Noninvasive Differentiation of Pulmonary Arterial and Venous Hypertension Using Conventional and Doppler Tissue Imaging Echocardiography

doi:10.1016/j.echo.2007.10.003

Journal of the American Society of Echocardiography

Volume 21, Issue 6, June 2008, Pages 715-719

https://doi.org/10.1016/j.echo.2007.10.003 Get rights and content

To determine whether pulmonary arterial hypertension (PAH) and pulmonary venous hypertension (PVH) can be differentiated noninvasively, we reviewed data on 44 patients with pulmonary artery systolic pressure greater than or equal to 40 mm Hg by echocardiography and cardiac catheterization performed within 7 days of each other. Based on left ventricular end-diastolic pressure or pulmonary capillary wedge pressure, 20 patients were classified as having PVH and 24 as having PAH. Early (E) and late (A) diastolic mitral inflow velocities, deceleration time, early diastolic mitral annular velocity (E'), and E/A and E/E' ratios were remeasured in the two groups. Compared with patients with PAH, those with PVH had significantly higher E (107.8 ± 27.3 vs 65.0 ± 24.0 cm/s, P < .001), E/A (2.4 ± 1.0 vs 0.9 ± 0.4, P < .001), and E/E' (14.3 ± 4.3 vs 5.1 ± 1.9, P < .001), and significantly lower A (55.5 ± 33.5 vs 74.1 ± 20.8 cm/s, P < .001), E' (8.0 ± 2.5 vs 13.1 ± 3.6 cm/s, P = .001), and deceleration time (148.5 ± 49.0 vs 192.3 ± 41.9 milliseconds, P = .003). The area under receiver operating characteristic curve was 97% for E/E' and 91% for E/A. Optimal cutoff for diagnosing PVH was 9.2 for E/E' (sensitivity 95%, specificity 96%) and 1.7 for E/A (sensitivity 75%, specificity 91%). PAH and PVH may be differentiated by readily obtainable conventional and tissue Doppler parameters.

Section snippets

Participants

Permission to review patient records was granted by the institutional review board at our facility. We examined clinical, catheterization, and echocardiographic records of patients being evaluated or treated in the pulmonary hypertension and heart failure clinics of an urban academically affiliated hospital from January 2004 to November 2006. From these records we identified 27 patients from the heart failure clinic and 30 from the pulmonary hypertension clinic who had undergone right-heart

Results

Of the 47 patients evaluated, 3 patients from the pulmonary hypertension clinic were excluded because of discordance between clinical and hemodynamic criteria for PAH and PVH. Of the remaining 27 patients from the pulmonary hypertension clinic with concordant clinical and hemodynamic data, 24 had pulmonary capillary wedge pressure or LV end-diastolic pressure less than 15 mm Hg and were classified as having PAH, and 3 had pulmonary capillary wedge pressure or LV end-diastolic pressure greater

Discussion

In this study of patients with pulmonary hypertension undergoing cardiac catheterization and echocardiography, several standard Doppler and Doppler tissue imaging parameters were significantly different in patients with PAH compared with patients with PVH secondary to cardiac disease. Of the parameters evaluated, E/E' and E/A were the best discriminators of PVH and PAH. An E/E' ratio greater than 9.2 and an E/A ratio greater than 1.7 had the optimal sensitivity and specificity for

Conclusion

In patients with pulmonary hypertension, E/E' and E/A ratios measured using conventional and Doppler tissue imaging can reliably differentiate PAH and PVH secondary to cardiac disease. These easily obtainable parameters should be routinely assessed during initial screening echocardiographic examination of patients with suspected pulmonary hypertension and may improve the cost-effectiveness and speed of the subsequent workup.

