Estimation Of Right Atrial Pressure Research Articles

Observation of blood motion in the internal jugular vein by contact and contactless photoplethysmography during physiological testing: case studies.

Central venous pressure is an estimate of right atrial pressure and is often used to assess hemodynamic status. However, since it is measured invasively, non-invasive alternatives would be of great utility. The aim of this preliminary study was a) to investigate whether photoplethysmography (PPG) can be used to characterize venous system fluid motion and b) to find the model for venous blood volume modulations. For this purpose, we monitored the internal jugular veins using contact (cPPG) and video PPG during clinically validated physiological tests: abdominojugular test (AJT) and breath holding (BH). Video PPG and cPPG signals were captured simultaneously on the left and right sides of the neck, respectively. ECG was also captured using the same clinical monitor as cPPG. Two volunteers underwent AJT and BH with head up/down, each with: baseline (15s), experiment (15s), and recovery (15s). Video PPG was split into remote PPG (rPPG) and micromotion detection. All signal modalities were significantly affected by physiological testing. Moreover, cPPG and micromotion waveforms exhibited primary features of jugular vein waveforms and, therefore, have great potential for venous blood flow monitoring. Specifically, remote patient monitoring applications may be enabled by this methodology, facilitating physical collection without a specially trained care provider.

Seeing beneath the surface: Harnessing point-of-care ultrasound for internal jugular vein evaluation.

Point-of-care ultrasound (POCUS) of the internal jugular vein (IJV) offers a non-invasive means of estimating right atrial pressure (RAP), especially in cases where the inferior vena cava is inaccessible or unreliable due to conditions such as liver disease or abdominal surgery. While many clinicians are familiar with visually assessing jugular venous pressure through the internal jugular vein, this method lacks sensitivity. The utilization of POCUS significantly enhances the visualization of the vein, leading to a more accurate identification. It has been demonstrated that combining IJV POCUS with physical examination enhances the specificity of RAP estimation. This review aims to provide a comprehensive summary of the various sonographic techniques available for estimating RAP from the internal jugular vein, drawing upon existing data.

Correlation between echocardiographic estimation of right atrial pressure and invasive measurement of central venous pressure in postoperative pediatric patients with congenital heart disease: a prospective observational study

BackgroundRight atrial pressure plays a critical role as a hemodynamic parameter in diagnosing pulmonary hypertension and other cardiac diseases, as well as guiding the treatment and prognosis of various cardiac disorders. If there is no obstruction between the inferior or superior vena cava (SVC) as central veins and the right atrium, the pressures in these veins could be considered equal to the right atrial pressure. This study aimed to examine the correlation between echocardiographic methods for estimating right atrial pressure and invasive measurements of central venous pressure (CVPi) in infants and children with congenital heart disease during the 48 h after cardiac surgery and to establish regression equations for echocardiographic estimation of central venous pressure (CVPe).ResultsWe prospectively enrolled 43 infants and children, ranging in age from 6 months to 16 years, including 20 males and 23 females. We found a significant correlation between CVPi and the ratio of the maximal diameter of IVC to the maximal diameter of the descending aorta ratio (IVCmax/DAOmax) (r = 0.529, P < 0.001), SVCS/D velocity ratio (SVCS/D) (r = 0.462, P = 0.006), right atrial vertical diameter (RAVD) (r = 0.409, P = 0.01), area (r = 0.384, P = 0.014), and tricuspid valve A wave acceleration rate (TVAAR) (r = 0.315, P = 0.048). Multiple regression analysis yielded an equation for estimating central venous pressure using four parameters related to the IVC, SVC, tricuspid valve, and right atrium. The equation is as follows: estimated CVP = 4.36 + (2.35 × IVCmax/DAOmax) + (1.06 × SVCS/D) + (0.059 × RAVD) + (0.001 × TVAAR). This equation is strongly correlated with CVPi (Pearson r = 0.698, P = 0.002).ConclusionsThe estimation of central venous pressure through a multi-parametric equation that included the ratio of the maximal diameter of the inferior vena cava to the maximal diameter of the descending aorta, the ratio of S to D velocity of the superior vena cava, the vertical diameter of the right atrium, and the acceleration rate of the A wave of the tricuspid valve demonstrated a robust correlation with invasively measured central venous pressure. To assess the accuracy of predicted pressures by this equation, further investigations are required to apply this innovative multi-parametric formula to a prospective population of pediatric patients with congenital heart disease.

