scholarly journals Diagnostic value of right heart and pulmonary artery catheterization in patients with suspected pulmonary hypertension. Part 1. Methodology of the procedure, nosology of the diseases and vasoreactivity testing

2020 ◽  
Vol 26 (6) ◽  
pp. 64-76
Author(s):  
Yu. M. Sirenko ◽  
I. O. Zhyvylo ◽  
G. D. Radchenko
Keyword(s):  
Pulmonary Hypertension ◽  
Cardiac Index ◽  
Pulmonary Artery ◽  
Pulmonary Vascular Resistance ◽  
Vascular Resistance ◽  
Right Heart Catheterization ◽  
Heart Catheterization ◽  
Pulmonary Artery Catheterization ◽  
Right Heart ◽  
The Mean

The aim – critical review of our own experience, its compliance with current recommendations and data from international registries, as also assessment of pulmonary and systemic hemodynamics obtained in patients with pulmonary arterial hypertension (PAH) in Ukraine. Materials and methods. 220 procedures of the right heart and pulmonary artery catheterization were performed in 195 patients with medium or high probability of PAH according to echocardiography in compliance with current recommendations. All patients were hospitalized at National Scientific Center “M.D. Strazhesko Institute of Cardiology” of NAMS of Ukraine with suspected PAH (primary) or with worsening of the disease course (repeatedly) or in order to confirm the status of vasoreactivity (repeated).Results and discussion. 220 successful catheterization procedures were performed. Primary (diagnostic) right heart catheterization was performed in 195 patients, and repeated – in 25. A diagnosis of pulmonary hypertension was confirmed in 178 patients. In 17 patients, according to the results of catheterization, the diagnosis of PAH was excluded: the mean pressure in the pulmonary artery was less than 20 mm Hg. The structure of nosology in patients who underwent right heart catheterization was as follows: idiopathic PAH was fixed in 68 (38 %) patients, of which 11 (6 %) were vasoreactive; PAH associated with connective tissue diseases – in 21 (12 %) patients; PAH associated with HIV infection in – 4 (2 %) patients; PAH associated with portal hypertension – in 4 (2 %) patients; PAH associated with congenital heart disease – in 26 (15 %) patients; chronic thromboembolic pulmonary hypertension – in 50 (28 %) patients. Vasoreactivity testing was performed in 33 patients with idiopathic PAH. In 11 of them it was positive (33 %). In patients with a positive vasoreactivity testing, the mean pulmonary artery pressure decreased by an average of 21.8 mm Hg to the level of 26.5 mm Hg (p 0.0001), while the cardiac index increased by 31 % and reached 3.8 l · min · m–2 (p<0.1). Pulmonary vascular resistance decreased by 6.4 Wood units to the level of 2.7 Wood units (p<0.0001). In patients with a negative vasoreactivity testing, the decrease in mean pulmonary artery pressure and pulmonary vascular resistance was not statistically significant (p>0.05), and no changes in the cardiac index were detected. Conclusions. Based on the experience of our center, hemodynamic assessment using catheterization is safe and remains the diagnostic standard for PAH. Catheterization is necessary to clarify 4 parameters that are critical for the clinical profile of patients with pulmonary hypertension: right atrium pressure, pulmonary vascular resistance, cardiac output, pulmonary wedge pressure. Patients with idiopathic PAH also need to have vasoreactivity evaluated in order to predict sensitivity to calcium channel blockers therapy, the presence of which is associated with better treatment and survival outcomes.

Abstract 1597: Safety and Efficacy of Inhaled Iloprost Via a Disposable Nebulizer in Heart Failure Patients With Elevated Pulmonary Vascular Resistance

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
David Baran ◽  
Luis H Arroyo ◽  
Jill Hebron ◽  
Candace Carr ◽  
Mark J Zucker
Keyword(s):  
Heart Failure ◽  
Cardiac Output ◽  
Pulmonary Vascular Resistance ◽  
Vascular Resistance ◽  
Right Heart Catheterization ◽  
Heart Catheterization ◽  
Right Heart ◽  
Heart Failure Patients ◽  
Inhaled Iloprost ◽  
The Mean

