Doppler Estimation of Pulmonary Artery Systolic Pressure Revisited

Previous attempts at noninvasive estimation of pulmonary artery systolic pressure (PA_S) were limited by the inability to identify adequate spectral signals of tricuspid regurgitation (TR) in a significant proportion of patients. Recently, image and color flow directed continuous-wave Doppler have enabled spectral mapping of previously undetectable TR jets. Accordingly, 30 consecutive patients underwent two-dimensional and continuous-wave Doppler echocardiograms immediately before right heart catheterization. PA_S was calculated as ∑ (4V²+ RA) where Vis the maximal velocity of the TR jet in ml sec and RA is right atrial pressure as estimated by the caval respiratory index. Twenty-eight patients (93%) had detectable signals of TR. Directly measured PA_S ranged from 21 to 95 mmHg (mean ± SD, 40 ± 18). Correlation between Doppler and catheter-measured PA_S was R-sq = 0.93 with a standard error of the estimate of 4.7 mmHg. Accurate results were obtained over a wide range of pulmonary pressures. Thus, noninvasive determination of PA_S is feasible in most patients including those with normal PA_S, and correlates extremely well with direct measurements.     

应用肺灌注显像预测病人肺动脉压力

研究 Ｌ Ｓ法在预测病人肺动脉压力方面的功效。　方法：对２２ 例患者于术前行肺灌注显像研究,应用 Ｌ Ｓ法计算出肺动脉压力（ Ｐ Ａ Ｐ）,并与病人心导管资料或术中测压资料做对比。　结果：计算出的 Ｐ Ａ Ｐ与测出的 Ｐ Ａ Ｐ呈明显相关（ｒ＝ ０．９２, Ｐ＝ ０００１）,与病人心胸比率（ｒ＝ ０．７５, Ｐ＝ ０．０００１）,肺细血管嵌压（ｒ＝ ０．９０, Ｐ＝ ０．０００９）和全肺阻力（ｒ＝０．８０, Ｐ＝ ０．０１）明显相关;该方法诊断肺动脉高压的敏感度和特异度均为 ９２％ ,阳性抑然比为１１．５,阴性抑然比为０．０８７。　结论： Ｌ Ｓ法可准确直接地预测病人肺动脉压力。     

Effects of HIV Infection on Pulmonary Artery Pressure in Children

BackgroundPulmonary hypertension may complicate human immunodeficiency virus (HIV) infection and result in right ventricular (RV) failure and premature death. There are limited data of the effects of childhood HIV infection or antiretroviral therapy (ART) on pulmonary artery pressure (PAP).ObjectivesTo establish if there is an association between childhood HIV infection or its treatment and pulmonary artery pressure.MethodsThe study conducted a cross-sectional study of 102 HIV-infected (48 ART-naïve, 54 ART-exposed) and 51 HIV-uninfected children in Jakarta, Indonesia, to estimate PAP using echocardiography parameters: tricuspid regurgitation peak velocity (TRV), left ventricular systolic index and diastolic eccentricity index (EI), and RV systolic function, assessed by tricuspid annulus plane systolic excursion. The association between either ART-naive or ART-exposed HIV and PAP was explored using general linear modelling adjusted for potential confounders.ResultsART-exposed HIV-infected children had higher TRV (adjusted difference: 0.36 m/s; 95% confidence interval [CI]: 0.12 to 0.60; p = 0.003) and diastolic EI (adjusted difference 0.06; 95% CI: 0.01 to 0.11; p = 0.02) than did uninfected children. The EI in ART-exposed children was significantly higher than normal. ART-naive HIV-infected children had a lower tricuspid annulus plane systolic excursion (adjusted difference: –2.2 mm; 95% CI: –3.73 to –0.71; p = 0.004), despite no difference in TRV (adjusted difference: 0.18 m/s; 95% CI: –0.06 to 0.43 m/s; p = 0.14). Seven (13%) ART-exposed and 4 (8.3%) ART-naïve HIV-infected children had pulmonary hypertension. Within-HIV group comparisons showed that accounting for lower respiratory tract infections attenuated the lower RV systolic function in ART-naïve children but not in ART-exposed children (difference: –1.1 mm; 95% CI:–2.8 to 0.7 mm; p = 0.22), but not the higher left ventricular eccentricity indexes in the ART-exposed children (systolic difference: 0.07; 95% CI: 0.02 to 0.12; p = 0.007; diastolic difference: 0.08; 95% CI: 0.02 to 0.14; p = 0.006).ConclusionsART-exposed HIV infection is associated with higher estimated PAP. Reduced RV systolic function is seen in ART-naïve HIV infection. Lower respiratory tract infection partly explains lower systolic RV function in ART-naïve relative to ART-exposed HIV infection.     

Pulmonary Artery Pressure,Gender, Menopause,and Pregnancy in Schistosomiasis-Associated Pulmonary Hypertension

Background

Schistosomiasis-associated pulmonary arterial hypertension (SPAH) is a major concern worldwide. However, the role of gender specific contributing factors in SPAH is unknown.

Objective

We investigated how systolic pulmonary artery pressure (SPAP) values and the presence of severe SPAP relate to gender, menopausal status, and pregnancy history in SPAH patients.

Methods

Seventy-nine patients diagnosed with SPAH from 2000 to 2009 were assessed and 66 were enrolled in the study. Information about age, menopausal status, pregnancy, echocardiography-derived SPAP, and invasive mean pulmonary artery pressure (mPAP) was collected from medical records. The relation between values of SPAP and mPAP and their agreement for severe disease were assessed. Regression models assessed the association of gender, menopausal status, and pregnancy history with SPAP values and the presence of severe SPAP.

