envelope. Avoid post-PVC beats. Triangular contour (V-wave cutoff sign) underestimates.
Calculator
Mean PA Pressure (mPAP)
Method 1: mPAP = ⅓·PASP + ⅔·PAEDP
Method 2: mPAP = 79 − (0.45 × AccT)
Method 3: mPAP = 90 − (0.62 × AccT) if AccT <120 ms
Method 4: mPAP = 4·(early PR V)² + RAP
Method 2: mPAP = 79 − (0.45 × AccT)
Method 3: mPAP = 90 − (0.62 × AccT) if AccT <120 ms
Method 4: mPAP = 4·(early PR V)² + RAP
mm Hg
mm Hg
ms
m/s
Calculator
PVR — Abbas Echo Method
PVR (WU) = (TR Vmax / RVOT VTI) × 10 + 0.16
Normal <1.5 WU · Abnormal >2.0 WU
Normal <1.5 WU · Abnormal >2.0 WU
m/s
cm
PVR (Abbas)
⚠️ Unreliable when PVR >8 WU. Invasive PVR preferred for treatment decisions.
Calculator
RV-PA Coupling (TAPSE/PASP)
TAPSE/PASP = TAPSE (mm) ÷ PASP (mm Hg)
Normal 0.5–0.7 · Uncoupling ≤0.32–0.40
Normal 0.5–0.7 · Uncoupling ≤0.32–0.40
mm
mm Hg
Interpretation Thresholds
Normal coupling0.5–0.7 mm/mm Hg
Borderline0.40–0.55 mm/mm Hg
Uncoupled<0.40 mm/mm Hg
High risk<0.32 mm/mm Hg
Calculator
PA End-Diastolic Pressure (PAEDP)
PAEDP = 4 × (PR end-diastolic velocity)² + RAP
Resting PR end-diastolic velocity ≥2.2 m/s = abnormal
Resting PR end-diastolic velocity ≥2.2 m/s = abnormal
m/s
PAEDP
Calculator
Estimated PCWP
PCWP = 1.24 × (mitral E/e′) + 1.9
Normal <12–15 mm Hg · Elevated >15 mm Hg
Normal <12–15 mm Hg · Elevated >15 mm Hg
cm/s
cm/s
Estimated PCWP
⚠️ Inaccurate in LVAD, paced rhythm, AF, mitral prosthesis, MAC, MS, severe MR.
RV Systolic Function — Graded Severity
All parameters are graded into severity ranges per 2025 ASE. Use multiple parameters; no single value is definitive.
TAPSE Normal
>1.7
cm
TDI S′ Normal
>9.5
cm/s
FAC Normal
>35
%
3D RVEF Normal
>45
%
RV Systolic Function — Graded Severity
| Parameter | Normal | Mild ↓ | Moderate ↓ | Severe ↓ |
|---|---|---|---|---|
| TAPSE (cm) | >1.7 | 1.3–1.7 | 1.0–1.3 | ≤1.0 |
| TDI S′ (cm/s) | >9.5 | 7.2–9.5 | 5.0–7.2 | ≤5.0 |
| FAC (%) | >35 | 29–35 | 22–29 | ≤22 |
| 3D RVEF (%) | >45 | 39–45 | 32–39 | <32 |
| RVFWS (%) | >−20 | −15 to −20 | −11 to −15 | <−11 |
| RVGLS (%) | >−17 | −13 to −17 | −9 to −13 | ≤−9 |
| MPI — TDI | <0.55 | 0.55–0.62 | 0.62–0.70 | ≥0.70 |
| MPI — PW | <0.40 | 0.40–0.49 | 0.49–0.57 | ≥0.57 |
| RVOT VTI (cm) | >18 | Reduced VTI = reduced SV | ||
| RVOT AccT (ms) | >105 | 80–105 | 60–80 | ≤60 |
| RV dP/dt (mm Hg/s) | >400 | <400 = reduced — load-dependent | ||
RV Diastolic Function — Two Contexts
📖 The guideline provides two separate frameworks: (1) Table 1 grades deceleration time by severity; (2) Table 6 classifies diastolic pattern (impaired/pseudonormal/restrictive). These are distinct uses — the table below shows the pattern classification (Table 6).
