Estimating Mean Pulmonary Artery Pressure Research Articles

Relationship between Plasma D-Dimer Level and Pulmonary Hypertension as well as Right Ventricle Dysfunction in Patient Post Pneumonia COVID-19

Background: High rate of coagulopathy and pulmonary thromboembolism in coronavirus disease 2019 (COVID-19), which is represented by an increase in plasma D-Dimer levels is believed to be related to pulmonary hypertension (PH) and right ventricle (RV) dysfunction. Objective: To evaluate the relationship between plasma D-Dimer levels with PH and RV dysfunction assessed from transthoracic echocardiography (TTE) in patients post COVID-19 pneumonia. Methods: Observational research with a cross-sectional design. Estimated mean pulmonary arterial pressure (mPAP) was calculated from Mahan's formula obtained from pulmonary artery acceleration time (PAAT) and RV function was assessed from RV free wall strain (RV FWS), tricuspid annular plane systolic excursion (TAPSE), and fractional area change (FAC). D-Dimer levels during hospitalisation were obtained from medical records and actual D-Dimer was obtained at the time of echocardiography. Results: Total 40 patients post-COVID-19 pneumonia underwent TTE in a median of 11 days after negative PCR. There was a significant correlation between peak D-Dimer levels with mPAP (r=0.526, p<0.001), RV FWS (r=-0.506, p=0.001), TAPSE (r=-0.498, p=0.001), and FAC (r=0.447, p=0.004). Multivariate analysis found peak D-Dimer ≥4530 µg/L independently associated with PH with odds ratio (OR) 6.6, (95% CI 1.1-10; p=0.048), but not with RV dysfunction. Conclusion: Peak D-Dimer level correlates with echocardiographic parameters of RV function and mPAP in patients with COVID-19 infection. Peak D-Dimer ≥4530 µg/L might increase risk of PH, but not RV dysfunction in patient post pneumonia COVID-19.

The accuracy and influencing factors of Doppler echocardiography in estimating pulmonary artery systolic pressure: comparison with right heart catheterization: a retrospective cross-sectional study

BackgroundNoninvasive assessment of pulmonary artery systolic pressure by Doppler echocardiography (sPAPECHO) has been widely adopted to screen for pulmonary hypertension (PH), but there is still a high proportion of overestimation or underestimation of sPAPECHO. We therefore aimed to explore the accuracy and influencing factors of sPAPECHO with right heart catheterization (RHC) as a reference.MethodsA total of 218 highly suspected PH patients who underwent RHC and echocardiography within 7 days were included. The correlation and consistency between tricuspid regurgitation (TR)-related methods and RHC results were tested by Pearson and Bland–Altman methods. TR-related methods included peak velocity of TR (TR Vmax), TR pressure gradient (TR-PG), TR mean pressure gradient (TR-mPG), estimated mean pulmonary artery pressure (mPAPECHO), and sPAPECHO. With mPAP ≥ 25 mm Hg measured by RHC as the standard diagnostic criterion of PH, the ROC curve was used to compare the diagnostic efficacy of sPAPECHO with other TR-derived parameters. The ratio (sPAPECHO–sPAPRHC)/sPAPRHC was calculated and divided into three groups as follows: patients with an estimation error between − 10% and + 10% were defined as the accurate group; patients with an estimated difference greater than + 10% were classified as the overestimated group; and patients with an estimation error greater than − 10% were classified as the underestimated group. The influencing factors of sPAPECHO were analyzed by ordinal regression analysis.ResultssPAPECHO had the highest correlation coefficient (r = 0.781, P < 0.001), best diagnostic efficiency (AUC = 0.98), and lowest bias (mean bias = 0.07 mm Hg; 95% limits of agreement, − 32.08 to + 32.22 mm Hg) compared with other TR-related methods. Ordinal regression analysis showed that TR signal quality, sPAPRHC level, and pulmonary artery wedge pressure (PAWP) affected the accuracy of sPAPECHO (P < 0.05). Relative to the good signal quality, the OR values of medium and poor signal quality were 0.26 (95% CI: 0.14, 0.48) and 0.23 (95% CI: 0.07, 0.73), respectively. Compared with high sPAPRHC level, the OR values of low and medium sPAPRHC levels were 21.56 (95% CI: 9.57, 48.55) and 5.13 (95% CI: 2.55, 10.32), respectively. The OR value of PAWP was 0.94 (95% CI: 0.89, 0.99). TR severity and right ventricular systolic function had no significant effect on the accuracy of sPAPECHO.ConclusionsIn this study, we found that all TR-related methods, including sPAPECHO, had comparable and good efficiency in PH screening. To make the assessment of sPAPECHO more accurate, attention should be paid to TR signal quality, sPAPRHC level, and PAWP.

