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. 2025 Jul 9;23(1):15.
doi: 10.1186/s12947-025-00351-5.

Validation of noninvasive indices of right ventricular diastolic function. Simultaneous echocardiography and pressure-volume catheterization studies

Candelas Pérez Del Villar #  1   2 , Raquel Prieto-Arévalo #  3   4 , Jorge García-Carreño  5   6 , Pablo Martínez-Legazpi  5   7 , Daniel Rodríguez-Pérez  7 , Yolanda Benito  5   6 , Antonia Delgado-Montero  5   6 , J Carlos Antoranz  7 , M Mar Desco  7 , Cristian Herrera Flores  8 , Rafael Corisco Beltrán  5 , Francisco Fernández-Avilés  5   6 , Javier Bermejo  5   6
Affiliations

Validation of noninvasive indices of right ventricular diastolic function. Simultaneous echocardiography and pressure-volume catheterization studies

Candelas Pérez Del Villar et al. Cardiovasc Ultrasound. .

Abstract

Background: The reliability of the recommended echocardiographic methods for assessing RV diastolic function has been questioned. We aimed to validate noninvasive indices of RV diastolic function, derived from tricuspid Doppler and myocardial deformation metrics, against intrinsic diastolic chamber properties and filling pressures.

Methods: We obtained simultaneous high-fidelity pressure-volume loops and echocardiographic data in separate animal and clinical settings: (1) a porcine model of acute hemodynamic interventions (n = 13), and (2) patients with Fallot tetralogy and pulmonary hypertension (n = 9). These designs allow for within- and between-subject validation. From the PV loops data, we obtained the reference values of RV stiffness (S+), elastic recoil (S-) and relaxation (τ) constants, as well as the contribution of passive properties to instantaneous diastolic pressures.

Results: In the animal setting, only the tricuspid E/A ratio and e' velocity weakly correlated with S+ (Rrm:0.36 and 0.28 respectively, p < 0.01 for both). In the clinical group, no correlation was found between the echocardiographic indices and the intrinsic diastolic properties. Isovolumic relaxation time and early diastolic global strain-rate (GSR) correlated with mean right atrial pressure (RAP) (Spearman r: -0.73 and 0.85, respectively, p < 0.05 for both). E/e' and E/GSR ratio were not associated with RAP. Tricuspid e' and GSR negatively correlated with passive pressure component (only due to) at valve opening (Rrm -0.27 and - 0.33, respectively, p < 0.01 for both).

Conclusions: Recommended echocardiographic indices of RV diastolic function do not reflect intrinsic RV diastolic properties. Therefore, the application of these indices for inferring RV diastolic function and filling pressures is limited.

Keywords: Diastolic function; Echocardiography; Elastic recoil; Relaxation; Right ventricle; Stiffness.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The clinical study protocol complied with the Declaration of Helsinki and was approved by the Committee on Ethics in Drug Research of the Gregorio Marañón Health Research Institute (282/12 and 335/16). All patients provided written informed consent to participate in the study. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Schematic overview of the experimental (left) and clinical (right) study protocols
Fig. 2
Fig. 2
Echocardiographic imaging acquisition and analysis protocol. Tricuspid pulsed-Doppler inflow spectrogram (panel A), tricuspid annulus color Doppler tissular imaging (DTI) (panel B), RV speckle tracking deformation analysis (panel D-E) and RV 3D echocardiography and volumetric analysis (panel C and F)
Fig. 3
Fig. 3
PV data analysis and intrinsic diastolic properties. An example of right ventricular (RV) pressure–volume (PV) loops acquired during inferior vena cava occlusion (panel A). Schematic decomposition of RV pressure into active (yellow) and passive (green) diastolic components (panel B). The total pressure is shown in red. A magnified view of the early filling phase is shown in the inset. Schematic representation of the global optimization algorithm used to obtain intrinsic diastolic properties (panel C). RV diastolic pressure is modeled as the sum of a relaxation-mediated component and a component arising from passive myocardial properties, with the corresponding equations shown. formula image is the net sum of active (Pa) and passive (Pp) components, V0: the equilibrium volume and TVO: the instant of tricuspid valve opening
Fig. 4
Fig. 4
Scatterplots of stiffness (S+) constant vs. tricuspid e’ velocity (panel A) and mean right atrial pressure vs. E/e’ (panel B) in the experimental dataset. Data from each animal are plotted individually for each phase. Global (dashed line) and individual (solid line) mixed model linear fittings are superimposed
Fig. 5
Fig. 5
Relationship between intrinsic diastolic properties (relaxation -τ- and stiffness -S+; panel A and B) and mean right atrial pressure (RAP; panel C and D) and echocardiography diastolic indices in the clinical dataset. Mean individual values with the regression solid line are plotted. The dotted ellipse represents the 95% confidence level for a t-distribution
Fig. 6
Fig. 6
Scatterplot of e’ velocity vs. the passive pressure component at tricuspid valve opening in experimental dataset. Data from each animal are plotted individually for each phase. Global (dashed line) and individual (solid line) mixed model linear regressions are superimposed
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