Abstract 12544: Point-of-Care Ultrasound Estimation of Right Atrial Pressure Predicts Early Readmission in Patients With Acute Decompensated Heart Failure

Introduction: We previously developed and validated a highly accurate non-invasive, point-of-care ultrasound (POCUS) technique that uses right internal jugular vein (RIJV) compliance to predict elevated right atrial pressure (RAP). We sought to determine whether this POCUS technique would predict 30-day readmission in acute decompensated heart failure (ADHF) patients. Hypothesis: POCUS-based estimation of RAP at the time of discharge can predict 30-day readmission in patients with ADHF. Methods: In this prospective cohort study, consecutive patients admitted with ADHF were screened for eligibility. POCUS images of the RIJV at end-expiration and at maximal expansion during Valsalva were collected daily during the patient’s stay. To assess compliance, the change in cross-sectional area (CSA) of the RIJV induced by Valsalva was calculated using ImageJ and referred to as the distensibility index (DI). From ROC analysis, a DI≥66% was considered negative for elevated RAP while a DI&lt;66% was considered positive (PPV 87%). 30 days post-discharge, readmission data were collected from patients’ EMR and a follow-up phone call. Sensitivity/specificity and predictive value analyses were conducted based on readmission data for those discharged with positive and negative tests. Results: A total of 237 admitted patients were eligible for this analysis. Patients discharged with a POCUS-estimated elevated RAP had a 30 day readmission rate 3.5 times greater than those discharged with normal POCUS-estimated RAP (26.7% vs 7.6%). POCUS-based normal RAP at discharge had a 92.4% negative predictive value (NPV) for avoiding 30-day readmission (P&lt;.001). A subset of patients in this cohort (n=81) were admitted to a local community hospital. In this setting, POCUS estimation of RAP at discharge had a 95.7% NPV (P&lt;.001) for avoiding 30-day readmission, and patients discharged with a POCUS-based elevated RAP had a 30-day readmission rate 9.6 times greater than those discharged with a normal POCUS test (41.2% vs 4.3%) . Conclusions: POCUS estimation of RAP strongly predicts avoidance of 30-day readmission for ADHF. Using this technique to guide discharge planning, potentially to reduce readmission for ADHF, deserves further investigation in a prospective randomized trial.

Evaluation of an artificial intelligence-based system for echocardiographic estimation of right atrial pressure

Current noninvasive estimation of right atrial pressure (RAP) by inferior vena cava (IVC) measurement during echocardiography may have significant inter-rater variability due to different levels of observers’ experience. Therefore, there is a need to develop new approaches to decrease the variability of IVC analysis and RAP estimation. This study aims to develop a fully automated artificial intelligence (AI)-based system for automated IVC analysis and RAP estimation. We presented a multi-stage AI system to identify the IVC view, select good quality images, delineate the IVC region and quantify its thickness, enabling temporal tracking of its diameter and collapsibility changes. The automated system was trained and tested on expert manual IVC and RAP reference measurements obtained from 255 patients during routine clinical workflow. The performance was evaluated using Pearson correlation and Bland-Altman analysis for IVC values, as well as macro accuracy and chi-square test for RAP values. Our results show an excellent agreement (r=0.96) between automatically computed versus manually measured IVC values, and Bland-Altman analysis showed a small bias of -\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$-$$\\end{document}0.33 mm. Further, there is an excellent agreement ((p<0.01\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$(p<0.01$$\\end{document}) between automatically estimated versus manually derived RAP values with a macro accuracy of 0.85. The proposed AI-based system accurately quantified IVC diameter, collapsibility index, both are used for RAP estimation. This automated system could serve as a paradigm to perform IVC analysis in routine echocardiography and support various cardiac diagnostic applications.

