Predictor Of Pulmonary Capillary Wedge Pressure Research Articles

Left atrial strain rate during atrial contraction predicts raised pulmonary capillary wedge pressure: evidence for left atrio-ventricular interaction

This study aimed to assess the relationship between different LA strain components and PCWP as well as to the relationship with other established methods. We studied 144 symptomatic patients, age 63 ± 14 years, 54 males, using conventional transthoracic echocardiography protocols, including LA and LV myocardial deformation from speckle tracking technique investigations along with simultaneous right heart catheterization (RHC) using established techniques. From RHC, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) were measured and pulmonary vascular resistance (PVR) calculated. LA strain rate during atrial contraction (LASRa) was the strongest correlate with PCWP (r2 = − 0.40, p < 0.001), over and above both LASR during LV systole (LASRs) and LA longitudinal strain during ventricular systole (LASs) (r2 = 0.21 and 0.19, respectively, p < 0.001 for both). The correlation between LASRa and PCWP was stronger in patients with post-capillary PH compared to pre-capillary PH (r2 = 0.21 vs. r2 = 0.02, respectively). The strongest relationship between LASRa and PCWP was in patients with enlarged LA volume > 34 ml/m2 (r2 = 0.60, p < 0.001). In all patients LASRa < = 0.9 1/s was 88% accurate in predicting LA pressure > 15 mmHg which was superior to recently proposed uni- and multi-variable models. LASR during atrial contraction is the strongest predictor of PCWP, particularly in patients with post-capillary PH and with dilated LA cavity. Furthermore, it proved superior to recently proposed uni- and multi-variable based algorithms. Its close relationship with LV strain rate counterpart reflects important left heart chamber interaction in patients with raised LA pressure.

Compromised left atrial function and increased size predict raised cavity pressure: a systematic review and meta-analysis.

This meta-analysis assesses left atrial (LA) cavity and myocardial function measurements that predict pulmonary capillary wedge pressure (PCWP). PubMed-MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Central Registry were searched up to December 2018 for studies on the relationship of LA diameter, LA indexed volume (LAVI max, LAVI min), peak atrial longitudinal (PALS), peak atrial contraction (PACS) strain and total emptying fraction (LAEF) with PCWP. Eighteen studies with 1343 patients were included. Summary sensitivity and specificity (with 95% CI) for evaluation of diagnostic accuracy and the best cut-off values for different LA indices in predicting raised PCWP were estimated using summary receiver operating characteristic analysis. The pooled analysis showed association between PCWP and LA diameter: Cohen's d=0·87, LAVI max: d=0·92 and LAVI min: d=1·0 (P<0·001 for all). A stronger correlation was found between PCWP and PALS: d=1·26, and PACS: d=1·62, total EF d=1·22 (P<0·0001 for all). PALS ≤19% had a summary sensitivity of 80% (65-90) and summary specificity of 77% (52-92), positive likelihood ratio (LR+) 3·74, negative likelihood ratio (LR-) <0·25 and DOR>15·1 whereas LAVI ≥34mlm-2 had summary sensitivity of 75% (55-89) and summary specificity 77% (57-90), with LR+ >3, LR- 0·32 and DOR >10·1. Compromised LA myocardial function and increased size predict raised cavity pressure. These results should assist in optimum follow-up of patients with fluctuating LA pressure.

Noninvasive estimation of pulmonary capillary wedge pressure in patients with mitral regurgitation: A speckle tracking echocardiography study

