Precapillary Precapillary Pulmonary Hypertension Research Articles

Deep learning to assess right ventricular ejection fraction from two-dimensional echocardiograms in precapillary pulmonary hypertension.

Precapillary pulmonary hypertension (PH) is characterized by a sustained increase in right ventricular (RV) afterload, impairing systolic function. Two-dimensional (2D) echocardiography is the most performed cardiac imaging tool to assess RV systolic function; however, an accurate evaluation requires expertise. We aimed to develop a fully automated deep learning (DL)-based tool to estimate the RV ejection fraction (RVEF) from 2D echocardiographic videos of apical four-chamber views in patients with precapillary PH. We identified 85 patients with suspected precapillary PH who underwent cardiac magnetic resonance imaging (MRI) and echocardiography. The data was divided into training (80%) and testing (20%) datasets, and a regression model was constructed using 3D-ResNet50. Accuracy was assessed using five-fold cross validation. The DL model predicted the cardiac MRI-derived RVEF with a mean absolute error of 7.67%. The DL model identified severe RV systolic dysfunction (defined as cardiac MRI-derived RVEF<37%) with an area under the curve (AUC) of.84, which was comparable to the AUC of RV fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) measured by experienced sonographers (.87 and.72, respectively). To detect mild RV systolic dysfunction (defined as RVEF ≤ 45%), the AUC from the DL-predicted RVEF also demonstrated a high discriminatory power of.87, comparable to that of FAC (.90), and significantly higher than that of TAPSE (.67). The fully automated DL-based tool using 2D echocardiography could accurately estimate RVEF and exhibited a diagnostic performance for RV systolic dysfunction comparable to that of human readers.

Echocardiographic estimation of right ventricular diastolic stiffness based on pulmonary regurgitant velocity waveform analysis in precapillary pulmonary hypertension.

Right ventricular (RV) diastolic stiffness is an independent predictor of survival and is strongly associated with disease severity in patients with precapillary pulmonary hypertension (PH). Therefore, a fully validated echocardiographic method for assessing RV diastolic stiffness needs to be established. This study aimed to compare echocardiography-derived RV diastolic stiffness and invasively measured pressure-volume loop-derived RV diastolic stiffness in patients with precapillary PH. We studied 50 consecutive patients with suspected or confirmed precapillary PH who underwent cardiac catheterization, magnetic resonance imaging, and echocardiography within a 1-week interval. Single-beat RV pressure-volume analysis was performed to determine the gold standard for RV diastolic stiffness. Elevated RV end-diastolic pressure (RVEDP) was defined as RVEDP ≥ 8 mmHg. Using continuous-wave Doppler and M-mode echocardiography, an echocardiographic index of RV diastolic stiffness was calculated as the ratio of the atrial-systolic descent of the pulmonary artery-RV pressure gradient derived from pulmonary regurgitant velocity (PRPGDAC) to the tricuspid annular plane movement during atrial contraction (TAPMAC). PRPGDAC/TAPMAC showed significant correlation with β (r = 0.54, p < 0.001) and RVEDP (r = 0.61, p < 0.001). A cut-off value of 0.74 mmHg/mm for PRPGDAC/TAPMAC showed 83% sensitivity and 93% specificity for identifying elevated RVEDP. Multivariate analyses indicated that PRPGDAC/TAPMAC was independently associated with disease severity in patients with precapillary PH, including substantial PH symptoms, stroke volume index, right atrial size, and pressure. PRPGDAC/TAPMAC, based on pulmonary regurgitation velocity waveform analysis, is useful for the noninvasive assessment of RV diastolic stiffness and is associated with prognostic risk factors in precapillary PH.

Elevated pulmonary vascular resistance is associated with increased lung transplant waitlist mortality among patients with chronic obstructive pulmonary disease and pulmonary hypertension: a retrospective cohort analysis

