The diagnostic accuracy of Doppler echocardiography in assessment of pulmonary artery systolic pressure: a meta-analysis

Team-based approach to identify cardiac toxicity in critically ill hematopoietic stem cell transplant recipients

INTRODUCTION

We observed pulmonary hypertension (PH), pericardial effusions, and left ventricular systolic dysfunction (LVSD) in multiple critically ill hematopoietic stem cell transplant (HSCT) recipients. We implemented routine structured echocardiography screening for HSCT recipients admitted to the pediatric intensive care unit (PICU) using a standardized multidisciplinary process.

METHODS

HSCT recipients admitted to the PICU with respiratory distress, hypoxia, shock, and complications related to transplant-associated thrombotic microangiopathy were screened on admission and every 1-2 weeks thereafter. Echocardiography findings requiring intervention and/or further screening included elevated right ventricular pressure, LVSD, and moderate to large pericardial effusions. All echocardiograms were compared to the patient's routine pretransplant echocardiogram.

RESULTS

Seventy HSCT recipients required echocardiography screening over a 3-year period. Echo abnormalities requiring intervention and/or further screening were found in 35 (50%) patients. Twenty-four (34%) patients were noted to have elevated right ventricular pressure; 14 (20%) were at risk for PH, while 10 (14%) had PH. All patients with PH were treated with pulmonary vasodilators. LVSD was noted in 22 (31%) patients; 15/22 (68%) received inotropic support. Moderate to large pericardial effusions were present in nine (13%) patients, with six needing pericardial drain placement.

DISCUSSION

Echocardiographic abnormalities are common in critically ill HSCT recipients. Utilization of echocardiogram screening may allow for early detection and timely intervention for cardiac complications in this high-risk cohort.

Evaluation of the hemodynamics and right ventricular function in pulmonary hypertension by echocardiography compared with right-sided heart catheterization

The present study aimed to evaluate hemodynamics and right ventricular function in patients with pulmonary hypertension (PH) using transthoracic echocardiography and to compare these results with measurements obtained using right-sided heart catheterization (RHC). A total of 75 patients with PH were examined using echocardiography and RHC. Patients were divided into the following two groups according to their difference between SPAP_echo and SPAP_RHC measurement: The overestimated group and underestimated group. The overestimated group included the subgroups group_over-A (difference <20 mmHg) and group_over-B (difference ≥20 mmHg), and the underestimated group included group_under-A (absolute value of the difference <20 mmHg) and group_under-B (absolute value of the difference ≥20 mmHg). SPAP_echo measurements were revealed to be significantly positively correlated with SPAP_RHC measurements (r=0.794; P<0.01). Among all echocardiographic measurements, only tricuspid annular plane systolic excursion (TAPSE) was significantly different between groups; it was increased in group_over-A and group_under-A compared with group_over-B (P<0.01). Although SPAP measurements obtained using echocardiography were significantly positively correlated with those obtained using RHC, a high proportion of overestimation or underestimation of SPAP by echocardiography remained.

Modern diagnosis of chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) should be suspected in patients presenting persistent dyspnea three months after a pulmonary embolism or in patients presenting with acute pulmonary embolism and suggestive images on the CT-scan. For these patients, a specific diagnostic work-up should be performed. First step consists of the ventilation/perfusion (V/Q) scan which is a good screening test due to its high sensitivity and high negative predictive value. Pulmonary angiography remains the gold standard approach for the confirmation of the diagnosis and pre-surgical evaluation of CTEPH. New emerging technologies such as Dual-Energy Computed Tomography angiography (DECT) and Computed Tomography angiography (CTA) are developing and broadly available. These non invasive methods provide diagnostic information similar to conventional pulmonary angiography and surgical operability information. They are to be considered as an alternative in the diagnostic approach of patients with CTEPH as presented in the ESC/ERS guidelines. Haemodynamic measurement whiles exercising during right heart catheterization may improve diagnostic sensitivity of CTEPH and could therefore be used as a diagnostic test in patient with normal haemodynamic at rest.

Echocardiographic Assessment of Right Ventricle Dimensions and Function After Exposure to Extreme Altitude: Is an Expedition to 8000 m Hazardous for Right Ventricular Function?

