The Diagnostic Value of Transthoracic Echocardiography Parameters Under the New Diagnostic Criteria for Pulmonary Hypertension

Artificial Intelligence-Based Echocardiography in Pulmonary Arterial Hypertension.

59-Year-Old Woman With Fatigue, Dyspnea, and Lower Extremity Edema

Funding Acknowledgements Type of funding sources: None. Introduction. Tricuspid annular plane systolic excursion (TAPSE) is a widely used parameter for the assessment of right ventricular (RV) systolic function in candidates for lung transplant (LT). However, its accuracy after surgery is not well established. In our study, we aim to evaluate the feasibility of TAPSE after LT and compare it with other classic parameters of RV function. Methods. 144 patients underwent LT between January 2014 and June 2017 in our center. Mean age was 55 years (65 % men). Double LT was performed in 65%, being most common etiology pulmonary fibrosis followed by chronic pulmonary obstructive disease. 9% of LT candidates had severe pulmonary hypertension (PH), defined as mean pulmonary artery pressure (PAP) over 45 mmHg on right heart catheterization. We retrospectively analyzed echocardiographic studies at baseline and 4 weeks after LT in 94 patients. Nine of them had prior severe pulmonary hypertension. We measured RV fractional area change (FAC) and systolic displacement of tricuspid annulus-TAPSE as main parameters of RV systolic function, as well as right atrium (RA) area. Results. We found a significant improvement in RV FAC (39 ± 9% vs. 44 ± 6%, p < 0.001) and a reduction in RA area (16 ± 6 cm2 vs. 12 ± 5 cm2; p < 0.001) after lung transplant in the global study group. This was remarkably significant when prior severe pulmonary hypertension was present (RV FAC 24 ± 9% vs. 43 ± 6%, RA area 27 ± 8 cm2 vs. 14 ± 4 cm2; p < 0.000). However, postoperative TAPSE was significantly lower (21 ± 3 mm vs. 17 ± 2 mm; p < 0.000), and it did not show any significant change in the PH subgroup (p = 0.89). We found a good correlation between TAPSE and RV FAC on pre-transplant echocardiographic study (r = 0.76; p < 0.000), whereas this relation did not remain after LT (r = 0.26; p 0.06). Conclusion. Right ventricular systolic function globally improved after LT, and this is particularly pronounced in candidates with severe PH. In contrast, TAPSE paradoxically deteriorates on post-surgery echocardiogram. According to our findings, TAPSE may not be a reliable parameter for the assessment of RV systolic function after lung transplant.

<b>Background:</b> The prognosis of pulmonary hypertension (PH) depends heavily on the response of the right ventricle (RV) to the increased afterload. It is, however, unclear why RV adaptation is more benign in some patients, whereas other progress rapidly towards RV failure, which is associated with an adverse outcome. We investigated metabolic pathways that may influence the response of the RV to PH. <b>Methods:</b> Plasma proteomic analysis was performed in patients with established PH, including idiopathic pulmonary arterial hypertension (PAH), chronic thromboembolic PH (CTEPH), and Eisenmenger syndrome. Protein levels were correlated to a composite echocardiographic score (1 point each): tricuspid annular plane systolic excursion (TAPSE) &lt;15mm, systolic/diastolic duration (S/D) ratio ≥1.5, right atrial (RA) area ≥25cm2, RA/left atrial (LA) area ≥1.5. <b>Results:</b> Seventy-one patients with PH were included (64% F, 42[31-51] years). TAPSE was 18[16-21] mm (&lt;15mm in 18.5%), S/D ratio was 1.3[1.1-1.6] (≥1.5 in 37.3%), RA area was 21.1[16.6-27.0]cm2 (≥25cm2 in 30.4%) and the RA/LA area was 1.2[1.0-1.5] (≥1.5 in 32.4%). Over one half (38, 53.5%) of patients had a composite score of ≥1. There was no significant difference in the proportion of patients with a composite score of ≥1 between PH subgroups (p=0.6). Serum protein levels most strongly related to the composite score were CCL16(p&lt;0.001) and NT-proBNP(p&lt;0.001). Additionally, serum ACE2, TFF3 and IL-6 levels were related to RV dysfunction (all p&lt;0.01). <b>Conclusions:</b> Several plasma proteins are associated with markers of RV function in precapillary PH. Larger studies are needed to compare cardiometabolic profiles in PH subtypes with variable RV adaptation.