BackgroundThe latest European Society of Cardiology and European Respiratory Society guidelines have changed the definition of both pre-capillary pulmonary hypertension (PH) and severe PH in chronic lung disease. The clinical significance of these new criteria are unclear among patients with chronic obstructive pulmonary disease (COPD)-PH. We aim to examine the clinical significance of the new PH definitions with regards to lung transplant waitlist mortality amongst patients with COPD-PH.MethodsThis was a retrospective cohort study of adult patients with COPD-PH listed for lung transplantation. Kaplan–Meier survival analyses were performed comparing patients with newly defined pre-capillary PH to those without pre-capillary PH and comparing patients with severe PH, defined as pulmonary vascular resistance (PVR) > 5 WU, to those without severe PH. Both mean pulmonary artery pressure (mPAP) and PVR were analyzed for potential cut-off points associated with increased waitlist mortality. Predictors of waitlist mortality were identified via Cox regression.ResultsAmong 6495 patients with COPD-PH listed for lung transplantation, pre-capillary PH was not associated with increased waitlist mortality (logrank p = 0.43), while severe PH was (logrank p < 0.001). Both severe PH (HR 1.79, 95% CI 1.22–2.60, p = 0.003) and PVR > 3.9 WU (HR 1.49, 95% CI 1.14–1.95, p = 0.004) were independently and significantly associated with increased waitlist mortality.ConclusionsPVR may serve as a strong predictor of lung transplant waitlist mortality among patients with COPD-PH as compared to other pulmonary hemodynamic parameters when predicting transplant waitlist mortality.

Right ventricular myocardial work by echocardiography: non-invasive assessment of right ventricle function in patients with pulmonary hypertension

Abstract Background Right ventricular myocardial work (RVMW) assessed by transthoracic echocardiography allows to study and analyze the right ventricular (RV) function non-invasively, using RV pressure-strain loops. The association between these novel indexes of RVMW and invasive hemodynamic parameters has not yet been extensively studied, namely in precapillary pulmonary hypertension (PH) population. In right heart catheterization, stroke volume directly reflects right ventricular function in response to its load, and has prognostic implication in PH. Objectives To evaluate the relationship between RVMW and stroke volume index (SVi) measured invasively by right heart catheterization (RHC), in a cohort of patients with group I and group IV PH. Methods A prospective registry of pre-capillary PH patients evaluated in a single tertiary center was used. Echocardiography and RHC were performed in the same day. Dedicated software for left ventricle myocardial work was used for the RV. RV global myocardial work index (RVGWI) was calculated as the area of the RV pressure-strain loops. From RVGWI, RV global constructive work (RVGCW; work contributing to myocardial shortening during systole and lengthening during isovolumic relaxation), RV global wasted work (RVGWW; work contributing to myocardial lengthening during systole and shortening during isovolumic relaxation), and RV global work efficiency (RVGWE; relation between RVGCW and RVGWW) were estimated. Pearson’s correlation was applied to assess correlations between continuous variables. Results 17 pts (80% women, mean age 67 ± 10 years) were included. The average of mean pulmonary arterial pressure (mPAP) was 33 mmHg (± 9,5), of pulmonary vascular resistance (PVR) was 5,7 WU (± 5,1) and of SVi was 40,7 ml/m2 (± 10,8). Conventional echocardiographic parameters for the evaluation of RV systolic function, such as TAPSE, annular tricuspid s’ velocity and fractional area change (FAC), did not correlate with SVi. Moreover, right ventricle-pulmonary artery (RV-PA) coupling and RV GLS also did not correlate with this invasive parameter of right ventricle function. Of the RVMW indexes, RVGWW and RVGWE strongly correlated with SVi: as this invasive parameter decreases, RVGWW (r = -0,560, p = 0,019) increases significantly, whereas RVGWE (r= 0,539, p = 0,026) declines (Fig 1). In our population, RVGWI and RVGCW didn’t correlate significantly with SVi. Conclusions Finding non-invasive methods to evaluate RV function is essential in patients with RV hemodynamic overload, since conventional echocardiographic parameters do not perform well, and RV function is central in prognosis assessment in this population. Novel echocardiographic assessment of RVMW seems to provide a promising index of RV function in PH patients, as demonstrated with its correlation with SVi.Figure 1:Correlation of RVMW with SVi.

Assessing the optimal MAP target in pre-capillary PH patients with RV failure: A retrospective analysis.

Right ventricular failure (RVF) in pre-capillary pulmonary hypertension (PH) is associated with high morbidity and mortality. While mean arterial pressure (MAP) goals have been well established in critical care literature, the optimal MAP target for patients with RVF secondary to pre-capillary PH remains unknown. The objective of this study was to evaluate the difference in outcomes between patients who were managed with different MAP targets. We retrospectively analyzed records of 60 patients who were admitted to the intensive care unit for decompensated RVF secondary to pre-capillary PH. The records were stratified into two groups: 30 patients who were treated with a static MAP goal of either 65 or 70 mmHg (MAP65/70) and 30 patients who received a dynamic MAP goal (MAPCVP) determined by invasively obtained central venous pressure or right atrial pressure. The dynamic MAP group had a statistically significant decrease in in-hospital mortality and incidence of acute kidney injury compared to the static MAP cohort.