Kurdziel, Marta, Jarosław Wasilewski, Karolina Gierszewska, Anna Kazik, Gracjan Pytel, Jacek Wacławski, Adam Krajewski, Anna Kurek, Lech Poloński, and Mariusz Gąsior. Echocardiographic assessment of right ventricle dimensions and function after exposure to extreme altitude: Is an expedition to 8000 m hazardous for right ventricular function? High Alt Med Biol 18:330-337, 2017.-Although the right ventricle (RV) is under great hypoxic stress at altitude, still little is known what happens to the RV after descent. The aim of this study was to evaluate RV dimensions and function after exposure to extreme altitude. Therefore, echocardiographic examination was performed according to a protocol that focused on the RV in 11 healthy subjects participating in an expedition to K2 (8611 m) or Broad Peak (BP, 8051 m). In comparison to measurements before the expedition, after 7-8 weeks of sojourn above 2300 meters with the aim of climbing K2 and BP, the RV Tei index increased (0.5 ± 0.1 vs. 0.4 ± 0.1; p = 0.028), and RV free wall longitudinal systolic strain (RVFWLSS) decreased (-23.1% ± 2.7% vs. -25.9% ± 2.4%; p = 0.043). Decrease in peak systolic strain and strain rate was observed in the basal and mid segments of the RV free wall (respectively: -24.4% ± 4.4% vs. -30.9% ± 6.5%; -1.4 ± 0.3 s^-1 vs. -1.8 ± 0.3 s^-1; -28.7% ± 3.9% vs. -34% ± 3.3%; -1.5 ± 0.2 s^-1 vs. -1.9 ± 0.3 s^-1; p for all <0.05). The linear RV dimensions, the proximal and distal RV outflow tracks, increased (respectively: 31.3 ± 4 mm vs. 29.2 ± 3 mm, p = 0.025; 27 ± 2.7 mm vs. 24.8 ± 3 mm, p = 0.012). We found that exposure to extreme altitude may cause RV dilatation and a decrease in RV performance. The Tei index and RVFWLSS are sensitive performance indices to detect changes in RV function after the exposure to hypoxic stress. The observed alterations seem to be a manifestation of physiological adaptation to high-altitude condition in healthy individuals.

Predictors of mid-term prognosis and adverse factors in acute pulmonary embolism

BACKGROUND

To explore the differences in short and middle term adverse factors of pulmonary embolism (PE) outcome.

METHODS

This was a single-center retrospective study of inpatients admitted from Zhongshan Hospital, Fudan University, with first-time PE. Clinical data were collected from patients with objectively confirmed PE, and a 2-year follow up was conducted.

RESULTS

The sample contained 310 patients with PE, ranging in age from 18 to 86 years old (mean 63.28 ± 15.30) and including 165 men (53.2%) and 145 women (46.8%). Successful treatment was achieved in 285 cases (91.9%) and unsuccessful treatment turned out in 25 cases (8.1%). Logistical regression analysis showed that massive PE [odds ratio (OR) = 23.625, 95% confidence interval (CI) 6.248-89.333], hypoxemia (OR = 11.915, 95% CI 1.900-74.727), leukocytosis (OR = 9.120, 95% CI 2.227-37.349) and active cancer (OR = 6.142, 95% CI 1.233-30.587) were associated with a poor prognosis for acute PE in the short term (in hospital). Seventy-seven PE cases with complete electronic records were finally included in the follow up. Cox regression analysis showed that elevated pulmonary artery systolic pressure (PASP, ⩾50 mmHg) (HR = 9.240, 95% CI, 2.307-37.013) and active cancer with PE (HR = 3.700, 95% CI, 1.010-13.562) were associated with an increased risk of mid-term mortality after a follow-up period of 2 years.

CONCLUSIONS

Massive PE, hypoxemia, leukocytosis and active cancer may contribute to a poor prognosis for patients with acute PE in hospital. Elevated PASP and active cancer may negatively impact survival time and increase the risk of death for patients with acute PE after 2-year follow up. Short-term adverse factors of acute PE are not exactly the same as the mid-term risk factors of acute PE.

The prognostic importance of the diastolic pulmonary gradient, transpulmonary gradient, and pulmonary vascular resistance in patients undergoing transcatheter aortic valve replacement

OBJECTIVES

To evaluate the association between markers of precapillary pulmonary hypertension (PH) and survival in transcatheter aortic valve replacement (TAVR).

BACKGROUND

The importance of precapillary PH has been sparsely investigated in patients undergoing TAVR. It may prove an important risk factor for poor outcomes.

METHODS

We identified patients at our institution undergoing TAVR with a baseline right heart catheterization (RHC) demonstrating PH. We evaluated the association between markers of precapillary PH and survival including the diastolic pulmonary gradient (DPG), transpulmonary gradient (TPG), and pulmonary vascular resistance (PVR). A multivariable analysis was performed using Cox Proportional Hazards Models, adjusting for age, gender, body mass index, and pulmonary artery systolic pressure (PASP) on echocardiography.

