Right Atrial Pressure In Patients Research Articles

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.

Assessment of right atrial function in inferior wall AMI

Background: Approximately 30–50% of patients with inferior infarction have some involvement of the right ventricle. The right ventricular (RV) infarction almost invariably develops in association with a large infarction of the adjacent septum and inferior 0 walls, but isolated infarction of the right ventricle is seen in just 3–5% of autopsy-proven cases of MI. This study is designed to assess the right atrial (RA) functions in inferior wall acute myocardial infarction (AMI) (IWMI) echocardiographically and to compare it with patients who do not have history of ischemic heart disease (IHD) but having risk factors for IHD.  Aims and Objectives: The aims of this study were to study the patients presenting with Inferior wall MI IWMI for RA function. Materials and Methods: Patients admitted in the Cardiology ward of R G Kar Medical College and Hospital with IWMI from March 2020 to March 2022 were included in the study. Results: Average Measurement of RA volume index (RAVI) and RA Pressure (RAP) was highest among patients with IWMI+RV myocardial infarction (RVMI). Out of 100 IWMI patients, 33 had high RAVI and RAP and out of 100 non-IHD patients none had high RAVI. Conclusion: In our study, there was no statistically significant difference in average RAVI and RAP in patients presenting with IWMI and in patients with risk factors for myocardial infarction but without AMI. However, patients presented with IWMI+RVMI showed statistically significant increased RAVI and RAP as compared to inferior wall AMI only.

Role of Inferior Vena Cava Dynamics for Estimating Right Atrial Pressure in Congenital Heart Disease.

Inferior vena cava (IVC) size and collapsibility (IVC dynamics) are used for estimating right atrial pressure (RAP). However, the diagnostic performance of the American Society of Echocardiography IVC criteria for estimating RAP in patients with congenital heart disease are unknown. The purpose of this study was to assess the role of IVC dynamics for estimating RAP in adults with congenital heart disease. We conducted a retrospective study of adults with congenital heart disease that underwent cardiac catheterization and echocardiogram at Mayo Clinic (2003-2019). IVC diameter was measured at inspiration (IVCmin) and end-expiration (IVCmax), and IVC collapsibility index (IVCCI) was calculated. Based on 918 patients, we observed a good correlation between IVCmax and invasive RAP (r=0.56, P<0.001); IVCmin and RAP (r=0.58, P<0.001); and IVCCI (r=-0.72, P<0.001). There was excellent correlation between invasive RAP and estimated RAP using IVCCI (r=0.80, P<0.001). We observed that IVCCI <60% had superior diagnostic performance as compared with American Society of Echocardiography criteria (IVCmax >2.1 cm, area under the curve difference 0.15, P<0.001; IVCCI <50%, area under the curve difference 0.09, P=0.008; combination of IVCmax >2.1 cm; and IVCCI <50%, area under the curve difference 0.06, P=0.02). Estimated RAP >10 mm Hg based on IVCCI had comparable prognostic performance as invasive RAP but superior prognostic performance as the American Society of Echocardiography criteria. IVCCI <60% was the best criterion to identify patients with elevated RAP. IVCCI was comparable to invasively measured RAP in its relation to prognosis. Further studies are required to determine whether the use of IVCCI in clinical decision-making will improve clinical outcomes in this population.

Effect Of Tricuspid Regurgitation On Decongestion And Right Atrial Pressure Changes In Patients With Decompensated Heart Failure