The potential of cystatin C as a predictive biomarker in pulmonary hypertension

BackgroundCystatin C is a novel biomarker to identify renal dysfunction and cardiovascular risk.ObjectiveThe aim of this study was to investigate the role of cystatin C in non-invasive risk prediction in a large cohort of patients with pre-capillary pulmonary hypertension (PH).MethodWe retrospectively analyzed pre-capillary PH patients with available cystatin C and hemodynamic data derived from right heart catheterization.ResultsA total of 398 consecutive patients with confirmed pre-capillary PH were recruited from Fuwai Hospital between November 2020 and November 2021. Over a median duration of 282 days, 72 (18.1%) of these patients experienced clinical worsening. Cystatin C levels significantly correlated with cardiac index (r = -0.286, P < 0.001), mixed venous oxygen saturation (r = -0.216, P < 0.001), and tricuspid annular plane systolic excursion (r = -0.236, P < 0.001), and high cystatin C levels independently predicted a poor prognosis after adjusting potential confounders in different models (all P < 0.05). A three-group non-invasive risk model was constructed based on the combined assessment of the cystatin C and WHO-FC using dichotomous cut-off value. Those patients with higher cystatin C (≥ 1.0 mg/L) and a worse WHO-FC experienced the highest risk of endpoint occurrence. The predictive capacity of this model was comparable to that of an existing invasive risk stratification model (area under curve: 0.657 vs 0.643, P = 0.619).ConclusionsCystatin C levels were associated with disease severity and prognosis in patients with pre-capillary PH. A combination of high cystatin C and advanced WHO-FC identifies patients at particularly high risk of clinical deterioration.

Right ventricular myocardial work characterization in patients with pulmonary hypertension and association with pulmonary hypertension severity

Abstract Funding Acknowledgements Type of funding sources: None. Background Right ventricular myocardial work (RVMW) assessed by transthoracic echocardiography allows to study and analyze the right ventricular (RV) function non-invasively, using RV pressure-strain loops. The association between these novel indexes of RVMW and invasive hemodynamic parameters has not yet been extensively studied, namely in precapillary pulmonary hypertension (PH) population. Objectives To evaluate the relationship between RVMW and the severity of PH through invasive indices of right heart catheterization (RHC) in a cohort of patients with group I and group IV PH. Methods A prospective registry of pre-capillary PH patients evaluated in a single tertiary center was used. Echocardiography and right heart catheterization were performed in the same day. Dedicated software for left ventricle myocardial work was used for the RV. RV global myocardial work index (RVGWI) was calculated as the area of the RV pressure-strain loops. From RVGWI, RV global constructive work (RVGCW; work contributing to myocardial shortening during systole and lengthening during isovolumic relaxation), RV global wasted work (RVGWW; work contributing to myocardial lengthening during systole and shortening during isovolumic relaxation), and RV global work efficiency (RVGWE; relation between RVGCW and RVGWW) were estimated. Pearson’s correlation was applied to assess correlations between continuous variables. Results 17 pts (80% women, mean age 67 ± 10 years) were included. Conventional echocardiographic parameters for the evaluation of RV systolic function, such as TAPSE, annular tricuspid s’ velocity and fractional area change (FAC), did not correlate with mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR). Strong correlations were found between right ventricle-pulmonary artery (RV-PA) coupling and mPAP (r = -0,655, p = 0,006) and RVP(r = - 0,610, p = 0,017), as well as with RV GLS (r = 0,749, p = 0,001 and r = 0,622, p = 0,01, respectively). Of the RVMW indexes, RVGWI, RVGWW and RVGWE strongly correlated with mPAP and PVR: as these invasive parameters increase, RVGWI (r = -0,581, p = 0,015 and r = -0,536, p = 0,027, respectively) and RVGWE (r = -0,779, p &amp;lt; 0,001 and r = -0,773, p &amp;lt; 0,001, respectively) decline significantly, whereas RVGWW (r = 0,735, p = 0,001 and r = 0,800, p &amp;lt; 0,001) increases. In our population, only RVGCW didn’t correlate significantly with high afterload (r= −0,304, p = 0,235 for mPAP, and r = -0,181, p = 0,488 for RVP). Conclusions New methods to evaluate RV function are crucial in patients with RV hemodynamic overload, since conventional echocardiographic parameters do not perform well. Novel echocardiographic assessment of RVMW are associated with severity of PH in our population.