Effectiveness of 2‐dimensional shear wave elastography for noninvasive and reliable estimation of right atrial pressure in dogs with induced volume overload

Two-dimensional shear wave elastography (2D-SWE) provides information on hepatic elastic modulus as shear wave velocity (SWV). To assess SWV using 2D-SWE in dogs with induced volume overload, investigate the relationship between this information and right atrial pressure (RAP) measured by invasive right heart catheterization, and also evaluate the difference in SWV before and after diuretic administration. Six healthy beagles. Prospective experimental study. Right heart catheterization and 2D-SWE were performed in 6 anesthetized beagles at baseline and after the induction of volume overload. Volume overload was induced by IV hydroxyethyl starch 70/0.5 infusion (100 mL/kg/h). Furosemide (4-6 mg/kg, IV) was administered, and the SWVs were measured. Shear wave velocity showed a significant gradual increase during acute volume overload compared to baseline. SWV was significantly positively correlated with RAP (P < .0001, ρ = 0.9729). The area under the curve of SWV to predict RAP at >10, >15, and >20 mm Hg was 0.9896 (95% confidence interval [95% CI], 0.9690-1.000), 0.9907 (95% CI, 0.9701-1.000), and 0.9722 (95% CI, 0.9280-1.000), respectively. The SWV after diuretic use decreased significantly. Two-dimensional shear wave elastography might be useful for noninvasive and reliable estimation of RAP in dogs with acute volume overload and has potential as a quantitative biomarker for evaluating therapeutic response in dogs with right sided congestive heart failure.

271 AUTOMATED REAL TIME ECHOCARDIOGRAPHIC TOOL FOR EDGE TRACKING OF INFERIOR VENA CAVA AND NON-INVASIVE ESTIMATION OF RIGHT ATRIAL PRESSURE

Abstract The non-invasive estimation of right atrial pressure (RAP) would be a key advancement in several clinical scenarios, in which the knowledge of central venous filling pressure is vital for patients’ management. The echocardiographic estimation of RAP proposed by Guidelines, based on inferior vena cava (IVC) size and respirophasic collapsibility, is exposed to operator and patient dependent variability. We introduce an automated real time method to process ultrasound scans of IVC and to measure pulsatility indexes, which are then used, together with other non-invasive measurements, to estimate RAP. Specifically, our method is based on the cardiac collapsibility (cardiac caval index - CCI), tested in a monocentric retrospective cohort of patients undergoing echocardiography and right heart catheterization (RHC) within 24 hour in condition of clinical and therapeutic stability (170 patients, age 64±14, male 45%, with pulmonary arterial hypertension, heart failure, valvular heart disease, dyspnea or other pathologies). IVC size and CCI were integrated with other standard echocardiographic features using machine-learning approaches. Three RAP classes (low &amp;lt;5 mmHg, intermediate 5-10 mmHg and high &amp;gt;10 mmHg) were generated and RHC values used as comparator. Our classifications showed a higher accuracy than Guidelines (71% and 61% for our machine-learning method and Guidelines, respectively), promoting the integration of IVC and echocardiographic features for an improved non-invasive estimation of RAP.