70 Estimation of pulmonary arterial pressures by tricuspid regurgitation: a comparison with invasive data

Abstract Aims The evaluation of the haemodynamic of pulmonary circulation is essential in various pathological conditions. Right heart catheterization (RHC) is the gold standard for the measurement of pressures and resistances in this context. However, since indications for RHC are limited, a more accessible estimation method would be helpful. This study aimed to explore the reliability of an echocardiographic method based on tricuspid regurgitation (TR) to estimate mean, systolic and diastolic pulmonary arterial (PA) pressures in a cohort of patients with advanced heart failure considered for heart transplantation. Methods and results All consecutive patients with advanced heart failure considered for heart transplantation from 2016 to 2021 that had already performed right heart catheterization (RHC) as part of the workup and with an available echocardiographic exam were included (n = 91). Mean PA pressure was obtained adding mean right ventricular-right atrial (RV-RA) gradient to mean RA pressure. Systolic PA pressure was obtained adding maximum RV-RA gradient to mean RA pressure. Diastolic PA pressure was derived from mean and systolic PA pressures. Results were compared with PA pressures by RHC. Median time between RHC and echocardiography was 0 months [interquartile range (IQR): 0–3.5]. Median age was 58 years (IQR: 52–61.5), most of the patients were men (83.5%). The absolute mean difference between mean, systolic and diastolic PA pressures by RHC and echocardiography was 0.46 ±9.78 mmHg, 2.18 ±12.92 mmHg and −2.30 ±8.61 mmHg, respectively. PA pressures by echocardiography significantly correlated with PA pressures by RHC (mean PA pressure: r = 0.460, P &amp;lt; 0.001; systolic PA pressure: r = 0.520, P &amp;lt; 0.001; diastolic PA pressure: r = 0.372, P &amp;lt; 0.001). AUC for prediction of pulmonary hypertension, defined as mean PA &amp;gt; 25 mmHg, by mean PA pressure by echocardiography was 0.828 and a cut-off of 25.5 mmHg demonstrated a high specificity (sensibility 66.7%, specificity 93.2%). Conclusions Estimation of pulmonary arterial pressures through an echocardiographic method mainly based on tricuspid regurgitation gradients is reliable and an estimated mean pulmonary arterial pressure &amp;gt;25.5 mmHg has a high specificity for predicting pulmonary hypertension.

The soluble guanylate cyclase stimulator, 1-nitro-2-phenylethane, reverses monocrotaline-induced pulmonary arterial hypertension in rats

AimsWe examined the effects of treatment with 1-nitro-2-phenylethane (NP), a novel soluble guanylate cyclase stimulator, on monocrotaline (MCT)-induced PAH in rats. Main methodsAt day 0, male adult rats were injected with a single subcutaneous (s.c.) dose of monocrotaline (60 mg/kg). Control (CNT) rats received an equal volume of monocrotaline's vehicle only (s.c.). Four weeks later, MCT-treated rats were treated orally for 14 days with NP (50 mg/kg/day) (MCT-NP group) or its vehicle (Tween 2%) (MCT-V group). At the end of the treatment period and before invasive hemodynamic study, rats of all experimental groups were examined by echocardiography. Key findingsWith respect to CNT rats, MCT-V rats showed significant; (1) increases in pulmonary artery (PA) diameter, RV free wall thickness and end-diastolic RV area, and increase of Fulton index; (2) decreases in maximum pulmonary flow velocity, PA acceleration time (PAAT), PAAT/time of ejection ratio, and velocity-time integral; (3) increases in estimated mean pulmonary arterial pressure; (4) reduction of maximal relaxation to acetylcholine in aortic rings, and (5) increases in wall thickness of pulmonary arterioles. All these measured parameters were significantly reduced or even abolished by oral treatment with NP. SignificanceNP reversed endothelial dysfunction and pulmonary vascular remodeling, which in turn reduced ventricular hypertrophy. NP reduced pulmonary artery stiffness, normalized the pulmonary artery diameter and alleviated RV enlargement. Thus, NP may represent a new therapeutic or a complementary approach to treatment of PAH.

Noninvasive Assessment of Right Ventricle Function and Pulmonary Artery Pressure Using Transthoracic Echocardiography in Women With Pre-Eclampsia: An Exploratory Study.