Clinical Phenotype and Outcomes of Pulmonary Hypertension Associated with Myeloproliferative Neoplasms: A Population-based Study.

Rationale: Precapillary pulmonary hypertension (PH) is a rare and largely unrecognized complication of myeloproliferative neoplasms (MPNs), including polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (MF). Objectives: To describe characteristics and outcomes of MPN-associated PH. Methods: We report clinical, functional, and hemodynamic characteristics, classification, and outcomes of patients with PV, ET, or primary MF in the French PH registry. Measurements and Main Results: Ninety patients with MPN (42 PV, 35 ET, 13 primary MF) presented with precapillary PH with severe hemodynamic impairment, with a median mean pulmonary arterial pressure and pulmonary vascular resistance of 42 mm Hg and 6.7 Wood units, respectively, and impaired clinical conditions, with 71% in New York Heart Association functional classes III/IV and having a median 6-minute-walk distance of 310 m. Half of the patients were diagnosed with chronic thromboembolic PH (CTEPH); the other half were considered to have group 5 PH. MF was preferentially associated with group 5 PH, whereas PV and ET were generally related to CTEPH. Proximal lesions were diagnosed in half of the patients with CTEPH. Thromboendarterectomy was performed in 18 selected patients with high risk of complications (5 early deaths). Overall survival at 1, 3, and 5 years was 67%, 50%, and 34% in group 5 PH and 81%, 66%, and 42% in CTEPH, respectively. Conclusions: PH is a life-threatening condition potentially occurring in MPN. There are multiple mechanisms, with equal diagnoses of CTEPH and group 5 PH. Physicians should be aware that PH strongly affects the burden of patients with MPN, especially in group 5 PH, with unknown pathophysiological mechanisms.

Effects of ranolazine on right ventricular function, fluid dynamics, and metabolism in patients with precapillary pulmonary hypertension: insights from a longitudinal, randomized, double-blinded, placebo controlled, multicenter study.

Right ventricular (RV) function is a major determinant of outcome in patients with precapillary pulmonary hypertension (PH). We studied the effect of ranolazine on RV function over 6 months using multi-modality imaging and biochemical markers in patients with precapillary PH (groups I, III, and IV) and RV dysfunction [CMR imaging ejection fraction (EF) < 45%] in a longitudinal, randomized, double-blinded, placebo-controlled, multicenter study of ranolazine treatment. Enrolled patients were assessed using cardiac magnetic resonance (CMR) imaging, 11C-acetate and 18-F-FDG positron emission tomography (PET), and plasma metabolomic profiling, at baseline and at the end of treatment. Twenty-two patients were enrolled, and 15 patients completed all follow-up studies with 9 in the ranolazine arm and 6 in the placebo arm. RVEF and RV/Left ventricle (LV) mean glucose uptake were significantly improved after 6 months of treatment in the ranolazine arm. Metabolomic changes in aromatic amino acid metabolism, redox homeostasis, and bile acid metabolism were observed after ranolazine treatment, and several changes significantly correlated with changes in PET and CMR-derived fluid dynamic measurements. Ranolazine may improve RV function by altering RV metabolism in patients with precapillary PH. Larger studies are needed to confirm the beneficial effects of ranolazine.

Clinical relevance and prognostic value of renal Doppler in acute decompensated precapillary pulmonary hypertension.

We aim to evaluate the clinical relevance and the prognostic value of arterial and venous renal Doppler in acute decompensated precapillary pulmonary hypertension (PH). The renal resistance index (RRI) and the Doppler-derived renal venous stasis index (RVSI) were monitored at admission and on Day 3 in a prospective cohort of precapillary PH patients managed in intensive care unit for acute right heart failure (RHF). The primary composite endpoint included death, circulatory assistance, urgent transplantation, or rehospitalization for acute RHF within 90 days following inclusion. Ninety-one patients were enrolled (58% female, age 58 ± 16 years). The primary endpoint event occurred in 32 patients (33%). In univariate logistic regression analysis, variables associated with RRI higher than the median value were non-variable parameters (age and history of hypertension), congestion (right atrial pressure and renal pulse pressure), cardiac function [tricuspid annular plane systolic excursion (TAPSE) and left ventricular outflow tract- velocity time integral], systemic pressures and NT-proBNP. Variables associated with RVSI higher than the median value were congestion (high central venous pressure, right atrial pressure, and renal pulse pressure), right cardiac function (TAPSE), severe tricuspid regurgitation, and systemic pressures. Inotropic support was more frequently required in patients with high RRI (P = 0.01) or high RVSI (P = 0.003) at the time of admission. At Day 3, a RRI value <0.9 was associated with a better prognosis after adjusting to the estimated glomerular filtration rate. Renal Doppler provides additional information to assess the severity of patients admitted to the intensive care unit for acute decompensated precapillary PH.

