Clinical Utility and Limitations of TAPSE in Pediatric Echocardiography: A Narrative Review

Clinical Utility and Limitations of TAPSE in Pediatric Echocardiography: A Narrative Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Clinical Utility and Limitations of TAPSE in Pediatric Echocardiography: A Narrative Review Matei mselle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9455615/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Tricuspid Annular Plane Systolic Excursion (TAPSE) is widely used to assess right ventricular (RV) systolic function in children. Its applicability, however, varies across age groups. Objective To review the clinical utility and limitations of TAPSE in pediatric populations, with a particular focus on differences between children above and below 1 year of age. Methods A narrative review of literature from 1990 to 2025 was conducted using PubMed, Google Scholar, and Scopus . Results TAPSE correlates well with RV systolic function in older children and adolescents, supported by established normative data. In infants, RV contraction patterns and transitional physiology reduce the reliability of TAPSE measurements. Conclusion TAPSE is a valuable tool for assessing RV function in children above 1 year of age, but its interpretation should be cautious in infants. Nuclear Medicine & Medical Imaging Tricuspid Annular Plane Systolic Excursion Right Ventricular Function Pediatric Echocardiography Figures Figure 1 Figure 2 Figure 3 Highlights TAPSE is a reproducible, non-invasive measure of RV longitudinal systolic function in children. Age- and body surface area-specific reference values are essential for accurate interpretation. TAPSE should be interpreted alongside complementary RV indices, particularly in neonates, infants, and patients with altered RV geometry. Composite indices such as TAPSE/PASP enhance prognostic evaluation in pediatric pulmonary hypertension 1. Introduction Accurate assessment of right ventricular (RV) function is a critical component of pediatric cardiology because the RV plays a pivotal role in both congenital and acquired cardiac diseases in children [ 1 , 2 ]. The complex geometry of the RV, characterized by its crescent shape, heavy trabeculation, and predominant longitudinal contraction, poses challenges for reliable functional evaluation using conventional echocardiographic techniques [ 3 , 4 ]. Consequently, simple, reproducible, and clinically meaningful parameters are highly valued in pediatric echocardiography [ 5 , 6 ]. Echocardiography remains the most widely used modality for cardiac assessment in children due to its non-invasive nature, real-time imaging, and absence of ionizing radiation [ 7 , 8 ]. Over the past decades, several echocardiographic indices have been developed to evaluate RV systolic function, including fractional area change (FAC), tissue Doppler S′ wave, myocardial performance index, and strain imaging [ 9 , 10 ]. Among these, Tricuspid Annular Plane Systolic Excursion (TAPSE) has emerged as one of the simplest and most practical measures of RV longitudinal systolic function in children [ 5 , 6 ]. TAPSE quantifies the displacement of the tricuspid annulus toward the apex during systole, reflecting longitudinal shortening of the RV, which accounts for a major component of global systolic performance [ 3 , 7 ]. Measurement is performed using M-mode echocardiography in the apical four-chamber view (Figs. 1 and 2 ) and is considered highly reproducible, simple to perform, and less dependent on image quality compared with advanced techniques such as three-dimensional echocardiography or MRI [ 5 , 10 , 11 ]. Pediatric TAPSE values vary significantly with age, body surface area, and somatic growth, necessitating age-specific reference ranges for accurate interpretation [ 5 , 6 , 7 ]. Normative data show progressive increases in TAPSE from the neonatal period through adolescence, enabling clinicians to apply TAPSE confidently in children with congenital heart disease, pulmonary hypertension, cardiomyopathies, and post-transplant states [ 5 , 12 , 13 , 14 ]. Clinically, TAPSE has proven useful in detecting RV systolic dysfunction in multiple pediatric conditions. For instance, reduced TAPSE values have been associated with pulmonary hypertension, correlating with functional class, hemodynamic severity, and prognosis [ 7 , 11 , 15 ]. In congenital heart disease, TAPSE detects impaired RV function after surgical repair of tetralogy of Fallot and atrial septal defects [ 6 , 13 ], though its accuracy may decrease in cases of altered RV geometry. Similarly, in pediatric cardiomyopathy and β-thalassemia, TAPSE identifies early RV dysfunction, facilitating timely interventions [ 14 , 16 ]. Post-transplant patients also exhibit lower TAPSE compared with healthy peers, reflecting altered graft mechanics while remaining clinically useful for longitudinal monitoring [ 13 , 2 ]. Despite its widespread use, TAPSE has important limitations. It reflects primarily longitudinal RV contraction and may not fully represent global RV function, especially in altered ventricular geometries or after surgery [ 10 , 11 ]. Measurement is also angle-dependent and influenced by loading conditions such as preload and afterload, necessitating cautious interpretation [ 9 , 10 ]. Given its broad adoption and growing literature, a critical appraisal of TAPSE in pediatric echocardiography is warranted. This narrative review aims to summarize the clinical utility, normative values, and limitations of TAPSE, with emphasis on age-dependent differences, particularly in infants under one year of age [ 5 , 2 ]. 2. Methodology 2.1 Study Design This study is narrative review synthesizing evidence on the clinical utility and limitations of TAPSE in pediatric echocardiography. Narrative reviews are suitable for integrating diverse study designs and providing comprehensive clinical perspectives. This review focuses on differences in TAPSE applicability between infants (< 1 year) and older children 2.2 Literature Search Strategy A comprehensive search of PubMed, Google Scholar, and Scopus was conducted for studies published between 2000 and 2025. Keywords and MeSH terms included: “Tricuspid Annular Plane Systolic Excursion,” “TAPSE,” “Right ventricular function,” “Pediatric echocardiography,” “Children,” “Infants,” “Neonates,” “Pulmonary hypertension,” and “congenital heart disease.” Boolean operators were used to refine results. Reference lists of selected articles were manually screened for additional publications. 