Peak Tricuspid Regurgitation Velocity Research Articles

0147: Cardiac involvement in hemoglobin SC disease compared to homozygous sickle-cell anemia

Hemoglobin SC (HbSC) disease and homozygous sickle-cell anemia (SCA) are the most frequent genotypes (accounting for respectively 25% and 70%) of sickle-cell disease. Although the SCA cardiac involvement was well studied, the cardiac remodeling associated to HbSC has never been specifically investigated. The aim of the study was to describe the HbSC cardiac remodeling versus SCA. Using a case-control design, 61 HbSC (mean age 31.3±10.0 years, 36 women) patients underwent a comprehensive echocardiography and were compared to 61 SCA patients in stable conditions. LV end diastolic volume index and LV ejection fraction were measured by Simpson method. LV mass index, left atrial volume index, septal E/e’ ratio, peak tricuspid regurgitation velocity (TRV) and cardiac index were also measured as recommended. All the parameters were the average of three measures. Both LV morphological and diastolic functional parameters differed dramatically between the two groups of patients (table, mean±SD). Moreover, the pulmonary artery systolic pressure as estimated by TRV was lower in HbSC patients. Cardiac remodeling is very different in HbSC compared to SCA. Clinical interpretation of echocardiography data should be adjusted to each variant of the disease. Moreover, this study is further evidence that the both genotypes of sickle-cell disease have different organ involvements and should not be pooled in clinical studies. Specific guidelines for follow up of HbSC patients should be established. Abstratct 0147 – Table SCA patients (n=61) HbSC patients (n=61) p value Heart rate (beats/min) 70±11 72±10 0.26 LV mass index (g/m²) 103±26 77±16 <0.0001 LV end diastolic volume index (ml/m²) 92±19 64±15 <0.0001 Cardiac index (L/min/m²) 4.2±1.0 3.1±0.6 <0.0001 LV ejection fraction (%) 60±5 61±6 0.88 Septal E/e’ ratio 10.9±2.4 7.2±2.1 <0.0001 Left atrial volume index (ml/m²) 51.1±11.9 33.8±7.5 <0.0001 Tricuspid regurgitation velocity (m/s) 2.57±0.26 2.26±0.23 <0.0001 Tricuspid regurgitation velocity >2.5m/s, n(%) 34 (56) 4 (7) <0.0001

Prevalence of Pulmonary Arterial Hypertension in Korean Adult Patients with Systemic Sclerosis: Result of a Pilot Echocardiographic Screening Study.

BackgroundPulmonary arterial hypertension (PAH) is a major cause of morbidity and mortality among patients with systemic sclerosis (SSc). Early detection and prompt treatment of PAH associated with SSc (SSc-PAH) result in better prognosis. We conducted echocardiographic study to presume the prevalence of PAH in Korean adult SSc patients and to diagnose SSc-PAH in their early stages with right heart catheterization (RHC).MethodsWe performed free of charge echocardiographic study including 37 adult SSc patients at the Chungnam National University Hospital. The possibility of PAH is determined by the estimation of pulmonary arterial pressure by peak tricuspid regurgitation velocity of > 3.0 m/s. Patients with possible PAH were recommended to undergo RHC to confirm the diagnosis.ResultsIn 37 patients, 8 patients were suspected with PAH. Among them, 6 patients agreed to be examined with RHC, and 4 were confirmed with PAH. The prevalence of possible PAH was 21.6% (8 of 37 patients), and that of confirmed PAH was 10.8% (4 of 37 patients). Four patients who were confirmed with SSc-PAH through RHC have been treated with specific pulmonary vasodilators and maintained stable.ConclusionEight patients (21.6%) were possible PAH and 4 (10.8%) were diagnosed as SSc-PAH by RHC after the echocardiographic screening study of 37 adult SSc patients.