Prognostic Value of Respiratory Variation in Right Atrial Pressure in Patients With Precapillary Pulmonary Hypertension

Precapillary pulmonary hypertension (PH) is characterized by elevated mean pulmonary artery pressure from increased pulmonary vascular resistance (PVR). Lack of respiratory variation in right atrial pressure (RAP) can be viewed as a surrogate for severe PH and inability of the right ventricle (RV) to tolerate preload augmentation during inspiration. Is the lack of respiratory variation in RAP predictive of RV dysfunction and worse clinical outcomes in precapillary PH? We retrospectively reviewed RAP tracings of patients with precapillary PH who underwent right heart catheterization. Patients with respiratory variation in RAP (end expiratory - end inspiratory) ≤2 mmHg were considered to have effectively no meaningful variation in RAP. Lack of respiratory variation in RAP was associated with lower cardiac index by indirect Fick (2.34±0.09 vs. 2.76±0.1 L/min/m2, p=0.001), lower pulmonary artery saturation (60±1.02% vs 64±1.15%, p=0.007), higher PVR (8.9±0.44 vs 6.1±0.49 Wood units, p<0.0001), RV dysfunction on echocardiography (87.3% vs 38.8%, p<0.0001), higher proBNP (2163±2997 vs 633±402 ng/ml, p<0.0001), and more hospitalizations within 1 year for RV failure (65.4% vs 29.6%, p<0.0001). There was also a trend toward higher mortality at 1 year in patients with no respiratory variation in RAP (25.4% vs 11.1%, p=0.06). Lack of respiratory variation in RAP is associated with poor clinical outcomes, adverse hemodynamic parameters, and RV dysfunction in patients with precapillary PH. Larger studies are needed to further evaluate its utility in prognosis and potential risk stratification in patients with precapillary PH.

Noninvasive prediction of pre-capillary pulmonary hypertension (PH) component in patients with post-capillary PH

Pulmonary hypertension (PH) is a common situation in patients with cardiovascular risk factors and heart failure with preserved ejection fraction (HFpEF). Make the difference between isolated post-capillary PH (IpcPH), combined pcPH (CpcPH) or isolated pre-capillary PH prior to right heart catheterization (RHC) is challenging. However, only pre-capillary PH may benefit from pulmonary arterial hypertension (PAH)-specific therapy. Identify noninvasive parameters that can predict a precapillary component in these patients. Patients with a RHC-confirmed diagnostic of IpcPH or CpcPH [mean pulmonary artery pressure (mPAP) ≥ 20 mmHg, PA wedge pressure (PAWP) > 15 mmHg and pulmonary vascular resistance (PVR) < 3 WU or ≥ 3 WU, respectively] or PAH (mPAP ≥ 20 mmHg, PAWP ≤ 15 mmHg, PVR ≥ 3 WU) and a simultaneous clinical and biological assessment, echocardiography, pulmonary function tests and arterial blood gases, were retrospectively included (discovery cohort). Those with a left ventricular ejection fraction < 50% were excluded. Multivariable logistic regression analysis was used to identify variables associated with a precapillary component and ROC analysis to determine associated thresholds. Based on these results, an algorithm was built and externally validated (validation cohort). In all, 154 patients were included in the discovery cohort: 51 IpcPH, 51 CpcPH and 52 PAH. Median age was 66 years, 62% were female. Multivariable logistic regression and ROC analyses determined a diffusing capacity of the lung for carbon monoxide (DLCO) < 63% of predicted and the ratio of echocardiography-derived tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure (TAPSE/PASP) < 0.37 mm/mmHg as associated with CpcPH compared to IpcPH whereas LVEF ≤ 60% and left atrial dilatation as associated with CpcPH compared to PAH. An algorithm with high sensitivity and negative predictive value to avoid misclassification of patients with pre-capillary PH component in both discovery and validation cohorts is provided (Fig. 1). DLCO and TAPSE/PASP can accurately predict the presence of a precapillary component in patients with suspected PH in HFpEF. The externally validated algorithm may help physicians in the decision-making in case of PH suspicious in those patients.