| Parameter | Normal | Impaired Relaxation | Pseudonormal | Restrictive |
|---|---|---|---|---|
| E/A ratio | 0.8–<2.0 | <0.8 | 0.8–2.1 | >2.1 |
| DT (ms) — Pattern (Table 6) | 120–230 | >230 | 120–230 | <120 |
| e′/a′ ratio | 0.5–<1.8 | <1.0 | <1.0 | <1.0 |
| E/e′ | <6.0 | 6.0–7.3 | 7.3–8.4 | ≥8.5 |
| IVRT (ms) | ≤73 | >73 | >73 | >73 |
| HV S/D ratio | ≥1 | ≥1 | <1 | <1 |
| PA diastolic antegrade | No | No | Yes | Yes |
DT graded severity (Table 1): Normal 120–230 ms · Mild 87–<120 ms · Moderate 57–<87 ms · Severe ≤57 ms
e′/a′ graded severity (Table 1): Normal 0.5–<1.8 · Mildly abnormal 1.8–2.1 · Moderate >2.1–2.4 · Severe ≥2.5
e′/a′ graded severity (Table 1): Normal 0.5–<1.8 · Mildly abnormal 1.8–2.1 · Moderate >2.1–2.4 · Severe ≥2.5
RV Remodeling Stages in PH
Adaptive
Concentric RVH · Minimal dilation · Preserved RVEF and CO · Normal filling pressures · Preserved exercise capacity
Concentric RVH · Minimal dilation · Preserved RVEF and CO · Normal filling pressures · Preserved exercise capacity
Maladaptive
Chamber dilation (mid-cavity before basal) · Crescentic → spherical shape · Reduced mass · Fibrosis · Decreased function · Leftward apical traction
Chamber dilation (mid-cavity before basal) · Crescentic → spherical shape · Reduced mass · Fibrosis · Decreased function · Leftward apical traction
RV-PA Uncoupling
Contractile failure · Congestive RH failure · Restrictive diastolic dysfunction · TVA dilation → significant FTR · Ventricular interdependence and dyssynchrony
Contractile failure · Congestive RH failure · Restrictive diastolic dysfunction · TVA dilation → significant FTR · Ventricular interdependence and dyssynchrony
TR Severity Grading — Integrative (2025 ASE)
📖 Massive and Torrential categories added in 2025. ~60% of PAH patients have moderate-severe TR. V-wave cutoff sign (triangular CW contour) invalidates Bernoulli — do not use for RVSP in this setting.
| Parameter | Mild | Moderate | Severe | Massive | Torrential |
|---|---|---|---|---|---|
| Vena contracta width (mm) | <3 | 3–6.9 | ≥7 | 14–20 | ≥21 |
| EROA-PISA (mm²) | <20 | 20–39 | ≥40 | 60–79 | ≥80 |
| Regurgitant volume (mL) | <30 | 30–44 | ≥45 | 60–74 | ≥75 |
| 3D vena contracta area (cm²) | <0.40 | 0.40–0.59 | ≥0.60 | Not separately graded | |
| PISA radius @ Va 28 cm/s (mm) | <5 | 6–8.9 | ≥9 | — | |
| Hepatic vein flow | Systolic dominant | Systolic blunting | Systolic reversal | Reversal | Reversal |
| Tricuspid inflow E velocity | A-dominant | Variable | E ≥1.0 m/s | E-dominant | |
| CW Doppler contour | Soft, parabolic | Dense parabolic | Dense triangular, early peak | Dense triangular | |
Normal Values & Graded Severity Reference
Table 1 — 2025 ASE Guidelines. All parameters graded mild/moderate/severe for the first time.
