The Diagnostic Accuracy of Doppler Echocardiography in Assessment of Pulmonary Artery Systolic Pressure: A Meta‐Analysis

Background: Transthoracic echocardiography is commonly used to estimate pulmonary arterial systolic pressure (PASP) and to diagnose pulmonary hypertension (PH). However, some recent studies have questioned the accuracy of Doppler echocardiography (DE) in the assessment of PASP. The present meta‐analysis was performed to estimate the accuracy, sensitivity, and specificity of DE in the assessment of PASP. Methods: A literature search and data extraction of English and non‐English articles reported from May 1984 to January 2009 was performed independently by 2 investigators using MEDLINE and EMBASE databases. Articles were included if they compared DE with right heart catheterization (RHC) in the assessment of PASP. Nine articles met our criteria and were included in our meta‐analysis. We conducted a meta‐analysis of the results of these articles using fixed‐ and random‐effect models to estimate the accuracy, sensitivity, and specificity of DE in the assessment of PASP. Results: The correlation between PASP estimated by DE and RHC ranged from (r = 0.65, P < 0.001) to (r = 0.97, P < 0.001). The pooled sensitivity, specificity, and accuracy of DE for the diagnosis of PH were 88% (95% confidence interval [CI], 84–92%), 56% (95% CI, 46–66%), and 63% (95% CI, 53–73%), respectively. Conclusion: DE is a useful noninvasive modality to screen for PH and can reliably determine whether PASP is normal, mildly elevated, or markedly elevated. However, abnormal results from DE need to be confirmed by RHC.     

Pulmonary hypertension in interstitial lung disease: Limitations of echocardiography compared to cardiac catheterization

Background and objective

In interstitial lung disease (ILD), pulmonary hypertension (PH) is a major adverse prognostic determinant. Transthoracic echocardiography (TTE) is the most widely used tool when screening for PH, although discordance between TTE and right heart catheter (RHC) measured pulmonary haemodynamics is increasingly recognized. We evaluated the predictive utility of the updated European Society of Cardiology/European Respiratory Society (ESC/ERS) TTE screening recommendations against RHC testing in a large, well‐characterized ILD cohort.

Methods

Two hundred and sixty‐five consecutive patients with ILD and suspected PH underwent comprehensive assessment, including RHC, between 2006 and 2012. ESC/ERS recommended tricuspid regurgitation (TR) velocity thresholds for assigning high (>3.4 m/s), intermediate (2.9–3.4 m/s) and low (<2.8 m/s) probabilities of PH were evaluated against RHC testing.

Results

RHC testing confirmed PH in 86% of subjects with a peak TR velocity >3.4 m/s, and excluded PH in 60% of ILD subjects with a TR velocity <2.8 m/s. Thus, the ESC/ERS guidelines misclassified 40% of subjects as ‘low probability’ of PH, when PH was confirmed on subsequent RHC. Evaluating alternative TR velocity thresholds for assigning a low probability of PH did not significantly improve the ability of TR velocity to exclude a diagnosis of PH.

Conclusion

In patients with ILD and suspected PH, currently recommended ESC/ERS TR velocity screening thresholds were associated with a high positive predictive value (86%) for confirming PH, but were of limited value in excluding PH, with 40% of patients misclassified as low probability when PH was confirmed at subsequent RHC.

     

Predictors of persistent pulmonary hypertension after mitral valve replacement

Persistent pulmonary hypertension (P-PH) after mitral valve replacement (MVR) leads to an increased risk of morbidity and mortality. We sought to determine which factors were involved in its occurrence. Patients undergoing MVR for a 3-year period were collected in a retrospective way. We excluded those with an available follow-up shorter than 3 months. Sample size was 111 patients. PH was diagnosed if systolic pulmonary artery pressure (sPAP) estimated by Doppler echocardiography was >40 mmHg. Clinical, echocardiographic, and surgical factors were analyzed. P-PH was present in 42.3 % of patients after 12.6 months of mean follow-up. P-PH was more frequently observed in elderly and female patients, in those with severe degrees of PH before surgery, and significant tricuspid regurgitation (TR). On multivariable analysis, significant TR (OR 1.739; p = 0.01) and more severe degrees of PH before surgery (OR 1.761; p = 0.03) were significantly associated with the presence of P-PH after MVR. Surgical factors related to P-PH were prosthesis size and tricuspid annuloplasty: no need for the performing of tricuspid annuloplasty (OR 0.345; p = 0.025) and the implantation of a smaller prosthesis (OR 0.656; p = 0.004) were related to higher rates of P-PH after MVR. MVR was associated with high prevalence of P-PH after mid-term follow-up. Both PH and significant TR before surgery were associated with P-PH. Our data point out that MVR should be planned before the development of PH and greater TR. Smaller prosthetic size is also a risk factor for P-PH and bigger prostheses are desirable when possible.     