Right Ventricular Outflow Tract Doppler Envelope Notching Predicts Pulmonary Vascular Resistance in Patients with Advanced Liver Disease

Portopulmonary hypertension (POPH) affects 6% of liver transplant (LT) candidates and is associated with poor outcomes. Screening for POPH with a transthoracic echocardiogram (TTE) is the standard of care, but diagnosis requires right heart catheterization (RHC) which carries risks in pts with advanced liver disease (ALD). Systolic deceleration or “notching” of the right ventricular outflow tract Doppler flow velocity envelope (FVERVOT) correlates with high pulmonary vascular resistance (PVR) in mixed pulmonary hypertension (PH) but has not been validated in pts with ALD. The ratio of peak tricuspid regurgitant velocity (TRV, m/s) and time-velocity integral of the RVOT (TVIRVOT) per the formula PVR=TRV/TVIRVOT x 10 has been shown to reliably estimate PVR. We investigated whether PVR can be predicted by the shape of FVERVOT or estimated by the TRV/TVIRVOT ratio in pts undergoing evaluation for LT. We included 100 pts who underwent RHC and TTE as part of LT evaluation from 01/10 to 03/15. Median time between the two tests was 5 days. We categorized the shape of FVERVOT as no (NN), late-systolic (LSN) or mid-systolic (MSN) notching. Unpaired t-tests were used to compare sample means for continuous variables and linear regression analysis to test the correlation between invasive and non-invasive PVR. The mean patient age was 57±8.5 years; 50% were male with diverse etiologies of ALD (35% HCV, 21% alcoholic, 10% cryptogenic, 6% NASH, 4% autoimmune, 24% other) and 79% were transplanted. The prevalence of POPH as defined by PVR≥3 on RHC was 12%. Elevated systolic pulmonary artery pressure (PAPs≥40mmHg) on TTE was present in 54% and mean PAP≥25mmHg on RHC in 24%. The shape of the FVERVOT Doppler exhibited NN in 81%, LSN in 10% and MSN in 9%. Pts with either LSN or MSN had higher mean PAP than those with NN (28±9 vs 35±11mmHg, p=0.007) and higher transpulmonary gradient (TPG), diastolic pulmonary gradient (DPG) and PVR; the difference between LSN and MSN was not significant. TAPSE was lower in pts with LSN or MSN compared to NN (Fig 1), and non invasively estimated PVR was higher (1.8±0.5 vs 1.4±0.5 WU, p=0.003). Poor correlation was observed between noninvasive and invasive PVR (R2=0.10, p=0.001). RVOT notching and non-invasive PVR were poor predictors of mortality. Elevated PAPs on TTE was a sensitive but not specific screening tool for PVR≥3 (Sn=82%, Sp=48%). RVOT Doppler flow velocity notching reliably predicts POPH in pts with ALD.

Pulmonary hypertension in non-transfusion-dependent thalassemia: Correlation with clinical parameters, liver iron concentration, and non-transferrin-bound iron

BackgroundPulmonary hypertension is a major cardiac complication in non-transfusion-dependent thalassemia (NTDT). Several clinical and laboratory parameters, including iron overload, have been shown to have a positive correlation with the incidence of pulmonary hypertension. Non-transferrin-bound iron (NTBI) is a form of free-plasma iron that is a good indicator of iron overload.ObjectivesThe aim of this study was to determine the prevalence of pulmonary hypertension in patients with NTDT and to investigate its correlation with the clinical parameters, liver iron concentration (LIC) and NTBI.MethodsPatients with NTDT were evaluated using echocardiography, and magnetic resonance imaging for cardiac T2* and LIC. Pulmonary hypertension was defined as peak tricuspid regurgitation velocity ≥2.9 m/s measured using trans-thoracic echocardiography. Clinical parameters and the status of iron overload as determined by LIC, serum ferritin, and NTBI level were evaluated for their association with pulmonary hypertension.ResultsOf 76 NTDT patients, mean age 23.7 ± 8.5 years, seven patients (9.2%) had pulmonary hypertension. Previous splenectomy (71.4 vs. 24.6%, P-value 0.019), higher cumulative red blood cell (RBC) transfusions (received ≥10 RBC transfusions 85.7 vs. 33.3%, P-value 0.011), higher nucleated RBCs (353 ± 287 vs. 63 ± 160/100 white blood cells, P-value <0.001), and a high NTBI level (5.7 ± 3.0 vs. 3.3 ± 2.8 µmol/l, P-value 0.034) were associated with pulmonary hypertension. There was no significant correlation between LIC or serum ferritin and pulmonary hypertension.ConclusionPulmonary hypertension in NTDT is common, and is associated with splenectomy and its related factors. NTBI level shows a significant correlation with pulmonary hypertension.