Povezanost funkcionalnog statusa, nivoa natriuretskih peptida i ehokardiografskih parametara kod bolesnika sa prekapilarnom plućnom hipertenzijom

Introduction/Aim While echocardiography plays an important role in the follow-up of patients with precapillary pulmonary hypertension (PH), several studies have identified World Health Oganization's functional class (WHO FC), 6-minute walk distance (6MWD) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) as the strongest prognostic markers. We investigated the relationship between echocardiographic indices, functional status and NT-proBNP in patients with precapillary PH. Material and Methods A total of 23 patients were included in this retrospective study. Data were collected from routine risk assessments, including WHO FC, 6MWD, NT-proBNP, standard, strain and three-dimensional echocardiography. The echocardiographic data were analysed in terms of the patients' functional status as determined by WHO FC, 6MWD and NT-proBNP values. Results Patients in WHO FC III or IV had a shorter 6MWD [180 (interquartile range 85-240 m)] than patients in WHO FC I or II [409 (interquartile range 364-494 m), p=0.02)], while the difference in NT-proBNP was not statistically significant [FC I or II: 1297 (interquartile range 283-3196) versus FC III or IV: 343 (interquartile range 274-598) pg/ml, p=0.146]. There were inverse correlations between 6MWD and left and right ventricular longitudinal strain and a direct correlation between 6MWD and pulmonary acceleration time (r=0.73; p=0.001). NT-proBNP measurements were directly correlated with right heart dimensions and right ventricular strain and inversely correlated with pulmonary acceleration time (r=-0.70; p=0.004). Conclusion Standard and advanced echocardiographic indices of right ventricular structure, function and hemodynamics correlate with functional status and natriuretic peptide levels in a heterogeneous cohort of patients with precapillary PH and may be useful ancillary parameters in clinical practice.

Different Causes of Functional Tricuspid Valve Regurgitation Are Linked to Differences in Tricuspid Valve and Right-Sided Heart Geometry and Function: 3D Echocardiography Study.

Background and Objectives: The aim of this study was to clarify the tricuspid valve (TV) and right ventricular (RV) geometry and function characteristics using 3D echocardiography-based analysis and to identify echocardiographic predictors for severe tricuspid regurgitation (TR) in different etiologies of functional TR (fTR). Methods and Results: The prospective study included 128 patients (median age 64 years, 57% females): 109 patients with moderate or severe fTR (69-caused by dominant left-sided valvular pathology (LSVP), 40 due to precapillary pulmonary hypertension (PH)), and 19 healthy controls. The 2D and 3D-transthoracic echocardiography analysis included TV, right atrium, RV geometry, and functional parameters. All the RV geometry parameters as well as 3D TV parameters were increased in both fTR groups when compared to controls. Higher RV diameters, length, areas, volumes, and more impaired RV function were in PH group compared to LSVP group. PH was associated with larger leaflet tenting height, volume, and more increased indices of septal-lateral and major axis tricuspid annulus (TA) diameters. LVSP etiology was associated with higher anterior-posterior TA diameter and sphericity index. Univariate and multivariate logistic regression and ROC analyses revealed that different fTR etiologies were associated with various 2D and 3D echocardiographic parameters to predict severe TR: major axis TA diameter and TA perimeter, the leaflet tenting volume had the highest predictive value in PH group, septal-lateral systolic TA diameter-in LSVP group. The 3D TA analysis provided more reliable prediction for severe fTR. Conclusions: TV and RV geometry vary in different etiologies of functional TR. Precapillary PH is related to more severe RV remodeling and dysfunction and changes of TV geometry, when compared to LSVP group. The 3D echocardiography helps to determine echocardiographic predictors of severe TR in different fTR etiologies.