Echocardiographic Screening for Pulmonary Hypertension in Stable COPD Out-Patients and NT-proBNP as a Rule-Out Test

Abstract

Pulmonary hypertension (PH) worsens the prognosis in chronic obstructive pulmonary disease (COPD). The diagnosis of PH is established by right heart catheterisation (RHC), while echocardiography can be used for screening. We aimed to asses the outcome of echocardiographic screening for PH in a group of stable COPD out-patients, and to evaluate NT-proBNP as a first line screening tool. Criteria for PH on echocardiography were a tricuspid regurgitation pressure gradient > 40 mmHg, a tricuspid annular plane systolic excursion < 1.8 cm or right ventricular dilatation. Positively screened patients were asked to undergo RHC. Results (Mean ± SEM): 16 of 117 patients (14%) had PH on echocardiography. They had a higher mortality (hazard ratio for death: 2.7 ± 1.3, p = 0.037) and lower six minute walk test (224 ± 33 vs. 339 ± 15, p = 0.006). NT-proBNP below 95 ng/l excluded PH on echocardiography with a negative predictive value of 100 (95% CI: 89–100%). RHC was obtained in six patients screened positive. In three of these, PH was not confirmed. Conclusions: Signs of PH on echocardiography as defined here was found in 14% and had prognostic significance in COPD. A value of NT-proBNP less than 95 ng/l may be used to exclude signs of PH.     

Non-invasive evaluation of systolic pressure of the pulmonary artery in patients with tricuspid regurgitation, using Doppler echocardiography

STUDY OBJECTIVE: To quantify the systolic pulmonary artery pressure (SPAP) by continuous wave Doppler echocardiography and record the prevalence of tricuspid regurgitation (TR). DESIGN: Prospective analysis of 42 patients (pts), submitted to right heart catheterization (RHC). SETTING: Pts referred to the Echocardiographic Laboratory at Sta. Marta Hospital - H.C.L. PATIENTS: Sequential sample of 42 pts with several cardiac pathologies, subjected to RHC and 2D Doppler Echocardiography. INTERVENTIONS: The right ventricular and SPAP were recorded in the hemodynamic exam. We considered pulmonary hypertension (PH) if SPAP was greater than 35 mmHg or mean pressure greater than 20 mmHg. The pts were divided into two groups: I-pts without PH and II-pts with PH. The 2D Doppler echocardiography was made within 24 H of the hemodynamic one. Peak gradient (pg) of TR and the correlation with catheterization data were analysed. RESULTS: Hemodynamic--The mean SPAP in the sample was 46 +/- 21.5 mmHg (27 +/- 4.6 in group I and 55 +/- 20.2 mmHg in II). In 35 pts with TR the mean SPAP was 50.3 +/- 21.2 mmHg. Doppler--The pressure gradient was 40 +/- 18.7 mmHg. 57% pts of the group I and 96% II had TR p less than 0.001. The correlation between Doppler gradient and SPAP was r = 0.95, and no change was noted when 7 is used as a constant. CONCLUSION: Continuous wave Doppler echocardiography is a non invasive technic useful to the quantitative analysis of SPAP.     

Utility of echocardiography in assessment of pulmonary hypertension secondary to COPD.

Studies have confirmed the close correlation of echocardiographically estimated pulmonary arterial pressure with invasive measurements in patients with chronic obstructive pulmonary disease (COPD), but there are few data on utility of echocardiographic measurement in assessing pulmonary arterial hypertension (PH) in COPD and correlation with pulmonary function tests. Presence or absence of tricuspid regurgitation (TR) was determined by Doppler echocardiography in 73 consecutive COPD patients attending a hospital outpatient clinic. Transtricuspid pressure gradient (TTPG) was calculated. PH was defined as TTPG > or =30 mmHg. Patients also underwent spirometry, forced expiratory volume in one second (FEV1), single breath gas transfer (carbon monoxide transfer coefficient; (K(CO)) and carbon monoxide diffusing capacity of the lung; D(L,CO)) and arterial blood gas measurement. Measurable TR was observed in 56/73 patients (77%). There were no differences between the group in which TR was observed compared to that in which it was absent, with regard to age, smoking history nor pulmonary function variables. PH was seen in 31/56 cases (55%), with good reproducibility. There were statistically significant correlations of TTPG with FEV1 (r=-0.26, p=0.05), Kco (r=-0.31, p=0.04) and D(L,CO) (r = -0.42, p = 0.006) expressed as % pred. Stepwise regression analysis showed that age and K(CO) combined provide a multivariate model for prediction of TTPG. It is concluded the presence and degree of pulmonary arterial hypertension is readily and reliably determined by echocardiography in the majority of chronic obstructive pulmonary disease patients. Pulmonary arterial hypertension is common in severe chronic obstructive pulmonary disease and transtricuspid pressure gradient correlates with spirometry and indices of gas transfer, similar to previous invasive studies. In view of the adverse effects of pulmonary arterial hypertension on morbiditv and mortality routine echocardiography in patients with severe chronic obstructive pulmonary disease may be warranted.     