BackgroundEchocardiographic parameters to predict pulmonary capillary wedge pressure (PCWP) in mitral regurgitation (MR) are not yet elucidated. We reported that PCWP could be accurately estimated by novel KT index which is defined as log10[left atrial (LA) emptying function (EF)/LA volume]. We examined the usefulness of the KT index as a predictor of PCWP in primary and secondary MR with sinus rhythm and also MR with atrial fibrillation. MethodsLA dimension, strain, volume, EF, and E/e′ were measured in moderate to severe MR with sinus rhythm (n=58, age: 67±8 years) and MR with atrial fibrillation (n=24, age: 69±11 years) just before catheterization and in normal subjects (n=26, age: 67±11 years) using speckle tracking echocardiography. MR with sinus rhythm was divided into primary MR (n=27) and secondary MR (n=31). The estimated PCWP (ePCWP) was calculated as 10.8–12.4×KT index. ResultsThere was a correlation between PCWP and LA dimension, E/e′, minimum LA volume index, active LAEF, total LAEF, or LA strain (r=0.32, r=0.31, r=0.55, r=−0.61, r=−0.51, and r=−0.50, respectively, p<0.05). The better correlation was found between PCWP and ePCWP in MR including both primary and secondary MR and also MR with atrial fibrillation (r=0.70, r=0.67, and r=0.58, respectively, p<0.01). Multiple regression analysis revealed that ePCWP was an independent predictor of PCWP in MR. The ePCWP demonstrated good diagnostic accuracy (area under the curve of 0.86) and sensitivity (81%) and specificity (71%) to predict elevated PCWP >15mmHg using a cut-off of 16mmHg. ConclusionThe ePCWP was the reliable echocardiographic parameter to predict PCWP in primary and secondary MR and might also be useful in MR with atrial fibrillation. The ePCWP may have an incremental value in a clinical setting.

Tissue Doppler-Derived Myocardial Acceleration during Isovolumetric Contraction Predicts Pulmonary Capillary Wedge Pressure in Patients with Significant Mitral Regurgitation

The aim of this study was to determine whether isovolumic contraction velocity (IVV) and acceleration (IVA) predict pulmonary capillary wedge pressure (PCWP) in mitral regurgitation. Forty-four patients with mitral regurgitation were studied. PCWP was invasively measured. IVV, IVA and the ratio IVRT/Te′–E (where IVRT = isovolumic relaxation time, and Te′–E = time difference between the onset of mitral annular e′ and mitral flow E waves) were measured. Mean age was 59.2 ± 13.3 y. Twenty-six patients had an ejection fraction ≥55%, and 18 patients had an ejection fraction <55%. IVRT/Te′–E was impossible in 11 patients because Te′–E = zero. PCWP correlated with IVV, IVA and IVRT/Te′–E; overall (r = −0.714, −0.892 and, −0.752, all p < 0.001), ejection fraction ≥55 (r = −0.467, −0.749, −0.639, p = 0.016, <0.001, 0.003) and ejection fraction <55% (r = −0.761, −0.911 and −0.833, all p < 0.001). Similar correlations were found for sinus and atrial fibrillation. Our study suggests that IVV and IVA correlate with PCWP in patients with mitral regurgitation irrespective of systolic function or rhythms and, thus, can be alternatives to the tedious IVRT/Te′–E, especially when impossible because Te′–E = 0.

COMBINED ATRIOVENTRICULAR LONGITUDINAL STRAIN RATE DURING ISOVOLUMIC CONTRACTION PREDICTS PULMONARY CAPILLARY WEDGE PRESSURE IN PATIENTS WITH SYSTOLIC DYSFUNCTION