733 NT-PROBNP CONCENTRATIONS ACROSS PULMONARY HYPERTENSION GROUPS

Abstract Background Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) are found in both pre-capillary pulmonary hypertension (PH), including pulmonary arterial hypertension, PH associated with hypoxia/lung disease and chronic thromboembolic pulmonary hypertension, and post-capillary PH associated with left heart disease. We asked the question of whether NT-proBNP concentrations differ among these PH subtypes. Methods Based on right heart catheterization (RHC) data collected at our institution between Jan. 2019 and Dec. 2021, 146 patients were classified as no PH, pre-capillary PH, isolated post-capillary PH (iPC-PH) or combined pre- and post-capillary PH (cPC-PH) according to the 2022 ESC/ERS guidelines (GL). NT-proBNP values were compared across PH groups by Kruskal-Wallis test with Bonferroni correction. The characteristics of subjects with pre-capillary PH and NT-proBNP ≤ or &amp;gt;1.100 pg/mL, a cut-off for severity proposed by the 2022 GL, were compared by chi-square test, T-test, or Mann-Whitney test, as appropriate. We also applied the hemodynamic definitions of the 2018 6th World Symposium on PH (6WSPH) and of the 2015 GL, examined the differences in the distribution of PH groups with the McNemar test, and reassessed NT-proBNP concentrations. Results 44 (30%) of patients did not have PH, 38 (26%) had pre-capillary PH, 18 (12%) had iPC-PH, and 46 (32%) had cPC-PH. NT-proBNP levels were progressively higher from pre-capillary PH to iPC-PH to cPC-PH (Figure). Interestingly, the 25th percentile of the cPC-PH group was 1.138 pg/mL, close to the 1.100 pg/mL cut-off. Compared with patients with pre-capillary PH and NT-proBNP ≤1.100 pg/mL, those with &amp;gt;1.100 pg/mL NT-proBNP had larger right ventricle basal diameter [50 (43-53) vs 43 (36-45) mm; p=0.02], lower TAPSE/sPAP ratio [0.21 (0.15-0.25) vs 0.35 (0.25-0.43), p=0.01], more often massive tricuspid regurgitation (83% vs 20%, p&amp;lt;0.001), higher pulmonary vascular resistance [9.5 (7.6-15.1) vs 5.7 (2.7-7.8) WU; p=0.004], and lower stroke volume index [28 (17-32) vs 36 (32-50) mL/m2; p=0.002]. The proportion of no PH decreased and the one of cPC-PH increased when the 6WSPH or the 2015 GL criteria were used (p for trend &amp;lt;0.001). Nonetheless, the trend of NT-proBNP remained similar to that observed with the 2022 GL definitions (Figure). Conclusions A gradient of NT-proBNP exists across PH groups, with the highest values being in cPC-PH. The concentrations of NT-proBNP in severe pre-capillary PH overlap with those in cPC-PH, indirectly confirming the validity of this biomarker to discriminate the severity of pre-capillary PH.

Prevalence and risk prediction value of tricuspid regurgitation by echocardiography in precapillary pulmonary hypertension

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

Tricuspid valve geometry alterations in different aetiologies of functional regurgitation: 3D echocardiography study

Abstract Introduction Evaluation of tricuspid annulus (TA) has many challenges due to its complex three-dimensional shape. The 3D-echocardiography is a gold standard method for accurate assessment of tricuspid valve (TV). Studies investigating TV geometry in different aetiologies of tricuspid regurgitation (TR) are still scarce. Aim The aim was to clarify the TV geometry characteristics in different aetiologies of functional TR (FTR). Methods Prospective observational cohort study enrolled 107 patients with functional moderate or severe TR and 10 healthy controls. FTR patients were divided into two groups according to the different aetiology of FTR: 1. TR caused by dominant left-sided valvular pathology (LSVP) – 68 patients (pts); 2. TR caused by precapillary pulmonary hypertension (PH) (invasively measured pulmonary capillary wedge pressure &amp;lt;15 mmHg) – 39 pts. Pts with ischemic heart disease (assessed by coronary angiography) were excluded from the analysis. The 3D-transthoracic echocardiography was performed and included the following parameters: the systolic and diastolic 4-chambers (septal–lateral), 2-chambers (anterior–posterior), major axis TA diameters, TA area, perimeter, leaflets tenting height and volume. All parameters have been indexed to body surface area. The 3D TV analysis was made using 4D Auto TVQ quantification software package (GE Healthcare, USA). The statistical analysis was performed using SPSS statistical software. Results Study cohort included 66% females; mean age was 65±11 years. TR severity, measured quantitatively, did not differ between FTR groups (ERA – 32±18 in LSVP vs 35±18 mm2 in PH group, p=0.219). The distribution of echocardiography parameters in study groups are shown in Table 1. All the 3D TV parameters were increased in both FTR groups when compared to controls. Precapillary PH was associated with larger leaflets tenting height, volume, and more increased indices of TA systolic and diastolic septal-lateral and major axis diameters. LVSP aetiology was associated with higher TA sphericity index. Conclusions Tricuspid valvular geometry differs between different aetiologies of functional TR. The implementation of 3D echocardiography is useful in the determination of TV geometry changes and might provide valuable tools in the evaluation of patients with functional TR. Funding Acknowledgement Type of funding sources: None.

Clinical Characteristics of Patients Undergoing Right Heart Catheterizations in Community Hospitals.

