Intestinal Barrier Dysfunction is Associated with Elevated Right Atrial Pressure in Patients with Advanced Decompensated Heart Failure

Right atrial pressure (RAP) is a key cardiac parameter of diagnostic and prognostic significance, yet current two-dimensional echocardiographic methods are inadequate for the accurate estimation of this haemodynamic marker. Right-heart trans-tricuspid Doppler and tissue Doppler echocardiographic techniques can be combined to calculate the right ventricular (RV) E/e’ ratio – a reflection of RV filling pressure which is a surrogate of RAP. A systematic search was undertaken which found seventeen articles that compared invasively measured RAP with RV-E/e’ estimated RAP. Results commonly concerned pulmonary hypertension or advanced heart failure/transplantation populations. Reported receiver operator characteristic analyses showed reasonable diagnostic ability of RV-E/e’ for estimating RAP in patients with coronary artery disease and RV systolic dysfunction. The diagnostic ability of RV-E/e’ was generally poor in studies of paediatrics, heart failure and mitral stenosis, whilst results were equivocal in other diseases. Bland-Altman analyses showed good accuracy but poor precision of RV-E/e’ for estimating RAP, but were limited by only being reported in seven out of seventeen articles. This suggests that RV-E/e’ may be useful at a population level but not at an individual level for clinical decision making. Very little evidence was found about how atrial fibrillation may affect the estimation of RAP from RV-E/e’, nor about the independent prognostic ability of RV-E/e’ . Recommended areas for future research concerning RV-E/e’ include; non-sinus rhythm, valvular heart disease, short and long term prognostic ability, and validation over a wide range of RAP.

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RIGHT ATRIAL PRESSURE TO STROKE VOLUME RATIO PREDICTS ADVERSE OUTCOMES IN ADVANCED HEART FAILURE

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(18)31373-1 ◽

2018 ◽

Vol 71 (11) ◽

pp. A832

Author(s):

Jigna Solanki ◽

Kenneth Bilchick ◽

Jose Tallaj ◽

Sula Mazimba

Keyword(s):

Heart Failure ◽

Stroke Volume ◽

Volume Ratio ◽

Advanced Heart Failure ◽

Adverse Outcomes ◽

Atrial Pressure ◽

Right Atrial ◽

Right Atrial Pressure

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Abstract 13180: Ultrasound Jugular Venous Pressure Collapse Point Predicts Elevated Right Atrial Pressure on Right Heart Catheterization in Obese and Nonobese Patients

Circulation ◽

10.1161/circ.142.suppl_3.13180 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Libo Wang ◽

Jonathan Harrison ◽

Elizabeth Dranow ◽

Lillian Khor

Keyword(s):

Heart Failure ◽

Venous Pressure ◽

Right Heart Catheterization ◽

Atrial Pressure ◽

Right Atrial ◽

Right Atrial Pressure ◽

Heart Catheterization ◽

Point Of Care Ultrasound ◽

Right Heart ◽

Simplified Approach

Introduction: Accurate intravascular volume status assessment is central to heart failure management, but current non-invasive bedside techniques remain a challenge. Visual inspection of jugular venous pulsation (JVP) is used as a surrogate for central venous pressure (CVP). Studies have shown variability and inaccuracy of the JVP exam in estimating CVP or right atrial pressure (RAP). Published methods of RAP estimation through internal jugular vein (IJV) ultrasonography are either complex or require offline analysis. We validated a simplified approach to ultrasonography of the JVP (uJVP) as a method to predict RAP. Methods: Adult patients undergoing right heart catheterization (RHC) were enrolled prior for IJV imaging with point of care ultrasound (POCUS) device, Butterfly iQ™. The IJV was identified on ultrasound with the patient reclined (head of bed between 30-45°) and followed cranially until tapering smaller than the adjacent carotid artery throughout the entirety of the respiratory cycle. The height of this collapse point from the sternal angle added to 5 centimeters was defined as ultrasound JVP (uJVP). Results: 77 participants underwent uJVP assessment on the same day prior to RHC. Average BMI was 33 kg/m 2 . The area under the curve (AUC) of uJVP and RAP greater than 10mmHg on RHC was 0.879 (95% CI 0.759-0.931, p<0.001), with AUC of 0.972 and 0.818 for non-obese and obese subgroups respectively, and AUC of 0.876 for elevated RAP and pulmonary capillary wedge pressure (PCWP). A uJVP cutoff of 9 or higher was 85% sensitive and 72% specific at identifying RAP greater than 10mmHg. Conclusion: We developed and validated a novel technique identifying the uJVP using POCUS which correlates with invasive RAP regardless of obesity. This technique predicted combined elevated left and right sided intracardiac pressures. The uJVP’s potential to enhance the diagnostic value of the bed-side examination in an increasingly obese heart failure population warrants further research.

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