The aim of the study was to evaluate the association between the tricuspid annular plane systolic excursion (TAPSE)/systolic pulmonary artery pressure (sPAP) ratio and estimated glomerular filtration rate (eGFR) and their association with mortality in the European Scleroderma Trials and Research (EUSTAR) cohort. Patients with systemic sclerosis (SSc) from the EUSTAR database with TAPSE, sPAP, and parameters required to calculate eGFR were included. Logistic regression and Cox regression analysis were performed to evaluate TAPSE/sPAP as a risk factor for chronic kidney disease (CKD) and overall survival. A total of 2,370 patients with SSc were included; 284 (12%) patients had CKD stage 3a-5. TAPSE/sPAP (odds ratio [OR] 0.479; 95% CI 0.310-0.743; P < 0.001), arterial hypertension (OR 3.118; 95% CI 2.173-4.475; P < 0.001), diastolic dysfunction (OR 1.670; 95% CI 1.148-2.428; P < 0.01), and N-terminal pro-B-type natriuretic peptide (OR 1.165; 95% CI 1.041-1.304; P < 0.01) were associated with CKD stage 3a-5. TAPSE/sPAP ≤0.32 mm/mm Hg (hazard ratio [HR] 3.589; 95% CI 2.236-5.761; P < 0.001), eGFR <60 mL/min per 1.73 m2 (HR 2.818; 95% CI 1.777-4.468; P < 0.001), and age (HR 1.782; 95% CI 1.348-2.356; P < 0.001) were the most significant predictive factors for all-cause mortality. A total of 276 patients with SSc had pulmonary hypertension (PH) confirmed by right-sided heart catheterization, with 69 (25%) having CKD stage 3a-5. No difference was found in eGFR between patients with PH with reduced or normal cardiac index. Reduced TAPSE/sPAP ratio is independently associated with CKD. TAPSE/sPAP ratio ≤0.32 mm/mm Hg and eGFR <60 mL/min per 1.73 m2 are prognostic factors for all-cause mortality. In patients with SSc with PH, eGFR is independent by reduced cardiac output.

Sex-Specific Differences in Echocardiographic Parameters of Risk Stratification in Pulmonary Arterial Hypertension.

Using the tricuspid annular plane systolic excursion (TAPSE)/pulmonary arterial systolic pressure (PASP) ratio as an index of right ventricular load adaptability, we aimed to evaluate early changes in right heart contractile function of patients with group1 pulmonary artery hypertension (PAH) after sequential combination PAH-specific therapy. Atotal of 49patients with group1 PAH and 31control participants were included in the study. The baseline clinical and echocardiographic data of the control and PAH group were compared. Subsequently, clinical and echocardiographic data of PAH patients before treatment and at 6months after PAH-specific treatment were analyzed. Asignificant increase in the TAPSE/PASP ratio was found in patients at 6months of PAH-specific treatment (0.25 ± 0.14; 0.33 ± 0.16, p < 0.001). Right atrial pressure (8 mm Hg [5-10]; 5 mm Hg [3-8], p < 0.001) and PASP (80.8 ± 30.6 mm Hg; 65.9 ± 25.7 mm Hg, p < 0.001) were significantly lower after sequential combination PAH-specific therapy. Negative correlations were found between the TAPSE/PASP ratio and N‑terminal pro-B-type natriuretic peptide (r = -0.524, p < 0.001), tricuspid regurgitation velocity (r = -0.749, p < 0.001), right atrial area (r = -0.298, p = 0.037), and right atrial pressure (r = -0.463, p = 0.001). In patients with group1 PAH, echocardiographic evaluation at the early stage of treatment (6months) shows asignificant improvement in the TAPSE/PASP ratio indicating right ventricular load adaptation. Comprehensive studies are needed on the routine use of the TAPSE/PASP ratio in the risk assessment of PAH patients.

BackgroundIn precapillary pulmonary hypertension (PH), the incidence of different tricuspid regurgitation (TR) degree is poorly defined. The impact of TR severity on pulmonary artery pressure (PAP) assessment and clinical risk stratification in precapillary PH remains unclear.MethodsA total of 207 patients diagnosed precapillary PH who underwent right heart catheterization (RHC) and echocardiography within 3 days were included. The severity of TR was graded as trace, mild, moderate and severe. Pearson correlation analysis was performed to evaluate the correlation between systolic PAP by echocardiography (sPAPECHO) and mean PAP by RHC (mPAPRHC) in different TR degree groups. The impact factors on risk stratification of precapillary PH were analyzed by logistic regression analysis.ResultsThe proportion of None, Trace, Mild, Moderate and Severe TR group was 2.4%, 23.7%, 39.1%, 28.5% and 6.3% respectively. Right atrium (RA) area increased gradually with TR aggravation (p < 0.001). Moderate and Severe TR group had higher N-terminal pro-B-type natriuretic peptide (p < 0.001), right atrial pressure (RAP) (p = 0.018), right ventricular basal diameter (RVD)/left ventricular basal diameter (LVD) ratio (p < 0.001), larger right ventricle (RV) (p < 0.001) and lower tricuspid annular plane systolic excursion (p = 0.006) compared with Trace and Mild group. TR-sPAPECHO in Moderate TR group had the greatest correlation coefficient with mPAPRHC (0.742, p < 0.001) followed by Mild (0.635, p < 0.001) and severe group (0.592, p = 0.033), while there was no correlation in Trace TR group (0.308, p = 0.076). Multivariate logistic regression showed three significant independent echocardiography predictors of high-risk precapillary PH: RVD/LVD ratio (OR = 5.734; 95%CI1.502–21.889, p = 0.011), RA area (OR 1.054; 95% CI 1.004–1.107, p = 0.035) and systolic annular tissue velocity of the lateral tricuspid annulus (S’) (OR 0.735, 95% CI 0.569–0.949, p = 0.018).ConclusionsPrecapillary PH was not necessarily accompanied by significant TR. None or Trace TRaccounted for 26% in our population and TR-sPAPECHO was not applicable to estimate PAP in these patients. RVD/LVD ratio, RA area and S’ can independently predict the high-risk patients with precapillary PH. TR may play an indirect role in risk stratification by affecting these indicators.