A Novel Method for Estimating Right Atrial Pressure With Point-of-Care Ultrasound

Current noninvasive estimation of right atrial pressure (RAP) by either bedside jugular venous pressure exam or inferior vena cava measurement during a comprehensive echocardiogram offers imprecise estimates of actual RAP. We enrolled 41 patients in a prospective, blinded study to validate a novel point-of-care ultrasound method using direct right atrial depth (RAD) measurement and jugular venous ultrasound to estimate RAP. Two subjects were excluded, and 39 were included in the final analysis. A parasternal long-axis view was obtained, and the depth of the noncoronary cusp attachment to the posterior left ventricular outflow tract was recorded as the RAD. This was added to an estimate of the jugular venous pressure obtained during a jugular vein ultrasound to calculate an estimated RAP (RAPUS). The RAPUS was compared to the RAP measurement during right heart catheterization (RAPcath) both as measured and as corrected for where the catheter was zeroed. The correlation coefficient between RAPcath and RAPUS was+0.75; regression R2, 0.56; and bias, -0.49mm Hg (95% CI, -1.42 to+0.43mm Hg), with the limits of agreement -5.56 to+7.24mm Hg and accuracy of 3mm Hg or less in 29 (74%) of the subjects. For the RAPUS corrected for the catheter zero point, the correlation coefficient between RAPcath and RAPUS was+0.72; regression R2, 0.52; and bias, -0.60mm Hg (95% CI, -1.60 to+0.39mm Hg), with the limits of agreement -5.56 to+7.24mm Hg and accuracy of 3mm Hg or less in 26 (67%) of the subjects. This simple ultrasound evaluation of RAD and the right jugular vein correlates well with actual RAP and can accurately estimate RAP within 3mm Hg in most patients. This has the potential to improve our bedside volume status exam, as well as improve the accuracy of RAP estimation during comprehensive echocardiogram.

Abstract 13758: Distension of the Upright Ultrasound Jugular Venous Pulse is Predictive of All-Cause Mortality in Patients Referred for Right Heart Catheterization

Introduction: Bedside central venous pressure assessment is integral to diagnosing and managing heart failure (HF). A noninvasive point of care ultrasound (POCUS) assessment of the jugular venous pressure (uJVP) was validated as accurate in predicting elevated right atrial pressure (RAP) on right heart catheterization (RHC) in HF patients. A qualitative assessment of uJVP in the upright position (uuJVP) was found to be highly specific for detecting elevated RAP. We compared the prognostic value of the distended uuJVP and elevated RAP in predicting one-year mortality. Hypothesis: We hypothesized that a distended uuJVP was predictive of all-cause mortality. Methods: Adult patients undergoing RHC underwent uuJVP assessment with POCUS. A distended uuJVP was defined as internal jugular venous distention to at least the same size as the adjacent common carotid artery during resting inspiration and expiration (Figure 1c). Patients were examined upright at 90 degrees with their back/neck supported, and followed for one year after undergoing same day uuJVP assessment and RHC. Elevated RAP was defined as ≥10 mmHg on RHC. Kaplan Maier analysis of all-cause mortality was performed. Results: 100 patients had a uuJVP assessment prior to RHC. The distended uuJVP correlated with a mean RAP of 15 mmhg (8.3-17.1 mmHg) (Figure 1d) with a specificity of 94.6% for predicting RAP of ≥10 mmHg. Multivariate cox regression analysis showed that patients with a distended uuJVP had an increased one-year mortality (HR 3.20, 95% [CI 1.24- 8.20], p=.02) similar to those with RAP ≥10 mmHg by RHC (HR 3.21, 95% CI [1.20-8.64], p=.02) (Figure 1a/1b). Of 27 deaths, 11 (40.7%) had positive uuJVP with a specificity of 79.7%, 95% CI (69.2%-88%). Conclusions: The bedside distended uuJVP was similarly predictive of all-cause one-year mortality as elevated RAP by RHC. The clinical application of this simple, qualitative ultrasound estimate of RAP warrants further investigation.

Non-Invasive Estimation of Right Atrial Pressure Using a Semi-Automated Echocardiographic Tool for Inferior Vena Cava Edge-Tracking.