(955) - Right Ventricular Outflow Tract Doppler Envelope Mid-Systolic Notching Predicts Pulmonary Vascular Disease in Patients With Advanced Lung Disease

Mid-systolic notching of the right ventricular outflow tract (RVOT) Doppler flow velocity envelope (FVERVOT) correlates with high pulmonary vascular resistance (PVR) in patients with diverse etiologies of pulmonary hypertension (PH). The ratio of peak tricuspid regurgitant velocity (TRV) and time-velocity integral of the RVOT (TVIRVOT) provides a reliable non-invasive estimate of PVR. We investigated whether PVR can be predicted by the shape of FVERVOT or TRV/TVIRVOT in pts with advanced lung disease (ALD) undergoing lung transplant evaluation.

Quality of life in pulmonary arterial hypertension.

Quality of life in pulmonary arterial hypertension.

Prevalence and prognostic importance of pulmonary hypertension in dogs with myxomatous mitral valve disease.

BackgroundPulmonary hypertension (PH) is common in dogs with myxomatous mitral valve disease (MMVD) but its effect on clinical outcome has not been investigated.Hypothesis/objectivesThe presence of PH worsens the outcome in dogs with MMVD. To compare survival times of dogs with MMVD and PH to those without PH.AnimalsTwo hundred and twelve client‐owned dogs.MethodsCase review study. Medical records of dogs diagnosed with ACVIM stage B2 and C MMVD between January 2010 and December 2011 were retrospectively reviewed. Long‐term outcome was determined by telephone interview or from the medical record. End of the observation period was March 2013. PH was identified if tricuspid regurgitation peak velocity was >3 m/s.ResultsTwo hundred and twelve were identified. Eighty‐three dogs (39%) had PH. PH was more commonly identified in stage C compared to B2 (P < .0001). One hundred and five (49.5%) dogs died during the observation period. Median survival time for the entire study population was 567 days (95% CI 512–743). Stage C (P = .003), the presence of PH (P = .009), left atrial to aortic root ratio (LA/Ao) >1.7 (P = .0002), normalized left‐ventricular end‐diastolic diameter (LVEDn) >1.73 (P = .048), and tricuspid regurgitation pressure gradient (TRPG) >55 mmHg (P = .009) were associated with worse outcomes in the univariate analyses. The presence of TRPG >55 mmHg (HR 1.8 95% CI 1–2.9; P = .05) and LA/Ao > 1.7 (HR 2 95% CI 1.2–3.4; P = .01) remained significant predictors of worse outcome in the multivariate analysis.Conclusions and Clinical ImportanceIn dogs with MMVD, moderate to severe PH worsens outcome.

Quantification of trans-pulmonary physiology in ‘athlete’ population – a validation study of novel echocardiographic parameter “ePLAR”

Background: The “echocardiographic Pulmonary to Left Atrial Ratio” (ePLAR) is a new non-invasive parameter describing the physiologic relationship between pulmonary arterial pressure and left atrial pressure. It is derived using Doppler echocardiography and calculated from peak tricuspid regurgitation velocity (TR Vmax) divided by the transmitral E wave: medial DTI E’ wave ratio (E/E’). We sought to establish normal ePLAR values for an ‘athlete’ population. Methods: A retrospective analysis of patients undergoing treadmill stress echocardiogram between 2013 and 2014 was conducted. Patients who achieved high workload (greater than 17 METs) on treadmill exercise stress test were identified and the recorded resting TR Vmax, E/E’ ratio and ePLAR values were compared to established population normal ePLAR reference values. Results: The stress echocardiograms of 120 patients (average age 45±13.5 years; 88% male) were evaluated. The mean achieved METs was 18±1.6. The mean TR Vmax was 2.2±0.3 m/s, the mean E/E’ ratio was 7.4±1.9, and the mean ePLAR was 0.32±0.09 m/s. No statistically significant difference was found between age-stratified mean ePLAR values for athletes compared to normal population group. Conclusions: ePLAR is a novel echocardiographic parameter that is easily obtained during routine stress echocardiogram. In this cohort of ‘athlete’ population, their trans-pulmonary physiology as measured by ePLAR did not appear to differ significantly compared to normal population.