BackgroundRecognition of precapillary pulmonary hypertension (PH) has significant implications for patient management. However, the low a priori chance to find this rare condition in community hospitals may create a barrier against performing a right heart catheterization (RHC). This could result in misclassification of PH and delayed diagnosis/treatment of precapillary PH. Therefore, we investigated patient characteristics and echocardiographic parameters associated with the decision whether to perform an RHC in patients with incident PH in 12 Dutch community hospitals.Methods and ResultsIn total, 275 patients were included from the OPTICS (Optimizing PH Diagnostic Network in Community Hospitals) registry, a prospective cohort study with patients with incident PH; 157 patients were diagnosed with RHC (34 chronic thromboembolic PH, 38 pulmonary arterial hypertension, 81 postcapillary PH, 4 miscellaneous PH), while 118 patients were labeled as probable postcapillary PH without hemodynamic confirmation. Multivariable analysis showed that older age (>60 years), left ventricular diastolic dysfunction grade 2–3, left atrial dilatation were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension‐associated conditions, right atrial dilatation, and tricuspid regurgitation velocity ≥3.7 m/s favor an RHC performance.ConclusionsOlder age and echocardiographic parameters of left heart disease were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension‐associated conditions, right atrial dilation, and severe PH on echocardiography favored an RHC performance. As such, especially elderly patients may be at an increased risk of diagnostic delays and missed diagnoses of treatable precapillary PH, which could lead to a worse prognosis.

Determinants of altered left ventricular suction in pre-capillary pulmonary hypertension.

Although the left ventricular (LV) dysfunction in pre-capillary pulmonary hypertension (PH) has been recently recognized, the mechanism of LV dysfunction in this entity is not completely understood. We thus aimed to elucidate the determinants of intraventricular pressure difference (IVPD), a measure of LV suction, in pre-capillary PH. Right heart catheterization and echocardiography were performed in 86 consecutive patients with pre-capillary PH (57 ± 18 years, 85% female). IVPD was determined using colour M-mode Doppler to integrate the Euler equation. In overall, IVPD was reduced compared to previously reported value in normal subjects. In univariable analyses, QRS duration (P = 0.028), LV ejection fraction (P = 0.006), right ventricular (RV) end-diastolic area (P < 0.001), tricuspid annular plane systolic excursion (P = 0.004), and LV early-diastolic eccentricity index (P = 0.009) were associated with IVPD. In the multivariable analyses, RV end-diastolic area and LV eccentricity index independently determined the IVPD. Aberrant ventricular interdependence caused by RV enlargement could impair the LV suction. This study first applied echocardiographic IVPD, a reliable marker of LV diastolic suction, to investigate the mechanism of LV diastolic dysfunction in pre-capillary PH.

Mild pulmonary hemodynamic alterations in patients with systemic sclerosis: relevance of the new 2022 ESC/ERS definition of pulmonary hypertension and impact on mortality

Background and objectiveThe definition of pre-capillary pulmonary hypertension (PH) has been modified, with lowering of the mean pulmonary arterial pressure (mPAP) threshold from 25 to 20 mmHg and addition of a mandatory criterion of pulmonary vascular resistance (PVR) ≥ 2 Wood units (WU). Our objectives were: 1/ to estimate the proportion of patients reclassified as having pre-capillary PH when using the new 2022 ESC/ERS hemodynamic criteria (i.e. mPAP 21-24 mmHg and PVR ≥ 2 WU), and to describe their clinical characteristics and outcome; and 2/ to study the relationship between PVR and survival in patients with mPAP > 20 mmHg.MethodsWe retrospectively analyzed consecutive SSc patients included in our National Reference Center for a first right-heart catheterization between 2003 and 2018. The association between survival and PVR was studied using smoothing splines.ResultsWe included 126 SSc patients with mPAP > 20 mmHg. Among them, 16 (13%) had a baseline mPAP value between 21 and 24 mmHg and PVR ≥ 2 mmHg and were reclassified as pre-capillary PH; 10 of which (62%) raised their mPAP ≥ 25 mmHg during follow-up. In patients with mPAP > 20 mmHg, we observed a linear relation between PVR and mortality for values < 6 WU.ConclusionA significant proportion of SSc patients is reclassified as having pre-capillary PH with the new 2022 ESC/ERS hemodynamic definition. Lowering the PVR threshold from 3 to 2 WU captures patients at risk of raising their mPAP > 25 mmHg, with a possibly less severe disease.