The non-invasive estimation of right atrial pressure (RAP) would be a key advancement in several clinical scenarios, in which the knowledge of central venous filling pressure is vital for patients’ management. The echocardiographic estimation of RAP proposed by Guidelines, based on inferior vena cava (IVC) size and respirophasic collapsibility, is exposed to operator and patient dependent variability. We propose novel methods, based on semi-automated edge-tracking of IVC size and cardiac collapsibility (cardiac caval index—CCI), tested in a monocentric retrospective cohort of patients undergoing echocardiography and right heart catheterization (RHC) within 24 h in condition of clinical and therapeutic stability (170 patients, age 64 ± 14, male 45%, with pulmonary arterial hypertension, heart failure, valvular heart disease, dyspnea, or other pathologies). IVC size and CCI were integrated with other standard echocardiographic features, selected by backward feature selection and included in a linear model (LM) and a support vector machine (SVM), which were cross-validated. Three RAP classes (low < 5 mmHg, intermediate 5–10 mmHg and high > 10 mmHg) were generated and RHC values used as comparator. LM and SVM showed a higher accuracy than Guidelines (63%, 71%, and 61% for LM, SVM, and Guidelines, respectively), promoting the integration of IVC and echocardiographic features for an improved non-invasive estimation of RAP.

Accuracy of echocardiographic estimations of right heart pressures in adult heart transplant recipients.

BackgroundAccurate assessment of right atrial pressure (RAP) and pulmonary artery systolic pressure (PASP) is critical in the management of heart transplant recipients. The accuracy of echocardiography in estimating these pressures has been debated.ObjectiveTo assess the correlation and agreement between echocardiographic estimations of right heart pressures with those of respective invasive hemodynamic measurements by right heart catheterization (RHC) in adult heart transplant recipients.MethodsThis is a prospective evaluation of 84 unique measurements from heart transplant recipients who underwent RHC followed by standard echocardiographic evaluation within 159 ± 64 min with no intervening medication changes. The relationship between noninvasive pressure estimations and invasive hemodynamic measurements was examined.ResultsMean RAP was 7 ± 5 mmHg and mean PASP was 33 ± 8 mmHg by RHC. There was no significant correlation between echocardiographic estimation of RAP and invasive RAP (Spearman's rho = −0.05, p = .7), and no significant agreement between these two variables (weighted kappa = −0.1). There was a modest correlation between echocardiographic estimation of PASP and invasive PASP (r = .39, p = .002). Bland‐Altman analysis showed a mean bias of 2.1 ± 9 mmHg (limits of agreement = −15 to 20 mmHg).ConclusionIn heart transplant recipients, there is no significant correlation or agreement between echocardiographic RAP estimation and invasively determined RAP. Noninvasive PASP estimation correlates significantly but modestly with invasively measured PASP. Further refinement of echocardiographic methods for assessment of RAP is warranted in this unique patient population.

Peripheral Venous Pressure-Assisted Exercise Stress Echocardiography in the Evaluation of Pulmonary Hypertension During Exercise in Patients With Suspected Heart Failure With Preserved Ejection Fraction.

Identification of elevated pulmonary artery (PA) pressures during exercise may provide diagnostic, prognostic, and therapeutic implications in heart failure with preserved ejection fraction. Although widely performed, exercise stress echocardiography may underestimate true PA pressures due to the difficulty in estimating right atrial pressure (RAP) during exercise. We hypothesized that peripheral venous pressure (PVP) could allow for reliable estimation of RAP, and thus PA pressures during exercise stress echocardiography. In protocol 1, we investigated the accuracy of PVP compared with simultaneously measured RAP at rest and during exercise right heart catheterization in 19 subjects. In protocol 2, we examined whether the addition of PVP to Doppler exercise echocardiography (tricuspid regurgitant velocity) would increase the ability to identify exercise-induced pulmonary hypertension compared with inferior vena cava-based RAP estimation in 60 patients with dyspnea. In protocol 1, PVP was strongly correlated with simultaneously measured RAP at rest and during exercise (r=0.77 and 0.90), with little overestimation of invasively measured RAP (bias 3.4 mm Hg at rest and 1.7 mm Hg during exercise). In protocol 2, PVP increased dramatically during exercise echocardiography (14±5 mm Hg) while an increase in inferior vena cava-based RAP was modest (6±4 mm Hg). Exercise PA pressures calculated from PVP and tricuspid regurgitant velocity were significantly higher than those estimated from inferior vena cava and the use of PVP increased the proportion of patients with exercise-induced pulmonary hypertension from 40% to 68%. PVP may prevent underestimation of PA pressures during exercise echocardiography and could be a preferred approach to identify exercise-induced pulmonary hypertension in patients with suspected heart failure with preserved ejection fraction.