Background : Pulmonary vascular resistance (PVR) is routinely measured in patients (pts) being evaluated for a heart transplant. Pts with a high PVR are often treated with a milrinone or intravenous vasodilator “challenge” to establish that the PVR is not “fixed”. However, all current agents have dose-limiting side effects such as arrhythmias and hypotension. Inhaled iloprost would be an option but it is given with a costly adaptive aerosol delivery device. In addition, the efficacy and safety of this drug in left heart failure is poorly studied. Methods : 10 adult heart failure pts who were found to have a PVR of greater than 200 dyne-sec on routine right heart catheterization were enrolled. 50 micrograms (mcg) of iloprost was inhaled while in the catheterization laboratory using a disposable nebulizer and outflow filter, over 10 minutes. Hemodynamics were monitored at baseline, following drug inhalation, and 20 minutes later. Results : The average age of the patients (6 male, 4 female) was 64.8 ± 8.9 years. The mean left ventricular ejection fraction was 20.6 ± 8.6 %. The mean creatinine clearance (Cockroft-Gault) was 48.7 ± 18.9 ml/hr. The mean arterial pressure (MAP), pulmonary artery systolic (PAS), PA diastolic (PAD), PCWP, transpulmonic gradient (TPG), cardiac output (CO), and PVR at baseline, 10 minutes and 20 minutes post-inhalation are detailed below. Iloprost significantly reduced PAS, TPG and PVR without changes in MAP, PAD, PCWP or CO. These effects remained significant at study completion as well. There were no adverse events noted. Conclusion : Iloprost inhalation was well tolerated in heart failure patients undergoing right heart catheterization. Inhalation of 50 mcg of iloprost via a simple hospital nebulizer was associated with safe, rapid, and significant declines in indices of pulmonary vascular tone, without affecting cardiac output or PCWP. Further investigation of this novel use of iloprost is warranted. Results

scholarly journals Results of pulmonary thromboendarterectomy depending on different levels of pulmonary vascular resistance and angiographic index of the pulmonary artery lesion

2020 ◽  
Vol 17 (1) ◽  
pp. 62-68
Author(s):  
Vilnur V. Gazizov ◽  
Kirill V. Mershin ◽  
Evgenii A. Tabak’yan ◽  
Stanislav A. Partigulov ◽  
Zarina S. Valieva ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Pulmonary Artery ◽  
Pulmonary Vascular Resistance ◽  
Vascular Resistance ◽  
Postoperative Period ◽  
Right Heart Catheterization ◽  
Early Postoperative Period ◽  
Heart Catheterization ◽  
Group 2 ◽  
Different Levels

Objective. Pulmonary endarterectomy is a first-choice treatment for patients with chronic thromboembolic pulmonary hypertension. Data describing the results of the operation with different levels of pulmonary vascular resistance (PVR) depending on the spread and percentage of pulmonary artery disease are not declared in the world literature. The aim of our study is to evaluate and compare the hospital results of the operation in patients with different levels of pulmonary vascular resistance, depending on the CT-angiographic index of the pulmonary artery lesion. Materials and methods. A retro-prospective study was conducted, which included 52 patients. All patients were divided into 2 groups, depending on the levels of pulmonary vascular resistance (PVR): group 1 included 31 patients with PVR1000 dynes/cm5, group 2 21 patients with PVR1000 dynes/cm5. Data of the preoperative right heart catheterization in groups 1 and 2, respectively: mean pulmonary artery pressure (mPAP) 44.48.3 and 56.99.6 mm Hg, pulmonary artery wedge pressure 7.32.4 and 61.5 mm. Hg, cardiac output (CO) 3.90.9 and 3.20.6 l/min, cardiac index (CI) 20.5 and 1.60.4 l/min/m2, PVR 767174 and 1272.6186.4 dynsec/cm5. The operation was carried out bilaterally according to a standard protocol with cardiopulmonary bypass, deep hypothermia and circulatory arrest. Results. Data of the right heart catheterization on the first day after the operation in first and second groups, respectively: mPAP 28.56.3 and 35.784.2 mm Hg, PVR 253.3985.5 and 333.9101.9 dynes/cm5, CO 5.370.9 and 5, 21.1 l/min, CI 2.690.39 and 2.60.4 l/min/m2. There was a significant decrease of pulmonary hypertension (p0.05) in the early postoperative period, in both groups. However, a detailed analysis of the obtained data revealed that in patients with pulmonary vascular resistance of more than 1000 dynes/cm5 with a pulmonary artery lesion index of less than 50%, a significant course of the early postoperative period along the combined endpoint was observed. The intensive care unit stay was 4 days in average in both groups. The need for a tracheostomy for the prolongation of artificial ventilation of the lungs was in 2 and 1 cases in first and second groups, respectively. In the first group, there were 5 cases of transient neurological disorders, which regressed at the time of discharge. Two patients in the second group died. Conclusion. Despite the varying levels of baseline PVR, a significant improvement in hemodynamic parameters is observed in the early postoperative period, although patients in group 2 were less proven to normalization of pulmonary hemodynamics. However, a detailed comparative analysis revealed that the most severe category of patients are patients with PVR1000 dynes/cm5, with pulmonary artery lesion index of less than 50%. Thus, the calculation of the CT-angiographic index of pulmonary artery diseases an additional diagnostic method to rate the risks of surgery, especially in patients with a high level of preoperative pulmonary hypertension