Background and objectivePre-eclampsia (PEC) is associated with the release of anti-angiogenic factors that are incriminated in raising systemic and pulmonary vascular resistance (PVR). Compared to the left heart and systemic circulation, much less attention has been paid to the right heart and pulmonary circulation in patients with PEC. We used transthoracic echocardiography (TTE) to estimate pulmonary artery (PA) pressure and right ventricular (RV) function in women with PEC.Materials and methodsWe conducted a case-control study at a tertiary care academic center. Ten early PEC (<34-week gestation) and nine late PEC (≥34-week gestation) patients with 11 early and 10 late gestational age-matched controls were enrolled. Two-dimensional TTE was performed on all patients. The estimated mean PA pressure (eMPAP) was calculated based on PA acceleration time (PAAT). PVR was estimated from eMPAP and RV cardiac output (RV CO). RV myocardial performance index (RV MPI), tricuspid annular plane systolic excursion (TAPSE), tissue tricuspid annular displacement (TTAD), and lateral tricuspid annular tissue peak systolic velocity (S’) were measured.ResultsCompared to early controls, in early PEC, the eMPAP and estimated PVR (ePVR) were elevated, PAAT was reduced, RV MPI was increased, TTAD was reduced, and TAPSE and TV S’ were unchanged. Compared to late controls, in late PEC, the eMPAP and ePVR were elevated, PAAT was reduced, and RV MPI was increased, while TAPSE, TTAD, and TV S’ were unchanged.ConclusionsIn a sample of women with PEC, early PEC was found to be associated with increased eMPAP and ePVR and subclinical decrement of RV function as assessed by TTE. TTE may be a useful noninvasive screening tool for early detection of pulmonary hypertension and RV dysfunction in PEC. An adequately powered longitudinal study is needed to determine the implications of these findings on long-term outcomes.

Cardiac reserve by 6-minute walk stress echocardiography in systemic sclerosis

ObjectivesThere is a high prevalence of left ventricular diastolic dysfunction (LVDD) in systemic sclerosis (SSc) which is associated with high mortality. Thus, early detection of LVDD could be important in...

Abstract 13566: Clinical Utility of Noninvasive Assessment of Flow-pressure Relationship in Scleroderma

Introduction: Cardiac involvement in Systemic sclerosis (SSc), especially left ventricular diastolic dysfunction (DD), is high prevalence and associated with high mortality. Thus, the early detection of left ventricular DD might be important to manage SSc. Recent study has shown that exercise stress test may evaluate an early stage of heart failure in patients with normal resting echocardiogram. Hypothesis: We hypothesized that SSc patients with normal resting hemodynamics may present early phase of left ventricular DD by exercise echocardiogram, leading to the model of predicting long-term outcomes. Methods: Between January 2014 and December 2018, we prospectively enrolled 140 SSc patients who underwent 6-minute walk (6MW) stress echocardiographic studies with normal range of estimated mean pulmonary arterial pressure (mPAP) (&lt;25mmHg) and mean pulmonary artery wedge pressure (mPAWP) (&lt;15mmHg) at rest. We used ΔmPAP/Δcardiac output (CO) to assess pulmonary vascular reserve and ΔmPAWP/ΔCO to assess left ventricular (LV) reserve between resting and post-6MW point. Results: During a median period of 3.6 years, 25 patients (18%) reached the composite outcome. Both ΔmPAP/ΔCO and ΔmPAWP/ΔCO in patients with events were significantly higher than in ones without events (8.9±3.8mmHg/l/min vs. 3.0±1.7mmHg/l/min; p=0.002, and 2.2±0.9mmHg/l/min vs. 0.9±0.5mmHg/l/min; p&lt;0.001, respectively). In addition, ΔmPAWP/ΔCO is strongly associated with events (p=0.04) in patients with normal ΔmPAP/ΔCO (≤median value), although ΔmPAWP/ΔCO had weak impact in patients with abnormal ΔmPAP/ΔCO (&gt;median value) (p=0.23). Conclusions: Exercise echocardiography revealed impaired LV functional reserve in SSc patients with normal resting hemodynamics. Furthermore, in the group of normal pulmonary vascular function, the patients with impaired LV functional reserve had significantly shorter event-free survival than the ones with non-impaired LV function. Thus, the evaluation of early left ventricular DD with 6MW may detect high-risk group in SSc patients.