RESULTS

We identified 133 patients with PH on RHC. Of these 111 had low DPG and 22 had high DPG. All 3 markers of precapillary PH were associated with worse survival post TAVR, with OR of 2.1 (95% CI 1.1-3.9, P = 0.02), 3.4 (95% CI 1.8-6.4, P < 0.001) and 2.5 (95% CI 1.4-4.5, P = 0.003) for high DPG, TPG, and PVR, respectively. On multivariable analysis, both TPG and PVR remained predictors of worse survival, with OR of 3.4 (95% CI 1.7-6.9, P = 0.001) and 2.5 (95% CI 1.4-4.5, P = 0.003). Echocardiographic PASP and DPG were not predictive of survival.

CONCLUSIONS

In patients undergoing TAVR, parameters of precapillary PH are associated with lower survival, and provide incremental prognostication over echocardiographic PASP. RHC should continue to play an important role in risk stratification prior to TAVR. © 2017 Wiley Periodicals, Inc.

Pros and Cons of Echocardiography in the Screening, Diagnosis and Follow-up of Patients with Systemic Sclerosis Pulmonary Arterial Hypertension – a Rheumatologist's Perspective

Purpose

Our objective was to review the evidence regarding echocardiography in patients with systemic sclerosis (SSc) and possible pulmonary hypertension (PH).

Methods

The literature was reviewed. In addition, a survey was conducted of 315 rheumatologists/internists with a self-declared interest in SSc, to determine their preferred use of echocardiograms.

Results

The most relevant literature findings come from two studies, the DETECT study and one from the Australian Scleroderma Interest Group. In both these studies, it appears that the use of non-echocardiographic variables such as pulmonary function tests (PFTs) and values of serum N-terminal pro-brain natriuretic peptide (NT-proBNP), are adequate on their own in suggesting which patients are at high risk of PH. Echocardiograms added very little information and in fact may confuse the picture by appearing to be normal when in fact underlying PH is present. With regard to the survey, 157 physicians (49.8%) responded. Of those, 67% felt that an echocardiogram should be ordered on every patient with SSc every year. Ninety-five percent (95%) said the reason was to screen for the development of significant PH, 65% said the reason was to screen for the development of significant intrinsic cardiac disease and 38% said that the reason was to adhere to accepted international recommendations.

Conclusions

Despite popular belief and current recommendations, in the opinion of the author, echocardiograms are not necessary in every SSc patient every year. Cheaper tests such as PFTs and NT-proBNP are adequate in most cases to suggest when a right heart catheterization should be performed.

The injured heart: early cardiac effects of hematopoietic stem cell transplantation in children and young adults

We hypothesized that subclinical cardiac injury in the peri-transplant period is more frequent than currently appreciated in children and young adults. We performed echocardiographic screening on 227 consecutive patients prior to hematopoietic stem cell transplantation (HSCT), and 7, 30 and 100 days after transplant. We measured cardiac biomarkers cardiac troponin-I (cTn-I), and soluble suppressor of tumorigenicity 2 (sST2) prior to transplant, during conditioning, and days +7, +14, +28 and +49 in 26 patients. We subsequently analyzed levels of cTn-I every 48-72 h in 15 consecutive children during conditioning. Thirty-two percent (73/227) of patients had a new abnormality on echocardiogram. New left ventricular systolic dysfunction (LVSD) occurred in 6.2% of subjects and new pericardial effusion in 27.3%. Eight of 227 (3.5%) patients underwent pericardial drain placement, and 5 (2.2%) received medical therapy for clinically occult LVSD. cTn-I was elevated in 53.0% of all samples and sST2 in 38.2%. At least one sample had a detectable cTn-I in 84.6% of patients and an elevated sST2 in 76.9%. Thirteen of fifteen patients monitored frequently during condition had elevation of cTn-I. Echocardiographic and biochemical abnormalities are frequent in the peri-HSCT period. Echocardiogram does not detect all subclinical cardiac injuries that may become clinically relevant over longer periods.

Non-invasive diagnosis of pulmonary hypertension from lung Doppler signal: a proof of concept study

Transthoracic Parametric Doppler (TPD) is a novel ultrasound technique recently developed for the investigation of pulmonary blood vessels. Lung Doppler Signals (LDS) recorded from TPD provide information regarding the functional mechanical characteristics of pulmonary blood vessels. We aimed to define the specific profile of LDS generated from TPD imaging in patients with pulmonary hypertension (PH), and to evaluate the diagnostic performance of LDS to detect PH using right heart catheterization (RHC) as gold standard reference. Seventy nine PH patients and 79 healthy controls matched for age, gender and BMI were recruited in a prospective case-control multicenter study. LDS recordings were performed by TPD consisting of a pulsed Doppler with a 2 MHz single element transducer. LDS were recorded within 24 h of RHC. Following LDS extraction, classification and performance evaluation were performed offline using a support vector machine (k-fold cross validation method). The best LDS parameters for PH detection were (1) peak velocity of the systolic (S) and diastolic (D) signals, (2) the rise slope of the S and D signals, and (3) time to peak of the S signal. Overall, the sensitivity and specificity of TPD for detection of PH were 82.7 % (95 % CI 81.3-84.1) and 87.4 % (95 % CI 86.3-88.5), respectively, with an area under the receiver operating curve of 0.95 (95 % CI 0.94-0.96). Detection rate of PH increased progressively with the level of mean pulmonary artery pressure. LDS recorded by TPD display a specific profile in PH and appears to be a promising and reliable tool for PH diagnosis. Further studies are required to confirm the clinical usefulness of LDS.