Abstract 16108: Right Ventricular Strain is a More Sensitive Marker of Right Ventricular Dysfunction Than Right Ventricular Ejection Fraction in a Cohort of Patients With Idiopathic Pulmonary Arterial Hypertension

Introduction: Strain has been shown to be more sensitive that ejection fraction in detecting subclinical dysfunction in the left ventricle. A number of echocardiographic parameters associated with right heart size and function have been shown to be impaired in idiopathic pulmonary arterial hypertension (IPAH) but there is minimal data on which may be the most sensitive. Aim: To characterize the changes in functional and echocardiographic indices of right ventricular (RV) size and function, in a cohort of IPAH patients followed serially to determine if strain is a more sensitive measure of RV dysfunction than RVEF. Methods: Thirty patients (24 women, mean age 46.8 ± 5.3 years) with newly diagnosed IPAH were prospectively recruited and followed with serial transthoracic echocardiograms (TTE; Philips Medical Systems, Andover, MA) 6 monthly for up to 18 months. A range of 2D and 3D echocardiographic measures of right ventricular dimensions and function, including right ventricular ejection fraction (RVEF) and systolic longitudinal strain (LS), was assessed at each time point after commencing treatment using vendor independent software (TomTec, Germany). Functional status was assessed at18 months. Statistical analyses were performed using JMP statistical package (SAS Institute In. Cary, NC) Results: 3D RV volumes, ejection fraction, mass, 2D global strain and 2D free wall strain all show significant changes over 18 months (p-value &lt; 0.05; ANOVA of repeated measures) although peak tricuspid regurgitant velocity, RV systolic pressure and stroke volume do not. However, RV global strain and RV free wall strain showed significant changes within 6 months after diagnosis but not RVEF, peak TR velocity or RVSP. The degree of change in the RV free wall strain change at 18 months but not RVSP, RV mass or RVEF, was also associated with an abnormal 6 min walk test (18 months change, p=0.03). Conclusion: RV global and free wall strain demonstrate significant decreases prior to RVEF, peak TR velocity and RVSP hence may be more more sensitive measures of RV dysfunction in patients with IPAH. These results may help guide treatment decisions and highlight the potential value of echocardiography in detecting subacute cardiac pathology.

Intra-operative assessment of pulmonary artery pressure by transoesophageal echocardiography.

The clinical value of the estimation of systolic pulmonary artery pressure, based on Doppler assessment of peak tricuspid regurgitant velocity using transoesophageal echocardiography, is unclear. We studied 109 patients to evaluate the feasibility of obtaining adequate Doppler recordings, and compared Doppler estimates with values measured using a pulmonary artery catheter in a subset of 33 patients. Tricuspid regurgitation was evaluated at the mid-oesophageal level at 0-120° using Doppler echocardiography. A Doppler signal was defined as adequate if there was a ≤20° alignment and a full envelope. Doppler estimates of systolic pulmonary artery pressure within 10mmHg and 15% of the value recorded with the pulmonary artery catheter were considered to be in sufficient agreement. Adequate Doppler signals were obtained in 64/109 (59%) patients before and 54/103 (52%) after surgery. Doppler estimates by transoesophageal echocardiography were within 10mmHg and 15% of values recorded with the pulmonary artery catheter in 28/33 (75%) patients and 22/31 (55%) patients, respectively. In 7 (21%) patients, the echocardiographic Doppler measurement exceeded the measured systolic pulmonary artery pressure by more than 30%. Our study indicates that estimation of the systolic pulmonary artery pressure using transoesophageal Doppler echocardiography is not a reliable and clinically useful method in anaesthetised patients undergoing mechanical ventilation.

