Echocardiographic probability of pulmonary hypertension: a validation study

2022 ◽  
pp. 2102548
Author(s):  
Michele D'Alto ◽  
Marco Di Maio ◽  
Emanuele Romeo ◽  
Paola Argiento ◽  
Ettore Blasi ◽  
...  

BackgroundAccording to current guidelines, the diagnosis of pulmonary hypertension (PH) relies on echocardiographic probability followed by right heart catheterization. How echocardiography predicts PH recently re-defined by a mean pulmonary artery pressure (mPAP) >20 mmHg instead of ≥25 mmHg and pulmonary vascular disease defined by a pulmonary vascular resistance (PVR) >3 or >2 Wood units has not been established.MethodsA total of 278 patients referred for PH underwent a comprehensive echocardiography followed by a right heart catheterization. Fifteen patients (5.4%) were excluded because of insufficient quality echocardiography.ResultsWith PH defined by a mPAP >20 mmHg, 23 patients had no PH, 146 had pre-capillary and 94 post-capillary PH. At univariate analysis, maximum velocity of tricuspid regurgitation (TRV) ≥2.9 and ≤3.4 m s−1, left ventricle (LV) eccentricity index >1.1, right ventricle (RV) outflow tract (OT) notching or acceleration time <105 ms, RV-LV basal diameter >1 and PA diameter predicted PH, whereas inferior vena cava diameter and right atrial area did not. At multivariable analysis, only TRV ≥2.9 m s−1 independently predicted PH. Additional independent prediction of PVR >3 Wood units was offered by LV eccentricity index >1.1 and RVOT acceleration time <105 ms and/or notching, but with no improvement of optimal combination of specificity and sensibility or positive prediction.ConclusionsEchocardiography as recommended in current guidelines can be used to assess the probability of re-defined PH in a referral center. However, the added value of indirect signs is modest and sufficient quality echocardiographic signals may not be recovered in some patients.

2020 ◽  
Vol 13 (3) ◽  
Author(s):  
W. H. Wilson Tang ◽  
Jennifer D. Wilcox ◽  
Miriam S. Jacob ◽  
Erika B. Rosenzweig ◽  
Barry A. Borlaug ◽  
...  

Background: Invasive hemodynamic evaluation through right heart catheterization plays an essential role in the diagnosis, categorization, and risk stratification of patients with pulmonary hypertension. Methods: Subjects enrolled in the PVDOMICS (Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics) program undergo an extensive invasive hemodynamic evaluation that includes repeated measurements at rest and during several provocative physiological challenges. It is a National Institutes of Health/National Heart, Lung, and Blood Institute initiative to reclassify pulmonary hypertension groups based on clustered phenotypic and phenomic characteristics. At a subset of centers, participants also undergo an invasive cardiopulmonary exercise test to assess changes in hemodynamics and gas exchange during exercise. Conclusions: When coupled with other physiological testing and blood -omic analyses involved in the PVDOMICS study, the comprehensive right heart catheterization protocol described here holds promise to clarify the diagnosis and clustering of pulmonary hypertension patients into cohorts beyond the traditional 5 World Symposium on Pulmonary Hypertension groups. This article will describe the methods applied for invasive hemodynamic characterization in the PVDOMICS program. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02980887.


2021 ◽  
Author(s):  
Ashwin Venkateshvaran ◽  
Natavan Seidova ◽  
Hande Oktay Tureli ◽  
Barbro Kjellström ◽  
Lars H Lund ◽  
...  