Inferior Vena Cava Edge Tracking Echocardiography: A Promising Tool with Applications in Multiple Clinical Settings.

Ultrasound (US)-based measurements of the inferior vena cava (IVC) diameter are widely used to estimate right atrial pressure (RAP) in a variety of clinical settings. However, the correlation with invasively measured RAP along with the reproducibility of US-based IVC measurements is modest at best. In the present manuscript, we discuss the limitations of the current technique to estimate RAP through IVC US assessment and present a new promising tool developed by our research group, the automated IVC edge-to-edge tracking system, which has the potential to improve RAP assessment by transforming the current categorical classification (low, normal, high RAP) in a continuous and precise RAP estimation technique. Finally, we critically evaluate all the clinical settings in which this new tool could improve current practice.

Use of Handheld Ultrasound to Estimate Right Atrial Pressure in a Pulmonary Hypertension Clinic

Rationale: Point-of-care ultrasonography is an invaluable asset for inpatient decision-making. Whether handheld ultrasound can be used in the outpatient management of pulmonary hypertension is unknown. Objectives: We investigated whether a handheld ultrasound estimate of right atrial pressure correlates with B-type natriuretic peptide (BNP) and clinical outcome over time in outpatients with pulmonary hypertension. Methods: This prospective study included outpatients in a Pulmonary Hypertension Comprehensive Care Center clinic who had a same-day BNP concentration. We used a handheld ultrasound to measure inferior vena cava size and collapsibility, which were used to estimate right atrial pressure (eRAP) and categorize it as normal, intermediate, or high. Correlation analysis was used to compare these ultrasound measurements with BNP at baseline and over time. Cox regression was used to determine whether these measurements were associated with time to clinical worsening. Results: Ninety patients (60% Group 1 pulmonary hypertension) were enrolled. Patients with an intermediate or high eRAP category at baseline had higher BNP concentrations than patients with normal eRAP. For every transition in eRAP category (e.g., from normal to intermediate) between clinic visits, BNP changed by an average of 155 pg/ml (95% confidence interval [CI], 84-227). Higher baseline eRAP category was independently associated with more than twofold increased risk for clinical worsening (hazard ratio, 2.44; 95% CI, 1.47-4.07). Conclusions: Right atrial pressure estimated by portable handheld ultrasound correlates with BNP at baseline and serially over time. Furthermore, eRAP is independently associated with clinical worsening. The use of portable handheld ultrasound to estimate right atrial pressure should be considered in pulmonary hypertension clinics. Clinical trial registered at clinicaltrials.gov (NCT02873039).