High Cardiac Output By Microfistulas: A New Pulmonary Hypertension Mechanism in Patients with Myelofibrosis and the Impact of the Treatment with Ruxolitinib

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 4065-4065
Author(s):  
Jose Maria Segovia ◽  
Emilio Ojeda ◽  
Gomez-Bueno Manuel Francisco ◽  
Rafael Fores ◽  
Jose A Garcia-Marco ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Cardiac Output ◽  
Pulmonary Vascular Resistance ◽  
Vascular Resistance ◽  
Right Heart Catheterization ◽  
Heart Catheterization ◽  
Right Heart ◽  
High Cardiac Output ◽  
Advanced Phase ◽  
The Impact

Abstract Background: Pulmonary Hypertension (PH) is a well-known complication of the advanced phase of Myeloproliferative Diseases (MPD) such as Polycythemia Vera (PV), Essential Thrombocytopenia (ET) and Myelofibrosis (MF). Although initially attributed to increased pulmonary vascular resistance (group 1 PH of the WHO classification), this entity was classified in 2009 in group 5 PH (unknown mechanism and miscellaneous PH). Our aim was to describe the prevalence and possible causes of PH in a series of patients with MF. Methods: We studied a series of patients with Primary MF or Secondary MF to other MPD with cardiac ultrasound, right heart catheterization and scintigraphy after intraarterial infusion of Tc99-labeled albumin macroaggregates. Results: We studied 11 consecutive patients with MF (7 male, mean age 58 years, 4 with MF post-PV, 4 post-TE and 3 Primary MF) during the period 2009-2014. All of them had mutations of JAK-2 gene, fibrosis in bone marrow biopsy and visceromegaly (all with intermediate-2 or higher IPSS). Median NTproBNP levels were 4597 pg/ml (range 175-5700). Echocardiogram showed high systolic pulmonary pressure in most cases, with a mean of 54 ± 17 mmHg (range 35-80). Right heart catheterization showed high cardiac output (HCO) in all patients (table 1). After ruling out other causes of HCO, a scintigraphy was performed after administration of Tc99-labeled albumin macroaggregates in descending thoracic aorta. In every case, a percentage of the labeled macroaggregates (6.1 ± 2.0% of the radioactivity) were plugged in the pulmonary capillary bed, what is diagnostic of the presence of microfistulas in infradiaphragmatic territory. In two of these patients, scintigraphies were performed at diagnosis and after been treated with the anti-JAK drug Ruxolitinib (Novartis Pharma). A favourable impact of this drug was obtained in the two cases, probably due to a reduction of spleen volume. Conclusion: Most patients with MF show pulmonary hypertension associated with high cardiac output caused by microfistulas, without significant increase in pulmonary resistance. This finding has important clinical implications, because pulmonary vasodilators (once recommended) should be contraindicated, since they could cause worsening of the clinical picture. Ruxolitinib could resolve PH in MF and a prospective study in this sense could be indicated. Table 1. Patient 1 2 3 4 5 6 7 8 9 10 11 Pulmonary Artery Pres. (S/D/Mean) 58/38/ 42 69/41/ 50 48/29/ 40 84/26/ 45 57/17/ 30 22/17 / 19 51/16 / 28 22/9 / 13 25/8 / 14 71/23 / 39 30/7 / 15 Pulmonary wedge pres. 28 37 27 13 9 7 13 7 8 12 6 Cardiac output (l/min) 12.5 8.0 11 7.1 8 7.3 8.7 6.7 7.45 6 7.8 Cardiac index (l/m/m2) 5.5 4.0 6.6 3.6 5 4 4.8 4.0 4.5 3.9 5.1 Pulmonary vascular resistance (Wood U.) 1.2 1.4 1.2 4.5 2.6 3 1.7 0.9 0.8 4.5 1.1 Disclosures Ojeda: Alexion Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Fores:Alexion Pharmaceuticals: Consultancy, Speakers Bureau.

scholarly journals Effect of abnormal right heart structures on the diagnosis of pulmonary hypertension

2018 ◽  
Vol 8 (2) ◽  
pp. 204589401877305 ◽  
Author(s):  
Batool AbuHalimeh ◽  
Milind Y. Desai ◽  
Adriano R. Tonelli
Keyword(s):  
Pulmonary Hypertension ◽  
Pulmonary Artery ◽  
Right Heart Catheterization ◽  
The Other ◽  
Heart Catheterization ◽  
Right Heart ◽  
Cardiac Lesions ◽  
The Right ◽  
The Impact ◽  
Heart Lesions