Abstract BACKGROUND. Accurate assessment of pulmonary artery (PA) pressures is integral to diagnosis, follow-up and therapy selection in pulmonary hypertension (PH). Despite wide utilization, the accuracy of echocardiography to estimate PA pressures has been debated. We aimed to evaluate echocardiographic accuracy to estimate right heart catheterization (RHC) based PA pressures in a large, dual-centre hemodynamic database. METHODS. Consecutive PH referrals that underwent comprehensive echocardiography within 3 hours of clinically indicated right heart catheterization were enrolled. Subjects with absent or severe, free-flowing tricuspid regurgitation (TR) were excluded. Accuracy was defined as mean bias between echocardiographic and invasive measurements on Bland-Altman analysis for the cohort and estimate difference within ±10mmHg of invasive measurements for individual diagnosis. RESULTS. In 419 subjects, echocardiographic PA systolic and mean pressures demonstrated minimal bias with invasive measurements (+2.4 and +1.9mmHg respectively) but displayed wide limits of agreement (-20 to +25 and -14 to +18mmHg respectively) and frequently misclassified subjects. Recommendation-based right atrial pressure (RAP) demonstrated poor precision and was falsely elevated in 32% of individual cases. Applying a fixed, median RAP to echocardiographic estimates resulted in relatively lower bias between modalities when assessing PA systolic (+1.4mmHg; 95% limits of agreement +25 to –22mmHg) and PA mean pressures (+1.4mmHg; 95% limits of agreement +19 to -16mmHg).CONCLUSIONS. Echocardiography accurately represents invasive PA pressures for population studies but may be misleading for individual diagnosis owing to modest precision and frequent misclassification. Recommendation-based estimates of RAPmean may not necessarily contribute to greater accuracy of PA pressure estimates.


2021 ◽  
Author(s):  
Camila Farnese Rezende ◽  
Eliane Viana Mancuzo ◽  
Maria Carmo P Nunes ◽  
Ricardo de Amorim Corrêa

Abstract Purpose: Studies in the context of research have shown a significant disagreement between the echocardiographic measurement of the systolic pulmonary artery pressure (sPAP) and right atrial pressure (RAP) and that obtained by right heart catheterization (RHC). We compare measurements of sPAP and RAP, verified by transthoracic echocardiogram (TTE) with those detected by RHC in patients being investigated for pulmonary hypertension (PH). Methods: Cross-sectional study was performed in a context of usual clinical practice in the public referral center for PH, including patients with high or intermediate echocardiographic probability of pulmonary arterial hypertension and chronic thromboembolic PH. Bland-Altman test was used to assess the agreement amongthe values and ROC curve to identify sPAP and tricuspid regurgitation velocity (TRV) values ​​with better accuracy. Clinically acceptable differences of 10 mmHg for sPAP and 5 mmHg for RAP were considered.Results: Ninety-five patients were included. The Bland-Altman analysis showed a bias of 8.03 mmHg for sPAP and -3.30 mmHg for RAP. Area under the curve for sPAP and TRV measured by TTE were 0.936(95% CI: 0.836-1.0) and 0.919(95% CI: 0.837-1.0), respectively. According to the pre-defined pressure differences, only 33.4% of the echocardiographic estimate of sPAP and 55.1% of RAP were accurate, as compared to the measurements obtained by RHC. Conclusions: Real life study revealed that echocardiographic evaluation demonstrated a high discriminatory power for diagnosis of PH, but sPAP and RAP measurements showed significant disagreements in relation to hemodynamic measures. The technical improvement of diagnostic services may contribute to the earlier recognition of this condition by TTE.


2020 ◽  
Vol 9 (22) ◽  
Author(s):  
Mona Lichtblau ◽  
Patrick R. Bader ◽  
Stéphanie Saxer ◽  
Charlotte Berlier ◽  
Esther I. Schwarz ◽  
...  

Background We investigated changes in right atrial pressure (RAP) during exercise and their prognostic significance in patients assessed for pulmonary hypertension (PH). Methods and Results Consecutive right heart catheterization data, including RAP recorded during supine, stepwise cycle exercise in 270 patients evaluated for PH, were analyzed retrospectively and compared among groups of patients with PH (mean pulmonary artery pressure [mPAP] ≥25 mm Hg), exercise‐induced PH (exPH; resting mPAP <25 mm Hg, exercise mPAP >30 mm Hg, and mPAP/cardiac output >3 Wood Units (WU)), and without PH (noPH). We investigated RAP changes during exercise and survival over a median (quartiles) observation period of 3.7 (2.8–5.6) years. In 152 patients with PH, 58 with exPH, and 60 with noPH, median (quartiles) resting RAP was 8 (6–11), 6 (4–8), and 6 (4–8) mm Hg ( P <0.005 for noPH and exPH versus PH). Corresponding peak changes (95% CI) in RAP during exercise were 5 (4–6), 3 (2–4), and −1 (−2 to 0) mm Hg (noPH versus PH P <0.001, noPH versus exPH P =0.027). RAP increase during exercise correlated with mPAP/cardiac output increase ( r =0.528, P <0.001). The risk of death or lung transplantation was higher in patients with exercise‐induced RAP increase (hazard ratio, 4.24; 95% CI, 1.69–10.64; P =0.002) compared with patients with unaltered or decreasing RAP during exercise. Conclusions In patients evaluated for PH, RAP during exercise should not be assumed as constant. RAP increase during exercise, as observed in exPH and PH, reflects hemodynamic impairment and poor prognosis. Therefore, our data suggest that changes in RAP during exercise right heart catheterization are clinically important indexes of the cardiovascular function.