Solving the Pulmonary Hypertension Paradox in Patients With Severe Tricuspid Regurgitation by Employing Artificial Intelligence

ObjectivesThis study aimed to improve echocardiographic assessment of pulmonary hypertension (PH) in patients presenting with severe tricuspid regurgitation (TR).BackgroundEchocardiographic assessment of PH in patients with severe TR carries several pitfalls for underestimation, hence concealing the true severity of PH in very sick patients in particular, and ultimately obscuring the impact of PH on survival after transcatheter tricuspid valve intervention (TTVI).MethodsAll patients in this study underwent TTVI for severe TR between 2016 and 2020. To predict the mean pulmonary artery pressure (mPAP) solely based on echocardiographic parameters, we trained an extreme gradient boosting (XGB) algorithm. The derivation cohort was constituted by 116 out of 162 patients with both echocardiography and right heart catheterization data, preprocedurally obtained, from a bicentric registry. Moreover, 142 patients from an independent institution served for external validation.ResultsSystolic pulmonary artery pressure was consistently underestimated by echocardiography in comparison to right heart catheterization (40.3 ± 15.9 mm Hg vs 44.1 ± 12.9 mm Hg; P = 0.0066), and the assessment was most discrepant among patients with severe defects of the tricuspid valve and impaired right ventricular systolic function. Using 9 echocardiographic parameters as input variables, an XGB algorithm could reliably predict mPAP levels (R = 0.96, P < 2.2 × 10^-16). Moreover, patients with elevations in predicted mPAP levels ≥29.9 mm Hg showed significantly reduced 2-year survival after TTVI (58.3% [95% CI: 41.7%-81.6%] vs 78.8% [95% CI: 68.7%-90.5%]; P = 0.026). Importantly, the poor prognosis associated with elevation in predicted mPAP levels was externally confirmed (HR for 2-year mortality: 2.9 [95% CI: 1.5-5.7]; P = 0.002).ConclusionsPH in patients with severe TR can be reliably assessed based on echocardiographic parameters in conjunction with an XGB algorithm, and elevations in predicted mPAP levels translate into increased mortality after TTVI.     

Midterm Clinical and Echocardiographic Results of a Modified De Vega Tricuspid Annuloplasty for Repair of Functional Tricuspid Regurgitation

Background

There is an ongoing debate whether the tricuspid valve (TV) should be repaired with a suture annuloplasty or a prosthetic ring.

Methods

Two hundred thirty-seven patients underwent a modified De Vega tricuspid annuloplasty for tricuspid regurgitation (TR) as part of the cardiac surgical procedure. Follow-up information was obtained for 230 patients, with a mean follow-up time of 6.5 ± 3.2 years. Analysis is based on Doppler echocardiographic evaluation. Survival and development of recurrent TR were evaluated by Kaplan-Meier analysis. Risk factors for recurrent TR were identified and analyzed by multivariable ordinal longitudinal methods.

Results

No deaths had occurred at the time of follow-up. Early predischarge echocardiography quantified TR as 1+ in 227 patients (95.8%), 2+ in 8 patients (3.4%), and 3+ in 2 patients (0.8%). No patients had TR classified as 4+. The mean TR grade decreased from 3.4 ± 0.2 preoperatively to 1.6 ± 0.6 on predischarge echocardiography (P < 0.01). During follow-up, the most recent echocardiogram showed TR was 1+ in 88.3% of patients, 2+ in 10.4% of patients, 3+ in 1.3% of patients, and 4+ in 0% of patients, with a small increase in mean TR compared with predischarge echocardiography. No patient required TV reoperation. Risk factor analysis revealed that higher preoperative regurgitation grade, higher systolic pulmonary arterial pressure (sPAP), and preoperative New York Heart Association (NYHA) grade IV were independent predictors of recurrent TR. Five-year actuarial freedom from congestive heart failure (CHF) and late TR were 86.7% ± 2.4% and 88.5% ± 0.2%, respectively.