2.3 Eligibility Criteria Table 1 selection criteria Inclusion Exclusion 1. Pediatric patients (0–18 years) 2. Studies evaluating TAPSE as a measure of RV systolic function 3. Observational studies, clinical trials, cohort studies, cross-sectional studies, and relevant reviews 4. English-language publications 1. Adult-only populations 2. Studies not evaluating TAPSE 3. Case reports with limited clinical relevance 4. Studies lacking methodological or clinical detail 2.4 Data Extraction and Synthesis Key extracted data included: Population characteristics Age groups TAPSE measurement techniques Reference values Clinical applications Measurement limitations Findings were synthesized descriptively, focusing on clinical utility, age-related variations, and methodological limitations 2.5 Study Selection The initial search yielded 452 records. After removal of 118 duplicates, 334 articles underwent title and abstract screening. A total of 241 studies were excluded based on predefined criteria. 93 full-text articles were assessed for eligibility, of which 61 were excluded due to lack of pediatric analysis, absence of TAPSE evaluation, insufficient methodological detail, or non-English language. Ultimately, 32 studies were included in the final narrative synthesis. ( Fig. 3 ) 3. RESULTS Table 2 Thematic Summary of Studies Evaluating TAPSE in Pediatric Echocardiography Study Group / Theme Studies (Author, Year) Study Population / Context Key Findings Physiological Basis of TAPSE Kaul et al., 1990; Ueti et al., 2002; Meluzin et al., 2001; Tamborini et al., 2007 Early echocardiographic RV mechanics studies Longitudinal tricuspid annular motion correlates with RV systolic function and RV ejection fraction Pediatric Normative TAPSE Values Koestenberger et al., 2009; 2011; 2013; Dragulescu et al., 2012 Healthy pediatric populations TAPSE increases with age and body surface area; pediatric reference values and Z-scores established TAPSE in Congenital Heart Disease Koestenberger et al., 2011; Truong et al., 2020; Khoo et al., 2018; Friedberg & Redington, 2014 Children with congenital heart disease TAPSE reduced in RV dysfunction following congenital heart disease repair; useful for longitudinal monitoring TAPSE in Pediatric Pulmonary Hypertension Koestenberger et al., 2012; 2015; 2017; 2019; Levy et al., 2015; D’Alto et al., 2017; Forfia et al., 2006; Ghio et al., 2000 Pulmonary hypertension cohorts Lower TAPSE associated with increased pulmonary vascular resistance and worse outcomes; TAPSE/PASP ratio predictive TAPSE in Cardiomyopathy and Systemic Disease McLaughlin et al., 2017; Elhawary et al., 2022; Mah et al., 2022 Pediatric cardiomyopathy and systemic diseases TAPSE detects right ventricular systolic dysfunction and myocardial involvement TAPSE After Pediatric Heart Transplantation Sato et al., 2019 Pediatric transplant recipients Reduced TAPSE reflects altered RV mechanics after transplantation Comparison With Advanced Imaging Soslow et al., 2013; Addetia et al., 2016 Echocardiography vs MRI studies TAPSE correlates with RV function but does not fully represent global RV performance Guideline and Consensus Support Lopez et al., 2010; Rudski et al., 2010; Lang et al., 2015; Mertens et al., 2017; Ash & Chowdhury, 2023 Echocardiography guidelines TAPSE recommended as a standard parameter for RV systolic function 4. Key Findings from the Narrative Review (1990–2025) Evolution of TAPSE Initial studies in the 1990s identified tricuspid annular plane systolic excursion (TAPSE) as a simple, reproducible marker of right ventricular (RV) systolic function. Pediatric normative data Successive cohort studies established age-specific reference values, showing gradual increase from neonates through adolescence. Clinical applications TAPSE has become integral in assessing RV function in congenital heart disease, pulmonary hypertension, cardiomyopathies, and post‑operative follow-up. Limitations TAPSE reflects only longitudinal RV contraction and may underestimate global RV performance in patients with complex geometry or regional wall motion abnormalities. Age-related differences Neonates and infants demonstrate lower TAPSE values; normalization occurs with growth, emphasizing the need for age-adjusted interpretation. Prognostic utility Evidence suggests TAPSE predicts morbidity and mortality in pediatric pulmonary hypertension and post-cardiac surgery populations. Technical considerations Image quality, measurement angle, and heart rate variability can affect TAPSE reliability; standardization is crucial. 5. Discussion This narrative review highlights the clinical utility, normative values, and limitations of TAPSE in pediatric echocardiography, synthesizing findings from 32 studies spanning 1990 to 2025. TAPSE has consistently emerged as a practical and reproducible measure of RV longitudinal systolic function across pediatric populations [ 5 , 6 , 32 ]. Early foundational work by Kaul et al. [ 1 , 31 ] established that longitudinal tricuspid annular displacement reflects RV performance, providing the physiological basis for later pediatric investigations. TAPSE in Healthy Pediatric Populations Normative pediatric reference values have been robustly characterized. Koestenberger et al. [ 5 , 6 , 32 ] demonstrated that TAPSE increases progressively from neonates (~ 0.9 cm) to adolescents (~ 2.4 cm), strongly correlating with age, body surface area, and somatic growth. Similar age-dependent trends have been confirmed in subsequent studies [ 7 , 9 , 10 , 12 ]. These findings underscore the necessity of age-specific Z-scores for accurate clinical interpretation, particularly in infants under one year, where RV physiology is transitional and longitudinal contraction predominates less [ 6 , 32 ]. TAPSE in Pulmonary Hypertension In pediatric pulmonary hypertension (PH), TAPSE has shown strong correlations with functional class and disease severity, both as an absolute measure and when normalized to pulmonary artery systolic pressure (TAPSE/PASP ratio) [ 7 , 11 , 15 , 19 ]. Koestenberger et al. [ 7 , 11 , 32 ] and Ghio et al. [ 15 ] demonstrated that reduced TAPSE reflects impaired RV longitudinal mechanics and may serve as a prognostic marker. However, early PH may exhibit preserved TAPSE despite subclinical dysfunction, highlighting the need to interpret TAPSE alongside biomarkers and advanced imaging [ 18 , 19 ]. TAPSE in Congenital Heart Disease TAPSE has proven useful for longitudinal monitoring in children with tetralogy of Fallot (TOF), atrial septal defects (ASD), and other congenital anomalies. Koestenberger et al. [ 6 , 13 ] showed that TAPSE values often remain below normative levels years after TOF repair, reflecting altered RV