Comorbidity as a contributor to frequent severe acute exacerbation in COPD patients

Background

Comorbidities have a serious impact on the frequent severe acute exacerbations (AEs) in patients with COPD. Previous studies have used the Charlson comorbidity index to represent a conglomerate of comorbidities; however, the respective contribution of each coexisting disease to the frequent severe AEs remains unclear.

Methods

A retrospective, observational study was performed in 77 COPD patients who experienced severe AE between January 2012 and December 2014 and had at least 1-year follow-up period from the date of admission for severe AE. We explored the incidence of frequent severe AEs (≥2 severe AEs during 1-year period) in these patients and investigated COPD-related factors and comorbidities as potential risk factors of these exacerbations.

Results

Out of 77 patients, 61 patients (79.2%) had at least one comorbidity. During a 1-year follow-up period, 29 patients (37.7%) experienced frequent severe AEs, approximately two-thirds (n=19) of which occurred within the first 90 days after admission. Compared with patients not experiencing frequent severe AEs, these patients were more likely to have poor lung function and receive home oxygen therapy and long-term oral steroids. In multiple logistic regression analysis, coexisting asthma (adjusted odds ratio [OR] =4.02, 95% confidence interval [CI] =1.30–12.46, P=0.016), home oxygen therapy (adjusted OR =9.39, 95% CI =1.60–55.30, P=0.013), and C-reactive protein (adjusted OR =1.09, 95% CI =1.01–1.19, P=0.036) were associated with frequent severe AEs. In addition, poor lung function, as measured by forced expiratory volume in 1 second (adjusted OR =0.16, 95% CI =0.04–0.70, P=0.015), was inversely associated with early (ie, within 90 days of admission) frequent severe AEs.

Conclusion

Based on our study, among COPD-related comorbidities, coexisting asthma has a significant impact on the frequent severe AEs in COPD patients.

Assessment of pulmonary artery pressure by echocardiography-A comprehensive review

Pulmonary hypertension is a pathological haemodynamic condition defined as an increase in mean pulmonary arterial pressure ≥ 25 mmHg at rest, assessed using gold standard investigation by right heart catheterisation. Pulmonary hypertension could be a complication of cardiac or pulmonary disease, or a primary disorder of small pulmonary arteries. Elevated pulmonary pressure (PAP) is associated with increased mortality, irrespective of the aetiology. The gold standard for diagnosis is invasive right heart catheterisation, but this has its own inherent risks. In the past 30 years, immense technological improvements in echocardiography have increased its sensitivity for quantifying pulmonary artery pressure (PAP) and it is now recognised as a safe and readily available alternative to right heart catheterisation. In the future, scores combining various echo techniques can approach the gold standard in terms of sensitivity and accuracy, thereby reducing the need for repeated invasive assessments in these patients.

•

Raised artery pulmonary pressure (PAP) is associated with increased mortality.

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We review the eight published echo techniques to assess PAP by echocardiography.

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Knowledge of all the echo techniques could avoid need for invasive tests.

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A scoring system combining various echo-derived measurements of PAP is needed.

Estimating Right Atrial Pressure Using Ultrasounds: An Old Issue Revisited With New Methods

Knowledge of the right atrial pressure (RAP) values is critical to ascertain the existence of a state of hemodynamic congestion, irrespective of the possible presence of signs and symptoms of clinical congestion and cardiac overload that can be lacking in some conditions of concealed or clinically misleading cardiac decompensation. In addition, a more reliable estimate of RAP would make it possible to determine more accurately also the systolic pulmonary arterial pressure with the only echocardiographic methods. The authors briefly illustrate some of the criteria that have been implemented to obtain a non-invasive RAP estimate, some of which have been approved by current guidelines and others are still awaiting official endorsement from the Scientific Societies of Cardiology. There is a representation of the sometimes opposing views of researchers who have studied the problem, and the prospects for development of new diagnostic criteria are outlined, in particular those derived from the matched use of two- and three-dimensional echocardiographic parameters.

Age dependence of pulmonary artery blood flow measured by 4D flow cardiovascular magnetic resonance: results of a population-based study

BACKGROUND

It was our aim to systematically analyze pulmonary artery blood flow within different age-groups in the general population using 4D flow cardiovascular magnetic resonance (CMR) in order to provide a context for interpreting results of future studies (e.g., in pulmonary hypertension) using this technique.