Conclusions

A modified De Vega suture annuloplasty was effective at eliminating TR and producing right ventricular (RV) reverse remodelling at 5-year follow-up, although TR tends to increase with time.     

Value of Echocardiographic Right Ventricular and Pulmonary Pressure Assessment in Predicting Transcatheter Tricuspid Repair Outcome

ObjectivesThe aim of this study was to assess the value of echocardiographic right ventricular (RV) and systolic pulmonary artery pressure (sPAP) assessment in predicting transcatheter tricuspid edge-to-edge valve repair (TTVR) outcome.BackgroundRV dysfunction and pulmonary hypertension are associated with poor prognosis and are systematically sought during tricuspid regurgitation evaluation. The value of echocardiographic assessment in predicting TTVR outcome is unknown.MethodsData were taken from the TriValve (Transcatheter Tricuspid Valve Therapies) registry, which includes patients undergoing TTVR at 14 European and North American centers. The primary outcome was 1-year survival free from hospitalization for heart failure, and secondary outcomes were 1-year survival and absence of hospital admission for heart failure at 1 year.ResultsOverall, 249 patients underwent TTVR between June 2015 and 2018 (mean tricuspid annular plane systolic excursion [TAPSE] 15.8 ± 15.3 mm, mean sPAP 43.6 ± 16.0 mm Hg). Tricuspid regurgitation grade ≥3+ was found in 96.8% of patients at baseline and 29.4% at final follow-up; 95.6% were in New York Heart Association functional class III or IV initially, compared with 34.3% at follow-up (p < 0.05). Final New York Heart Association functional class did not differ among TAPSE and sPAP quartiles, even when both low TAPSE and high sPAP were present. Rates of 1-year survival and survival free from hospitalization for heart failure were 83.9% and 78.7%, respectively, without significant differences according to baseline echocardiographic RV characteristics (TAPSE, fractional area change, and end-diastolic area) and sPAP (p > 0.05 for all).ConclusionsTTVR provides clinical improvement, with 1-year survival free from hospital readmission >75% in patients with severe tricuspid regurgitation. Conventional echocardiographic parameters used to assess RV function and sPAP did not predict clinical outcome after TTVR.     

Exercise capacity in idiopathic pulmonary fibrosis: the effect of pulmonary hypertension

Background and objective: Increased pulmonary arterial pressure (PAP) usually coexists with impaired lung function in IPF. Data on the effect of pulmonary hypertension (PH) on cardiopulmonary responses during exercise in IPF patients is very limited. We sought to investigate the impact of PH on exercise capacity and the correlation between systolic PAP (sPAP) and pulmonary function testing, as well as cardiopulmonary exercise parameters, in patients with IPF and PH. Methods: Eighty‐one consecutive patients with IPF, who were evaluated over a 6‐year period, were retrospectively studied. Patients underwent pulmonary function testing, Doppler echocardiography and maximal cardiopulmonary exercise testing. PH was defined as sPAP > 35 mm Hg. Results: PH was diagnosed in 57% of the patients. Categorization of patients according to severity of PH indicated a significant reduction in maximum work rate, peak O₂ uptake, anaerobic threshold and peak O₂ pulse in those with sPAP > 50 mm Hg. In IPF patients with PH, estimated sPAP correlated with peak O₂ uptake, anaerobic threshold, peak O₂ pulse and end‐tidal CO₂ at anaerobic threshold, while the strongest correlation was between sPAP and ventilatory equivalent for CO₂ at anaerobic threshold (r = 0.611, P < 0.001). There were no differences in pulmonary function or exercise parameters indicative of lung volume reduction, across the patient categories, and none of these parameters correlated with sPAP. Conclusions: PH has a negative impact on exercise capacity in IPF patients. In IPF patients with PH, resting sPAP correlated with exercise parameters indicative of gas exchange and circulatory impairment, but not with defective lung mechanics.     