The role of calcium channel blockers for the treatment of pulmonary arterial hypertension: How much do we actually know and how could they be positioned today?

Background: Since survival of patients with pulmonary hypertension (PH) is closely related to right ventricular (RV) function, assessment of RV function is important for patients with PH. Right atrial (RA) area and/or RA pressure have also been reported to serve as prognostic predictors for adverse outcomes for in PH patient. Accordingly, we tested the hypothesis that the addition of RA remodeling to RV function enhances the capability of the latter to predict long-term outcome for PH patients. Methods: We studied 82 PH patients, all of whom underwent echocardiography and right heart catheterization. RV function was calculated by averaging the three regional peak speckle-tracking longitudinal strains from RV free wall (RV-free). RA remodeling was assessed as the RA area traced planimetrically at end-systole. Pre-defined cutoffs for RV dysfunction and RA remodeling were RV-free≤19.4% and RA area of &gt;18cm2, respectively. Long-term unfavorable outcome events were tracked for 2.0 years. Results: RA area correlated with mean RA pressure (r=0.62, p&lt;0.001), as well as with tricuspid E/E’ (r=0.38, p=0.001). However, RA area with RV restrictive filling was significantly larger than with others (all p&lt;0.05). Kaplan-Meier analysis revealed that patients with RV-free ≤19.4% had worse long-term outcomes than those with RV-free &gt;19.4% (log-rank p=0.01), as did patients with RA area&gt;18cm2 compared with those with RA area ≤18cm2 (log-rank p&lt;0.05). For sequential Cox models, a model based on hemodynamic parameters of RV performance (χ2 =3.11) was improved by addition of brain natriuretic peptide, World Health Organization functional class (χ2 =9.24; p&lt;0.05), and RV-free (χ2 =17.11; p=0.005), and further improved by addition of RA area (χ2 =21.36, p&lt;0.05). Conclusions: The combined assessment of RV function and RA remodeling results in more accurate prediction of long-term outcome, and may well have clinical implications for better management of PH patients.

BackgroundTo explore the association between the ratio of tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP), and long- and short-term outcomes in mechanically ventilated septic shock patients.MethodsSeptic shock patients admitted to the intensive care unit (ICU) were screened for enrollment. Echocardiographic parameters including TAPSE and tricuspid regurgitation velocity, haemodynamic and respiratory parameters, and prognostic data were obtained.ResultsOne hundred eighteen subjects were enrolled in this study, among whom 75 survived and 43 died at the one-year follow-up. ROC curve analysis revealed that the TAPSE/PASP ratio was able to assess one-year all-cause mortality with an area under the curve of 0.817 (95% CI: 0.739–0.896, p < 0.001) and the optimal cutoff value was 0.50 mm/mmHg. Kaplan-Meier survival analysis showed that one-year all-cause mortality was significantly higher in patients with TAPSE/PASP ≤0.5 mm/mmHg than in patients with TAPSE/PASP > 0.5 mm/mmHg (log-rank 32.934, p < 0.001). According to the Cox regression survival analyses, the TAPSE/PASP ratio was independently associated with one-year all-cause mortality (HR 0.007, 95% CI:0.000–0.162, p = 0.002) and ICU mortality (HR 0.027, 95% CI:0.001–0.530, p = 0.017). According to the multivariable analysis, the TAPSE/PASP ratio was an independent variable associated with mechanical ventilation (MV) duration (standard coefficient − 0.240, p = 0.010).ConclusionThe TAPSE/PASP ratio demonstrated prognostic value for one-year all-cause mortality, ICU mortality and MV duration in mechanically ventilated septic shock patients.