<h3>Background</h3> Tricuspid Regurgitation (TR) is a common risk factor for acute decompensated heart failure (ADHF). However, less is known about the impact of TR on the response of non-invasive indices of decongestion such as weight loss/fluid loss, and right atrial pressure (RAP) to diuretic therapy. We examined these associations in patients hospitalized with ADHF. <h3>Methods</h3> We studied 54 consecutive advanced HF patients admitted for ADHF, who underwent two right heart catheterizations during their hospitalization. These patients also had two-dimensional echocardiographic (TTE) assessments performed during the same hospitalization. <h3>Results</h3> Most patients were African American (65%), men (77%) with a mean age of 58 years. Twenty-one (39%) patients had at least moderate and severe TR (mod-sev TR) vs 33 (61%) had no to mild TR (no-mild TR). Compared to patients with mod-sev TR, those with no-mild TR had similar mean weight loss (3.7 ± 7.7 vs. 3.7 ± 7.6 kg, <i>p</i>=0.35) and similar mean fluid loss of (7.8 ± 8.7 vs. 8 ± 9 liters, <i>p</i>=0.62). The 2 groups had similar mean RAP at baseline (no-mild TR 15 ± 7.8 mm Hg; mod-sev TR 16 ± 5.9 mm Hg; <i>p=</i>0.59). They also had similar changes in mean RAP after diuresis (-5.8 ± 8.9 mm Hg vs. -6.6 ± 6.9 mm Hg, <i>p</i>=0.72). There was modest correlation noted between net fluid loss and weight loss in no-mild TR group (<i>r=</i>0.44; <i>p=</i>0.01) whereas no correlation was noted between net fluid loss and weight loss in mod-sev group (<i>r=</i>0.86; <i>p</i>=0.99). There was also no correlation between change in weight and change in RAP (no-mild TR <i>r=</i>0.12; <i>p=</i>0.51; mod-sev TR <i>r=</i>0.11; <i>p=</i>0.68) or change in fluid balance and change in RAP (no-mild TR <i>r=</i>0.01; <i>p</i>=0.95; mod-sev TR <i>r=</i>0.35; <i>p</i>=0.94) in either group. <h3>Conclusion</h3> In patients with advanced heart failure admitted with acute decompensation, there is no effect of TR on decongestion or changes in RAP as conventional noninvasive methods to assess decongestion such as change in weight and in fluid balance, poorly reflect changes in RAP in patients with no-mild TR and those with mod-sev TR. This warrants a need to identify novel non-invasive markers of decongestion in patients admitted with acute decompensated heart failure.

Abstract 10952: Increased Hepatic T1 Mapping Prediction of Elevated Right Atrial Pressure in Patients with Dilated Cardiomyopathy

Introduction: Elevated right atrial pressure (RAP) exhibits residual congestion and poor clinical outcomes in patients with heart failure (HF). In HF patients, persistent high RAP causes liver damage, which leads to liver fibrosis. Recent advances in T1 mapping of the liver using MRI allow the quantification of liver fibrosis. Hypothesis: Hepatic T1 mapping value may predicts high RAP in patients with chronic HF. Methods: We examined the data from the consecutive 40 patients with DCM ( 60 ± 13 years, 27 men) who underwent 3 Tesla cardiac and liver MRI, which were conducted within seven days of right heart catheterization. RV end-diastolic volume (RVEDV), end-systolic volume (RVESV), RV ejection fraction (RVEF), right atrial (RA) and left atrial (LA) volume, left ventricular end-diastolic volume (LVEDV), end-systolic volume (LVESV), LV ejection fraction (LVEF) and LV mass index (LVMI) were calculated from cine cardiac MRI. Native T1 mapping image (T1 short modified look locker inversion recovery-ShMOLLI- sequence) was acquired the heart and the liver (Figure A). Patients were divided into two groups according to RAP; high ( ≥ 8 mmHg; n=10) and low ( &lt;8 mmHg; n=30). Results: Ten patients had high RAP. There were no significant differences in LVEDV,LVESV, LVEF, LVMI, RVEDV, RVESV and RVEF between patients with high RAP group and those without ( 192 ± 54 ml vs 212 ± 57 ml; 136 ± 49 ml vs 154 ± 51 ml; 30 ± 9 % vs 28 ± 8 %; 79 ± 21 g/m 2 vs 81 ± 22 g/m 2 ; 45 ± 27 ml vs 46 ± 19 ml; 27 ± 18 ml vs 25 ± 15 ml; 42 ± 19% vs 46 ± 18%, respectively). The hepatic T1 mapping value was higher in the high RAP group ( 845 ± 47 ms vs 759 ± 90 ms, p &lt; 0.01) and exhibited a positive correlation with RAP ( R = 0.34, P &lt; 0.05). The hepatic T1 mapping value of ≥ 820ms was the optimal cutoff values for identifying high RAP ( T1: sensitivity, 89%; specificity, 72%; AUC, 0.80, Figure B). Conclusion: Increased native T1 mapping value of the liver may be helpful in non-invasively estimating elevated RAP.