Prognostic Value of Echocardiographic Changes in Patients with Pulmonary Arterial Hypertension Receiving Parenteral Prostacyclin Therapy

It is unknown whether the echocardiographic changes observed after treatment of patients with pulmonary arterial hypertension have prognostic value. Subjects with pulmonary arterial hypertension, confirmed by right heart catheterization, who underwent Doppler echocardiography before (baseline) and after 1 year of treatment (follow-up) with parenteral prostacyclin analogues were retrospectively identified. Echocardiographic parameters were measured offline by two investigators. A total of 48 patients were included (mean age, 45 ± 14 years; 83% women). Compared with baseline, follow-up echocardiography showed reductions in right atrial area (mean percentage change, 12 ± 25%; P < .001), right ventricular (RV) basal and middle cavity dimensions (mean percentage change, 8.5 ± 14% [P < .001] and 6.8 ± 17% [P = .005], respectively), and peak tricuspid regurgitant velocity (mean percentage change, 10 ± 14%; P < .001). Tricuspid annular plane systolic excursion (mean percentage change, 36 ± 43%; P < .001) and RV outflow tract time-velocity integral (mean percentage change, 48 ± 66%; P < .001) increased. During a median follow-up period of 52.5 months (interquartile range, 20.5-80 months), 18 patients (37.5%) died, mostly (n = 15 [83%]) from progression of pulmonary arterial hypertension. The changes in RV end-diastolic area (hazard ratio [HR per 10% decrease, 0.73; 95% confidence interval [CI], 0.57-0.93), tricuspid valve regurgitation velocity (HR per 10 cm/sec decrease, 0.58; 95% CI, 0.37-0.89), RV outflow tract velocity-time integral (HR per 10% increase, 0.90; 95% CI, 0.83-0.98), and subjective RV function (HR per 1 unit of improvement [e.g., from moderate to mild], 0.55; 95% CI, 0.31-0.96) were associated with overall mortality. Echocardiographic parameters that estimate RV systolic pressure and assess RV morphology and function improve after 1 year of prostacyclin analogue treatment, and the degree of change has prognostic implications.

P09 Pulmonary artery pressures in school age children born very prematurely

AimBronchopulmonary dysplasia, which occurs most frequently in extremely prematurely born infants, can be complicated by pulmonary hypertension due to dysregulation of angiogenesis and increased muscularisation of the pulmonary arteries. (1)...

Effect of imatinib as add-on therapy on echocardiographic measures of right ventricular function in patients with significant pulmonary arterial hypertension

Imatinib mesylate, as add-on therapy in patients with pulmonary arterial hypertension (PAH) who remain inadequately treated despite receiving at least two PAH-specific drugs, improves exercise capacity and haemodynamics. We evaluated whether 24 weeks of add-on therapy with imatinib compared with placebo also improves right ventricular (RV) function assessed by echocardiography. Echocardiograms were obtained at baseline, 12 weeks, and 24 weeks in 74 patients randomized to imatinib or placebo in the Imatinib in Pulmonary arterial hypertension, a Randomized Efficacy Study (IMPRES) trial. Right ventricular function was assessed by tissue Doppler tricuspid annular peak systolic velocity (TA S'), tricuspid annular plane systolic excursion (TAPSE), RV Tei index, and RV fractional area change. Between-treatment-group differences in the changes from baseline to week-24 were assessed using an ANCOVA with the last observation carried forward. At week-24 patients randomized to imatinib demonstrated greater improvements in TA S' (1.6 ± 2.3 imatinib vs. 0.5 ± 2.4 cm/s placebo, P = 0.007) and RV Tei index (-0.11 ± 0.18 imatinib vs. 0.05 ± 0.18 placebo, P = 0.005) compared with placebo, but not in TAPSE (0.07 ± 0.44 imatinib vs. 0.03 ± 0.32 cm placebo, P = 0.08). Imatinib therapy was also associated with significant reduction in peak tricuspid regurgitation velocity, increase in LV size, and improvement in LV early diastolic relaxation velocity. Among patients with advanced PAH who remain symptomatic on at least two PAH-specific drugs, treatment with imatinib compared with placebo is associated with significant improvements in echocardiographic measures of RV function, in addition to LV size and LV early diastolic relaxation. NCT00902174 (Clinicaltrials.gov).