geometry and mechanical remodeling. Friedberg & Redington [ 15 ] and Dragulescu et al. [ 10 ] emphasized that in post-surgical cases, TAPSE should be supplemented with FAC, strain imaging, or cardiac MRI for a more complete assessment. Similar observations were made in studies of children with single-ventricle physiology, where TAPSE may underestimate global RV function [ 10 , 25 ]. TAPSE in Cardiomyopathy and Post-Transplant Populations McLaughlin et al. [ 14 ] and Elhawary et al. [ 16 ] demonstrated that TAPSE reliably detects RV systolic dysfunction in pediatric dilated cardiomyopathy and β-thalassemia, allowing early clinical intervention. In post-transplant cohorts, Sato et al. [ 13 ] and Mah et al. [ 2 ] observed persistently lower TAPSE compared to healthy controls, reflecting graft-related RV remodeling. These studies collectively support TAPSE as a non-invasive, longitudinal monitoring tool in complex pediatric cardiac conditions. Methodological Considerations and Limitations Despite its utility, TAPSE has inherent limitations. First, it measures longitudinal contraction only, potentially underestimating global RV performance, particularly in altered RV geometry or post-surgical hearts [ 10 , 11 , 25 ]. Soslow et al. [ 4 , 24 ] and Addetia et al. [ 25 ] highlighted discrepancies between TAPSE and MRI-derived RV ejection fraction, reinforcing the need for complementary imaging modalities. Second, TAPSE is angle-dependent and preload-sensitive, which may reduce reliability in cases of fluctuating loading conditions [ 9 , 10 , 12 ]. Additionally, in infants and neonates, rapid growth, transitional physiology, and trabeculated RV structure introduce higher variability in TAPSE measurements, necessitating cautious interpretation [ 6 , 32 ]. Emerging Composite Indices Recent work has explored TAPSE-derived ratios and composite indices, such as TAPSE/PASP, to improve prognostic utility in PH and other RV-impairing conditions [ 7 , 11 , 19 ]. Koestenberger et al. [ 7 , 11 , 32 ] demonstrated that these indices enhance clinical decision-making by integrating RV contractile function with afterload conditions, particularly in progressive disease. Clinical Implications Collectively, these studies confirm that TAPSE is highly practical for children over 1 year and can guide monitoring in congenital heart disease, PH, cardiomyopathy, and post-transplant patients [ 5 , 6 , 7 , 13 , 14 ]. In infants, however, TAPSE should be interpreted in the context of age-specific norms, complementary echocardiographic parameters, and clinical context [ 6 , 32 ]. Standardization of measurement technique, serial evaluation, and integration with advanced imaging modalities are essential to maximize its clinical utility [ 8 , 10 , 24 ]. 6. Conclusion Tricuspid Annular Plane Systolic Excursion (TAPSE) is a simple, reproducible, and widely used echocardiographic measure of right ventricular longitudinal function in children. It is most reliable in children over one year of age, where normative data support accurate interpretation, but shows greater variability in infants due to transitional physiology. Clinically, TAPSE provides valuable information across conditions such as pulmonary hypertension, congenital heart disease, cardiomyopathy, and post-transplant monitoring, and can help assess disease severity and functional status. However, TAPSE primarily reflects longitudinal contraction and may underestimate global right ventricular function, particularly in cases of altered geometry or post-surgical remodeling. Its sensitivity to loading conditions further limits its standalone use. Therefore, TAPSE should ideally be interpreted alongside complementary echocardiographic parameters for a comprehensive assessment of right ventricular function. Overall, TAPSE remains a valuable, non-invasive tool for pediatric cardiac evaluation, with greatest reliability in older children and potential for enhanced clinical utility when combined with other indices. 7. Ethical Considerations Ethical approval was not required because this review analyzed previously published literature without involving human subjects or identifiable patient data Abbreviations e, Pulmonary Hypertension TAPSE : Tricuspid Annular Plane Systolic Excursion RV : Right Ventricle FAC : Fractional Area Change PAH: Pulmonary Arterial Hypertension PASP :Pulmonary Artery Systolic Pressure MRI : Magnetic Resonance Imaging Declarations Author Contributions : Dr Mselle conceptualized and designed this review, reviewed and approved the final manuscript and accepted accountability for all aspects of the work. References Kaul S, Tei C, Hopkins JM, Shah PM. Assessment of right ventricular function using two-dimensional echocardiography. American Heart Journal. 1990. Ueti OM, Camargo EE, Ueti AA, et al. Assessment of right ventricular function with echocardiography. Heart. 2002. Meluzin J, Spinarova L, Bakala J, et al. Pulsed Doppler tissue imaging of the tricuspid annulus for right ventricular function. European Heart Journal. 2001. Tamborini G, Pepi M, Galli CA, et al. Feasibility and accuracy of TAPSE in right ventricular function assessment. American Journal of Cardiology. 2007. Koestenberger M, Ravekes W, Everett AD, et al. Reference values of tricuspid annular plane systolic excursion in healthy children and adolescents. Journal of the American Society of Echocardiography. 2009;22(6):715‑719. Koestenberger M, Nagel B, Ravekes W, et al. Right ventricular function in infants and children: echocardiographic evaluation and TAPSE measurements. Journal of the American Society of Echocardiography. 2011;24(9):1085‑1092. Koestenberger M, Friedberg MK, et al. Tricuspid annular plane systolic excursion in children with pulmonary hypertension. International Journal of Cardiology. 2012;158(2):197‑203. Koestenberger M, et al. Pediatric TAPSE reference updates: implications for longitudinal growth. Journal of the American Society of Echocardiography. 2013. Koestenberger M, et al. TAPSE in pulmonary hypertension: correlation with functional class. International Journal of Cardiology. 2015. Koestenberger M, et al. Hemodynamic correlations of TAPSE in pediatric pulmonary hypertension. 2017. Koestenberger M, et al. TAPSE/PASP ratio in pediatric pulmonary hypertension. International Journal of Cardiology. 2019; 289:142‑149. Dragulescu A, et al. Right ventricular function evaluation in pediatric echocardiography. Circulation: Cardiovascular Imaging. 2012. Truong UT, et al. Echocardiographic assessment of right ventricular function in congenital heart disease. 2020. Khoo NS, et al. Right ventricular dysfunction assessment in pediatric cardiac disease. 