Diagnostic utility of right atrial reservoir strain to identify elevated right atrial pressure in heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background. Accurate non-invasive estimation of right atrial pressure (RAP) is essential to assess volume status and optimize therapy in heart failure (HF). This study aimed to evaluate the utility of right atrial reservoir strain (RASr) assessed by speckle-tracking echocardiography to identify elevated RAP in HF and compare diagnostic performance with the recommendation-based estimate employing inferior vena cava size and collapsibility (RAPIVC). Methods. Association between RASr and invasive RAP (RAPInvasive) was examined in 103 HF subjects that underwent standard echocardiography with speckle-tracking strain analysis directly followed by right heart catheterization. The discriminatory ability of RASr to identify RAPInvasive &amp;gt; 7mmHg was evaluated and compared with RAPIVC. Results. RASr demonstrated a significant association with RAPInvasive (β = -0.41, p &amp;lt; 0.001) and strong discriminatory ability to identify subjects with RAPInvasive &amp;gt; 7mmHg (AUC = 0.78; 95% CI 0.68-0.87; p &amp;lt; 0.001). At a cut-off value of -15%, RASr demonstrated 78% sensitivity, 72% specificity, 72% positive predictive value and 77% negative predictive value to identify elevated RAPInvasive. In comparison, RAPIVC (AUC = 0.71) demonstrated 89% sensitivity, 32% specificity, 55% positive predictive value and 77% negative predictive value with high false positive rate. In subjects with intermediate RAPIVC (8mmHg), RASr maintained significant diagnostic ability to identify elevated RAPInvasive (AUC = 0.69; 95% CI 0.52 to 0.85, p = 0.03). Conclusions. RASr demonstrates strong ability to identify elevated RAP and may be useful as a novel noninvasive estimate of RAP in HF management.

Echocardiographic RV-E/e' for predicting right atrial pressure: a review.

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

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

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

Diagnostic utility of right atrial reservoir strain to identify elevated right atrial pressure in heart failure

BackgroundAccurate non-invasive estimation of right atrial pressure (RAP) is essential to assess volume status and optimize therapy in heart failure (HF). This study aimed to evaluate the utility of right atrial reservoir strain (RASr) assessed by speckle-tracking echocardiography to identify elevated RAP in HF and compare diagnostic performance with estimated RAP employing inferior vena cava size and collapsibility (RAPIVC), in addition to RA area. MethodAssociation between RASr and invasive RAP (RAPInvasive) was examined in 103 HF subjects that underwent standard echocardiography with speckle-tracking strain analysis directly followed by right heart catheterization. The discriminatory ability of RASr to identify RAPInvasive > 7 mmHg was evaluated and compared with RAPIVC and RA area. ResultsRASr demonstrated association with RAPInvasive (β = −0.41, p < 0.001) and was an independent predictor when adjusted for potential confounders (β = −0.25, p < 0.001). Further, RASr showcased strong discriminatory ability to identify subjects with RAPInvasive > 7 mmHg (AUC = 0.78; 95% CI 0.68–0.87; p < 0.001). At a cut-off value of −15%, RASr displayed 78% sensitivity and 72% specificity to identify elevated RAPInvasive. In comparison, RAPIVC (AUC = 0.71; 95% CI 0.61–0.81; p < 0.001) demonstrated 89% sensitivity and 32% specificity with high false positive rate. RA area (AUC = 0.66; 95% CI 0.55–0.76, p = 0.005) displayed 64% sensitivity and 53% specificity. ConclusionsRASr demonstrates good ability to identify elevated RAP and relatively stronger diagnostic performance when compared with conventional non-invasive measures. RASr may be useful as a novel noninvasive estimate of RAP in HF management.

P892 Accuracy of right atrial pressure estimation using a multi-parameter approach derived from Inferior vena cava semi-automated edge-tracking echocardiography