METHODS

An age-stratified sample (n = 126) of the population of the city of Freiburg, Germany, underwent ECG-triggered and navigator-gated 4D flow CMR at 3 T of the pulmonary arteries and the thoracic aorta. Analysis planes were placed in the main, left, and right pulmonary artery using dedicated software. Study participants were divided into three groups (1:20-39; 2:40-59; and 3:60-80 years of age). Subsequently, pulmonary blood flow was visualized, quantified and compared between groups.

RESULTS

Time-to-peak of systolic antegrade flow was shorter, peak and average velocities and flow volumes were lower in older subjects. At the end of systole, retrograde flow in the main pulmonary artery was observed in all but one subject. Subsequently, a second antegrade flow peak occurred in diastole which was lower in older subjects. Age was an independent predictor of hemodynamic change after adjustment for cardiovascular risk factors and body-mass-index. During systole, abnormal vortices occurred in the main pulmonary artery in four male subjects.

CONCLUSIONS

Comprehensive analysis of pulmonary blood flow was feasible in all subjects. We were able to detect an independent effect of ageing on pulmonary hemodynamics reflecting increased vessel stiffness and reduced pulmonary circulation. Findings of this study may be helpful for discriminating physiological from pathological flow in patients with pulmonary diseases in the future.

B-Lines in Assessment of Pulmonary Hypertension in Patients With Interstitial Lung Diseases: Feasibility of Transthoracic Lung Sonographic Signs

OBJECTIVES

This study was conducted to evaluate the value of sonographic B-lines (previously called "comet tail artifacts") in assessment of pulmonary hypertension in patients with interstitial lung diseases.

METHODS

One hundred thirty-four patients with clinically diagnosed interstitial lung diseases complicated by pulmonary hypertension underwent transthoracic lung sonography and Doppler echocardiography for assessment of the presence of B-lines, the distance between them, and the pulmonary artery (PA) systolic pressure. A correlation analysis and a receiver operating characteristic curve analysis were performed.

RESULTS

All patients had diffuse bilateral B-lines. The maximum number of B-lines seen in any positive zone (not a summation) was significantly correlated with the severity of PA systolic pressure (r= 0.812; P< .0001), and a linear regression equation could be demonstrated: that is, y = 6.06 x + 17.57, where x and y represent the number of B-lines and PA systolic pressure, respectively. A cutoff of more than 4 B-lines seen in any positive zone had 89.5% sensitivity, 85.0% specificity, and 87.2% accuracy in predicting elevated PA pressure (>30 mm Hg).

CONCLUSIONS

The number of B-lines is useful in assessment of pulmonary hypertension, especially when tricuspid regurgitation and pulmonary valve regurgitation do not exist or cannot be satisfactorily measured by Doppler echocardiography.

Hemodynamic assessment in the contemporary intensive care unit: a review of circulatory monitoring devices

The assessment of the circulating volume and efficiency of tissue perfusion is necessary in the management of critically ill patients. The controversy surrounding pulmonary artery catheterization has led to a new wave of minimally invasive hemodynamic monitoring technologies, including echocardiographic and Doppler imaging, pulse wave analysis, and bioimpedance. This article reviews the principles, advantages, and limitations of these technologies and the clinical contexts in which they may be clinically useful.

Detection of coronary artery disease in diabetic hypertensive patients using conventional transthoratic echocardiography at rest

To investigate the usefulness of conventional transthoratic echocardiography in identifying coronary artery disease (CAD) in diabetic hypertensive patients, transthoratic echocardiography and coronary angiography were performed in 122 diabetic hypertensive patients with suspected CAD. Correlation analysis, multivariate analysis and receiver operating characteristic curve (ROC) analysis were done. Diabetic hypertensive patients with CAD had significantly smaller coronary sinus diameter (Dcs), less velocity time integral (VTI), less coronary sinus flow (Flow) and less Flow divided by left ventricular mass (Flow/LVM) at rest versus normal participants (P < 0.01) and diabetic hypertensive patients without CAD (P < 0.05). The VTI, Dcs, Flow, LVM and Flow/LVM all showed significant correlations with the maximal percent stenosis of the coronary artery lesions (P < 0.05). However, only Flow showed statistically significant correlations with the maximal percent stenosis of the coronary artery lesions (P < 0.01) when multiple stepwise regression analysis was performed. For predicting CAD (angiographically proven, >50%) in diabetic hypertensive patients, the area under the ROC (AUC) was 0.92 for Flow, and a cut-off of <220 ml/min had a 93.2% sensitivity, 87.9% specificity and 91.3% accuracy. For predicting a >70% coronary artery stenosis, the AUC was 0.88 for Flow, and a cut-off of <147 ml/min had an 89.5% sensitivity, 87.4% specificity and 88.5% accuracy. Conventional transthoratic echocardiography can effectively and sensitively detect the CAD in diabetic hypertensive patients at rest. The reduced coronary sinus flow is a sensitive and specific predictor of CAD in diabetic hypertensive patients.