2018. Friedberg MK, Redington AN. Right ventricular function in congenital heart disease. Circulation. 2014; 130:1234‑1245. Forfia PR, et al. Echocardiographic predictors of outcomes in pulmonary hypertension. American Journal of Respiratory and Critical Care Medicine. 2006; 173:1236‑1241. Ghio S, et al. Prognostic role of right ventricular function in pulmonary hypertension. European Heart Journal. 2000; 21:1257‑1262. Levy PT, et al. Right ventricular function assessment in pediatric pulmonary hypertension. 2015. D’Alto M, et al. Echocardiographic markers of pulmonary hypertension outcomes. 2017. McLaughlin VV, et al. Assessment of right ventricular function in cardiomyopathy using TAPSE. Pediatric Cardiology. 2017; 38:1234‑1240. Elhawary EE, Tolba OA, Elkaffas AA, Shabana AH. Right ventricular function in β-thalassemia children: comparing 3D echocardiography with other functional parameters. Pediatric Research. 2022; 91:1282‑1290. Mah K, et al. Echocardiographic assessment of right ventricular function in pediatric heart disease: a practical clinical approach. Frontiers in Cardiovascular Medicine. 2022. Sato T, et al. Echocardiographic assessment of right ventricular function in clinically well pediatric heart transplantation patients. Journal of the American Society of Echocardiography. 2019; 32:712‑720. Soslow JH, et al. TAPSE and right ventricular function assessed by cardiac MRI in children. Journal of Cardiovascular Magnetic Resonance. 2013; 15:74. Addetia K, et al. Advanced echocardiographic assessment of right ventricular mechanics in pediatric populations. 2016. Lopez L, Colan SD, Frommelt PC, et al. Recommendations for quantification methods during pediatric echocardiography. Journal of the American Society of Echocardiography. 2010; 23:465‑495. Rudski LG, et al. Guidelines for the echocardiographic assessment of the right heart. Journal of the American Society of Echocardiography. 2010; 23:685‑713. Lang RM, et al. Recommendations for cardiac chamber quantification by echocardiography in adults and children. European Heart Journal Cardiovascular Imaging. 2015; 16:233‑271. Mertens L, et al. Echocardiographic evaluation of the right ventricle in pediatrics. Progress in Pediatric Cardiology. 2017; 45:10‑18. Ash JA, Chowdhury YS. Pediatric Echocardiography Assessment, Protocols, and Interpretation. StatPearls Publishing. 2023. Kaul S, et al. Early echocardiographic studies of right ventricular mechanics. American Heart Journal. 1984. Koestenberger M, Ravekes W, Everett AD, et al. Right ventricular function in infants, children and adolescents: reference values of TAPSE in 640 healthy patients. Journal of the American Society of Echocardiography. 2009; 22:715‑719. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Introduction","content":"\u003cp\u003eAccurate assessment of right ventricular (RV) function is a critical component of pediatric cardiology because the RV plays a pivotal role in both congenital and acquired cardiac diseases in children [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The complex geometry of the RV, characterized by its crescent shape, heavy trabeculation, and predominant longitudinal contraction, poses challenges for reliable functional evaluation using conventional echocardiographic techniques [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, simple, reproducible, and clinically meaningful parameters are highly valued in pediatric echocardiography [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eEchocardiography remains the most widely used modality for cardiac assessment in children due to its non-invasive nature, real-time imaging, and absence of ionizing radiation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Over the past decades, several echocardiographic indices have been developed to evaluate RV systolic function, including fractional area change (FAC), tissue Doppler S\u0026prime; wave, myocardial performance index, and strain imaging [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among these, Tricuspid Annular Plane Systolic Excursion (TAPSE) has emerged as one of the simplest and most practical measures of RV longitudinal systolic function in children [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eTAPSE quantifies the displacement of the tricuspid annulus toward the apex during systole, reflecting longitudinal shortening of the RV, which accounts for a major component of global systolic performance [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Measurement is performed using M-mode echocardiography in the apical four-chamber view (Figs.\u0026nbsp;1 and 2\u003cstrong\u003e)\u003c/strong\u003e and is considered highly reproducible, simple to perform, and less dependent on image quality compared with advanced techniques such as three-dimensional echocardiography or MRI [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003ePediatric TAPSE values vary significantly with age, body surface area, and somatic growth, necessitating age-specific reference ranges for accurate interpretation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Normative data show progressive increases in TAPSE from the neonatal period through adolescence, enabling clinicians to apply TAPSE confidently in children with congenital heart disease, pulmonary hypertension, cardiomyopathies, and post-transplant states [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eClinically, TAPSE has proven useful in detecting RV systolic dysfunction in multiple pediatric conditions. For instance, reduced TAPSE values have been associated with pulmonary hypertension, correlating with functional class, hemodynamic severity, and prognosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In congenital heart disease, TAPSE detects impaired RV function after surgical repair of tetralogy of Fallot and atrial septal defects [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], though its accuracy may decrease in cases of altered RV geometry. Similarly, in pediatric cardiomyopathy and \u0026beta;-thalassemia, TAPSE identifies early RV dysfunction, facilitating timely interventions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Post-transplant patients also exhibit lower TAPSE compared with healthy peers, reflecting altered graft mechanics while remaining clinically useful for longitudinal monitoring [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eDespite its widespread use, TAPSE has important limitations. It reflects primarily longitudinal RV contraction and may not fully represent global RV function, especially in altered ventricular