The diagnosis of pulmonary hypertension (PH) requires a right heart catheterization (RHC) that reveals a mean pulmonary artery pressure ≥ 25 mmHg. The pulmonary artery catheter traverse the right atrium and ventricle on its way to the pulmonary artery. The presence of abnormal right heart structures, i.e. thrombus, vegetation, benign or malignant cardiac lesions, can lead to complications during this procedure. On the other hand, avoidance of RHC delays the diagnosis and treatment of PH, an approach that might be associated with worse outcomes. This paper discusses the impact of right heart lesions on the diagnosis of PH and suggests an approach on how to manage this association.

scholarly journals Preoperative Evaluation of Pulmonary Hypertension in Lung Transplant Candidates: Echocardiography Versus Right Heart Catheterization

2021 ◽  
Author(s):  
Tal Abu ◽  
Amos Levi ◽  
David Hasdai ◽  
Mordechai R. Kramer ◽  
Tamir Bental ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Pulmonary Artery ◽  
Preoperative Evaluation ◽  
Systolic Pressure ◽  
Area Under The Curve ◽  
Right Heart Catheterization ◽  
Mean Value ◽  
Pulmonary Artery Systolic Pressure ◽  
Heart Catheterization ◽  
Right Heart

Abstract Background - Right heart catheterization (RHC) and echocardiography are both routinely used for pulmonary artery systolic pressure (PASP) assessment in lung transplantation (LT) candidates, although this is not mandated by current guidelines. We aimed to explore the correlation between PASP estimated by echocardiography to that measured by RHC, in this population in order to assess the necessity of RHC. Methods - From a retrospective registry of 393 LT candidates undergoing RHC and echocardiography during 2015-2019, patients were assessed for the presence of pulmonary hypertension (PH), defined as mean pulmonary artery pressure (mPAP) above 20 mmHg, according to two methods – echocardiography and RHC. The primary outcome was the correlation between the PASP estimated by echocardiography to that measured by RHC. Secondary outcomes were the prediction value of the echocardiographic evaluation and its accuracy. Results - The mean value of PASP estimated by echocardiography was 49.5±20.0 mmHg, compared to 42.5±18.0 mmHg measured by RHC. The correlation between the two measurements was moderate (Pearson’s correlation: r=0.609, p<0.01). Echocardiography PASP measurements were moderately discriminative to diagnose PH, with an area under the curve (AUC) of 0.72 (95% CI 0.66-0.76). Echocardiographic overestimation of PASP of more than 10 mmHg was found in 35.0% of the patients, and underestimation was found in 11.6% of the patients.Conclusion - In the pre-surgical evaluation of LT candidates, echocardiographic estimation of PASP had moderate correlation and limited accuracy compared to the PASP measured by RHC. We thus recommend performing routine RHC to all LT candidates, regardless of the echocardiographic estimation of PASP.

scholarly journals Accuracy of Echocardiographic Estimates of Pulmonary Artery Pressures in Pulmonary Hypertension: Insights From the KARUM Hemodynamic Database

2021 ◽  
Author(s):  
Ashwin Venkateshvaran ◽  
Natavan Seidova ◽  
Hande Oktay Tureli ◽  
Barbro Kjellström ◽  
Lars H Lund ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Pulmonary Artery ◽  
Population Studies ◽  
Right Heart Catheterization ◽  
Right Atrial ◽  
Heart Catheterization ◽  
Limits Of Agreement ◽  
Right Heart ◽  
Minimal Bias

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.

Acute hemodynamic changes and long term prognostic impact of pulmonary hypertension in patients undergoing percutaneous mitral valve edge to edge repair

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
B Koell ◽  
S Ludwig ◽  
O Bhadra ◽  
A Gossling ◽  
N Schofer ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Mitral Valve ◽  
Pulmonary Artery ◽  
Right Heart Catheterization ◽  
Heart Catheterization ◽  
Prognostic Impact ◽  
Right Heart ◽  
The Impact