RV Chamber Dimensions
| Parameter | Normal | Mild | Moderate | Severe |
|---|---|---|---|---|
| RV basal diameter (cm) | <4.1 | 4.1–4.4 | 4.4–4.9 | >4.9 |
| RV basal index (cm/m²) | <2.4 | 2.4–2.6 | 2.6–2.9 | >2.9 |
| RV midventricular (cm) | <3.5 | 3.5–3.8 | 3.8–4.2 | >4.2 |
| RV longitudinal (cm) | <8.2 | 8.2–8.9 | 8.9–9.6 | >9.6 |
| RV wall thickness (cm) | <0.5 | 0.5–0.7 | 0.7–0.9 | >0.9 |
| RVOT PLAX (cm) | <3.3 | 3.3–3.5 | 3.5–3.9 | >3.9 |
| RVOT PSAX proximal (cm) | <3.4 | 3.4–3.8 | 3.8–4.1 | >4.1 |
| RVOT PSAX distal (cm) | <2.9 | 2.9–3.0 | 3.0–3.3 | >3.3 |
| RV EDA (cm²) | <25 | 25–28 | 28–32 | >32 |
| RV ESA (cm²) | <14 | 14–16 | 16–19 | >19 |
| PA diameter (cm) | <2.5 | 2.5–3.0 | 3.0–3.5 | >3.5 |
RA Dimensions
| Parameter | Normal | Mild | Moderate | Severe |
|---|---|---|---|---|
| RA major axis (cm) | <5.4 | 5.4–5.8 | 5.8–6.3 | >6.3 |
| RA minor axis (cm) | <4.2 | 4.2–4.7 | 4.7–5.1 | >5.1 |
| RA area (cm²) | <19 | 19–22 | 22–24 | >24 |
| RAVi MOD (mL/m²) | <30 | 30–36 | 36–41 | >41 |
| RAVi area-length (mL/m²) | <33 | 33–38 | 39–44 | >44 |
| RA ESV 3D index (mL/m²) | <42 | 42–49 | 49–57 | >57 |
| RA EDV 3D index (mL/m²) | <20 | 20–23 | 23–27 | >27 |
3D RV Volumes
| Parameter | Normal | Mild | Moderate | Severe |
|---|---|---|---|---|
| 3D RV EDV (mL) | <130 | 130–150 | 150–170 | >170 |
| 3D RV EDVi (mL/m²) | <90 | 90–103 | 103–115 | >115 |
| 3D RV ESV (mL) | <66 | 66–77 | 77–89 | >89 |
| 3D RV ESVi (mL/m²) | <41 | 41–48 | 48–55 | >55 |
Hemodynamic Parameters — Normal Ranges & Grading
| Parameter | Normal | Mild elevation | Moderate elevation | Severe elevation | Notes |
|---|---|---|---|---|---|
| Peak TR velocity (m/s) | <2.8 | 2.8–3.1 | 3.2–3.5 | ≥3.6 | ≥2.9 m/s, OR ≥2.8 m/s with ≥2 adjunctive signs → PH probability ↑ |
| RVSP (mm Hg) | ≤34 | 35–49 | 50–69 | ≥70 | = PASP if no PS or RVOT obstruction |
| RAP (mm Hg) | 0–5 (mean 3) | 5–10 (mean 8) | 10–15 | ≥15 (high ≥20) | Report as discrete number: 3, 8, 15, or 20 |
| RVOT AccT (ms) | >105 | 80–105 | 60–80 | ≤60 | "W sign" mid-systolic notch = high PVR |
| PR end-diastolic V (m/s) | <2.2 | ≥2.2 = abnormal | For PAEDP estimation | ||
| TAPSE/PASP (mm/mm Hg) | 0.5–0.7 | 0.40–0.55 | 0.32–0.40 | <0.32 | Primary RV-PA coupling index |
| LVEI (D2/D1) | = 1.0 | Volume overload >1 end-diastole | Pressure overload >1 end-systole | PH threshold for probability scoring: >1.1 | |
| IVC diameter (mm) | ≤21 | 21–25 | >25 + no variation = RAP 20 | Measured 0.5–3.0 cm from RA ostium | |
| PA/Aorta ratio | <1.0 | ≥1.0 = abnormal | Sens 84%, Spec 84%, AUC 0.91 | ||
Pre- vs Post-Capillary Phenotypes
Echo can suggest the PH phenotype and guide workup. Definitive classification requires invasive RHC.