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Echocardiography is the primary imaging modality used for the clinical evaluation of left ventricular (LV) diastolic function. Using two-dimensional together with transmitral, mitral annular, and pulmonary venous Doppler data, conclusions may be drawn regarding the relaxation and compliance properties of the ventricle that can be used for estimating LV filling pressure. Echocardiographic estimation of LV filling pressure has been shown to be especially useful for evaluating patients with dyspnea of unknown etiology as well as those with heart failure with preserved ejection fraction. Moreover, echocardiographic estimation of LV filling pressure can be used for clinical decision making on day-to-day basis. This article discusses the pathophysiology of diastolic dysfunction and provides a comprehensive review of its echocardiographic evaluation.
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Pulmonary hypertension due to left heart disease, also known as group 2 pulmonary hypertension according to the European Society of Cardiology/European Respiratory Society classification, is the most common cause of pulmonary hypertension. In patients with left heart disease, the development of pulmonary hypertension favours right heart dysfunction, which has a major impact on disease severity and outcome. Over the past few years, this condition has been considered more frequently. However, epidemiological studies of group 2 pulmonary hypertension are less exhaustive than studies of other causes of pulmonary hypertension. In group 2 patients, pulmonary hypertension may be caused by an isolated increase in left-sided filling pressures or by a combination of this condition with increased pulmonary vascular resistance, with an abnormally high pressure gradient between arteries and pulmonary veins. A better understanding of the conditions underlying pulmonary hypertension is of key importance to establish a comprehensive diagnosis, leading to an adapted treatment to reduce heart failure morbidity and mortality. In this review, epidemiology, mechanisms and diagnostic approaches are reviewed; then, treatment options and future approaches are considered.
L’hypertension pulmonaire liée aux maladies du cœur gauche, aussi classée comme hypertension pulmonaire du groupe 2 de la classification de l’ESC/ERS 2015, est la cause la plus fréquente d’hypertension pulmonaire. Chez les patients avec une maladie cardiaque gauche avancée, le développement d’une hypertension pulmonaire favorise la dysfonction cardiaque droite qui marque un tournant péjoratif dans l’évolution de la maladie. Cette hypertension pulmonaire est principalement causée par une augmentation des pressions de remplissage gauches, liée à une augmentation de la volémie ou à d’autres mécanismes. Dans certains cas évolués, il existe en plus une augmentation des résistances vasculaires pulmonaires, le gradient de pression entre les artères et les veines pulmonaires devenant anormalement élevé. En cardiologie, la découverte d’une hypertension pulmonaire doit conduire à un bilan étiologique bien codifié. Une meilleure compréhension des conditions sous-jacentes est d’une importance capitale pour établir un diagnostic complet, conduisant à un traitement adapté pour réduire l’évolution vers l’insuffisance cardiaque et la mortalité. Dans cette revue, l’épidémiologie, les mécanismes et approches diagnostiques sont exposés ; ensuite, les options thérapeutiques et les perspectives sont discutées.
Usefulness of Echocardiography/Doppler to Reliably Predict Elevated Left Ventricular End-Diastolic Pressure in Patients With Pulmonary Hypertension
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The ability of echocardiography (echo)/Doppler to predict elevated left ventricular (LV) end-diastolic pressure (EDP) specifically among patients with pulmonary hypertension is not well defined. This was a retrospective analysis of 161 patients referred to a specialized pulmonary hypertension clinic. A model based on an American Society of Echocardiography (ASE)/European Association of Echocardiography (EAE) joint statement was evaluated, and a new model was developed using univariate linear regression and multivariable logistic regression for potentially better prediction of elevated LVEDP. The study cohort had a median pulmonary arterial pressure was 34.0 mm Hg and pulmonary vascular resistance was 3.7 Wood units; 81 patients (51%) had LVEDP >15 mm Hg on invasive testing. Doppler E/A, E/e′ (septal, lateral, and average), e′/a′ (lateral and average), and left atrial volume and diameter all had significant correlation with LVEDP (p <0.05). The ASE/EAE model performed poorly (sensitivity 54% and specificity 66%) for detecting elevated LVEDP. Only echo/Doppler grade 3 diastolic dysfunction had an LVEDP significantly different from other grades (grade 0 to 2, median 15 mm Hg, interquartile range 13 to 22 mm Hg; grade 3, median 22 mm Hg, interquartile range 19 to 32 mm Hg; p <0.01). An experimental model was statistically significant in its prediction of elevated LVEDP (area under the receiver operating characteristic curve 0.7, p <0.001) but demonstrated poor performance (sensitivity 67% and specificity 61%). In conclusion, numerous echo/Doppler measurements correlate with elevated LV filling pressure. However, both the ASE/EAE model and our experimental model had poor test performance that did not permit confident identification of elevated LVEDP.