Impact of Severe Tricuspid Regurgitation on Accuracy of Echocardiographic Pulmonary Artery Systolic Pressure Estimation

INTRODUCTION

Transthoracic Doppler echocardiography (DE) is recommended for screening and monitorization of pulmonary arterial hypertension (PAH). However, some recent studies have suggested that Doppler echocardiographic pulmonary artery systolic pressure (PASP) estimates may frequently be inaccurate. Some hemodynamic and echocardiographic factors are known to contribute to discordant results. The aim of this study was to determine whether severe tricuspid regurgitation (TR) has any impact on true estimation of PASP by DE.

MATERIALS AND METHODS

We retrospectively identified all PAH patients who underwent right heart catheterization (RHC) and had an echocardiogram within the same hospitalization period. Patients were divided into two groups according to the presence of severe TR: Group 1 consisted of 36 patients with mild-moderate TR and group 2 of 36 patients with severe TR. For these two groups, the agreement between echocardiographic and catheterization PASP measurements was evaluated by Bland-Altman analysis, separately.

RESULTS

In group 1, the bias for the echocardiographic estimates of the PASP was 2.5 mmHg and 62.5% of the echocardiographic estimates were accurate (≤10 mmHg difference with RHC measurement). In group 2, the bias was 16.25 mmHg and echocardiography was accurate in 37.5% of the patients. To clarify the association between PASP overestimation on DE and the presence of severe TR, regression analysis was performed. Severe TR was found as the only independent predictor of PASP overestimation on echocardiography after multivariate analysis.

CONCLUSION

The results of the study show that in patients with PAH, the presence of severe TR is associated with an overestimated PASP measurement on echocardiography.

CT-base pulmonary artery measurement in the detection of pulmonary hypertension: a meta-analysis and systematic review

To summarize the performance of CT-based main pulmonary artery diameter or pulmonary artery to aorta ratio (PA:A ratio) measurement in detection of pulmonary hypertension by a systematic review and meta-analysis. A comprehensive literature search was performed to identify studies determining diagnostic accuracy of main pulmonary artery diameter or PA:A ratio measurement for pulmonary hypertension. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess the quality of the included studies. A bivariate random-effects model was used to pool sensitivity, specificity, positive/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR). Summary receiver operating characteristic (SROC) curves and area under the curve (AUC) were used to summarize overall diagnostic performance. This meta-analysis included 20 publications involving 2134 subjects. Summary estimates for main pulmonary artery diameter measurement in the diagnosis of pulmonary hypertension were as follows: sensitivity, 0.79 (95% CI 0.72-0.84); specificity, 0.83 (95% CI 0.75-0.89); PLR, 4.68 (95% CI 3.13-6.99); NLR, 0.26 (95% CI 0.20-0.33); DOR, 18.13 (95% CI 10.87-30.24); and AUC 0.87. The corresponding summary performance estimates for using the PA:A ratio were as follows: sensitivity, 0.74 (95% CI 0.66-0.80); specificity, 0.81 (95% CI 0.74-0.86); PLR, 3.83 (95% CI, 2.70-5.43); NLR, 0.33 (95% CI 0.24-0.44); DOR, 11.77 (95% CI 6.60-21.00); and AUC 0.84. Both main pulmonary artery diameter and PA:A ratio are helpful for diagnosing pulmonary hypertension. Nevertheless, the results of pulmonary artery measurement should be interpreted in parallel with the results of traditional tests such as echocardiography.

Abnormal echocardiography 7 days after stem cell transplantation may be an early indicator of thrombotic microangiopathy

Cardiac complications after hematopoietic stem cell transplantation (HSCT) can lead to significant morbidity and mortality. Cardiac evaluation during the first 100 days after HSCT is usually performed only if clinically indicated, and no studies have examined whether routine screening is beneficial in this patient population at high risk for tissue injury. We conducted a single-center prospective clinical study to screen for cardiac complications in pediatric and young adult patients. One hundred consecutive HSCT patients underwent scheduled echocardiographic screening on day +7 after transplantation, independent of their clinical condition. At least 1 abnormality was identified in 30% of cases. Seventeen children had a pericardial effusion, 13 elevated right ventricular pressure, and 3 reduced left ventricular function. Survival was reduced in children with any echocardiographic abnormality at day 7 (67% versus 80% in those with and without, respectively, abnormality, P = .073). Moreover, raised right ventricular pressure at day +7 was significantly associated with transplant-associated thrombotic microangiopathy (TA-TMA; P = .004) and may indicate early vascular injury in the lungs. These data suggest that echocardiography 7 days after HSCT can detect early cardiac complications of HSCT and may identify early vascular injury associated with TA-TMA.

