Doppler echocardiography reliably predicts pulmonary artery wedge pressure in patients with chronic heart failure with and without mitral regurgitation

This prospective study compared exercise test and intravenous fluid challenge in a single right heart catheter procedure to detect latent diastolic heart failure in patients with echocardiographic heart failure with preserved ejection function. We included 49 patients (73% female) with heart failure with preserved ejection function and pulmonary artery wedge pressure ≤15 mmHg. A subgroup of 26 patients had precapillary pulmonary hypertension. Invasive haemodynamic and gas exchange parameters were measured at rest, 45° upright position, during exercise, after complete haemodynamic and respiratory recovery in lying position, and after rapid infusion of 500 mL isotonic solution. Most haemodynamic parameters increased at both exercise and intravenous fluid challenge, with the higher increase at exercise. Pulmonary vascular resistance decreased by –0.21 wood units at exercise and –0.56 wood units at intravenous fluid challenge ( p = 0.3); 20% (10 of 49) of patients had an increase in pulmonary artery wedge pressure above the upper limit of 20 mmHg at exercise, and 20% above the respective limit of 18 mmHg after intravenous fluid challenge. However, only three patients exceeded the upper limit of pulmonary artery wedge pressure in both tests, i.e. seven patients only at exercise and seven other patients only after intravenous fluid challenge. In the subgroup of pulmonary hypertension patients, only two patients exceeded pulmonary artery wedge pressure limits in both tests, further five patients at exercise and four patients after intravenous fluid challenge. A sequential protocol in the same patient showed a significantly higher increase in haemodynamic parameters at exercise compared to intravenous fluid challenge. Both methods can unmask diastolic dysfunction at right heart catheter procedure, but in different patient groups.

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Prognostic Impact of the Pulmonary Artery Pulsatility Index in Patients with Chronic Heart Failure and Severe Mitral Regurgitation Undergoing Percutaneous Edge-to-Edge Repair

Cardiology ◽

10.1159/000510283 ◽

2020 ◽

Vol 146 (1) ◽

pp. 74-84

Author(s):

Rico Osteresch ◽

Kathrin Diehl ◽

Johannes Schmucker ◽

Azza Ben Ammar ◽

Oana Solyom ◽

...

Keyword(s):

Heart Failure ◽

Regression Analysis ◽

Chronic Heart Failure ◽

Mitral Regurgitation ◽

Pulmonary Artery ◽

Primary Endpoint ◽

Pulsatility Index ◽

Operative Risk ◽

Prognostic Impact

Background: Pulmonary artery (PA) pulsatility index (PAPi), calculated as (PA systolic pressure – PA diastolic pressure)/right atrial pressure, emerged as a novel predictor of right ventricular failure in patients with acute inferior myocardial infarction, advanced heart failure, and severe pulmonary hypertension. However, the prognostic utility of PAPi in transcatheter mitral valve repair (TMVR) using the MitraClip® system has never been tested. Objective: To assess the prognostic impact of PAPi in patients with severe functional mitral regurgitation (MR) and chronic heart failure (CHF) undergoing TMVR. Methods: Consecutive patients with severe functional MR (grade 3+ or 4+) and CHF who underwent successful TMVR (MR ≤2+ at discharge) were enrolled and divided into 3 groups according to PAPi (A: low PAPi ≤2.2; B: intermediate PAPi 2.21–3.99; C: high PAPi ≥4.0). The primary endpoint was a composite of all-cause mortality and rehospitalization due to CHF during a mean follow-up period of 16 ± 4 months. The impact of PAPi on prognosis was assessed by a receiver-operating characteristic (ROC) analysis and a multivariable Cox proportional hazard regression analysis investigating independent predictors for outcome. Results: 78 patients (A: n = 27, B: n = 28, C: n = 23) at high operative risk (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 18.8 vs. 21.5 vs. 20.6%; nonsignificant) were enrolled. Mean PAPi was 1.6 ± 0.41 vs. 2.9 ± 0.53 vs. 6.8 ± 3.5; p < 0.001). Patients with low PAPi showed significantly higher rates of early rehospitalization for heart failure at the 30-day follow-up (14.9 vs. 7.1 vs. 4.3%; p = 0.04). In the long term, a significantly lower event-free survival for the combined primary endpoint was observed in the low PAPi group (44.4 vs. 25.0 vs. 20.3%; log-rank p = 0.016). ROC curve analysis revealed that optimal sensitivity and specificity were achieved using a PAPi cutoff of 2.46 (sensitivity 83%, specificity 78.3%, area under the curve 0.82 [0.64–0.99]; p = 0.01). In Cox regression analysis, PAPi ≤2.46 was an independent predictor for the combined primary endpoint (hazard ratio 2.85; 95% confidence interval 1.15–7.04; p = 0.023). Conclusions: PAPi is strongly associated with clinical outcome among patients with CHF and functional MR undergoing TMVR. A PAPi value ≤2.46 predicts a worse prognosis independent of other important clinical, echocardiographic, and hemodynamic factors. Therefore, PAPi may serve as a new parameter to improve patient selection for TMVR.

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