Effect of genotype on pulmonary hypertension risk in patients with thalassemia

Pulmonary hypertension is one of the major complications in patients with non-transfusion-dependent thalassemia (NTDT). Patients with NTDT have distinct genetic subgroups. Therefore, the effects of different genotype groups on pulmonary hypertension risk in patients with NTDT were assessed. A cross-sectional study was conducted in patients with NTDT aged ≥ 10 yr old at Srinagarind University Hospital and Udonthani Hospital, Thailand. Pulmonary hypertension risk was defined as peak tricuspid regurgitation velocity > 2.9 m/s by trans-thoracic echocardiography. Clinical characteristics and laboratory data that literature has indicated as risk factors for pulmonary hypertension were collected. The effect of genotype group on pulmonary hypertension risk was evaluated by using multivariate logistic regression analysis. Of 219 patients, pulmonary hypertension risk was found in 24 patients (10.96%). All patients were categorized into two groups according to genetic data that included: (i) β-thalassemia (139, 63.5%), (ii) α-thalassemia and combined α and β-thalassemia (80, 36.5%). Genotype groups were statistically and significantly associated with pulmonary hypertension risk based on the adjusted odds ratios after adjustment for other factors. Patients with β-thalassemia had a statistically significant higher risk for pulmonary hypertension risk (odds ratio = 9.47, P = 0.036) compared to patients with α-thalassemia and patients with combined α and β-thalassemia. The genotype group is an independent risk factor for pulmonary hypertension in patients with NTDT. Echocardiography should be routinely recommended for all patients with β-thalassemia. Routine screening in patients with α-thalassemia and combined α and β-thalassemia, however, may not be necessary or should focus on the older population.

Effects of respiration on the velocity of tricuspid regurgitation and estimation of systolic pulmonary artery pressure in patients with right ventricle systolic dysfunction

Objective. We investigated the effects of quiet respiration on the peak velocity of tricuspid regurgitation (TR) and estimation of systolic pulmonary artery pressure (SPAP) in patients with right ventricle (RV) systolic dysfunction using Doppler echocardiography. Methods. Continuous-wave Doppler spectra of TR were recorded in 32 patients with and 28 controls without RV systolic dysfunction. Electrocardiography and respiratory tracing were recorded simultaneously. Expiratory and inspiratory peak velocities of TR were acquired and averaged for five consecutive respiratory cycles. The SPAP during expiration and inspiration was calculated. Results. The velocity of TR and SPAP was not significantly different between expiration and inspiration in controls (2.77 ± 0.23 and 2.82 ± 0.26 m/s, P = 0.776; 35.94 ± 4.96 and 36.18 ± 5.12 mmHg, P = 0.747), whereas the velocity of TR and SPAP decreased significantly from expiration to inspiration in patients with RV systolic dysfunction (3.27 ± 0.35 and 2.59 ± 0.22 m/s, P < 0.001; 53.72 ± 7.39, 38.45 ± 5.63 mmHg, P < 0.001). Conclusions. Quiet respiration has significant effects on the velocity of TR in patients with RV systolic dysfunction. This factor should be taken into account when using Doppler echocardiography to estimate these patients’ SPAP, and the measurements should be performed in patients at the end of expiration.