Group 1 — Pre-Capillary (PAH)
- Normal/small left heart; normal LA size
- Normal mitral E/e′ (<8)
- Dilated RV: RV/LV >1, RA ≥19 cm², RVH
- LVEI >1.1 — septal flattening esp. in systole
- RVOT AccT ≤105 ms; PR end-diastolic V ≥2.2 m/s
- Peak TRV ≥2.9 m/s
- TAPSE/PASP <0.55; <0.32 = high risk uncoupling
- PA diameter >25 mm; dilated IVC; HVs/HVd <1
- Younger patients; no major CV comorbidities
Group 2 — Post-Capillary (Left Heart Disease)
- LV hypertrophy and/or chamber dilation
- Reduced or preserved EF
- Normal LVEI (<1.2) — not septal flattening
- Dilated LA
- ≥Grade 2 LV diastolic dysfunction
- Mitral E/e′ >14 = pathologic
- ≥Mild-moderate mitral or aortic valve disease
- Peak TRV ≥2.9 m/s (RVSP elevated)
- Right heart normal until late disease
- Older patients; hypertension, obesity, DM, AF
Group 3 — Pre-Capillary (Lung Disease / Hypoxia)
- Lung-interference limits acoustic windows → subcostal
- Often shared risk factors with Group 2
- ≥Grade 1 LV diastolic dysfunction common
- Normal mitral E/e′ unless concomitant Group 2
- Normal or small RV with RVH until late
- Preserved RV function until late
- Peak TRV ≥2.9 m/s when PH present
- COPD, ILD, hypoxia, sleep apnea, obesity hypoventilation
Group 4 — Pre-Capillary (CTEPH)
- Often shared CV risk factors → LVH, LA enlargement
- Normal mitral E/e′ unless concomitant Group 2
- Resembles Group 1 PAH in right heart appearance
- Mild RA/RV enlargement with RVH until late
- Abnormal RV function; peak TRV ≥2.9 m/s
- History of PE / DVT; V/Q mismatch on nuclear scan
- Treatment-specific: surgical endarterectomy, balloon PA angioplasty
Distinguishing Pre- vs Post-Capillary — Key Parameters
| Parameter | Pre-Capillary (Group 1/3/4) | Post-Capillary (Group 2) |
|---|---|---|
| Mitral E/e′ | <8 (normal) | >14 (pathologic) |
| LA size | Normal | Enlarged |
| LVEI pattern | Systolic flattening (>1.1) | Normal or early diastolic only |
| LV diastolic function | Normal (Grade 0–1) | Grade 2–3 common |
| LV EF / size | Normal or small LV | Reduced EF or hypertrophy |
| PCWP estimate | <15 mm Hg | >15 mm Hg |
| Mitral/aortic disease | None or incidental | Common (≥mild-moderate) |
| Response to fluid challenge | PCWP stable | PCWP rise >18 or E/e′ rise >12 |
| Patient profile | Younger, fewer CV comorbidities | Older, HTN/DM/obesity/AF |
Fluid Challenge Protocol
250–500 mL crystalloid over 15–30 min. Positive test: PCWP rise >18 mm Hg or mitral E/e′ rise >12 → occult LV diastolic dysfunction / unmasked post-capillary disease.
Exercise Hemodynamics
Abnormal pulmonary vascular response: Rest-to-stress RVSP rise ≥20 mm Hg or peak RVSP ≥50 mm Hg.
Post-capillary pattern: Mitral E/e′ at exercise >12; worsening MR or TR with stress.
Exercise PH definition (ESC/ERS): mPAP/CO slope >3 mm Hg·min/L (Wood units equivalent). The "3.0–3.5" range reflects diagnostic uncertainty at borderline values.
Echo stress criteria: Rest-to-stress RVSP rise ≥20 mm Hg, or peak stress RVSP ≥50 mm Hg = abnormal pulmonary vascular response.
Prognostic sign: PASP rise ≥30 mm Hg with exertion = preserved RV contractile reserve = better survival.
Post-capillary pattern: Mitral E/e′ at exercise >12; worsening MR or TR with stress.
Exercise PH definition (ESC/ERS): mPAP/CO slope >3 mm Hg·min/L (Wood units equivalent). The "3.0–3.5" range reflects diagnostic uncertainty at borderline values.
Echo stress criteria: Rest-to-stress RVSP rise ≥20 mm Hg, or peak stress RVSP ≥50 mm Hg = abnormal pulmonary vascular response.
Prognostic sign: PASP rise ≥30 mm Hg with exertion = preserved RV contractile reserve = better survival.
RAP Estimation Algorithm
IVC-based method. Report RAP as a discrete value — not a range. (Fig. 3, 2025 ASE Guidelines)
IVC Assessment
Measure IVC at end-expiration, 0.5–3.0 cm proximal to RA ostium (subcostal long-axis). M-mode preferred. Observe collapse with sniff and quiet respiration.
Step 1: IVC Diameter?
↓ ≤21 mm
Collapse with sniff?
↓ ≥50%
RAP = 3 mm Hg
(range 0–5)
(range 0–5)
↓ <50%
RAP = 8 mm Hg
Assess secondary indices
Assess secondary indices
↓ >21 mm
Collapse with sniff?