Noninvasive model including right ventricular speckle tracking for the evaluation of pulmonary hypertension

AIM To find parameters from transthorathic echocardiography(TTE) including speckle-tracking(ST) analysis of the right ventricle(RV) to identify precapillary pulmonary hypertension(PH).METHODS Forty-four patients with suspected PH undergoing right heart catheterization(RHC) were consecutively included(mean age 63.1 ± 14 years, 61% male gender). All patients underwent standardized TTE including ST analysis of the RV. Based on the subsequent TTE-derived measurements, the presence of PH was assessed: Left ventricular ejection fraction(LVEF) was calculated by Simpsons rule from 4Ch. Systolic pulmonary artery pressure(s PAP) was assessed with continuous wave Doppler of systolic tricuspid regurgitant velocity and regarded raised with values ≥ 30 mmH g as a surrogate parameter for RA pressure. A concomitantly elevated PCWP was considered a means to discriminate between the precapillary and postcapillary form of PH. PCWP was considered elevated when the E/e' ratio was 12 as a surrogate for LV diastolic pressure. E/e' ratio was measured by gauging systolic and diastolic velocities of the lateral and septal mitral valve annulus using TDI mode. The results were then averaged with conventional measurement of mitral valve inflow. Furthermore, functional testing with six minutes walking distance(6MWD), ECG-RV stress signs, NT pro-BNP and other laboratory values were assessed.RESULTS PH was confirmed in 34 patients(precapillary PH, n = 15, postcapillary PH, n = 19). TTE showed significant differences in E/e' ratio(precapillary PH: 12.3 ± 4.4, postcapillary PH: 17.3 ± 10.3, no PH: 12.1 ± 4.5, P = 0.02), LV volumes(ESV: 25.0 ± 15.0 mL, 49.9 ± 29.5 m L, 32.2 ± 13.6 m L, P = 0.027; EDV: 73.6 ± 24.0 mL, 110.6 ± 31.8 mL, 87.8 ± 33.0 mL, P = 0.021) and systolic pulmonary arterial pressure(sP AP: 61.2 ± 22.3 mm Hg, 53.6 ± 20.1 mm Hg, 31.2 ± 24.6 mm Hg, P = 0.001). STRV analysis showed significant differences for apical RV longitudinal strain(RVAS: -7.5% ± 5.6%, -13.3% ± 4.3%, -14.3% ± 6.3%, P = 0.03). NT pro-BNP was higher in patients with postcapillary PH(4677.0 ± 7764.1 pg/m L, precapillary PH: 1980.3 ± 3432.1 pg/mL, no PH: 367.5 ± 420.4 pg/mL, P = 0.03). Patients with precapillary PH presented significantly more often with ECG RV-stress signs(P = 0.001). Receiver operating characteristics curve analyses displayed the most significant area under the curve(AUC) for RVAS(cut-off -6.5%, AUC 0.91, P 0.001), sPAP(cut-off 33 mmH g, AUC 0.86, P 0.001) and ECG RV stress signs(AUC 0.83, P 0.001). The combination of these parameters had a sensitivity of 82.8% and a specificity of 17.2% to detect precapillary PH. CONCLUSION The combination of non-invasive measurements allows feasible assessment of PH and seems beneficial for the differentiation between the pre- and postcapillary form of this disease.     

Predictors of Severe Tricuspid Regurgitation in Patients with Permanent Pacemaker or Automatic Implantable Cardioverter-Defibrillator Leads

Patients with permanent pacemaker or automatic implantable cardioverter-defibrillator (AICD) leads have an increased prevalence of tricuspid regurgitation. However, the roles of cardiac rhythm and lead-placement duration in the development of severe tricuspid regurgitation are unclear.We reviewed echocardiographic data on 26 consecutive patients who had severe tricuspid regurgitation after permanent pacemaker or AICD placement; before treatment, they had no organic tricuspid valve disease, pulmonary hypertension, left ventricular dysfunction, or severe tricuspid regurgitation. We compared the results to those of 26 control subjects who had these same devices but no more than mild tricuspid regurgitation.The patients and control subjects were similar in age (mean, 81 ±6 vs 81 ±8 yr; P = 0.83), sex (male, 42% vs 46%; P = 0.78), and left ventricular ejection fraction (0.60 ±0.06 vs 0.58 ± 0.05; P = 0.4). The patients had a higher prevalence of atrial fibrillation (92% vs 65%; P=0.01) and longer median duration of pacemaker or AICD lead placement (49.5 vs 5 mo; P < 0.001). After adjusting for age, sex, and right ventricular systolic pressure by multivariate logistic regression analysis, we found that atrial fibrillation (odds ratio=6.4; P = 0.03) and duration of lead placement (odds ratio=1.5/yr; P = 0.001) were independently associated with severe tricuspid regurgitation.Out study shows that atrial fibrillation and longer durations of lead placement might increase the risk of severe tricuspid regurgitation in patients with permanent pacemakers or AICDs.Key words: Atrial fibrillation/complications, cardiac pacing, artificial/adverse effects, defibrillators, implantable/adverse effects, disease progression, echocardiography, electrodes, implanted/adverse effects, pacemaker, artificial/adverse effects, risk factors, tricuspid valve insufficiency/diagnosis/etiology, ventricular dysfunction, right/diagnosis/etiologyPatients with permanent pacemaker (PPM) or automatic implantable cardioverter-defibrillator (AICD) leads have an increased prevalence of significant tricuspid regurgitation (TR). Tricuspid regurgitation can be caused by various mechanisms, including pulmonary hypertension, direct lead interference with valve closure, tricuspid valve leaflet trauma from laceration and perforation, infective endocarditis, and fibrous adherence of pacemaker leads to the tricuspid valve apparatus.¹ Patients with long-standing atrial fibrillation (AF) can also develop severe TR even when their tricuspid valves are structurally normal.² In addition, patients with PPM leads have an increased prevalence of TR.³ Investigators in several large studies concluded that having a PPM or AICD increases the degree of TR in some patients.^1,3–5 However, it is unclear whether the chronic presence of device leads results in increased TR. We therefore sought to determine the predictors of severe TR in patients who have PPM or AICD leads. We hypothesized that a longer duration of PPM or AICD lead placement and the presence of AF were the chief risk factors.     