2020 ◽  
Vol 10 (3) ◽  
pp. 204589402095022
Author(s):  
Anjali Vaidya ◽  
Jessica R. Golbus ◽  
Natasha A. Vedage ◽  
Jeremy Mazurek ◽  
Farhan Raza ◽  
...  

This study validated a novel virtual echocardiography screening tool (VEST), which utilized routinely reported echocardiography parameters to predict hemodynamic profiles in pulmonary hypertension (PH) and identify PH due to pulmonary vascular disease (PHPVD). Direct echocardiography imaging review has been shown to predict hemodynamic profiles in PH; however, routine use often overemphasizes Doppler-estimated pulmonary artery systolic pressure (PASPDE), which lacks discriminatory power among hemodynamically varied PH subgroups. In patients with PH of varying subtypes at a tertiary referral center, reported echocardiographic findings needed for VEST, including left atrial size, E:e’ and systolic interventricular septal flattening, were obtained. Receiver operating characteristic analyses assessed the predictive performance of VEST vs. PASPDE in identifying PHPVD, which was later confirmed by right heart catheterization. VEST demonstrated far superior discriminatory power than PASPDE in identifying PHPVD. A positive score was 80.0% sensitive and 75.6% specific for PHPVD with an area under the curve of 0.81. PASPDE exhibited poorer discriminatory power with an area under the curve of 0.56. VEST’s strong discriminatory ability remained unchanged when validated in a second cohort from another tertiary center. We demonstrated that this novel VEST using three routine parameters that can be easily extracted from standard echocardiographic reports can successfully capture PH patients with a high likelihood of PHPVD. During the Covid-19 pandemic, when right heart catheterization and timely access to experts at accredited PH centers may have limited widespread availability, this may assist physicians to rapidly and remotely evaluate PH patients to ensure timely and appropriate care.


2020 ◽  
Vol 41 (Supplement_1) ◽  
Author(s):  
J O S Santoso ◽  
R P Prakoso ◽  
R S Simamora ◽  
H S M Muliawan ◽  
B B S Siswanto

Abstract Background Pulmonary hypertension is a serious complication that can develop in patients with secundum Atrial Septal Defect (ASD) and based on Euro Heart Survey, 24,77% of ASD patients develop PH. The gold-standard for the diagnosis of pulmonary hypertension in ASD is right heart catheterization. However, in low-middle income country like Indonesia, right heart catheterization only available in a few centers while Indonesia is often referred as the world’s largest archipelago. Thus, there is a huge number of undiagnosed and untreated patients with ASD-PH in Indonesia, especially in patients who lives in rural and isolated area. This research was initiated to investigate the diagnostic value of simple 12-lead ECG in the diagnosis of pulmonary hypertension in ASD with the intention to help doctors in isolated area. Method We performed a cross-sectional study analyzing the 12-lead ECG and mean arterial pressure collected from right heart catheterization from 120 patients with secundum ASD aged &gt; 18 years old. The 12-lead ECG collected within 24 hours before RHC procedure. Results We analyzed the ECG and RHC from 60 subjects diagnosed with pulmonary hypertension and 60 subjects without pulmonary hypertension. We found that R in lead V1 + S in lead V6&gt; 12,5 mV, right axis deviation (RAD), and RV strain were independent predictors of pulmonary hypertension in secundum ASD. Based on Receiver Operator Characteristics (ROC), we obtained that R in V1 + S in V6&gt; 12,5 mm, right axis deviation (RAD), and RV strain has an Area Under of Curve (AUC) of 80,8%, 70,5%, and 85,6% respectively. We developed a scoring system and a score of &gt;5 have a sensitivity of 90%, specificity of 84,4%, positive predictive value of 84,4%, negative predictive value of 90%, and accuracy of 87,1%. We also developed a predictor for pulmonary vascular disease (low flow and high resistance PH) to predict wether the defect can be closed. We obtained that R in V6 + S in V6 &gt; 27,5 mm can predict a low flow high resistance pulmonary hypertension in secundum ASD with an AUC of 77,1% (CI 95% 58-96,1%) Conclusion ECG score of 12-lead ECG derived from this study can be used to predict PH in secundum ASD. It may help cardiologists or general practitioners in rural and isolated area to diagnose pulmonary hypertension in ASD and plan the best management for the patients.