Echocardiographic assessment of right heart indices in dogs with elevated pulmonary artery pressure associated with chronic respiratory disorders, heartworm disease, and chronic degenerative mitral valvular disease

The aim of this study was to evaluate right ventricular (RV) remodeling and right heart failure associated with different causes of elevated pulmonary arterial pressure (PAP) in dogs. In total, 169 client-owned dogs with tricuspid regurgitation (TR) and 40 client-owned clinically healthy dogs were included. Dogs with TR were further categorised as suffering from chronic respiratory disorders (CRD), heartworm disease (HWD), mild/moderate chronic degenerative mitral valvular disease (CDMD), and severe CDMD. Among the echocardiographic indices of the right heart, no significant difference in the tricuspid annular plane systolic excursion to aortic root diameter ratio was found among the clinical healthy controls and the four different TR categories. No significant differences in TR peak velocity and pulmonic regurgitation peak velocity were found among dogs in the four different TR categories. The ratio of the right to left ventricular basal diameter in the right ventricular-focused view was significantly higher in dogs with chronic respiratory disorders and dogs with heartworms. Left ventricular compression quantified using the eccentricity index and the ratio of the main pulmonary artery to aortic root diameter were significantly higher in dogs with HWD. Their right ventricular acceleration to ejection time (AT/ET) was significantly lower in dogs with HWD. Based on these findings, we conclude that right heart indices are affected by CRD, HWD, and moderate to severe CDMD. However, right heart indices derived from left heart measurements might be underestimated in dogs with CDMD.

Pressure reflection in the pulmonary circulation by echocardiography in patients with left heart disease indicates reactive pulmonary hypertension

Background and aims: The two hemodynamic profiles in Left Heart Disease (LHD) with Pulmonary Hypertension (PH), passive PH with increased pulmonary venous pressure and reactive PH with increased Pulmonary Vascular Resistance (PVR), cannot be distinguished non-invasively. We hypothesized that echocardiographic signs of Pressure Reflection (PR) in the pulmonary circulation can be used to diagnose reactive PH. Methods: The study comprised 122 patients that were divided into three groups: patients without PH (No PH, n=61), patients with PH (pulmonary artery mean pressure, PAMP≥25 mmHg) and normal PVR (Passive PH, n=29) and patients with increased PVR (Reactive PH, n=32). Echocardiography and Right Heart Catheterization (RHC) was performed within 24 hours. Three PR variables were selected: the acceleration time in the Right Ventricular Outflow Tract (RVOT), the time interval between RVOT peak velocity and peak tricuspid regurgitant velocity and the right ventricular pressure increase after peak RVOT velocity. Separate cutoff values indicating either high likelihood (major criteria) or low likelihood (minor criteria) for PVR>3WU were investigated using Receiver Operator Characteristic (ROC) curves. Results: The mean±SD age was 50±14 years, and the percentage of males was 63%. Sixty-eight patients (56%) underwent RHC due to known or suspected LHD whereof 23 patients had dilated cardiomyopathy. Thirty-one patients (25%) were heart transplant recipients, 8 patients (7%) had cardiac amyloidosis and 15 patients (12%) were miscellaneous. No patient included in the study had PH or increased PVR due to other causes than left ventricular dysfunction. Sixty-six percent of patients with Reactive PH had mild to moderate PH (PAMP 25-40 mmHg). The proportion of patients with pulmonary capillary wedge pressure>15 mmHg was 14% in No PH, 97% in Passive PH and 74% in Reactive PH. The area under the ROC curve for PR variables was 0.82 to 0.89. With three major criteria present the likelihood of PVR>3 WU increases 27.3 fold (positive likelihood ratio) and absence of minor criteria decreases the likelihood 8.3 fold (negative likelihood ratio). Conclusions: Echocardiographic assessment of PR in patients with LHD can be used to identify or exclude reactive PH. Patients with reactive PH often have mild to moderate rather than severe PH.

Prognostic significance of tricuspid regurgitation peak velocity in patients with heart failure and preserved ejection fraction

Prognostic significance of tricuspid regurgitation peak velocity in patients with heart failure and preserved ejection fraction

Can echocardiography discriminate between pulmonary arterial hypertension and pulmonary hypertension related to left heart disease in patients with cardiovascular risk factors?