P1310STUDY OF RISK FACTORS AND PREVALENCE OF PULMONARY HYPERTENSION IN CKD 5D PATIENTS ON HEMODIALYSIS

Abstract Background and Aims Pulmonary hypertension (PH) in chronic kidney disease stage 5D (CKD5D) patients on haemodialysis (HD) is associated with increased morbidity and mortality. We studied the risk factors and prevalence of PH in patients on HD at our centre. We also studied its association with oxidative stress and markers of inflammation. Method After ethics committee clearance, we conducted a cross-sectional study on CKD5D patients at our centre from June 2016 to May 2017. Patients on maintenance HD for at least 3 months were included. Demographic, clinical, biochemical and trans-thoracic echocardiography details were collected. PH was defined as estimated mean pulmonary artery pressure (mPAP) greater than 25 mm Hg at rest. PH was further categorized into mild (mPAP b/w 25-40mmHg), moderate (mPAP b/w 40-60mmHg) and severe PH (mPAP &amp;gt; 60mmHg). Serum thiol and C Reactive protein (CRP) were studied as markers of oxidative stress and inflammation respectively. Data was analysed using SPSS version 16. Results Out of 52 patients, 28 (54%) had PH. Twenty four out of these patients had mild PH (Figure 1). None had severe PH. The baseline characteristics of patients with and without PH are shown in Figure 2. No clinical or biochemical factors (p&amp;gt;0.05) were found as significant risk factors in our study. CRP (p-0.76) (inflammatory marker) and Thiol levels (p-0.36) (oxidative stress marker) did not had any relationship with occurrence of PH. (Table 1). Conclusion CKD 5D patients on HD have high prevalence of PH. There were no identifiable risk factors. The prevalence of PH was not influenced by dialysis vintage, ultrafiltration, paratharmone levels, presence of co-morbidities, oxidative stress or inflammation.

P942 Outcome prediction by exercise stress echocardiography and cardiopulmonary exercise testing assessment in patients with heart failure

Abstract Background Cardiopulmonary exercise testing (CPX) is essential to the assessment of functional impairment and prognosis in patients with heart failure (HF). Peak oxygen consumption (peak VO2) continues to be considered the gold standard for assessing prognosis in HF. The minute ventilation-carbon dioxide production (VE-VCO2) slope has recently demonstrated prognostic significance in patients with HF. Ergometer stress echocardiography (Erg-Echo) is useful to evaluate the exercise-induced pulmonary hypertension and the potential cardiac dysfunction that are difficult to evaluate in the resting state. Objective The aim of this study is to evaluate the relationship between CPX and Erg-echo indices, and the usefulness of Erg-echo to determine the severity of cardiac dysfunction and the prognosis in patients with HF. Methods We studied 58 patients with HF (age 65.2 ± 11.9 years) and performed CPX and Erg-Echo. The peak VO2 and the VE-VCO2 slope were measured by CPX. Cardiac output (CO) and estimated mean pulmonary artery pressure (mPAP) were measured by Erg-Echo at rest and peak exercise load, and the change ratio (ΔmPAP / ΔCO) were calculated. We evaluated the clinical outcome during a1 year period. Results The ΔmPAP / ΔCO was significantly correlated with the peak VO2 (R = -0.6767, P &amp;lt;0.0001) and the VE-VCO2 slope (R = 0.6809, P &amp;lt;0.0001). Cardiovascular events (1 patient of cardiovascular death, 8 patients of re-hospitalization due to HF, 4 patients of myocardial ischemia, 2 patients of Cardiac Resynchronization Therapy (CRT) devices implantation, 1 patient of ventricular tachycardia) developed in 16 of the 58 patients (27.5%: Group CE) during the 1 year. The peak VO2 was significantly lower (12.1 ± 2.5 vs. 16.1 ± 3.1ml/min/kg, P &amp;lt;0.0001) and the VE-VCO2 slope was significantly higher (41.1 ±. 12.3 vs. 31.8 ± 6.1ml/ml, P &amp;lt;0.0001) in Group CE compared to the other 42 patients (Group N). The ΔmPAP was significantly higher (19.1 ± 4.4 vs. 14.9 ± 6.4, P = 0.0408) and the ΔCO was significantly lower (2.4 ± 1.2 vs. 4.1 ± 2.0, P = 0.0078), and the ΔmPAP / ΔCO was significantly higher (9.7 ± 4.6 vs. 4.4 ± 2.4, P &amp;lt;0.0001) in Group CE compared to Group N. Conclusions The ΔmPAP/ ΔCO by Erg-Echo is useful to evaluate the severity of cardiac dysfunction and the prognosis of HF patients.

Echocardiographic evaluation of the patients with borderline pulmonary hypertension