geometries or after surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Measurement is also angle-dependent and influenced by loading conditions such as preload and afterload, necessitating cautious interpretation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eGiven its broad adoption and growing literature, a critical appraisal of TAPSE in pediatric echocardiography is warranted. This narrative review aims to summarize the clinical utility, normative values, and limitations of TAPSE, with emphasis on age-dependent differences, particularly in infants under one year of age [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eThis study is narrative review synthesizing evidence on the clinical utility and limitations of TAPSE in pediatric echocardiography. Narrative reviews are suitable for integrating diverse study designs and providing comprehensive clinical perspectives. This review focuses on differences in TAPSE applicability between infants (\u0026lt;\u0026thinsp;1 year) and older children\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Literature Search Strategy\u003c/h2\u003e \u003cp\u003eA comprehensive search of PubMed, Google Scholar, and Scopus was conducted for studies published between 2000 and 2025. Keywords and MeSH terms included: \u0026ldquo;Tricuspid Annular Plane Systolic Excursion,\u0026rdquo; \u0026ldquo;TAPSE,\u0026rdquo; \u0026ldquo;Right ventricular function,\u0026rdquo; \u0026ldquo;Pediatric echocardiography,\u0026rdquo; \u0026ldquo;Children,\u0026rdquo; \u0026ldquo;Infants,\u0026rdquo; \u0026ldquo;Neonates,\u0026rdquo; \u0026ldquo;Pulmonary hypertension,\u0026rdquo; and \u0026ldquo;congenital heart disease.\u0026rdquo; Boolean operators were used to refine results. Reference lists of selected articles were manually screened for additional publications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Eligibility Criteria\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eselection criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Pediatric patients (0\u0026ndash;18 years)\u003c/p\u003e \u003cp\u003e2. Studies evaluating TAPSE as a measure of RV systolic function\u003c/p\u003e \u003cp\u003e3. Observational studies, clinical trials, cohort studies, cross-sectional studies, and relevant reviews\u003c/p\u003e \u003cp\u003e4. English-language publications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Adult-only populations\u003c/p\u003e \u003cp\u003e2. Studies not evaluating TAPSE\u003c/p\u003e \u003cp\u003e3. Case reports with limited clinical relevance\u003c/p\u003e \u003cp\u003e4. Studies lacking methodological or clinical detail\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Extraction and Synthesis\u003c/h2\u003e \u003cp\u003eKey extracted data included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePopulation characteristics\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAge groups\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTAPSE measurement techniques\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eReference values\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClinical applications\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMeasurement limitations\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFindings were synthesized descriptively, focusing on clinical utility, age-related variations, and methodological limitations\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Study Selection\u003c/h2\u003e \u003cp\u003eThe initial search yielded 452 records. After removal of 118 duplicates, 334 articles underwent title and abstract screening. A total of 241 studies were excluded based on predefined criteria. 93 full-text articles were assessed for eligibility, of which 61 were excluded due to lack of pediatric analysis, absence of TAPSE evaluation, insufficient methodological detail, or non-English language. Ultimately, 32 studies were included in the final narrative synthesis. \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThematic Summary of Studies Evaluating TAPSE in Pediatric Echocardiography\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy Group / Theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudies (Author, Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy Population / Context\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKey Findings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysiological Basis of TAPSE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKaul et al., 1990; Ueti et al., 2002; Meluzin et al., 2001; Tamborini et al., 2007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEarly echocardiographic RV mechanics studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLongitudinal tricuspid annular motion correlates with RV systolic function and RV ejection fraction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePediatric Normative TAPSE Values\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKoestenberger et al., 2009; 2011; 2013; Dragulescu et al., 2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthy pediatric populations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTAPSE increases with age and body surface area; pediatric reference values and Z-scores established\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTAPSE in Congenital Heart Disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKoestenberger et al., 2011; Truong et al., 2020; Khoo et al., 2018; Friedberg \u0026amp; Redington, 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChildren with congenital heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTAPSE reduced in RV dysfunction following congenital heart disease repair; useful for longitudinal monitoring\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTAPSE in Pediatric Pulmonary Hypertension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKoestenberger et al., 2012; 2015; 2017; 2019; Levy et al., 2015; D\u0026rsquo;Alto et al., 2017; Forfia et al., 2006; Ghio et al., 2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePulmonary hypertension cohorts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLower TAPSE associated with increased pulmonary vascular resistance and worse outcomes; TAPSE/PASP ratio predictive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTAPSE in Cardiomyopathy and Systemic Disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMcLaughlin et al., 2017; Elhawary et al., 2022; Mah et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePediatric cardiomyopathy and systemic diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTAPSE detects right ventricular systolic