2017 ◽  
Vol 7 (3) ◽  
pp. 674-683 ◽  
Author(s):  
Jared M. O’Leary ◽  
Tufik R. Assad ◽  
Meng Xu ◽  
Kelly A. Birdwell ◽  
Eric Farber-Eger ◽  
...  

Pulmonary hypertension (PH) is common in patients with chronic kidney disease (CKD) and associated with increased mortality but the hemodynamic profiles, clinical risk factors, and outcomes have not been well characterized. Our objective was to define the hemodynamic profile and related risk factors for PH in CKD patients. We extracted clinical and hemodynamic data from Vanderbilt’s de-identified electronic medical record on all patients undergoing right heart catheterization during 1998–2014. CKD (stages III–V) was defined by estimated glomerular filtration rate thresholds. PH was defined as mean pulmonary pressure ≥ 25 mmHg and categorized into pre-capillary and post-capillary according to consensus recommendations. In total, 4635 patients underwent catheterization: 1873 (40%) had CKD; 1518 (33%) stage 3, 230 (5%) stage 4, and 125 (3%) stage 5. PH was present in 1267 (68%) of these patients. Post-capillary (n = 965, 76%) was the predominant PH phenotype among CKD patients versus 302 (24%) for pre-capillary ( P < 0.001). CKD was independently associated with pulmonary hypertension (odds ratio = 1.4, 95% confidence interval = 1.18–1.65). Mortality among CKD patients rose with worsening stage and was significantly increased by PH status. PH is common and independently associated with mortality among CKD patients referred for right heart catheterization. Post-capillary was the most common etiology of PH. These data suggest that PH is an important prognostic co-morbidity among CKD patients and that CKD itself may have a role in the development of pulmonary vascular disease in some patients.


Author(s):  
Ashwin Venkateshvaran ◽  
Natavan Seidova ◽  
Hande Oktay Tureli ◽  
Barbro Kjellström ◽  
Lars H. Lund ◽  
...  

AbstractAccurate assessment of pulmonary artery (PA) pressures is integral to diagnosis, follow-up and therapy selection in pulmonary hypertension (PH). Despite wide utilization, the accuracy of echocardiography to estimate PA pressures has been debated. We aimed to evaluate echocardiographic accuracy to estimate right heart catheterization (RHC) based PA pressures in a large, dual-centre hemodynamic database. Consecutive PH referrals that underwent comprehensive echocardiography within 3 h of clinically indicated right heart catheterization were enrolled. Subjects with absent or severe, free-flowing tricuspid regurgitation (TR) were excluded. Accuracy was defined as mean bias between echocardiographic and invasive measurements on Bland–Altman analysis for the cohort and estimate difference within ± 10 mmHg of invasive measurements for individual diagnosis. In 419 subjects, echocardiographic PA systolic and mean pressures demonstrated minimal bias with invasive measurements (+ 2.4 and + 1.9 mmHg respectively) but displayed wide limits of agreement (− 20 to + 25 and − 14 to + 18 mmHg respectively) and frequently misclassified subjects. Recommendation-based right atrial pressure (RAP) demonstrated poor precision and was falsely elevated in 32% of individual cases. Applying a fixed, median RAP to echocardiographic estimates resulted in relatively lower bias between modalities when assessing PA systolic (+ 1.4 mmHg; 95% limits of agreement + 25 to − 22 mmHg) and PA mean pressures (+ 1.4 mmHg; 95% limits of agreement + 19 to − 16 mmHg). Echocardiography accurately represents invasive PA pressures for population studies but may be misleading for individual diagnosis owing to modest precision and frequent misclassification. Recommendation-based estimates of RAPmean may not necessarily contribute to greater accuracy of PA pressure estimates.


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