The prediction of right atrial pressure using electrocardiogram: a novel approach.

AimsPulmonary hypertension (PH) is a serious disorder that can complicate pulmonary and cardiovascular diseases. Right atrial (RA) pressure is a robust predictor of the pulmonary hypertension severity, which is measured via right heart catheterization. Limited studies have been carried out to assess the association between electrocardiogram data and the RA pressure as a prognostic factor of PH. In this study, the relation between P wave and PR segment changes with RA pressure was evaluated.Methods and resultsIn this study, 94 patients in PH groups of 1, 3, and 4, based on the World Health Organization classification, were entered. RA pressure was measured using the right heart catheterization. PR segment and P wave morphology in leads II and V1 were evaluated in patient's electrocardiogram. The median age of the patients was 35.5 years old in which 64.9% of them were female. The distribution of patients in groups 1, 3, and 4 PH were 77.7%, 5.3%, and 17%, respectively. Among the studied P wave and PR segment changes, PR segment depression in lead II and pulmonary P wave in lead V1 had significant relation with the RA pressure (P‐value <0.001). The sensitivity, specificity, and negative predictive values of PR segment depression for detection of patients with high RA pressure (RA pressure > 14 mmHg) were 80%, 84%, and 94%. The specificity and negative predictive values of pulmonary P wave in lead V1 were determined 89% and 88%.ConclusionsIt was found that the PR segment depression in lead II and pulmonary P wave in lead V1 associate with the RA pressure in patients with precapillary PH. PR segment depression had useful sensitivity, specificity, and negative predictive values, and the pulmonary P wave in lead V1 had acceptable specificity and negative predictive values for detection of patients with high RA pressure. Therefore, the electrocardiogram can be used as a screening tool for determination of pulmonary hypertension severity.

Impact of New Grading System and New Hemodynamic Classification on Long-Term Outcome in Patients With Severe Tricuspid Regurgitation.

A new grading of tricuspid regurgitation (TR) beyond severe has been proposed. However, few studies assessing the validity of such a new grading scheme of TR have been conducted. Therefore, we evaluated associations of TR grades beyond severe with patient outcome and hemodynamics. We retrospectively studied patients who underwent 2-dimensional echocardiography and were diagnosed with severe TR between January 2014 and December 2015. According to the vena contracta width of TR (VC), the patients were classified into 2 groups: VC under 14 mm (VC<14 mm) and VC 14 mm or greater (VC≥14 mm). Hemodynamic parameters were estimated by echocardiography and were obtained by right heart catheterization. Cardiovascular events were defined as cardiovascular death or admission for heart failure. A total of 679 patients (mean 72±17 years, 56% women) were included. During follow-up (median, 158 days; range, 29-891), 210 patients experienced cardiovascular events. By multivariate analysis, VC≥14 mm and left ventricular ejection fraction were independent predictors of cardiovascular events (hazard ratio, 1.57 [1.06-2.33]; hazard ratio, 0.99 [0.98-0.99], respectively). Patients with VC≥14 mm had significantly lower cardiac index (median, 1.8 versus 2.1 L/min per m2, P=0.001) and a higher prevalence of right atrial pressure 15 mm Hg (74% versus 60%, P<0.001) on echocardiography. Also, right heart catheterization confirmed higher right atrial pressure in patients with VC≥14 mm than those with VC<14 mm (16±8 versus 12±6 mm Hg, P=0.004). The new subset classification developed by cardiac index and right atrial pressure both on echocardiography predicted cardiovascular events (Log-rank P<0.001). The relationship of VC≥14 mm to adverse outcome and poor hemodynamics showed the clinical relevance and need of a new grading system beyond severe. The new hemodynamic subset classification provides additional prognostic value for cardiovascular events in patients with severe TR.