Hypoxia causes pulmonary vasoconstriction. Regional hypoxic vasoconstriction improves the matching of perfusion to alveolar ventilation. Global hypoxic vasoconstriction increases right ventricular afterload. The hypoxic pulmonary pressor response is universal in mammals and in birds, but with considerable interspecies and interindividual variability. Chronic hypoxia induces pulmonary hypertension in proportion to initial vasoconstriction. Prolonged hypoxic exposure is also associated with an increase in red blood cell mass, which aggravates pulmonary hypertension by an increase in blood viscosity. Hypoxic pulmonary hypertension in humans is usually mild to moderate, but pulmonary vascular pressure-flow relationships are steep, which corresponds to a substantial afterload on the right ventricle during exercise. A partial recovery of 10-25% of the hypoxia-induced decrease in maximal oxygen uptake has been reported with intake-specific pulmonary vasodilating interventions. Hypoxia has been reported to decrease myocardial fibre contractility in vitro. However, the acutely hypoxic right ventricle remains able to preserve the coupling of its contractility to increased afterload in intact animals. Echocardiographic studies of the right ventricle in healthy hypoxic human subjects show altered diastolic function, but systolic function that is preserved or even increased acutely and slightly depressed chronically. These findings are more pronounced in patients with chronic mountain sickness. Their clinical significance remains incompletely understood. Almost no imaging studies of right ventricular function have been reported in a minority of subjects who develop severe pulmonary hypertension and clinical right ventricular failure in hypoxia. No imaging studies of right ventricular function during hypoxic exercise in normal subjects are yet available. Thus, while it is plausible that the right ventricle limits exercise capacity in hypoxia, this still needs to be firmly established.

P3551Right ventricular dysfunction in heart failure patients with reduced ejection fraction with and without chronic respiratory diseases: A treacherous combination for the ominous outcome?

Large Granular Lymphocyte Leukemia and Precapillary Pulmonary Hypertension

Background Risk stratification in Pulmonary Arterial Hypertension (PAH) is based on multiparametric approach including invasive measurement of invasive right atrial pressure (RAP) by right heart catheterization (RHC). Therefore, following 2015 ESC/ERS pulmonary hypertension (PH) guidelines, RHC are frequently repeated every 4 to 6 months until RAP &amp;lt;8 mmHg. Purpose To explore the interest of right atrial area (RAA) and inferior vena cava (IVC) diameter measured by transthoracic echocardiography, as a surrogate for right atrial preload to detect RAP &amp;lt;8 mm Hg and avoid repeated RHC in PAH patients. Methods From a prospective single PAH referral center, we have included all patients with a diagnosis of PAH (confirmed by PH team). During the follow up, transthoracic echocardiography and a RHC was performed on the same day. RAA (cm2) was measured in the apical four-chamber view, at end-systole, just prior to tricuspid valve opening, excluding the area under tricuspid valve annulus. In the subcostal view, at 1.0 to 2.0 cm from the junction with the right atrium, IVC diameter (mm) was reported. Both RAA and IVC were compared to RAP. Results 97 PAH patients were included (35 males, mean age 65 ± 16y, mean arterial pressure was 45 ± 16 mmHg, cardiac index 3.0 ± 1.0 l/min/m² and right atrial pressure was 7.6 ± 4.7 mm Hg). Both IVC diameter and RAA averaged 18.1 ± 6.3mm and 22.5 ± 8.2 mm by echocardiography, respectively. IVC diameter and RAA had a significant but weak correlation with right atrial pressure &amp;lt;8 mmHg measured by RHC (r = 0.42, p &amp;lt; 0.01 and r = 0.41, p &amp;lt; 0.01, respectively). Targeting a good specificity (Sp = 0.75), ROC curves analysis identified 10 mm for the IVC diameter and 20 cm² for RAA if IVC diameter was &amp;gt; 10 but &amp;lt; 20 mm to predict RAP &amp;lt;8 mmHg (area under the curve = 0.72). Thus, in our cohort, 40% could have been followed-up non-invasively by echocardiography with IVC diameter ≤10 mm or &amp;gt;10 but &amp;lt;20 mm with RAA ≤20 cm² with only 2% of misclassification. For the remaining 58% unclassified PAH patients out of these echocardiographic ranges, RHC would have been requested. Conclusion In a cohort of PAH patients, targeting a low risk clinical worsening or death (identified by RAP &amp;lt;8 mmHg in RHC), echocardiography, with the use of IVC diameter ≤10 mm or &amp;gt;10 but &amp;lt;20 mm with RAA ≤20 cm², right heart catheterisation may be avoided in 40% of cases with extremely low misclassification.