Association of Pulmonary Hypertension with Mortality in Incident Peritoneal Dialysis Patients

BACKGROUND

The prognostic value of pulmonary hypertension at the start of peritoneal dialysis (PD) in patient survival is unclear.

METHODS

We conducted a retrospective study of incident patients who initiated PD therapy from January 2007 to December 2011, and followed up through June 2013. Pulmonary hypertension was defined as an estimated systolic pulmonary artery pressure (PAP) of ≥ 35 mm Hg using echocardiography. Clinical parameters and laboratory findings were compared between patients with and without pulmonary hypertension and a logistic regression model was elaborated. Patient outcomes (all-cause and cardiovascular mortality) were recorded during follow-up. Survival curves were constructed by the Kaplan-Meier method, and the influences of pulmonary hypertension on outcomes were analyzed by Cox regression models.

RESULTS

Pulmonary hypertension was prevalent in 99 (16.0%) of the 618 patients studied. The independent risk factors for pulmonary hypertension were female (odds ratio [OR] = 2.12; 95% confidence interval [CI]: 1.29 - 3.46), left atrial diameter (OR = 1.15; 95% CI: 1.10 - 1.20), left ventricular ejection fraction (OR = 0.97; 95% CI: 0.95 - 0.99), and serum sodium (OR = 0.94; 95% CI: 0.89 - 0.99). Over a median follow-up of 29.4 months, 93 patients (15.0%) died, 59.1% of them due to cardiovascular disease. Kaplan-Meier survival analysis showed that patients with pulmonary hypertension had worse overall rates of survival and cardiovascular death-free survival than those without pulmonary hypertension. After multivariate adjustment, pulmonary hypertension was independently associated with increased risk for both all-cause and cardiovascular mortality, with hazard ratios (HRs) of 2.10 (95% CI: 1.35 - 3.27) and 2.60 (95% CI: 1.48 - 4.56), respectively.

CONCLUSIONS

The prevalence of pulmonary hypertension at the start of PD was common and associated with increased risk of both all-cause and cardiovascular mortality in incident PD patients.

Reliability of noninvasive assessment of systolic pulmonary artery pressure by Doppler echocardiography compared to right heart catheterization: analysis in a large patient population

Background

Pulmonary artery pressure (PAP) is an important marker in cardiovascular disorders, being closely associated with morbidity and mortality. Noninvasive assessment by Doppler echocardiography is recommended by current guidelines. So far, the reliability of this method has been assessed only in small studies with contradictory results. Therefore, the aim of this study was to analyze the reliability of noninvasive PAP assessment by Doppler echocardiography compared to invasive measurements in a large patient population.

Methods and Results

We retrospectively analyzed data from a large tertiary cardiology department over 6 years in order to compare invasively measured PAP to estimated PAP from echocardiography examinations. N=15 516 patients fulfilled inclusion criteria and n=1695 patients with timely matched examinations (within 5 days) were analyzed. In n=1221 (72%) patients, pulmonary hypertension (PH) was diagnosed invasively (postcapillary PH: n=1122 [66%]; precapillary PH: n=99 [6%]). Systolic pulmonary artery pressure (sPAP) was 45.3±15.5 mm Hg by Doppler echocardiography and 47.4±16.4 mm Hg by right heart catheterization. Pearson's correlation coefficient was r=0.87 (P<0.0001). Mean right atrial pressure (RAP) was 12.0±5.7 mm Hg by right heart catheterization and was estimated to be 12.1±6.6 mm Hg by echocardiography (r=0.82, P<0.0001). Bland–Altman analysis showed a bias of −2.0 mm Hg for sPAP (95% limits of agreement −18.1 to +14.1 mm Hg) and +1.0 mm Hg for RAP (95% limits of agreement +0.1 to +1.9 mm Hg). Noninvasive diagnosis of pulmonary hypertension with Doppler echocardiography had a good sensitivity (87%) and specificity (79%), positive and negative predictive values (91% and 70%), as well as accuracy (85%) for a sPAP cut‐off value of 36 mm Hg (AUC 0.91, P<0.001, CI 0.90 to 0.93).

Conclusions

In this study, Doppler echocardiography proved to be a reliable method for the assessment of sPAP, being well suited to establish the noninvasive diagnosis of pulmonary hypertension in patients with cardiac diseases.

Limitations and strengths of doppler/echo pulmonary artery systolic pressure-right heart catheterization correlations: a systematic literature review

AIMS

Because many recent studies have questioned the accuracy of Doppler echocardiography (D) in determining pulmonary artery systolic pressure (PASP), we performed a detailed literature analysis attempting add clarity.

