DOPPLER HEMODYNAMICS Elevated Right Ventricular End-Diastolic Pressure by Doppler Echocardiography—A Case Report Bahaa M. Fadel, M.D., Khaled Al-Mulla, M.D., Bader Al-Mahdi, M.D., and Giovanni Di Salvo, M.D. Heart Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia Careful analysis of the right-sided Doppler signals provides important data regarding right heart hemodynamics. Here, we illustrate the value of the combined analysis of flow across the hepatic vein, tricuspid valve, and pulmonary valve for the diagnosis of elevated right ventricular end-diastolic pressure.(Echocardiography 2014;31:117–119) Key words: right ventricle, Doppler echocardiography, inferior vena cava Case Presentation: A 31-year-old male underwent a Ross procedure 13 years earlier for severe aortic regurgitation. On a routine echocardiogram (General Electric, Waukesha, WI, USA), the pulmonary valve (PV) homograft showed moderate regurgitation and stenosis with peak and mean gradients of 58 and 36 mmHg, respectively. Continuous-wave Dopp- ler demonstrated forward flow from the right ven- tricle (RV) into the pulmonary artery in late diastole suggestive of presystolic opening of the PV (Fig. 1). On pulsed-wave Doppler of the tricus- pid valve (TV) a prominent mid-diastolic flow reversal was noted (Fig. 1). Doppler of the hepatic vein (HV) showed a large A-wave reversal that consistently exceeded in duration the relatively small A-wave across the TV (Fig. 1). The findings on the HV, TV, and PV Doppler indicate the pres- ence of elevated right ventricular end-diastolic pressure (RVEDP). 1–4 The inferior vena cava (IVC) was dilated (23 mm) and showed poor inspira- tory collapse suggestive of elevated mean RA pressure. 5 The RV was mildly dilated based on an RV outflow tract diameter from the parasternal long-axis view of 36 mm (upper reference value: 30–35 mm) and RV basal diameter from the apical short-axis view of 46 mm (upper reference value: 39–45 mm). 6 Right ventricular systolic function was mildly reduced based on a fractional area change of 31% from the apical short-axis view (normal >35%). 6 Therapy with a loop diure- tic was initiated because of elevated mean RA pressure and RVEDP. Interrogation of HV flow provides valuable information regarding right heart hemodynam- ics. 7,8 The HV Doppler serves as a surrogate to the IVC Doppler due to shortcomings of the lat- ter. These include a wide angle of interrogation of the ultrasound beam with blood flow and significant changes in the IVC size with respira- tion that render the recording of flow technically challenging. Flow in the HVs is normally phasic with a dominant antegrade systolic (S) wave, an antegrade diastolic (D) wave, and small retro- grade waves in late systole (V) and late diastole (A) following atrial contraction. 7,8 Comparison of the flow profile in the HVs and across the TV provides insight into the RVEDP. This concept is similar to the assessment of the left ventricular end-diastolic pressure via comparison of the pulmonary venous and transmitral Doppler signals. 9 Under normal conditions, RA contraction results in a larger blood flow in the forward direc- tion (toward the RV) than backward (toward the HVs). The duration of the TV A-wave is usually sim- ilar or longer than the HV A-wave reversal at the same phase of the respiratory cycle (Fig. 2). Disorders that lead to abnormal RV diastolic function and reduced compliance cause an increase in the RVEDP that precedes the rise in mean RA pressure. 3 The elevated RVEDP is hemo- dynamically manifested by an abnormal and rapid rise in RV intracavitary pressure that occurs following RA contraction. The RV pressure rise causes an abrupt and premature closure of the TV and thus early termination of tricuspid flow as manifested by shortening of the A-wave dura- tion. Since blood can no longer proceed forward across the TV, it backflows into the HVs for a longer duration. Thus, a reliable sign of elevated RVEDP is a HV A-wave reversal that consistently exceeds in duration the A-wave across the TV. 1 Address for correspondence and reprint requests: Bahaa M. Fadel, M.D., King Faisal Specialist Hospital & Research Center, Heart Center, MBC # 16, Riyadh 11211, Saudi Arabia. Fax: 966-14427482; E‐mail: fadelbahaa@gmail.com 117 © 2013, Wiley Periodicals, Inc. DOI: 10.1111/echo.12377 Echocardiography