↓ ≥50%
RAP = 8 mm Hg
Assess secondary indices
Assess secondary indices
↓ <50%
RAP = 15 mm Hg
(range 10–20)
(range 10–20)
↓ IVC >25 mm + no respirophasic variation + dilated HVs
RAP = 20 mm Hg
Secondary Indices of Elevated RAP
May support reclassification of indeterminate cases in appropriate clinical context — not an automatic upgrade:
RA enlargement (area >18 cm²)
Bulging IAS into LA throughout cardiac cycle
Restrictive RV diastolic filling
Tricuspid E/e′ >6
HV filling fraction <55% (HVs/[HVs+HVd])
HVs/HVd <1 (loss of systolic predominance)
RAP Summary Table
| IVC | Collapse (sniff) | RAP (discrete) | Range |
|---|---|---|---|
| ≤21 mm | ≥50% | 3 mm Hg | 0–5 |
| ≤21 mm | <50% (indeterminate) | 8 mm Hg* | 5–10 |
| >21 mm | ≥50% (indeterminate) | 8 mm Hg* | 5–10 |
| >21 mm | <50% | 15 mm Hg | 10–20 |
| >25 mm, no variation, dilated HVs | None | 20 mm Hg | — |
*Assess secondary indices — may support reclassification to 15 mm Hg in appropriate clinical context, not mandatory
Caveats
Athletes and healthy young adults may have dilated IVC with low RAP
Pregnant women: IVC normally dilated
Positive-pressure ventilation: IVC collapse cannot reliably estimate RAP. IVC ≤21 mm in intubated patient → RAP <10 mm Hg only
Average HV velocities over ≥5 beats spanning ≥1 respiratory cycle
Report RAP as a discrete number — not a range
Hepatic Vein Filling Fraction
HV filling fraction = HVs / (HVs + HVd)
HVs/HVd <1 = loss of systolic predominance → elevated RAP
HV filling fraction <55% → elevated RAP
HVs/HVd <1 = loss of systolic predominance → elevated RAP
HV filling fraction <55% → elevated RAP
WHO/WSPH Clinical Classification of PH
Updated 6th/7th WSPH classification incorporated into 2025 ASE guidelines. Click each group to expand.
Group 1
Pulmonary Arterial Hypertension (PAH)
▶
- Idiopathic PAH (including CCB long-term responders)
- Heritable PAH (BMPR2, ALK1, ENG, SMAD9, CAV1, KCNK3 mutations)
- Drug and toxin-induced (anorectic agents, methamphetamine, dasatinib, etc.)
- Associated with CTD (scleroderma, SLE, MCTD, RA)
- Associated with HIV infection
- Associated with portal hypertension
- Associated with congenital heart disease (Eisenmenger, systemic-to-pulmonary shunts)
- Associated with schistosomiasis
- PAH with features of PVOD/PCH
- Persistent PH of the newborn
Screening recommended for: BMPR2 carriers, first-degree relatives with heritable PAH, HIV, CHD shunts, CTD (esp. systemic sclerosis), sickle cell disease (TRV ≥2.5 m/s as trigger).
Group 2
PH due to Left Heart Disease
▶
- HFpEF
- HFrEF / HFmrEF
- Specific cardiomyopathies: HCM, cardiac amyloidosis, Fabry disease, Chagas disease
- Aortic valve disease; mitral valve disease; mixed valvular disease
- Congenital/acquired post-capillary outflow obstruction
Most common cause of PH. Post-capillary phenotype. Normal LVEI is reassuring vs pre-capillary. Fluid challenge may unmask occult LV diastolic dysfunction.
Group 3
PH due to Lung Disease and/or Hypoxia
▶
- Obstructive lung disease (COPD, emphysema)
- Interstitial lung disease (IPF, UIP, NSIP)
- Mixed obstructive and restrictive pattern
- Other parenchymal lung diseases
- Restrictive non-parenchymal: hypoventilation syndromes (obesity-hypoventilation, neuromuscular diseases)
- Post-pneumonectomy
- Hypoxia without lung disease (high altitude, developmental abnormalities)
Subcostal views often required. RV function typically preserved until late. Diagnose PH at RVSP >35–40 mm Hg given baseline mild PH expected in severe lung disease.