METHODS AND RESULTS

Studies through 2011 comparing D and right heart catheterization (RHC) PASP, with at least 25 studied patients and reporting correlation coefficients (r) were identified. Patient demographics, study characteristics, the percent of patients studied for left or right heart pathologies, and study biases were determined. After adjusting for differing study sizes, each study's r value was used as a single datapoint and dichotomized above or below the entire cohort's mean values. From 32 studies 2604 D-RHC parings were reported. Their overall weighted r was 0.68 ± 0.19. Poorer correlations were found for right heart pathologies compared to left heart pathologies (r = 0.58 vs. 0.84, P < 0.001) and for normal PASP patients in a study compared to abnormal PASP patients (r = 0.55 vs. 0.82, P < 0.001). Studies with predominately right heart pathology had a significantly greater D-RHC time difference, fewer successful D determinations, a greater percentage of normal PASPs on RHC, and more between-method differences >10 mmHg. Metaregression analyses indicated that both right heart pathology predominance and a greater percent of normal PASPs on RHC remained associated with poorer correlations.

CONCLUSIONS

D PASP-RHC correlations were high and between-method differences less in patients with left heart pathology but were poorer for right heart diseases and studies with proportionately more normal PASPs on RHC for which further study is needed.

Volumetric evaluation of dual-energy perfusion CT for the assessment of intrapulmonary clot burden

AIM

To evaluate the volumetric values of intrapulmonary clots (IPCs) using 64-section dual-energy perfusion computed tomography (DEpCT).

MATERIALS AND METHODS

A total of 174 patients suspected of having acute pulmonary embolism (PE) underwent DEpCT, and acute PE was diagnosed in 48 of these patients. DEpCT images were three-dimensionally reconstructed with four threshold ranges: 1-120 HU (V₁₂₀), 1-15 HU (V₁₅), 1-10 HU (V₁₀), and 1-5 HU (V₅). Each relative value per V₁₂₀ was expressed as %V₁₅, %V₁₀ and %V₅. These values were compared with the d-dimer, pulmonary arterial (PA) pressure, right ventricular (RV) diameter, RV/left ventricular diameter ratio, PA diameter, and CT angiographic obstruction index (CTOI).

RESULTS

In patients with IPCs, PA pressure, d-dimer and volumetric values of DEpCT were significantly higher (p < 0.001). Relative volumetric values at DEpCT had better correlations with the PA pressure, PA diameter, and CTOI than absolute ones, and %V₅ especially had good correlations with PA pressure (r = 0.44, p = 0.02), PA diameter (r = 0.40, p = 0.005), and CTOI (r = 0.38, p = 0.009).

CONCLUSION

The relative volumetric evaluation of DEpCT images with a lower attenuation threshold range may be helpful for assessing right heart strain, because these values had good correlation with CTOI, pulmonary pressure, and diameter in suggesting right heart load.

Pulmonary artery distensibility in chronic obstructive pulmonary disease

BACKGROUND

Pulmonary hypertension (PH) is an important complication in the natural history of chronic obstructive pulmonary disease (COPD) and is caused by the remodeling of pulmonary arteries impairing the distensibility and stiffness of the major pulmonary arteries.

OBJECTIVES

To evaluate the pulmonary artery distensibility by transthoracic echocardiography in patients with COPD.

METHOD

We prospectively investigated COPD male patients and compared with healthy controls. In addition to right ventricle (RV) conventional echocardiographic parameters, right pulmonary artery fractional shortening(RPA-FS) and new pulmonary artery stiffness (PAS) parameters were compared.

RESULTS

Fifty-four COPD patients participated in the study and compared with a control group consisting of 24, all men, healthy, nonsmoking subjects. Six patients were excluded from study due to poor quality of echocardiographic recordings. The distensibility of PA evaluated by the RPA-FS parameter was found to be significantly lower in patients with COPD than it was in normal subjects (13.3 ± 8.1 vs. 27.6 ± 4.9,P :< 0.001) and correlated positively with tricuspid annular systolic excursion (TAPSE) (r = 0.566, P < 0.001) and pulmonary acceleration time (r = 0.607, P < 0.001) and correlated inversely with pulmonary artery systolic pressure (r = -0.587, P < 0.001), PAS(r = -0.479, P < 0.001) and functional capacity (r = -0.586, P < 0.001). Similar to this, PAS found to be impaired in COPD patients (29.5 ± 13.6 vs. 15.7 ± 4.1, P < 0.001) and correlated inversely RPA-FS (r = -0.479, P < 0.001). There were statistically significant difference for pulmonary artery distensibility (RPA-FS) and PAS parameters among the COPD subgroups with regard to NYHA functional capacity (P < 0.001).

CONCLUSION

In this study, we found that PAS and distensibility were worsened in COPD patients and correlated with decreased functional capacity.