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Heart failure with preserved ejection fraction (HFpEF) is a frequent cause of pulmonary hypertension (PH) that is not easy to differentiate from precapillary PH. We aimed to determine whether the characteristic features of the patients may help differentiate between HFpEF and precapillary PH.
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Citation Excerpt :
Alternatively, mPAP can be estimated using the PA acceleration time, the peak pulmonic regurgitation gradient, or by tracing the continuous wave Doppler tricuspid regurgitation profile and calculating the mean pressure gradient. Doppler assessment of mitral inflow, mitral annular tissue velocities, and pulmonary venous waveforms combined with left atrial volumes at echocardiography is useful in distinguishing PAH from PVH [31]. However, there is evidence that both mPAP and PASP as measured by echocardiography may be unreliable due to poor visualization of tricuspid and pulmonary valve insufficiency [32,33].
We propose a method for non-invasive quantification of hemodynamic changes in the pulmonary arteries resulting from pulmonary hypertension (PH).
Using a two-element Windkessel model, and input parameters derived from standard MRI evaluation of flow, cardiac function and valvular motion, we derive: pulmonary artery compliance (C), mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), pulmonary capillary wedge pressure (PCWP), time-averaged intra-pulmonary pressure waveforms and pulmonary artery pressures (systolic (sPAP) and diastolic (dPAP)). MRI results were compared directly to reference standard values from right heart catheterization (RHC) obtained in a series of patients with suspected pulmonary hypertension (PH).
In 7 patients with suspected PH undergoing RHC, MRI and echocardiography, there was no statistically significant difference (p < 0.05) between parameters measured by MRI and RHC. Using standard clinical cutoffs to define PH (mPAP > 25 mmHg), MRI was able to correctly identify all patients as having pulmonary hypertension, and to correctly distinguish between pulmonary arterial (mPAP > 25 mmHg, PCWP < 15 mmHg) and venous hypertension (mPAP > 25 mmHg, PCWP > 15 mmHg) in 5 of 7 cases.
We have developed a mathematical model capable of quantifying physiological parameters that reflect the severity of PH.
Management of pulmonary arterial hypertension
2015, Journal of the American College of Cardiology
Pulmonary hypertension (PH) is common and may result from a number of disorders, including left heart disease, lung disease, and chronic thromboembolic disease. Pulmonary arterial hypertension (PAH) is an uncommon disease characterized by progressive remodeling of the distal pulmonary arteries, resulting in elevated pulmonary vascular resistance and, eventually, in right ventricular failure. Over the past decades, knowledge of the basic pathobiology of PAH and its natural history, prognostic indicators, and therapeutic options has exploded. A thorough evaluation of a patient is critical to correctly characterize the PH. Cardiac studies, including echocardiography and right heart catheterization, are key elements in the assessment. Given the multitude of treatment options currently available for PAH, assessment of risk and response to therapy is critical in long-term management. This review also underscores unique situations, including perioperative management, intensive care unit management, and pregnancy, and highlights the importance of collaborative care of the PAH patient through a multidisciplinary approach.

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: This work was partially supported by the Schecter Family Foundation, Miami, Florida.

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Noninvasive Differentiation of Pulmonary Arterial and Venous Hypertension Using Conventional and Doppler Tissue Imaging Echocardiography

Section snippets

Participants

Results

Discussion

Conclusion

Clin Chest Med

Chest

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Chest

Chest

Am Heart J

J Am Coll Cardiol