Group 4
PH due to Pulmonary Artery Obstructions (CTEPH)
▶
- Chronic thromboembolic PH (CTEPH)
- Other PA obstructions: tumors, foreign bodies, parasites, congenital stenosis
Treatment-specific: surgical pulmonary endarterectomy is curative when operable. Balloon PA angioplasty for inoperable CTEPH. Riociguat approved for CTEPH.
Group 5
PH with Unclear and/or Multifactorial Mechanisms
▶
- Hematologic disorders: chronic hemolytic anemia, myeloproliferative disease, splenectomy
- Sarcoidosis, pulmonary Langerhans cell histiocytosis, neurofibromatosis type 1
- Metabolic disorders: glycogen storage disease, Gaucher disease, thyroid disorders
- Chronic renal failure with or without dialysis
- Pulmonary tumor thrombotic microangiopathy
- Fibrosing mediastinitis
- Complex congenital heart disease
Key 2025 Updates vs Prior Guidelines
What changed from the 2010 ASE right heart guideline. These are clinically significant — several require updating your echo workflow and reporting language.
Definitions Changed
PH Threshold — mPAP
2010: ≥25 mm Hg
→
2025: >20 mm Hg
Pre-Capillary PVR Threshold
2010: >3 WU
→
2025: >2 WU
Exercise PH
mPAP/CO slope >3.0–3.5 mm Hg·min/L (ESC/ERS, endorsed by ASE 2025)
Atriofunctional TR — New Phenotype
Isolated TV annular dilation (≥40 mm or >21 mm/m²) with preserved RV size/function; chronic AF or HFpEF. Distinct from functional TR due to RV dilation.
Grading — All New Severity Ranges
For the first time, every major RV/RA parameter has graded mild/moderate/severe ranges (not just a binary normal/abnormal cutoff):
RV basal diameter: Previously single cutoff >4.2 cm. Now graded: Mild 4.1–4.4, Moderate 4.4–4.9, Severe >4.9 cm
TAPSE: Previously single cutoff <1.7 cm. Now graded: Mild 1.3–1.7, Moderate 1.0–1.3, Severe ≤1.0 cm
FAC: Previously <35% = abnormal. Now: Mild 29–35%, Moderate 22–29%, Severe ≤22%
RA area: Previously >18 cm² = enlarged (binary). Now: Mild 19–22, Moderate 22–24, Severe >24 cm²
3D RVEF: New graded ranges: Normal >45%, Mild 39–45%, Moderate 32–39%, Severe <32%
RVOT AccT: Normal >105 ms. Mild PH 80–105, Moderate 60–80, Severe ≤60 ms
TR severity: Massive (EROA 60–79 mm²) and Torrential (≥80 mm²) grades added
New Framework — 3 Pillars
Pillar 1 — Structure
RV chamber dimensions (graded); RA area & RAVi (graded); PA diameter; IVS morphology (LVEI); RVWT
Pillar 2 — Function
TAPSE, S′, FAC (graded); 3D RVEF (graded); RV strain — RVFWS preferred (new standard); MPI; RVOT VTI & AccT
Pillar 3 — Hemodynamics
RVSP (averaged); RAP (discrete value); PAEDP; mPAP; PVR; PCWP; TAPSE/PASP coupling ratio; PH probability (low/intermediate/high)
New Concepts & Standards
RV-PA Coupling (TAPSE/PASP): Now a primary index in every PH report. Alternatives: RVFWS/PASP (superior in PAH), FAC/PASP
RV Strain (STE) — Recommended: RVFWS preferred to isolate RV from LV contractility. Should be performed when feasible for PH and at-risk patients — not absolutely required. Same vendor for serial comparison.
PH Probability Framework: Low/Intermediate/High based on TRV + signs from 3 categories (A: ventricles, B: PA, C: IVC/RA). Replaces single-threshold approach
RAP — Discrete Values: Report 3, 8, 15, or 20 mm Hg — not ranges. Secondary indices determine indeterminate cases
RA Strain: Decreased RA reservoir strain + increased RAVi predict clinical worsening in pre-capillary PH
Structured Reporting: Must include: graded RV size, RA area/RAVi, TAPSE/PASP ratio, RVSP with averaged beats, discrete RAP, PH probability statement
⚠️ Clinical Disclaimer: This app is an educational reference based on the 2025 ASE Guidelines (Mukherjee et al., JASE 2025;38:141–186). All calculated values are estimates. Echo assigns probability only — definitive PH diagnosis requires invasive right heart catheterization. Not a substitute for individual clinical judgment.