Outcome of significant functional tricuspid regurgitation after percutaneous mitral valvuloplasty

Background The outcome of significant functional tricuspid regurgitation (TR) associated with mitral stenosis (MS) after percutaneous mitral valvuloplasty (PMV) remains to be clarified. Methods From 265 patients who underwent PMV at our institution from 1995 to 2000 and who were regularly observed, we selected 71 patients (55 women, mean age 43 ± 11 years) who showed significant moderate to severe functional TR before PMV. We analyzed data from the echocardiograms performed before, 24 hours after, and long after the intervention (29 ± 12 months) and analyzed clinical outcomes. Resolution of TR was defined as trace or mild TR on the follow-up color Doppler study. Results Patients with moderate to severe TR showed more severe MS and pulmonary hypertension and more atrial fibrillation than patients with less than moderate TR. TR was resolved on the follow-up echocardiography in 23 of the 71 patients with significant TR before PMV (32%). The TR jet area before PMV (P < .05) and the late decrement of peak transmitral pressure gradient (P < .01) were independent determinants of resolution. TR was resolved in only 6.7% of patients (1/15) with an unsuccessful long-term PMV result, but was resolved in 39% of patients (22/56) with a successful long-term result (P < .05). During the clinical follow-up period (mean length 38 ± 20 months), 4 patients underwent open heart surgery 24 to 39 months after PMV, and there was no overall mortality. Conclusions Significant functional TR was associated with more severe MS, and it could be diminished when the transmitral pressure gradient was sufficiently relieved with PMV. (Am Heart J 2003;145:371-6.)     

Current trends in the management of pulmonary hypertension associated with respiratory disease in institutions approved by the Japanese Respiratory Society

BackgroundPulmonary hypertension (PH) often correlates with respiratory disease severity. Right heart catheterization (RHC) is recommended for the definitive diagnosis of PH associated with respiratory disease (R-PH). However, no previous studies have evaluated the perceived necessity for pulmonologists to use RHC for R-PH diagnosis, or the management of R-PH in Japan.MethodsQuestionnaires were mailed to 855 institutions, approved by the Japanese Respiratory Society. Questions included the prevalence and necessity of RHC and other methods in R-PH diagnosis, and current trends in the treatment of R-PH.ResultsQuestionnaires were returned from 289 institutions (34%). Patients with R-PH were examined by pulmonologists in 89% of institutions; some pulmonologists performed echocardiography (15%) and some RHC (13%). Echocardiography was used to diagnose R-PH in 99% of institutions and RHC was used in 36%. RHC was considered in cases of suspected PH in 49% of institutions and prior to initiation of pulmonary arterial hypertension (PAH)-specific therapy in 57%. Of patients diagnosed with R-PH, 47% were treated with ambulatory oxygen therapy. Furthermore, 98 of 145 institutions used PAH-specific therapy to treat R-PH. Of the 1355 patients who underwent RHC as a part of PH evaluation, 29% were confirmed to have PH, and 8% had severe PH with a mean pulmonary arterial pressure of ≥35 mmHg.ConclusionsThe current diagnostic and treatment modalities for R-PH in Japan were evaluated. Although few pulmonologists perform RHC for R-PH diagnosis in Japan, more than half consider using RHC for patients before initiating PAH-specific therapy.     