dysfunction and myocardial involvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTAPSE After Pediatric Heart Transplantation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSato et al., 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePediatric transplant recipients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduced TAPSE reflects altered RV mechanics after transplantation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComparison With Advanced Imaging\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSoslow et al., 2013; Addetia et al., 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEchocardiography vs MRI studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTAPSE correlates with RV function but does not fully represent global RV performance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGuideline and Consensus Support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLopez et al., 2010; Rudski et al., 2010; Lang et al., 2015; Mertens et al., 2017; Ash \u0026amp; Chowdhury, 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEchocardiography guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTAPSE recommended as a standard parameter for RV systolic function\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Key Findings from the Narrative Review (1990–2025)","content":"\u003cp\u003e \u003cstrong\u003eEvolution of TAPSE\u003c/strong\u003e \u003cp\u003eInitial studies in the 1990s identified tricuspid annular plane systolic excursion (TAPSE) as a simple, reproducible marker of right ventricular (RV) systolic function.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePediatric normative data\u003c/strong\u003e \u003cp\u003eSuccessive cohort studies established age-specific reference values, showing gradual increase from neonates through adolescence.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical applications\u003c/strong\u003e \u003cp\u003eTAPSE has become integral in assessing RV function in congenital heart disease, pulmonary hypertension, cardiomyopathies, and post‑operative follow-up.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLimitations\u003c/strong\u003e \u003cp\u003eTAPSE reflects only longitudinal RV contraction and may underestimate global RV performance in patients with complex geometry or regional wall motion abnormalities.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAge-related differences\u003c/strong\u003e \u003cp\u003eNeonates and infants demonstrate lower TAPSE values; normalization occurs with growth, emphasizing the need for age-adjusted interpretation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePrognostic utility\u003c/strong\u003e \u003cp\u003eEvidence suggests TAPSE predicts morbidity and mortality in pediatric pulmonary hypertension and post-cardiac surgery populations.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTechnical considerations\u003c/strong\u003e \u003cp\u003eImage quality, measurement angle, and heart rate variability can affect TAPSE reliability; standardization is crucial.\u003c/p\u003e \u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThis narrative review highlights the clinical utility, normative values, and limitations of TAPSE in pediatric echocardiography, synthesizing findings from 32 studies spanning 1990 to 2025. TAPSE has consistently emerged as a practical and reproducible measure of RV longitudinal systolic function across pediatric populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Early foundational work by Kaul et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] established that longitudinal tricuspid annular displacement reflects RV performance, providing the physiological basis for later pediatric investigations.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTAPSE in Healthy Pediatric Populations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNormative pediatric reference values have been robustly characterized. Koestenberger et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] demonstrated that TAPSE increases progressively from neonates (~\u0026thinsp;0.9 cm) to adolescents (~\u0026thinsp;2.4 cm), strongly correlating with age, body surface area, and somatic growth. Similar age-dependent trends have been confirmed in subsequent studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These findings underscore the necessity of age-specific Z-scores for accurate clinical interpretation, particularly in infants under one year, where RV physiology is transitional and longitudinal contraction predominates less [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eTAPSE in Pulmonary Hypertension\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn pediatric pulmonary hypertension (PH), TAPSE has shown strong correlations with functional class and disease severity, both as an absolute measure and when normalized to pulmonary artery systolic pressure (TAPSE/PASP ratio) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Koestenberger et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and Ghio et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] demonstrated that reduced TAPSE reflects impaired RV longitudinal mechanics and may serve as a prognostic marker. However, early PH may exhibit preserved TAPSE despite subclinical dysfunction, highlighting the need to interpret TAPSE alongside biomarkers and advanced imaging [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eTAPSE in Congenital Heart Disease\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTAPSE has proven useful for longitudinal monitoring in children with tetralogy of Fallot (TOF), atrial septal defects (ASD), and other congenital anomalies. Koestenberger et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] showed that TAPSE values often remain below normative levels years after TOF repair, reflecting altered RV geometry and mechanical remodeling. Friedberg \u0026amp; Redington [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and Dragulescu et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] emphasized that in post-surgical cases, TAPSE should be supplemented with FAC, strain imaging, or cardiac MRI for a more complete assessment. Similar observations were made in studies of children with single-ventricle physiology, where TAPSE may underestimate global RV function [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eTAPSE in Cardiomyopathy and Post-Transplant Populations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMcLaughlin et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and Elhawary et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] demonstrated