More Evidence Needed to Clarify the Role of Right Heart Imaging in PAH


Results are based on a series of surveys completed by 17 experts.

New survey results outline expert opinions on the role of right heart (RH) imaging in decision-making for treatment escalation in pulmonary arterial hypertension (PAH). Findings of the study were published in Pulmonary Circulation.

Results showed that RH imaging serves as an important tool for decisions about treatment escalation in patients, “but systematically collected evidence is needed to clarify its role,” authors wrote.

RH imaging can yield detailed information on the structure and function of the RH and its coupling with the pulmonary arterial system, they added. RH structure and function also serve as determinants of symptoms and prognosis in PAH.

Although numerous studies of RH imaging in PAH have identified echocardiography parameters that may have prognostic significance, only 3 of the 20 parameters studied are cited in guidelines. There is also little consensus around which “RH imaging variables are appropriate, how objective imaging should be incorporated into the standard of care, whether imaging provides value beyond standard assessments of risk, and how imaging should be used in treatment decision-making,” the researchers wrote.

To address this knowledge gap, they carried out a Delphi study that aimed to gather information from expert cardiologists and pulmonologists. The method is a systematic, qualitative structured technique used to generate group consensus in the absence of adequate data to develop evidence-based recommendations.

Seventeen physicians with expertise in PAH and RH imaging completed 3 surveys. The first survey used open-ended questions to gather information, while the second survey included a Likert scale and other questions to identify a consensus on topics identified in the first.

“Survey 3 contained Likert scale questions derived from Survey 2 and summary information on the results of Survey 2,” authors wrote.

Their analyses of responses revealed:

  • Consensus that RH imaging is likely to improve current risk stratification algorithms and help differentiate risk levels in patients at intermediate risk
  • Tricuspid annular plane systolic excursion, right ventricular fractional area change, right atrial area, tricuspid regurgitation, inferior venae cava diameter, and pericardial effusion should be part of routine echocardiography in PAH
  • Cardiac MRI is valuable but limited by cost and access
  • A pattern of abnormal RH imaging results should prompt consideration of hemodynamic evaluation and possible treatment escalation

Of the 17 participants, 6 specialized in pulmonology and 12 in cardiology. All panelists had a median of 20 years’ worth of experience treating PAH.

Panelists also agreed RH imaging can be beneficial for long-term monitoring and decisions about treatment escalation for patients with PAH.

“Improvement or normalization of RH imaging parameters may be a useful goal of therapy that provides earlier evaluation of patients' trajectory than clinical assessments,” the authors wrote.

However, the panelists did not reach consensus on any specific parameters or algorithms for risk assessment.

The lack of standardization, systemization, and use of echocardiographic imaging in data registries and large multicenter trials likely contributes to the wide variation in use of RH imaging, the authors wrote.

Overall, “this survey confirms the fundamental role of RH imaging in the monitoring and care of patients with PAH, highlights variability in the use of echocardiography in practice, provides consensus on which echocardiographic parameters should be included in the echocardiographic assessment of PAH patients, and indicates which parameters play a role in clinical decision-making,” researchers said.

Further incorporation of RH imaging into current risk assessment strategies may help improve quality and quantity of life for patients with PAH, they concluded.


Forfia P, Benza R, D’Alto M, et al. The heart of the matter: right heart imaging indicators for treatment escalation in pulmonary arterial hypertension. Pulm Circ. Published online May 21, 2023. doi:10.1002/pul2.12240

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