Aetiological distribution of pulmonary hypertension and the value of transthoracic echocardiography screening in the respiratory department: A retrospective analysis from China

Methods

The aetiological composition and clinical characteristics of patients with pulmonary hypertension (PH) hospitalised in the respiratory department were retrospectively analysed, as well as the correlation between transthoracic echocardiography (TTE) and right heart catheterization (RHC) for evaluating pulmonary artery systolic pressure (PASP) and mean pulmonary artery pressure (mPAP).

Results

Of 731 patients, 544 (74.42%) were diagnosed with PH by RHC. Pulmonary arterial hypertension (PAH) was the most common type of PH, accounting for 30.10%; PH due to lung disease and/or hypoxia accounted for 20.79%, and PH due to pulmonary artery obstructions accounted for 19.29%. TTE has the highest specificity for diagnosing PH due to pulmonary artery obstructions. The specificity was 0.9375, the sensitivity was 0.7361 and the area under the ROC curve (AUC) was 0.836. PASP, and mPAP estimated by TTE were different for various types of PH. In terms of PASP, TTE overestimated PASP in PH due to lung disease and/or hypoxia, but there was no significant difference compared with RHC (P > 0.05). TTE underestimates PAH patients' PASP compared with RHC. In terms of mPAP, TTE underestimated the mPAP of all types of PH, as there was a significant difference in the TTE-estimated mPAP of patients with PAH compared with RHC but not on other types of PH. Pearson correlation analysis of TTE and RHC showed a moderate overall correlation (rPASP 0.598, P < 0.001; rmPAP 0.588, P < 0.001).

Conclusions

Among the patients with PH in the respiratory department, patients with PAH accounted for the majority. TTE has high sensitivity and specificity for the diagnosis of PH due to pulmonary artery obstructions in the respiratory department.     

Does lowering pulmonary arterial pressure eliminate severe functional tricuspid regurgitation? Insights from pulmonary thromboendarterectomy

OBJECTIVES: Because pulmonary thromboendarterectomy (PTE) can result in an immediate reduction in pulmonary artery (PA) pressure, we sought to evaluate the effect of PTE on severe tricuspid regurgitation (TR) without tricuspid annuloplasty. BACKGROUND: Few data exist regarding the frequency and magnitude of functional TR improvement after reduction in PA pressure. METHODS: We identified 27 patients with severe TR, defined by a regurgitant index (RI) >33%, who underwent PTE. The RI, tricuspid annular diameter (TAD), apical displacement of leaflet coaptation, and estimated PA systolic pressure were determined on pre- and post-PTE echocardiograms. Patients were stratified based on resolution (RI < or =33%) or persistence (RI >33%) of severe TR. RESULTS: Comparing pre- and post-PTE echocardiography results, severe TR resolved in 19 of 27 (70%) patients. This group had a more effective PA systolic pressure reduction after PTE (49 +/- 20 mm Hg vs. 32 +/- 16 mm Hg by echocardiography, p = 0.075, and 37 +/- 16 mm Hg vs. 16 +/- 13 mm Hg by catheter measurement, p = 0.004). No difference was observed in TAD, apical displacement of the tricuspid valve, or other features compared with the group with persistent severe TR. There was a trend toward longer hospital stays in the group with persistent severe TR (19 +/- 15 days vs. 14 +/- 9 days; p = 0.55). CONCLUSIONS: After significant PA pressure reduction by PTE, severe functional TR with a dilated annulus may improve without annuloplasty despite dilated tricuspid annulus diameters.     

Pulmonary hypertension in patients with pulmonary fibrosis awaiting lung transplant.

Pulmonary hypertension (PH) may complicate idiopathic pulmonary fibrosis (IPF) but the prevalence of PH in IPF remains undefined. The present authors sought to describe the prevalence of PH in IPF. The lung transplant registry for the USA (January 1995 to June 2004) was analysed and IPF patients who had undergone right heart catheterisation (RHC) were identified. PH was defined as a mean pulmonary arterial pressure ((Ppa)) > or =25 mmHg and severe PH as a (Ppa) >40 mmHg. Independent factors associated with PH were determined. Of the 3,457 persons listed, 2,525 (73.0%) had undergone RHC. PH affected 46.1% of subjects; approximately 9% had severe PH. Variables independently associated with mild-to-moderate PH were as follows: need for oxygen, pulmonary capillary wedge pressure (P(pcw)) and forced expiratory volume in one second (FEV(1)). Independent factors related to severe PH included the following: carbon dioxide tension, age, FEV(1), P(pcw), need for oxygen and ethnicity. A sensitivity analysis in subjects with P(pcw) <15 mmHg did not appreciably alter the present findings. Pulmonary hypertension is common in idiopathic pulmonary fibrosis patients awaiting lung transplant, but the elevations in mean pulmonary arterial pressure are moderate. Lung volumes alone do not explain the pulmonary hypertension. Given the prevalence of pulmonary hypertension and its relationship with surrogate markers for quality of life (e.g. activities of daily living), future trials of therapies for this may be warranted.     