Objective To analyze and compare the changes of cardiac structure and function in patients with borderline pulmonary hypertension. Methods Echocardiographic data of 617 outpatients from February to October 2018 in Peking University People′s Hospital were retrospectively analyzed. According to the estimated mean pulmonary artery pressure (mPAP), the patients were divided into normal group (mPAP<19 mmHg), borderline group (19 mmHg≤mPAP<25 mmHg) and elevated group (mPAP≥25 mmHg). Results ①Compared with normal group，the patients were older in borderline group and elevated group[(39.2±10.1)years old vs (46.5±13.5)years old vs (51.8±14.2)years old，all P<0.001] and the proportions of male were relatively lower (69.9% vs 58.9% vs 54.4%，all P<0.01). The incidences of smoking，drinking and cardiovascular complications increased significantly. ②Compared with normal group，the left atrium[(30.2±8.2)ml/m2 vs (34.5±9.7)ml/m2，P<0.001]，left ventricle[(57.4±11.6)ml/m2 vs (60.6±12.5)ml/m2，P<0.01]and right atrium[(19.5±5.9)ml/m2 vs (22.6±7.0)ml/m2，P<0.001] were enlarged in borderline group.Left ventricular global long-axis strain (GLSLV) increased[(-20.1±2.5)% vs (-21.1±3.1)%，P<0.001]，but the long-axis strain in the middle segment of right ventricular free wall (GLSRVFWmid) decreased[(-31.4±6.6)%对(-27.2±8.8)%，P<0.001] in borderline group.Meanwhile，left ventricular diastolic function was impaired. ③Age，sex，right atrial volume，right ventricular area，RV-S′，GLSLV，GLSRVFWmid and mitral valve E/e′ were independent risk factors for mPAP elevation. Conclusions Early changes of cardiac structure and function exist in the patients with borderline pulmonary hypertension. Echocardiography is critical for the early diagnosis and follow-up monitoring of pulmonary hypertension. Key words: Echocardiography; Pulmonary hypertension; Mean pulmonary artery pressure

Effectiveness and short-term survival associated with adding sildenafil to conventional therapy in the management of children with pulmonary hypertension

Pulmonary hypertension (PH) in children is a life-threatening disease of complex underlying causes and poor prognosis. Oral therapy with sildenafil added to conventional treatments has improved patient outcomes in terms of exercise capacity and hemodynamics. This study aimed to address the efficacy of using oral sildenafil in children with PH and assess the short-term survival after therapy initiation.This is an observational study of 167 children aged 3 months to 17 years with pulmonary hypertension who were admitted to the Cardiology Department of Assiut University Children Hospital. The children were followed for 12 weeks between November 2014 and May 2016. The therapeutic effects of adding oral sildenafil plus conventional therapy were compared with those on conventional therapy alone. The main outcome measure was the change in the estimated mean pulmonary arterial pressure (mPAP) measured by echocardiography from the baseline to week 12 after initiation of therapy. The secondary endpoints were 12-week overall survival and improvement in oxygen saturation.All children were treatment-naïve with median age of 1 year. After 12 weeks of treatment, the mPAP was significantly reduced in the sildenafil-treated children compared to the conventional group (−17.4 ± 16.4 mmHg versus −7.9 ± 15.1 mmHg; p < .001). Multivariate regression analysis demonstrated a significant influence of adding sildenafil (p < .01) on the mPAP at 12-week follow up. Sildenafil was not associated with an increased risk of death, [Hazard ratio (HR): 1.16; 95% confidence intervals (CI), 0.68–2.00, p = .39]. Reduced ejection fraction heart failure and transposition of great arteries were significant factors associated with worse survival [HR: 2.46; 95% CI: 1.08–5.58, p = .03] and HR: 3.69; 95% CI: 1.04–13.11, p = .04, respectively].Addition of sildenafil to conventional therapy led to significant improvements in mPAP and oxygen saturation. However, it did not lower the mortality risk in children with pulmonary hypertension.

P6466Novel index with combined echocardiographic parameter and CT parameter (pPAT) is useful for screening pulmonary hypertension in Systemic Sclerosis Patients

Abstract Background Systemic sclerosis (SSc) patients with pulmonary arterial hypertension (PAH) had poor survival rate. Usual index of estimating PH is tricuspid regurgitate jet pressure gradient (TRPG). Accurate assessment of PAH is important for the management of SSc patients. However, estimated mean pulmonary arterial pressure (mPAP) using TRPG by echocardiography does not always reflect actual mPAP by right heart catheterization (RHC) in SSc patients. On the other hand, recent reports have shown that rPA, a ratio of diameter of pulmonary artery to ascending aorta (PA/Ao) calculated by computed tomography (CT), was associated with mPAP. However, both index are not sufficient for evaluation of PH. We hypothesized that the product of TRPG and rPA (pPAT) could estimate mPAP of SSc patients more accurately than TRPG or rPA. Purpose We investigated the usefulness of the product of TRPG and rPA for detecting actual mPAP in SSc patients. Methods Thirty-six SSc patients who suspected PH were enrolled retrospectively. We defined PH as resting mPAP from RHC of &gt;25 mmHg. We measured both a widest pulmonary artery diameter and an adjacent ascending aorta diameter at the same level of the bifurcation of the main pulmonary artery using CT images. Results The average age was 67 years old and average mPAP by RHC was 24.7 mmHg. Mean TRPG and mean rPA were 35.1 mmHg and 1.06, respectively. Furthermore, mean pPAT was 37.9. We found pPAT had a stronger correlation with actual mPAP (r=0.848, p&lt;0.001) than TRPG (r=0.754, p&lt;0.001) or rPA (r=0.584, p&lt;0.001). On ROC analysis, pPAT predicted PH with high accuracy for a cut-off of 33.1. In order to evaluate the usefulness of pPAT, we compared false-negative patients between two cutoff values of TRPG 34 mmHg described in ESC guideline and pPAT 33.1. Among the patients with TRPG &lt;34mmHg, 4 patients (18%) had PH. In contrast, when screening PH using pPAT, the diagnosis of PH was missed in only one patient. Figure 1 Conclusion The product of TRPG and PA/Ao (pPAT) could be a novel and useful noninvasive index for identifying PH in SSc patients.