BACKGROUND Reportedly, mitral annular velocities derived by tissue Doppler imaging (TDI)-during isovolumic contraction (IVV) can predict pulmonary capillary wedge pressure (PCWP) in heart failure patients with depressed ejection fraction (EF). We investigated the use of color TDI-derived left atrial (LA) and left ventricular (LV) longitudinal strain rate (SR) during isovolumic contraction (IC) to predict the invasively measured PCWP. METHODS AND RESULTS Forty patients referred with symptoms of heart failure were prospectively studied [age: 56±8 years, 12 (30%) females, and mean LVEF: 51±14%]. PCWP was measured invasively immediately after echocardiography. Mitral annular IVV was measured for all patients and SR during the IC and ejection were measured for the LV (LVSR-IC, LVSR-Ej) as well as the LA (LASR-IC, and LASR-Ej). Atrioventricular SR during IC and Ej (AVSR-IC, AVSR-Ej) was calculated as the sum of the LV and LA values. Patients were classified and compared based on their EF into 19 (49%) with EF≥55%, and 21 (51%) with EF<55%. No significant differences were noted for age, sex, risk factors, and medications between both patients with EF≥55% and EF<55%. Compared to EF≥55%, patients with EF<55% had lower IVV (4.63±1.2 vs. 7.01±1.9 cm/s, P<0.001), LVSR-Ej (1±0.3 vs. 1.2±0.2, P=0.03), LASR-IC (1.3±0.6 vs. 1.9±1, P=0.03), LASR-Ej (1.5±0.5 vs. 2.6±1.3 s-1, P=0.001), AVSR-IC (2±0.8 vs. 2.7±1.06 s-1, P=0.023), and AVSR-Ej (2.5±0.6 vs. 3.9±1.1 s-1, <0.001). LVSR-IC, LVSR-Ej, LASR-IC, AVSR-IC, and IVV correlated with PCWP in only in EF<55%, with the strongest correlation noted for AVSR-IC (r=-0.72, <0.001). Other correlates with PCWP in EF<55% were E/e' and left atrial volume (r=0.47, 0.7, P=0.04, 0.001; respectively). Multivariate regression revealed that in patients with EF<55% AVSR-IC was the only independent predictor of PCWP. Finally, IVV correlated with LVSR-IC and LASR-IC and this correlation became strongest with AVSR-IC (r=0.77, 0.001). CONCLUSION The combined LV and LA longitudinal SR during IC as represented by AVSR-IC showed a strong correlation with PCWP in patients with depressed EF. The correlation between mitral annular IVV and PCWP in those patients can be a product of this combination and may a function of atrioventricular mechanical coupling.

A novel minimally-invasive technique to predict pulmonary capillary wedge pressure utilizing jugular venous pressure and the tissue Doppler tricuspid/mitral annular velocities

Purpose: Accurate prediction of left heart filling pressure is critical to the management of patients with Heart Failure (HF). However, reliability of conventional prediction such as the ratio of early transmitral velocity to tissue Doppler mitral annular early diastolic velocity (E/Ea) is not satisfactory. Purpose of this study was to validate our newly developed technique to predict Pulmonary Capillary Wedge Pressure (PCWP) utilizing Jugular Venous Pressure (JVP) and the ratio of tissue Doppler peak systolic velocity of the tricuspid annulus (St) to that of the mitral annulus (Sm). Methods: In 10 anesthetized closed-chest dogs, PCWP and JVP were measured through catheters. St, Sm and E/Ea were measured by trans-thoracic tissue Doppler echocardiography. PCWP, JVP, St, Sm and E/Ea were recorded over a variable preload range in normal heart, in left HF induced by coronary artery embolization, and in right HF induced by pulmonary artery embolization. Results: Regression analysis of pooled 146 data sets indicated that PCWP (2–40 mmHg) and E/Ea (3–14) correlated weakly (Figure A), while PCWP and JVP·St/Sm (-1–32mmHg) correlated tightly (Figure B). Receiver-operating characteristic (ROC) analysis identified cutoffs that maximized the sum of sensitivity and specificity for detecting PCWP > 18 mmHg (Figure C). E/Ea >6 had 89% sensitivity and 73% specificity. JVP·St/Sm >11 mmHg had 90% sensitivity and 90% specificity. Area under ROC curve for JVP·St/Sm (0.94) was significantly larger than that for E/Ea (0.79) (p<0.001). ![Figure][1] Figure 1 Conclusions: JVP corrected by the relation between right and left ventricular functions, JVP·St/Sm, accurately predicts PCWP. Our technique to predict PCWP may be useful in the management of HF patients. [1]: pending:yes

Noninvasive estimation of pulmonary capillary wedge pressure using speckle tracking echocardiography in patients with preserved or reduced ejection fraction