Abstract Background Pulmonary hypertension (PH) due to left heart disease is the most common form of PH. Published literature suggests increased perisurgical mortality in patients undergoing surgical repair in the setting of preexisting PH. The data on the impact of preexisting PH on clinical outcomes after percutaneous Mitral Valve Edge-to-Edge Repair (pMVR) is limited to observational studies and rely mostly on echocardiographic data. Purpose The aim of the current study is to evaluate the influence of preexisting PH in patients undergoing pMVR analyzing periprocedural invasive right heart catheterization data. Methods Between September 2008 and July 2018, a total of 911 patients with moderate-to-severe or severe mitral regurgitation (MR) underwent pMVR at our center. This analysis includes 331 patients with a complete data set for pre- and postprocedural right heart catheterization and echocardiographic assessment as well as available follow-up information after the implantation. Patients are divided according to the etiology of PH. The combined primary endpoint consists of all-cause mortality and rehospitalization for heart failure. Furthermore, a sub-analysis is performed for all patients with preexisting post-capillary PH. Patients with post-capillary PH are divided into two groups based on a postprocedural decrease of pulmonary artery wedge pressure (mPAWP) below the threshold of 15mmHg. Univariate and multivariate Cox regression analyses are performed to assess the influence on long-term outcome. Results Of all 331 patients (57.7% [n= 191] male) undergoing pMVR, 195 (62.1%) had functional MR. Median ejection fraction was 40.5% (29.3, 54.0). Patients were followed-up for a maximum of 4.41 years and the median follow-up time was 1.98 years. Preexisting PH (mean pulmonary artery pressure ≥25 mmHg) was found in 236 (71.1%) patients: 49 patients had pre-capillary PH (≤15 mmHg), 187 had post-capillary PH (pcPH; n=183; mPAWP &gt;15 mmHg). In Kaplan-Meier analysis, no statistically significant difference could be found in overall mortality in patients without or with PH, irrespective of etiology (p=0.43). However, in patients suffering from post-capillary PH, patients with a postprocedural reduction of mPAWP below the threshold of 15mmHg showed a significantly lower risk for overall long-term mortality compared to patients without a relevant mPAWP reduction (p=0.018). Multivariate analysis revealed acute postprocedural decrease of mPAWP below 15mmHg in patients with post-capillary PH to have a significant influence on mortality (HR 2.81 [1.35, 5.86]; p=0.006; Figure 1). Conclusion In contrast to previously published findings, the present results were not able to show a significant impact of PH, disregarding its etiology, on outcome. Nevertheless, a postprocedural decrease of mPAWP below 15mmHg in patients with post-capillary PH is associated with a favorable outcome. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals Normal and Abnormal Relationships of Pulmonary Artery to Wedge Pressure During Exercise

2020 ◽  
Vol 9 (22) ◽  
Author(s):  
Robert F. Bentley ◽  
Madeleine Barker ◽  
Sam Esfandiari ◽  
Stephen P. Wright ◽  
Felipe H. Valle ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Pulmonary Artery ◽  
Right Heart Catheterization ◽  
Heart Catheterization ◽  
Left Heart ◽  
Healthy Individuals ◽  
Right Heart ◽  
Exercise Hemodynamics ◽  
Wedge Pressure

Background Resting right heart catheterization can assess both left heart filling and pulmonary artery (PA) pressures to identify and classify pulmonary hypertension. Although exercise may further elucidate hemodynamic abnormalities, current pulmonary hypertension classifications do not consider the expected interrelationship between PA and left heart filling pressures. This study explored the utility of this relationship to enhance the classification of exercise hemodynamic phenotypes in pulmonary hypertension. Methods and Results Data from 36 healthy individuals (55, 50–60 years, 50% male) and 85 consecutive patients (60, 49–71 years, 48% male) with dyspnea and/or suspected pulmonary hypertension of uncertain etiology were analyzed. Right heart catheterization was performed at rest and during semiupright submaximal cycling. To classify exercise phenotypes in patients, upper 95% CIs were identified from the healthy individuals for the change from rest to exercise in mean PA pressure over cardiac output (ΔmPAP/ΔCO ≤3.2 Wood units [WU]), pulmonary artery wedge pressure over CO (ΔPAWP/ΔCO ≤2 mm Hg/L per minute), and exercise PA pulse pressure over PAWP (PP/PAWP ≤2.5). Among patients with a ΔmPAP/ΔCO ≤3.2 WU, the majority (84%) demonstrated a ΔPAWP/ΔCO ≤2 mm Hg/L per minute, yet 23% demonstrated an exercise PP/PAWP >2.5. Among patients with a ΔmPAP/ΔCO >3.2 WU, 37% had an exercise PP/PAWP >2.5 split between ΔPAWP/ΔCO groups. Patients with normal hemodynamic classification declined from 52% at rest to 36% with exercise. Conclusions The addition of PP/PAWP to classify exercise hemodynamics uncovers previously unrecognized abnormal phenotypes within each ΔmPAP/ΔCO group. Our study refines abnormal exercise hemodynamic phenotypes based on an understanding of the interrelationship between PA and left heart filling pressures.

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