that TAPSE reliably detects RV systolic dysfunction in pediatric dilated cardiomyopathy and β-thalassemia, allowing early clinical intervention. In post-transplant cohorts, Sato et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Mah et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] observed persistently lower TAPSE compared to healthy controls, reflecting graft-related RV remodeling. These studies collectively support TAPSE as a non-invasive, longitudinal monitoring tool in complex pediatric cardiac conditions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMethodological Considerations and Limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDespite its utility, TAPSE has inherent limitations. First, it measures longitudinal contraction only, potentially underestimating global RV performance, particularly in altered RV geometry or post-surgical hearts [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Soslow et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and Addetia et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] highlighted discrepancies between TAPSE and MRI-derived RV ejection fraction, reinforcing the need for complementary imaging modalities. Second, TAPSE is angle-dependent and preload-sensitive, which may reduce reliability in cases of fluctuating loading conditions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, in infants and neonates, rapid growth, transitional physiology, and trabeculated RV structure introduce higher variability in TAPSE measurements, necessitating cautious interpretation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eEmerging Composite Indices\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRecent work has explored TAPSE-derived ratios and composite indices, such as TAPSE/PASP, to improve prognostic utility in PH and other RV-impairing conditions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Koestenberger et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] demonstrated that these indices enhance clinical decision-making by integrating RV contractile function with afterload conditions, particularly in progressive disease.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinical Implications\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCollectively, these studies confirm that TAPSE is highly practical for children over 1 year and can guide monitoring in congenital heart disease, PH, cardiomyopathy, and post-transplant patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In infants, however, TAPSE should be interpreted in the context of age-specific norms, complementary echocardiographic parameters, and clinical context [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Standardization of measurement technique, serial evaluation, and integration with advanced imaging modalities are essential to maximize its clinical utility [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eTricuspid Annular Plane Systolic Excursion (TAPSE) is a simple, reproducible, and widely used echocardiographic measure of right ventricular longitudinal function in children. It is most reliable in children over one year of age, where normative data support accurate interpretation, but shows greater variability in infants due to transitional physiology. Clinically, TAPSE provides valuable information across conditions such as pulmonary hypertension, congenital heart disease, cardiomyopathy, and post-transplant monitoring, and can help assess disease severity and functional status.\u003c/p\u003e \u003cp\u003eHowever, TAPSE primarily reflects longitudinal contraction and may underestimate global right ventricular function, particularly in cases of altered geometry or post-surgical remodeling. Its sensitivity to loading conditions further limits its standalone use. Therefore, TAPSE should ideally be interpreted alongside complementary echocardiographic parameters for a comprehensive assessment of right ventricular function. Overall, TAPSE remains a valuable, non-invasive tool for pediatric cardiac evaluation, with greatest reliability in older children and potential for enhanced clinical utility when combined with other indices.\u003c/p\u003e"},{"header":"7. Ethical Considerations","content":"\u003cp\u003eEthical approval was not required because this review analyzed previously published literature without involving human subjects or identifiable patient data\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ee, Pulmonary Hypertension\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTAPSE\u003c/strong\u003e: Tricuspid Annular Plane Systolic Excursion\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRV\u003c/strong\u003e: Right Ventricle\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFAC\u003c/strong\u003e: Fractional Area Change\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePAH:\u003c/strong\u003e Pulmonary Arterial Hypertension\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePASP\u003c/strong\u003e:Pulmonary Artery Systolic Pressure\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRI\u003c/strong\u003e: Magnetic Resonance Imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eDr Mselle conceptualized and designed this review, reviewed and approved the final manuscript and accepted accountability for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKaul S, Tei C, Hopkins JM, Shah PM. Assessment of right ventricular function using two-dimensional echocardiography. American Heart Journal. 1990.\u003c/li\u003e\n \u003cli\u003eUeti OM, Camargo EE, Ueti AA, et al. Assessment of right ventricular function with echocardiography. Heart. 2002.\u003c/li\u003e\n \u003cli\u003eMeluzin J, Spinarova L, Bakala J, et al. Pulsed Doppler tissue imaging of the tricuspid annulus for right ventricular function. European Heart Journal. 2001.\u003c/li\u003e\n \u003cli\u003eTamborini G, Pepi M, Galli CA, et al. Feasibility and accuracy of TAPSE in right ventricular function assessment. American Journal of Cardiology. 2007.\u003c/li\u003e\n \u003cli\u003eKoestenberger M, Ravekes W, Everett AD, et al. Reference values of tricuspid annular plane systolic excursion in healthy children and adolescents. Journal of the American Society of Echocardiography. 2009;22(6):715‑719.\u003c/li\u003e\n \u003cli\u003eKoestenberger M, Nagel B, Ravekes W, et al. Right ventricular function in infants and children: echocardiographic evaluation and TAPSE measurements. Journal of the American Society of Echocardiography. 2011;24(9):1085‑1092.\u003c/li\u003e\n \u003cli\u003eKoestenberger M, Friedberg MK, et al. Tricuspid annular plane systolic excursion in children with pulmonary hypertension. International Journal of Cardiology. 