Oesophageal or transgastric views for estimating mean pulmonary artery pressure with transoesophageal echocardiography: A prospective observational study.

Recent data suggest that in cardiac surgical patients, the pulmonary artery acceleration time (PAT) is useful for estimating mean pulmonary artery pressure (MPAP) noninvasively with transoesophageal echocardiography (TOE). The pulmonary valve can be visualised from multiple echocardiographic windows, but it is unclear which, if any, view correlates best with MPAP. To compare the PAT measured with TOE from oesophageal and transgastric views with MPAP obtained invasively with a pulmonary artery catheter. A prospective observational study. St. Vincent's Hospital, Melbourne, a university tertiary referral centre in Australia. Sixty-three patients having cardiac surgery were included in our study. All patients had insertion of both a TOE probe and pulmonary artery catheter; this is the routine standard of care in our centre. Nil. During a period of haemodynamic stability, the PAT was measured first from an oesophageal view and then immediately after from a transgastric view. The results were then compared with the invasively measured MPAP. Simultaneous measurements of MPAP and PAT were taken in 63 patients. In two patients, these measurements were not possible in the transgastric position due to an inability to visualise the right ventricular outflow tract and pulmonary valve. A Bland-Altman analysis of the PAT measured from the upper oesophageal and transgastric views showed a mean difference of 1 ms and limits of agreement of -18 to 16 ms. The area under the receiver operating curves for predicting pulmonary hypertension with PAT were upper oesophageal view 0.99 [95% confidence interval (CI), 0.98 to 1.00] and transgastric view 0.99 (95% CI, 0.97 to 1.00). The agreement between the results from these two views in the diagnosis of pulmonary hypertension (defined as PAT < 107 ms) was 93.4% with a kappa of 0.85 (95% CI, 0.59 to 1.00). There is an inverse curvilinear relationship between PAT and MPAP. Using a cut-off of 107 ms, the upper oesophageal view predicted pulmonary hypertension (defined as MPAP > 25 mmHg) with a sensitivity of 94.7% and specificity of 97.6%. The transgastric view predicted pulmonary hypertension with a sensitivity of 89.4% and specificity of 95.2%. Oesophageal and transgastric measurements of PAT have close agreement and a similar high ability to discriminate between people with and without pulmonary hypertension. The transgastric measurement was unobtainable in a small percentage of patients and required more probe manipulation. We would recommend PAT measurement in the upper oesophageal view.

Echocardiographic Estimation of Mean Pulmonary Artery Pressure: A Comparison of Different Approaches to Assign the Likelihood of Pulmonary Hypertension

Current guidelines advise using echocardiography for noninvasive estimation of the likelihood that a patient has pulmonary hypertension (PH). To estimate the echocardiographic probability of PH, the maximal tricuspid regurgitation velocity (TR Vmax) is recommended as the main parameter to use over more complex algorithms that provide an estimation of pulmonary artery pressure. This preference is based on concerns about inaccuracies and amplification of measurement errors that can occur from using derived variables. However, this has not been examined systematically. A retrospective database analysis was performed of invasively determined measurements of right heart pressure in 90 patients, corresponding echocardiographic estimations of pulmonary artery pressure, and additional parameters obtained within 24hours. Several algorithms were compared for their correlations and accuracy parameters. Although a Bland-Altman analysis demonstrated that all examined algorithms exhibited inaccuracies that could be clinically relevant in individuals, algorithms estimating mean pulmonary artery pressure (PAPm) on the basis of tricuspid regurgitation generally exhibited stronger correlations with invasively determined PAPm and more accurate identification of PH than did TR Vmax. Echocardiographic estimation of right atrial pressure >15mm Hg exhibited the highest odds ratio for invasively confirmed PH, suggesting that this parameter is of additional diagnostic value. Indeed, algorithms that also considered right atrial pressure performed best, whereas empirical algorithms, TR Vmax, and methods relying on pulmonary acceleration time exhibited weaker performance. Although all methods are associated with inaccuracies, echocardiographically determined PAPm was superior to the current guideline recommendation of using TR Vmax with regard to its correlation with invasively determined PAPm and the presence of PH. PAPm may be considered as an alternative to TR Vmax for evaluating the echocardiographic probability of PH.