Purpose: Echocardiographic parameters such as a ratio of early mitral inflow velocity (E) to atrial contraction flow velocity (A) and a ratio of E to mitral annular tissue velocity (e') were proposed to estimate left ventricular (LV) diastolic function and pulmonary capillary wedge pressure (PCWP). However, E/A and E/e' have limitations to use in various conditions. Noninvasive estimation of PCWP has not been elucidated. We have recently developed a novel index to estimate PCWP using left atrial (LA) emptying function (EF) and volume (LAV) assessed by speckle tracking echocardiography (STE) and named it kinetics-tracking (KT) index: log (active LAEF/ minimum LAV index). The estimated PCWP (ePCWP) was determined as 10.7 – 12.4 × KT index. The aim was to examine the usefulness of KT index in patients with preserved or reduced ejection fraction to estimate PCWP measured by cardiac catheterization. Methods: We measured phasic LAV and EF obtained from time-LA volume curves by STE during sinus rhythm in consecutive 128 patients (age 67±12, 80 men, 77 patients with LV ejection faction ≥55%) just before cardiac catheterization. Patients with atrial fibrillation, severe mitral regurgitation and mitral stenosis were excluded. LA volume and EF and E/e' were compared with PCWP measured by cardiac catheterization. Moreover, ePCWP estimated by 4 combinations of LA maximum or minimum volume and LA total or active EF was compared with PCWP by cardiac catheterization. Results: The maximum and minimum LAV index were correlated with PCWP (r=0.71 and r=0.78, respectively, p 15 mmHg were 95 and 88%, respectively (AUC = 0.97) using KT index of 17.8 as an optimal cutoff value. In multivariate regression analysis, only KT index was an independent parameter to estimate PCWP by cardiac catheterization in 128 subjects. Conclusions: For noninvasive estimation of LV diastolic function, the KT index is a novel and more accurate predictor of PCWP than LA function, volume solely or E/e'. KT index have an incremental value in routine clinical practice.

Can the left ventricular early diastolic tissue-to-blood time interval be used to identify a normal pulmonary capillary wedge pressure?

The pulsed Doppler early diastolic left ventricular (LV) tissue (e)-blood (E) onset temporal relationship (e-E) is suggested to predict pulmonary capillary wedge pressure (PCWP), through the formulas: tau = 32 + 0.7(e-E) and PCWP = LV end-systolic pressure x e(-IVRT/tau). Small changes/errors in E could influence the quotient IVRT/tau by oppositely affecting IVRT and e-E. At rest in 50 healthy individuals we noted: e-E: 2 +/- 14 ms; IVRT: 89 +/- 17 ms; calculated tau: 33 +/- 10 ms; and PCWP: 9 +/- 9 mmHg (> 12 mmHg in 28%). Non-pharmacological preload alterations in 14 individuals rendered an intraindividual 'PCWP'-fluctuation of up to 40 mmHg. This application may therefore not be clinically robust.

Determination of Pulmonary Capillary Wedge Pressure Using Pulsed Wave Doppler Echocardiography: Clinical Application of Range Ambiguity Phenomenon

To predict pulmonary capillary wedge pressure (PCWP) noninvasively, several Doppler combination indices have been developed. Recently, a fair correlation has been found between the time constant of isovolumic left ventricular (LV) relaxation (tau) and pulsed wave Doppler LV inflow propagation velocity (LVIPVpw) derived through the application of range ambiguity phenomenon. In the measurement of LVIPVpw, we can simultaneously measure the peak phantom E-wave velocity (Ep) from the same heartbeat. Hence, it is hypothesized that Ep/LVIPVpw is a useful index in predicting PCWP. In all, 29 patients who underwent elective cardiac catheterization for suggested coronary artery disease were included. Mean PCWP (mPCWP) obtained from right heart catheterization was compared with echocardiographic data before and 5 minutes after sublingual application of nitroglycerin (0.6 mg). Nitroglycerin caused a significant decrease in Ep and mPCWP, but not in LVIPVpw (P < .001, P < .001, and P = .687, respectively). By stepwise multiple linear regression analysis, only the Ep/LVIPVpw (beta = 0.832, P < .001) was the independent predictor of mPCWP. After nitroglycerin intake, the change in mPCWP was significantly correlated with the change in Ep/LVIPVpw (r = 0.455, P = .015). The sensitivity and specificity of Ep/LVIPVpw > 0.74 in predicting mPCWP > 15 mm Hg were 78% and 90%, respectively (area under curve 0.86). In conclusion, Ep/LVIPVpw derived from the same heartbeat provides a good estimate of mPCWP and can be used to rapidly track the change in mPCWP.