Results

Moderate correlation and good agreement for severe disease were found between mPAP and SPAP. Mean SPAP values were similar for men and women. A trend toward higher values of SPAP was found for non-menopausal women compared to men. Higher SPAP values were found for menopausal compared to non-menopausal women; the values were non-significant after adjustment for age. Pregnancy history had no association with SPAP. Menopause and positive pregnancy had no association with severe SPAP.

Conclusion

In SPAH patients, neither gender, nor menopausal status, nor pregnancy history showed independent correlation with SPAP values assessed by echocardiography.     

Pulmonary Artery Sarcoma Mimicking Pulmonary Embolism

Primary sarcomas that arise from major blood vessels are exceedingly rare, and some of the published cases have been autopsy reports. Most patients are adults. We report a case of pulmonary artery sarcoma in a 77-year-old man who presented with acute onset of dyspnea. Magnetic resonance imaging of the chest revealed a large mass within the pulmonary trunk and its main branches. Because massive pulmonary embolism was suspected, both anticoagulant and thrombolytic therapies were initiated. The patient responded poorly to these therapies, which then necessitated resection of both the mass and the pulmonary valve. A bioprosthetic porcine valve replaced the native valve, and we reconstructed the right ventricular outflow tract with a Dacron patch. Histopathologic examination revealed a high-grade sarcoma with focal myogenic and chondrogenic differentiation. The patient tolerated the procedure well and was discharged from the hospital on postoperative day 7. He was subsequently treated with chemotherapy and radiation and continued to show no evidence of disease.The diagnosis of pulmonary artery sarcoma should be suspected in patients who present with manifestations of pulmonary embolism, especially when there is no evidence of deep venous thrombosis and poor response to anticoagulant therapy. Multimodal therapy can provide prolonged survival.     

Pulmonary Artery Catheter-Associated Thrombosis

Transesophageal echocardiography has become increasingly important in the assessment of critically ill patients. We report a 39-year-old patient who was incidentally noted to have a large right intraatrial thrombus associated with an indwelling pulmonary artery catheter identified by transesophageal echocardiography. This led to eventual catheter removal by open venotomy. Careful examination of intravascular devices during transesophageal echocardiography may lead to early diagnosis of catheter-associated thrombosis and thus alter management appropriately.     

Idiopathic Pulmonary Artery Aneurysm

Pulmonary artery aneurysm (PAA) is an uncommon lesion, which may be associated with different etiologies including congenital cardiovascular diseases, systemic vasculitis, connective tissue diseases, infections, and trauma. Idiopathic PAA is sporadically diagnosed by exclusion of concomitant major pathology. We report a case of a 56-year-old female with an idiopathic pulmonary artery dilatation identified fortuitously by echocardiography and confirmed by contrast-enhanced computed tomography. Neither significant pulmonary valve dysfunction nor pulmonary hypertension and other cardiac abnormalities which might contribute to the PAA development were found. Here, we describe echocardiographic and computed tomography findings and review the literature on PAA management.     

Peripheral Pulmonary Artery Stenosis: Acute and Mid-term Results of High Pressure Balloon Angioplasty

Surgical angioplasty for branch pulmonary arterial stenosis (BPAS) is associated with a low success rate and a high mortality rate. The success rate of balloon angioplasty using low pressure balloon catheters is about 60%. Little data are available on the success rate using high-pressure balloon (HPB) catheters. Therefore, our goal is to report the procedural and mid-term success rates using HPB catheters for the treatment of BPAS and those factors associated with success. 38 patients (25 boys/13 girls) with BPAS underwent at least one attempt (48 procedures) of balloon angioplasty using HPB catheters. Their median age was 1.1 years (range, 0.1–22.1 year), and their median weight was 9.6 kg (range, 3.7–61 kg). Thirty patients (79%) had BPAS following surgical intervention for their cardiac defects (mostly post tetralogy of Fallot), and eight (21%) patients had the BPAS associated with Williams syndrome (2 patients), Alagille syndrome (one patient), unoperated tetralogy of Fallot (one patient), and congenital BPAS (4 patients). Twenty-six procedures involved the left pulmonary artery (LPA), and 22 procedures involved the right pulmonary artery (RPA). The overall acute success rate was 56% (27 of 48 vessels). The mean ± SD of the gradient across the stenotic segment decreased from 37 ± 20 to 23 ± 20 mmHg (P < 0.001), and the diameter of the narrowest segment improved from 3.5 ± 1.6 to 5.7 ± 2.5 mm (P < 0.001). The median RV/AO pressure ratio decreased from 0.64 to 0.52 (P = 0.009). The median ratio of balloon size to the diameter of the narrowest segment was 2.67 (range, 1.3–7.8). Lesion location (RPA) was associated with higher acute success rate (P = 0.03), but not with mid-term outcome. Acute (P = 0.006) and mid-term (P = 0.04) success were related to balloon diameter to vessel diameter ratio. At mid-term follow-up (median interval 2.5 years), 16 vessels (33%) were widely patent. Complications included perforation of a small branch pulmonary artery in one patient, resulting in hemoptysis with complete recovery. One patient developed pulmonary artery hypertension; two patients developed an aneurysm of the dilated segment; one patient developed femoral vein thrombosis; and one patient had a paradoxical embolus associated with a cerbrovascular accident. There were no procedure-related deaths. We conclude that BPAS is challenging to treat. The use of HPB angioplasty may avoid surgery or the permanence of stem implantation and should be the first intervention for this condition in the pediatric patient. Other interventions should be reserved for refractory stenosis.