Pulmonary hypertension in Nigerian adults with sickle cell anemia.

BackgroundSickle cell anemia (SCA) is the commonest hemoglobinopathy and is associated with high morbidity and mortality. Pulmonary hypertension (PH) is reported to play a significant role in this regard. There is very limited literature on PH in SCA in Nigeria.ObjectivesThe objectives of this study were to determine the prevalence of Doppler-derived PH in SCA, assess its influence on exercise capacity, and determine the correlates and predictors of measures of estimated pulmonary pressure.MethodsA total of 92 SCA subjects had echocardiography and 6-minute self-paced walking exercise. PH was diagnosed by Doppler echocardiography on finding a tricuspid regurgitant velocity (TRV) of ≥2.5 m/s. The pulmonary flow profile was also assessed to estimate mean pulmonary arterial pressure (MPAP).ResultsDoppler-derived PH was detected in 23.9% of adults with SCA. The 6-minute walking distance (6MWD) was significantly lower in SCA adults with PH than in those without PH (380.33 ± 63.17 m vs 474.28 ± 76.74 m; p = 0.014). TRV and estimated MPAP had a significant inverse correlation with the 6MWD (r = −0.442; p < 0.001 and r = −0.571; p < 0.001, respectively).ConclusionPH as derived by Doppler is common in Nigerian adults with SCA and has a significantly negative influence on exercise capacity. Screening for PH should be encouraged to optimize management and thus improve their quality of life and life expectancy.

Pulmonary Hypertension in Heart Failure Patients Presenting at OAUTHC, Ile-Ife, Nigeria.

BACKGROUNDPulmonary hypertension (PH) is common in heart failure patients. Literature on PH in heart failure is sparse in Nigeria. This study was carried out to determine the prevalence of PH in heart failure patients and ascertain the relationship between left ventricular systolic and diastolic function and the degree of PH.METHODSA total of 125 heart failure patients had echocardiography done. PH was diagnosed using tricuspid regurgitation jet and pulmonary ejection jet profile.RESULTSPH was present in 70.4% of heart failure patients. Estimated mean pulmonary arterial pressure increased with increasing severity of systolic and diastolic dysfunction and had significantly negative correlation with ejection fraction, fractional shortening, and early mitral annular tissue diastolic velocity (E′), but positive correlation with left ventricular end-systolic volume, right ventricular dimension, transmitral E to A ratio, and E/E′ ratio.CONCLUSIONPH is very common in heart failure and has significant relationship with left ventricular function.

Accuracy and Precision of Three Echocardiographic Methods for Estimating Mean Pulmonary Artery Pressure

Pulmonary hypertension is defined as resting mean pulmonary artery pressure (MPAP) ≥ 25 mm Hg. MPAP pressure estimation by right-sided heart catheterization (RHC) is considered the gold standard; however, its invasiveness limits repeated and frequent use. The purpose of this study was to compare the accuracy and precision of three echocardiographic methods for estimating MPAP. We prospectively studied 117 patients with simultaneous RHC and echocardiography. MPAP was calculated by three echocardiographic methods: (1) mean gradient method (adding the right ventricular-right atrial mean systolic gradient to the right atrial pressure), (2) Chemla equation (0.61 × systolic pulmonary artery pressure + 2 mm Hg), and (3) Syyed equation (0.65 × systolic pulmonary artery pressure + 0.55 mm Hg). MPAP calculated by these three methods was compared with that obtained invasively by RHC. The mean ± SD of the differences between invasive MPAP and the three echocardiographic methods were -1.6 ± 7.7 mm Hg for the mean gradient method, -3.7 ± 7.4 mm Hg for the Chemla formula, and -3.2 ± 7.6 mm Hg for the Syyed formula. Median absolute differences were 5.5 mm Hg (mean gradient), 5.7 mm Hg (Chemla; P = .45 vs mean gradient), and 6.0 mm Hg (Syyed; P = .23 vs mean gradient). Accuracy (calculated MPAP within 10 mm Hg of RHC-measured MPAP) was 81% (mean gradient), 77% (Chemla), and 76% (Syyed). Echocardiographic estimation of MPAP by the mean gradient method had similar accuracy and precision compared with the Chemla and Syyed methods. The acceptable accuracy of these methods suggests that they are equally suitable for clinical use.