Abstract Background In clinical practice, as stated in the ASE guidelines, the echocardiographic estimation of right atrial pressure (RAP) is based on the size of the inferior vena cava (IVC) and its inspiratory collapse. However, this method has proven to have limits of reliability and reproducibility. The use of a recently developed software that with a semi-automatic technique highlight the edges of the IVC could help to standardize the echocardiographic assessment of RAP. Aim of the study: The aim of the study was to assess feasibility and accuracy of a new semi-automated approach to estimate the RAP. Standard acquired echocardiographic images were processed with a semi-automatic technique, indexes related to the collapsibility of the vessel during inspiration (Caval Index, CI), during the whole respiratory cycle (Respiratory Caval Index, RCI) and through the heart cycle transmitted movements’ (Cardiac Caval Index (CCI) were derived (figure 1). Using these indexes, we developed two models: a) the Binary Tree Model (BTM), further divided in BTM3 and BTM5 (RAP estimated in 3 and 5 classes, respectively); b) the Regression Model (RM), further divided in RM linear (continuous model) and RM3 and RM5 (RAP estimated in 3 and 5 classes respectively). RAP assessed using these innovative techniques were compared with two standard estimation (SE) echocardiographic methods A and B. Direct RAP measurements obtained during a right heart catheterization (RHC), performed within 6 hours, were used as reference. Results 62 consecutive ‘all-comers’ patients that had a RHC were enrolled; 13 patients were excluded for technical reasons. Therefore 49 patients were included in this study (26 males and 23 females; mean age of 62.2 ± 15.2 years, 75.5% pulmonary hypertension, 34.7% severe left ventricular dysfunction and 51% right ventricular dysfunction). The two SE methods showed poor accuracy for RAP estimation (method A: ME = 51%, R2= 0.22; method B: ME = 69%, R2= 0.26). Instead, the new semi-automatic methods BTM3 and BTM5 based on parameters derived from IVC edge tracking (mean IVC diameter, CI, CCI and RCI) had a misclassification error of only 14% (R2 = 0.47) and 22% (R2 = 0.61), respectively, to classify RAP. The accuracy was lower for RM than BTM (RM3: ME = 61%, R2 = 0.39; RM5: ME = 55%, R2 = 0.39). However, the RM showed the lowest mean bias in estimating RAP: 0.23 [-8.34; 8.81] mmHg. Conclusions A multi-parametric approach using the new indexes, such as CCI and RCI, derived from a semi-automated edge tracking of the IVC is a promising tool for a more accurate estimation of RAP. This study proposes an innovative method for the non-invasive estimation of the RAP, which requires confirmation on larger population. Abstract P892 Figure 1

Right atrial pressure is under estimated by echocardiography in HFpEF patients

The estimation of right atrial pressure (RAP) is important for pulmonary pressure and right ventricular filling pressure estimation. The accuracy of the inferior vena cava study to evaluate RAP has been tested in a few studies, and never in patients with heart failure with preserved ejection fraction (HFpEF) Our study investigated whether the study of inferior vena cava (IVC) size and collapsibility was accurate in a cohort of patients with heart failure with preserved ejection fraction (HFpEF). Between January 2014 and December 2018, 142 patients with suspected HFpEF and pulmonary hypertension (PH), underwent right heart catheterization (RHC) and transthoracic echocardiography within 5 days in our referral centre. The estimating RAP according to IVC size and collapsibility were retrospectively determined. Patients were classified in 3 groups according to the current guidelines: ≤ 2.1 cm that collapses > 50% with a sniff suggested a normal RAP of 3 mm Hg, an IVC diameter > 2.1 cm that collapses < 50% with a sniff suggested a high RAP of 15 mm Hg. A RAP of 8 mmHg was suggested for the other patients. A total of 118 patients (83%) had a possible and complete IVC analysis. Mean RAP estimation by right heart catheterism was 13 ± 5 mmHg. Inferior vena cava at end expiration was 19 ± 7 mm. Thirty-eight patients had an echo estimate RAP of 3 mmHg, whereas hemodynamic RAP in this group was 10 ± 5 mmHg. Forty patients had an echo estimate RAP of 8 mmHg, whereas hemodynamic RAP in this group was 14 ± 5 mmHg. 37 patients had an echo estimate RAP of 15 mmHg, whereas hemodynamic RAP in this group was 17 ± 5 mmHg. The RAP difference estimation of echo and hemodynamics was > 5 mmHg in respectively 66%, 40% and 39% of the patients in each group ( Fig. 1 ). In HFpEF patients, RAP is high. The study of the IVC is feasible in most cases but the estimation of the RAP is hazardous. This could have consequence in the evaluation of pulmonary pressure.