Purpose: As the prevalence of cardiovascular risk (CV) factors is increasing by age, the diagnosis of pulmonary arterial hypertension (PAH) is becoming more challenging. The purpose of this study was to assess whether transthoracic echocardiography may help to differentiate between PAH and pulmonary hypertension (PH) related to left heart disease (PH-LHD) in PH patients with CV factors before cardiac catheterization. Methods: We retrospectively studied consecutive incident PH patients at a single centre between 01 January 2008 and 15 July 2011. All patients underwent cardiac catheterization. We selected those who had at least one of the following CV factors: systemic hypertension, type 2 diabetes mellitus, permanent atrial fibrillation, coronary artery disease, obesity or mitral and/or aortic disease. We divided the patients into two groups: a PAH group (PAH-CV) and a PH-LHD group. After Bonferroni correction the statistical threshold shifted to 0.001 level. Results: The results are shown in Table 1. View this table: Table 1. Comparison of echocardiographic features Conclusions: 1. In PHLHD left atrial and ventricular dimensions are greater than in PAH 2. In PAH the right ventricle expands at the expense of the left ventricle 3. In PAH tricuspid regurgitation peak velocity is higher and pericardial effusion is more common. These differences show the potentially helpful role of echocardiography in discrimination between PAH and PH-LHD in patients with PH and CV factors.

Pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a chronic and progressive disease leading to right heart failure and ultimately death if untreated. The first classification of PH was proposed in 1973. In 2008, the fourth World Symposium on PH held in Dana Point (California, USA) revised previous classifications. Currently, PH is devided into five subgroups. Group 1 includes patients suffering from idiopathic or familial PAH with or without germline mutations. Patients with a diagnosis of PAH should systematically been screened regarding to underlying mutations of BMPR2 gene (bone morphogenetic protein receptor type 2) or more rarely of ACVRL1 (activine receptor-like kinase type 1), ENG (endogline) or Smad8 genes. Pulmonary veno occusive disease and pulmonary capillary hemagiomatosis are individualized and designated as clinical group 1'. Group 2 'Pulmonary hypertension due to left heart diseases' is divided into three sub-groups: systolic dysfonction, diastolic dysfonction and valvular dysfonction. Group 3 'Pulmonary hypertension due to respiratory diseases' includes a heterogenous subgroup of respiratory diseases like PH due to pulmonary fibrosis, COPD, lung emphysema or interstitial lung disease for exemple. Group 4 includes chronic thromboembolic pulmonary hypertension without any distinction of proximal or distal forms. Group 5 regroup PH patients with unclear multifactorial mechanisms. Invasive hemodynamic assessment with right heart catheterization is requested to confirm the definite diagnosis of PH showing a resting mean pulmonary artery pressure (mPAP) of ≥ 25 mmHg and a normal pulmonary capillary wedge pressure (PCWP) of ≤ 15 mmHg. The assessment of PCWP may allow the distinction between pre-capillary and post-capillary PH (PCWP > 15 mmHg). Echocardiography is an important tool in the management of patients with underlying suspicion of PH. The European Society of Cardiology and the European Respiratory Society (ESC-ERS) guidelines specify its role, essentially in the screening proposing criteria for estimating the presence of PH mainly based on tricuspid regurgitation peak velocity and systolic artery pressure (sPAP). The therapy of PAH consists of non-specific drugs including oral anticoagulation and diuretics as well as PAH specific therapy. Diuretics are one of the most important treatment in the setting of PH because right heart failure leads to fluid retention, hepatic congestion, ascites and peripheral edema. Current recommendations propose oral anticoagulation aiming for targeting an International Normalized Ratio (INR) between 1.5-2.5. Target INR for patients displaying chronic thromboembolic PH is between 2–3. Better understanding in pathophysiological mechanisms of PH over the past quarter of a century has led to the development of medical therapeutics, even though no cure for PAH exists. Several specific therapeutic agents were developed for the medical management of PAH including prostanoids (epoprostenol, trepoprostenil, iloprost), endothelin receptor antagonists (bosentan, ambrisentan) and phosphodiesterase type 5 inhibitors (sildenafil, tadalafil). This review discusses the current state of art regarding to epidemiologic aspects of PH, diagnostic approaches and the current classification of PH. In addition, currently available specific PAH therapy is discussed as well as future treatments.