Evaluation of Various Empirical Formulas for Estimating Mean Pulmonary Artery Pressure by Using Systolic Pulmonary Artery Pressure in Adults

Mean pulmonary artery pressure (mPAP) may be estimated by using the classic rule of thumb, namely 2/3 x dPAP + 1/3 x sPAP, where dPAP = diastolic PAP and sPAP = systolic PAP. Studies have suggested that mPAP may be also estimated from sPAP alone. Pulmonary hypertension (PH) is usually defined by an invasive mPAP > 25 mm Hg, but the corresponding sPAP threshold remains to be established. Our study evaluated the accuracy and precision of various empirical formulas relating mPAP and sPAP in resting adults. Five previously published studies with individual high-fidelity PAPs were analyzed (n = 166 individuals, 57% of whom had PH). The time-averaged mPAP was compared with formula one (F1), the classic rule of thumb; formula two (F2) = dPAP + 0.41 x pulse PAP; formula three (F3) = square root of (sPAP x dPAP); formula four (F4) = 0.61 x sPAP + 2 mm Hg; and formula five (F5) = 2/3 x sPAP (parabolic shape). The mPAP ranged from 9 to 82 mm Hg and was related to sPAP (r(2) = 0.98). The most accurate formula was F4 (mean bias, 0.0 mm Hg). The most precise formula was F1 (SD of the bias, 1.6 mm Hg). Other formulas gave estimates of essentially similar accuracy, while F2 and F3 were more precise than F4 and F5. sPAP > 36 mm Hg could be used to diagnose PH (mPAP > 25 mm Hg) with a 97.9% sensitivity and 98.6% specificity. In resting adults, the most accurate estimate of mPAP was obtained by using sPAP only, while the combination of sPAP and dPAP gave the most precise mPAP estimate. The sPAP threshold of 36 mm Hg could be used to diagnose PH with high sensitivity and high specificity.

Predictors of isolated pulmonary hypertension in patients with systemic sclerosis and limited cutaneous involvement.

To determine whether there are factors, such as the diffusing capacity for carbon monoxide (DLCO) or pulmonary artery pressure (PAP) on echocardiogram, that can predict the development of pulmonary hypertension (PHT) in patients with limited scleroderma. Using the large Pittsburgh Scleroderma Databank, 106 patients who had the diagnosis of PHT after January 1, 1982, were matched with 106 controls by scleroderma subtype, age, sex, race, disease duration, and the mean time to the diagnosis of PHT after the initial Pittsburgh visit. Autoantibodies, vascular features, use of calcium channel blockers, extent of pulmonary function, and echocardiogram findings were determined at any time prior to the diagnosis of PHT (or prior to the matched time in controls). Patients with PHT had a mean DLCO of 52% of predicted at an average of 4.5 years prior to the diagnosis of PHT. This was markedly decreased compared with the values in controls, whose mean DLCO was 81% of predicted (P < 0.0001). The estimated mean PAP on echocardiogram was only slightly higher in the PHT patients compared with controls (34 mm Hg versus 29 mm Hg; P not significant). Nineteen PHT patients had 4 serial measurements of the DLCO during the 15 years prior to the diagnosis of PHT. The initial mean DLCO was 80% of predicted, which decreased in a linear manner to a mean of 35% of predicted at the time of diagnosis of PHT, whereas the value in controls remained at approximately 80% of predicted (P < 0.0001). PHT patients had more severe Raynaud's phenomenon and more severe digital tip ulcers, but they used calcium channel blockers significantly less frequently (37% versus 61% of controls; P < 0.01). The predominance of nucleolar autoantibodies and the absence of anti-Scl 70 antibody were associated with PHT. A decreasing DLCO is an excellent predictor of the subsequent development of isolated PHT in limited scleroderma. The DLCO may be significantly decreased for many years prior to the diagnosis of PHT. The presence of autoantibodies and the PAP may also be helpful predictors. The long-term use of calcium channel blockers may be protective, but newer agents that are more effective in treating PHT may also be helpful in altering the natural history of this serious complication in limited scleroderma.

Physiologic significance of nitric oxide and endothelin-1 in circulatory adaptation.

The purpose of the present paper was to evaluate the physiologic significance of nitric oxide (NO) and endothelin (ET)-1 in circulatory adaptation in the neonate. The serum levels of NO metabolites (NOx; the sum of nitrites and nitrates) and the plasma level of ET-1 were determined in 14 healthy full-term infants at 0-6 h, 24 h and 5 days after birth. We measured the heart rate, the mean systemic blood pressure and the mean pulmonary arterial pressure, estimated by pulsed Doppler echocardiography, at each time point. The serum concentration of NOx was lowest at birth and increased with age. The plasma concentration of ET-1 was highest at birth and decreased with age. The ratio of NOx to ET-1 was inversely related to the estimated mean pulmonary arterial pressure in the early neonatal period. The ratio of NOx to ET-1 was not correlated with the systemic blood pressure. Increased NO synthesis and decreased production of ET-1 during the early neonatal period may contribute to the decrease in pulmonary arterial pressure.