Change in Fibrosis-4 index Is Associated With Change in Right Atrial Pressure in Patients With Acute Heart Failure

Change in Fibrosis-4 index Is Associated With Change in Right Atrial Pressure in Patients With Acute Heart Failure

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.

Liver stiffness obtained by ElastPQ ultrasound shear wave elastography independently determines mean right atrial pressure.

We aimed to investigate the relationship between right atrial pressure (RAP) and liver stiffness (LS) determined by liver elastography (LE) during cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and conventional pacemaker (PM) implantation in patients without HF. 60 patients with HF who underwent CRT and 60 patients without HF who underwent PM were enrolled. Routine echocardiography and laboratory examinations were performed. Systolic, diastolic, and mean RAP measurements were performed inversely during PM implantation and LS measurement with ElastPQ technique. Systolic, diastolic, and mean RAP, left ventricular (LV) systolic-diastolic, right ventricular (RV) diastolic and left atrial diameters, tricuspid regurgitation pressure gradient, and RV-myocardial performance index (MPI) values were significantly higher in patients with HF (p < 0.05 each-one). LV ejection fraction and tricuspid annular plane systolic excursion values were significantly lower in patients with HF group (p < 0.05 each-one). LS values and inspiratory (Ins) and expiratory inferior vena cava (IVC) diameters were significantly higher in the patients with HF (p < 0.05 each-one). Mean RAP was found to be closely related to LS value, Ins-IVC diameter, RV-MPI, and NT-proBNP levels. LS value and Ins-IVC diameter were found to determine patients with mean RAP > 5mmHg and > 10mmHg. When the cut-off value of LS was taken as 7kPa, it was found that the mean RAP > 10mmHg with 89.6% sensitivity and 87.5% specificity. The non-invasive LS value determined by LE independently determines the mean RAP in patients with and without HF. According to our study results, > 7kPa value for LS determined in liver US may be predictive for increased mean RAP.

Echocardiographic surrogates of right atrial pressure in pulmonary hypertension

Right atrial pressure (RAP), a representative parameter of right heart failure, is very important for prognostic evaluation and risk assessment in pulmonary hypertension. However, its measurement requires invasive cardiac catheterization. In this study, we determined the most accurate echocardiographic surrogate of catheterization-based RAP. In 23 patients with pulmonary hypertension, a total of 66 cardiac catheterization procedures were performed along with 2-dimensional echocardiography. We evaluated tricuspid E/A, E', A' and E/E', and estimated RAP by the respirophasic variation of the inferior vena cava diameter (eRAP-IVCd) as possible surrogates of catheterization-based RAP. In simple linear regression analysis, E/A (R = 0.452, P = 0.0001) and eRAP-IVCd (R = 0.505, P < 0.0001) were positively correlated with catheterization-based RAP, whereas A' (R = - 0.512, P < 0.0001) was negatively correlated with RAP. In multiple regression analysis, A' was the most significant independent predictor of catheterization-based RAP (R = - 0.375, P = 0.0007). In 16 patients who had multiple measurements, there were a total of 43 measurements before and after medication changes. The absolute change in catheterization-based RAP was negatively correlated with the percent change in A'. Receiver operating characteristic curve analysis indicated that the optimal cut-off value of A' to predict a catheterization-based RAP > 10mmHg was 11.3cm/s (area under the curve = 0.782, sensitivity = 0.70, specificity = 0.78). In 20 measurements of 20 patients with left heart failure, catheterization-based RAP was not correlated with any of 5 echocardiographic parameters. However, it was closely correlated with catheterization-based pulmonary capillary wedge pressure. The echocardiographic parameter, A', was the best surrogate of catheterization-based RAP in patients with pulmonary hypertension.