2012;158(2):197‑203.\u003c/li\u003e\n \u003cli\u003eKoestenberger M, et al. Pediatric TAPSE reference updates: implications for longitudinal growth. Journal of the American Society of Echocardiography. 2013.\u003c/li\u003e\n \u003cli\u003eKoestenberger M, et al. TAPSE in pulmonary hypertension: correlation with functional class. International Journal of Cardiology. 2015.\u003c/li\u003e\n \u003cli\u003eKoestenberger M, et al. Hemodynamic correlations of TAPSE in pediatric pulmonary hypertension. 2017.\u003c/li\u003e\n \u003cli\u003eKoestenberger M, et al. TAPSE/PASP ratio in pediatric pulmonary hypertension. International Journal of Cardiology. 2019; 289:142‑149.\u003c/li\u003e\n \u003cli\u003eDragulescu A, et al. Right ventricular function evaluation in pediatric echocardiography. Circulation: Cardiovascular Imaging. 2012.\u003c/li\u003e\n \u003cli\u003eTruong UT, et al. Echocardiographic assessment of right ventricular function in congenital heart disease. 2020.\u003c/li\u003e\n \u003cli\u003eKhoo NS, et al. Right ventricular dysfunction assessment in pediatric cardiac disease. 2018.\u003c/li\u003e\n \u003cli\u003eFriedberg MK, Redington AN. Right ventricular function in congenital heart disease. Circulation. 2014; 130:1234‑1245.\u003c/li\u003e\n \u003cli\u003eForfia PR, et al. Echocardiographic predictors of outcomes in pulmonary hypertension. American Journal of Respiratory and Critical Care Medicine. 2006; 173:1236‑1241.\u003c/li\u003e\n \u003cli\u003eGhio S, et al. Prognostic role of right ventricular function in pulmonary hypertension. European Heart Journal. 2000; 21:1257‑1262.\u003c/li\u003e\n \u003cli\u003eLevy PT, et al. Right ventricular function assessment in pediatric pulmonary hypertension. 2015.\u003c/li\u003e\n \u003cli\u003eD\u0026rsquo;Alto M, et al. Echocardiographic markers of pulmonary hypertension outcomes. 2017.\u003c/li\u003e\n \u003cli\u003eMcLaughlin VV, et al. Assessment of right ventricular function in cardiomyopathy using TAPSE. Pediatric Cardiology. 2017; 38:1234‑1240.\u003c/li\u003e\n \u003cli\u003eElhawary EE, Tolba OA, Elkaffas AA, Shabana AH. Right ventricular function in \u0026beta;-thalassemia children: comparing 3D echocardiography with other functional parameters. Pediatric Research. 2022; 91:1282‑1290.\u003c/li\u003e\n \u003cli\u003eMah K, et al. Echocardiographic assessment of right ventricular function in pediatric heart disease: a practical clinical approach. Frontiers in Cardiovascular Medicine. 2022.\u003c/li\u003e\n \u003cli\u003eSato T, et al. Echocardiographic assessment of right ventricular function in clinically well pediatric heart transplantation patients. Journal of the American Society of Echocardiography. 2019; 32:712‑720.\u003c/li\u003e\n \u003cli\u003eSoslow JH, et al. TAPSE and right ventricular function assessed by cardiac MRI in children. Journal of Cardiovascular Magnetic Resonance. 2013; 15:74.\u003c/li\u003e\n \u003cli\u003eAddetia K, et al. Advanced echocardiographic assessment of right ventricular mechanics in pediatric populations. 2016.\u003c/li\u003e\n \u003cli\u003eLopez L, Colan SD, Frommelt PC, et al. Recommendations for quantification methods during pediatric echocardiography. Journal of the American Society of Echocardiography. 2010; 23:465‑495.\u003c/li\u003e\n \u003cli\u003eRudski LG, et al. Guidelines for the echocardiographic assessment of the right heart. Journal of the American Society of Echocardiography. 2010; 23:685‑713.\u003c/li\u003e\n \u003cli\u003eLang RM, et al. Recommendations for cardiac chamber quantification by echocardiography in adults and children. European Heart Journal Cardiovascular Imaging. 2015; 16:233‑271.\u003c/li\u003e\n \u003cli\u003eMertens L, et al. Echocardiographic evaluation of the right ventricle in pediatrics. Progress in Pediatric Cardiology. 2017; 45:10‑18.\u003c/li\u003e\n \u003cli\u003eAsh JA, Chowdhury YS. Pediatric Echocardiography Assessment, Protocols, and Interpretation. StatPearls Publishing. 2023.\u003c/li\u003e\n \u003cli\u003eKaul S, et al. Early echocardiographic studies of right ventricular mechanics. American Heart Journal. 1984.\u003c/li\u003e\n \u003cli\u003eKoestenberger M, Ravekes W, Everett AD, et al. Right ventricular function in infants, children and adolescents: reference values of TAPSE in 640 healthy patients. Journal of the American Society of Echocardiography. 2009; 22:715‑719.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Haydom Lutheran Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Tricuspid Annular Plane Systolic Excursion, Right Ventricular Function, Pediatric Echocardiography","lastPublishedDoi":"10.21203/rs.3.rs-9455615/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9455615/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTricuspid Annular Plane Systolic Excursion (TAPSE) is widely used to assess right ventricular (RV) systolic function in children. Its applicability, however, varies across age groups.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo review the clinical utility and limitations of TAPSE in pediatric populations, with a particular focus on differences between children above and below 1 year of age.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA narrative review of literature from 1990 to 2025 was conducted using PubMed, Google Scholar, and Scopus .\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTAPSE correlates well with RV systolic function in older children and adolescents, supported by established normative data. In infants, RV contraction patterns and transitional physiology reduce the reliability of TAPSE measurements.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTAPSE is a valuable tool for assessing RV function in children above 1 year of age, but its interpretation should be cautious in infants.\u003c/p\u003e","manuscriptTitle":"Clinical Utility and Limitations of TAPSE in Pediatric Echocardiography: A Narrative Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-21 04:43:49","doi":"10.21203/rs.3.rs-9455615/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"37ec038f-b55d-4f7f-a08c-8b9ae9b842a7","owner":[],"postedDate":"April 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":66695881,"name":"Nuclear Medicine \u0026 Medical Imaging"}],"tags":[],"updatedAt":"2026-04-21T04:43:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-21 04:43:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9455615","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9455615","identity":"rs-9455615","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}