Echo Doppler predictors of pulmonary artery hypertension in patients with systemic sclerosis

Objectives: Evaluate echocardiographic predictors of pulmonary artery hypertension (PAH) in a prospective cohort of patients with systemic sclerosis (SSc). Methods: 38 patients with SSc who did not have PAH and significant left heart disease, with peak tricuspid regurgitant velocity (TRV) ≤ 2.8 m/sec and systolic pulmonary artery pressure (sPAP) < 40 mmHg on echo Doppler were enrolled. Patients underwent: clinical assessment, NT‐proBNP, and DLco measurements. Echo Doppler evaluation included right ventricular (RV) dimensions, tricuspid annular plan systolic excursion, fractional area change, tricuspid DTI systolic velocity, Tei index, pulmonary flow acceleration time (AcT), ratio of TRV to RV outflow tract time–velocity integral (TVI) and a parameter of disturbed RV ejection (TRV/AcT). After a planned 12‐month follow‐up we evaluated the predictive value of these parameters for the development of PAH, as demonstrated by right heart catheterization (RHC). Criteria for RHC were TRV ≥ 3 m/sec or sPAP ≥ 40 mmHg. Results: Four patients developed PAH. Only TRV/TVI and TRV/AcT ratios significantly predicted PAH development (TRV/TVI ratio ≥ 0.16 [predefined and ROC confirmed]: OR 99, CI 95%: 4.865–2015, P = 0.004; TRV/AcT ratio ≥ 0.022 [predefined and ROC confirmed]: OR 12.68, CI 95% 1.163–379.3, P = 0.036). Both parameters showed a good diagnostic power (TRV/TVI ratio: ROC area 79%, sensitivity 75%, specificity 97% and diagnostic accuracy 94.74% for cutoff value of 0.16; TRV/AcT ratio: ROC area 75%, sensitivity 75%, specificity 71% and diagnostic accuracy 72% for cutoff value of 0.022). Conclusions: This prospective study identified increased values of the two ratios TRV/TVI and TRV/AcT as predictors of PAH in SSc. (Echocardiography 2011;28:860‐869)     

The three‐year incidence of pulmonary arterial hypertension associated with systemic sclerosis in a multicenter nationwide longitudinal study in France

Objective

An algorithm for the detection of pulmonary arterial hypertension (PAH), based on the presence of dyspnea and the findings of Doppler echocardiographic evaluation of the velocity of tricuspid regurgitation (VTR) and right‐sided heart catheterization (RHC), which was applied in a large multicenter systemic sclerosis (SSc) population, estimated the prevalence of PAH to be 7.85%. The aim of this observational study was to investigate the incidence of PAH and pulmonary hypertension (PH) during a 3‐year followup of patients from the same cohort (the ItinérAIR‐Sclérodermie Study).

Methods

Patients with SSc and without evidence of PAH underwent evaluation for dyspnea and VTR at study entry and during subsequent visits. Patients in whom PAH was suspected because of a VTR of 2.8–3.0 meters/second and unexplained dyspnea or a VTR of >3.0 meters/second underwent RHC to confirm the diagnosis.

Results

A total of 384 patients were followed up for a mean ± SD of 41.03 ± 5.66 months (median 40.92 months). At baseline, 86.7% of the patients were women, and the mean ± SD age of the patients was 53.1 ± 12.0 years. The mean ± SD duration of SSc at study entry was 8.7 ± 7.6 years. After RHC, PAH was diagnosed in 8 patients, postcapillary PH in 8 patients, and PH associated with severe pulmonary fibrosis in 2 patients. The incidence of PAH was estimated to be 0.61 cases per 100 patient‐years. Two patients who exhibited a mean pulmonary artery pressure of 20–25 mm Hg at baseline subsequently developed PAH.

Conclusion

The estimated incidence of PAH among patients with SSc was 0.61 cases per 100 patient‐years. The high incidence of postcapillary PH highlights the value of RHC in investigating suspected PAH.