Clinical Correlates and Prognostic Value of Elevated Right Atrial Pressure in Patients With Hypertrophic Cardiomyopathy

The clinical characteristics associated with elevated right atrial pressure (RAP) in hypertrophic cardiomyopathy (HCM) are unknown. Few data exist as to whether elevated RAP has prognostic implications in patients with HCM. This study investigated the clinical correlates and prognostic value of elevated RAP in HCM.Methods and Results:This retrospective cohort study was performed on 180 patients with HCM who underwent right heart catheterization between 1997 and 2014. Elevated RAP was defined as >8 mmHg. Baseline characteristics, mean pulmonary artery pressure, and mean pulmonary capillary wedge pressure (PCWP) were assessed for association with elevated RAP. The predictive value of elevated RAP for all-cause mortality and the development of atrial fibrillation (AF), ventricular tachycardia/fibrillation (VT/VF), and stroke was evaluated. Elevated RAP was associated with higher New York Heart Association class, dyspnea on exertion, orthopnea, edema, jugular venous distention, larger left atrial size, right ventricular hypertrophy, higher pulmonary artery pressure, and higher PCWP. RAP independently predicted all-cause mortality (adjusted hazard ratio [aHR] 2.18 per 5-mmHg increase, 95% confidence interval [CI] 1.05-4.50, P=0.04) and incident AF (aHR 1.85 per 5-mmHg increase, 95% CI 1.20-2.85, P=0.005). Elevated RAP did not predict VT/VF (P=0.36) or stroke (P=0.28). Elevated RAP in patients with HCM is associated with left-sided heart failure and is an independent predictor of all-cause mortality and new-onset AF.

Implications of Correcting for Right Atrial Pressure in Patients With Severe Aortic Stenosis Undergoing Fractional Flow Reserve

Implications of Correcting for Right Atrial Pressure in Patients With Severe Aortic Stenosis Undergoing Fractional Flow Reserve

Inferior vena cava diameter in acute decompensated heart failure as predictor of all-cause mortality.

Inferior vena cava (IVC) diameter can be used to approximate right atrial pressure in patients admitted for acute decompensated heart failure (ADHF). Recent studies linked IVC dilation to an increased risk of early re-admission and short-term mortality. Moreover, renal insufficiency (RI) is an established risk factor for mortality in ADHF and is associated with congestion. We hypothesized that the IVC diameter is a marker of all-cause mortality but its prognostic impact may be influenced by kidney function. We analyzed data of 1101 patients admitted for ADHF with available echocardiography of the IVC by chart review and death registry linkage. Patients were dichotomized according to a cut-off value of 21mm. Cox proportional hazards model was used to identify mortality predictors. A dilated IVC was detected in 474 (43.1%) patients. Overall, 400 (36.3%) patients died within 3 years. All-cause mortality was significantly higher in patients with dilated IVC [hazard ratio 1.45 (confidence interval 1.21-1.74); p < 0.001]. However, a dilated IVC was only associated with all-cause mortality in patients with RI function [hazard ratio 1.60 (confidence interval 1.26-2.03); p < 0.001] but not in patients with a preserved kidney function [hazard ratio 1.04 (confidence interval 0.72-1.50); P = 0.84]. IVC diameter was identified as an independent predictor for all-cause mortality in a Cox proportional hazards model with a significant interaction between IVC diameter and baseline kidney function. In conclusion, IVC dilation is a marker of high mortality risk in patients admitted for ADHF. However, this observation was confined to patients with RI.

Precision of Echocardiographic Estimates of Right Atrial Pressure in Patients with Acute Decompensated Heart Failure

Several methods that estimate right atrial pressure (RAP) from echocardiographic parameters have been proposed. However, their precision (i.e., how much they decrease RAP estimation uncertainty) is unknown. The aim of this prospective study was to evaluate and compare the precision of previously proposed RAP estimates in patients with acute decompensated heart failure. Echocardiographic and invasive hemodynamic data were acquired in 75 patients with acute decompensated heart failure. Measurements were made at the start and 48 to 72 hours after the beginning of treatment. RAP was estimated by method 1, using the cutoffs defined by inferior vena cava diameter (IVCd) and IVCd percentage change (IVCd%change) during inspiration, and by method 2, using IVCd%change and systolic to diastolic hepatic flow ratio (S/Dhep). Method 3 was used in patients with sinus rhythm, using the ratio of early tricuspid inflow and early diastolic tissue Doppler tricuspid annular velocities (E/E'ta). RAP was also estimated by resting IVCd, IVCd during inspiration, IVCd%change, right ventricular regional isovolumetric relaxation time, E/E'ta, right atrial volume index, S/Dhep, right ventricular Tei index, right ventricular E/A, and right atrial emptying fraction. Precision gain was measured as the difference between the standard deviation of RAP and the standard error of the estimate of RAP. Method 1 (r= 0.48, P < .05), IVCd during inspiration (r= 0.49, P < .0001), IVCd%change (r= 0.41, P<.0001) and IVCd (r= 0.40, P < .0001) had the highest correlation with RAP. The highest gain in precision was also observed with the above methods (9%, 13%, 9%, and 8%, respectively). All other parameters had poor correlation with RAP. In patients with advanced heart failure, echocardiographic RAP prediction methods showed only modest precision. Furthermore, none of the tested methods resulted in clinically relevant improvements of RAP estimates. Estimating RAP from a single IVCd measurement is at least as precise as using complex prediction methods.

Usefulness of Transient Elastography for Noninvasive and Reliable Estimation of Right-Sided Filling Pressure in Heart Failure

Accurate noninvasive assessment of right atrial pressure (RAP) is important for volume management in patients with heart failure (HF). Transient elastography is a noninvasive and reliable method to assess liver stiffness (LS). We investigated the value of LS for evaluation of RAP in patients with HF without structural liver disease. We measured LS using transient elastography (Fibroscan) in 31 patients undergoing right-sided cardiac catheterization (test group). The relation between LS and RAP found in the test group was used to derive the best-fit model to predict RAP. The applicability of the model was then tested in a validation group of 49 additional patients. There was an excellent correlation between LS and RAP in the test group (r = 0.95, p <0.0001; RAP = -5.8 + 6.7 × ln [LS]). Natural log transformation (ln) of LS provided the regression equation to predict RAP. When the equation model derived from the test group was applied to the validation group, predicted RAP correlated excellently with actual RAP (r = 0.90, p <0.0001). The receiver operating characteristic curve analyses in the test group showed that LS favorably compared with echocardiography for detecting RAP >10 mm Hg (area under the curve 0.958 vs 0.800, respectively, p = 0.047). In the validation group, LS with a cut-off value of 10.6 kPa for identifying RAP >10 mm Hg had a higher sensitivity and accuracy (p = 0.046 and p = 0.049, respectively) than echocardiography. In conclusion, LS may offer an accurate noninvasive diagnostic method to assess RAP in patients with HF.

Independent Prognostic Value of Right Atrial Pressure in Patients with Congestive Heart Disease

When significant pulmonary hypertension (PH) develops in association with left-sided heart disease (LHD), it leads to poor prognosis. Up to the present, mean pulmonary arterial pressure (mPAP) and right ventricular (RV) ejection fraction are reported as a predictor of survival. We sought a better understanding of the hemodynamic parameters in the patients with pulmonary arterial wedge pressure (PCW) ≥ 15 mmHg. It might improve the accuracy of the prognostic stratification of patients with congestive heart failure.

The Index of Microvascular Resistance (IMR) and Its Relationship to Left Ventricle End Diastolic Pressure and Right Atrial Pressure in Patients With Moderate Epicardial Coronary Artery Disease

Introduction and purpose: This was a prospective study of patients undergoing coronary angiography with moderate coronary artery disease using the index of microvascular resistance (IMR) to quantify microvascular function. In hypertensive heart disease and hypertrophic cardiomyopathy it is thought that elevated left heart filling pressures (LVEDP) is partially responsible for microvascular dysfunction observed in these patients. The purpose of this study was to evaluate correlations between right atrial pressure and left ventricular end diastolic pressure with microvascular dysfunction as measured by the index of microvascular resistance. It was hypothesised that higher RAP and higher LVEDP would be positively associated with worse microvascular function. The IMR is a validated, functional, quantitative assessment tool of the coronary microcirculation. Methods: The study enrolled 44 patients with moderate epicardial coronary artery disease and evaluated these patients right atrial pressures and left ventricular end diastolic pressure at the same time as invasively measuring the index of microvascular. Results: Statistical analysis demonstrated that right atrial pressure as well as LVEDP was poorly correlated with IMR and this did not reach statistical significance (p values of 0.35 and 0.96 respectively). Interestingly, the right atrial pressure was positively correlated (0.544) with left ventricular end diastolic pressure and this reached statistical significance (p = 0.0001). Conclusions: In this study there was no statistically significant correlation between LVEDP, RAP and IMR value. Microvascular function was shown to be independent of right atrial pressure and left ventricle end diastolic pressure. It is evident that coronary microvascular function is complex and warrants further evaluation.

Assessment of right atrial pressure using echocardiography and correlation with catheterization

Right ventricular systolic pressure is crucial for both treatment and prognosis of cardiovascular and pulmonary diseases. The proper measurement of right ventricular systolic pressure depends on an accurate estimation of right atrial pressure (RAP). There is no standard method for estimating RAP noninvasively. The purpose of this study was to compare different noninvasive methods, namely, inferior vena cava (IVC) size and inspiratory collapse, tissue Doppler derived E/E' (TV E/E') for estimating RAP, and their correlation with catheter-based measurements in patients with mitral valve stenosis with atrial fibrillation (AF) or normal sinus rhythm (NSR). The study group consisted of 39 patients (13 men, mean age 58.9 ± 11.8 years) with rheumatic mitral valve stenosis. We performed cardiac catheterization and transthoracic echocardiography on all patients. Mean RAP measured by catheterization was 9.7 ± 3.8 mmHg. No correlation was found between RAP and TV E/E' ratio, but there was a significant correlation between RAP and IVC diameter (r = 0.51, p < 0.05). Seventeen patients (43.6%) were in AF and 22 patients (56.4%) were in NSR. There was no correlation between TV E/E' ratio and RAP in patients with AF and in patients with NSR. RAP was correlated with collapsibility index in patients with AF (r = 0.56, p < 0.05). RAP was significantly correlated with IVC diameter (r = 0.62, p < 0.005) and collapsibility index (r = 0.49, p < 0.05) in patients with NSR. The combination of IVC diameter and collapsibility index is a simple a semiquantitative approach that might provide a better estimation of RAP.

Noninvasive Estimation of Right Ventricular Filling Pressure by Ratio of Early Tricuspid Inflow to Annular Diastolic Velocity in Patients with and Without Recent Cardiac Surgery

Few data are available on the evaluation of right ventricular (RV) diastolic function and filling pressures by echocardiography. We aimed to determine whether the ratio of early tricuspid inflow to annular diastolic velocity (E/E') could be used to estimate RV filling pressure in patients with and without recent cardiac surgery. In all, 101 data sets including invasive and echocardiographic measurements (42 after recent cardiac surgery) were simultaneously obtained from patients in the intensive care department. Tissue Doppler measurements were performed from the tricuspid annulus. E/E' was related to catheter right atrial pressure (RAP) measurements. E/E' correlated only moderately with RAP early after cardiac surgery (r = .41, P = .007), whereas E/E' correlated strongly with RAP in patients without cardiac surgery (r = .83, P < .0001). The sensitivity and specificity of E/E' 4 or greater were 88% and 85% for RAP 10 mm Hg or greater in patients who were not in the postcardiac surgery status (receiver operating characteristic area 0.93 [95% confidence interval: 0.86-0.99]) but 44% and 73% early after cardiac surgery (receiver operating characteristic area 0.56 [95% confidence interval: 0.37-0.75]). E/E' correlated more strongly with RAP when the RV systolic function was impaired. In repeated measurements from 12 patients, an increase of greater than 2 in E/E' was associated with an increase of 5 mm Hg or more in the RAP with a sensitivity of 67% and a specificity of 89%. E/E' is useful for noninvasive estimation of RV filling pressure and to detect serial changes in a wide range of clinical conditions but is a weak correlate of RAP early after cardiac surgery and in patients with normal RV function.