Diagnostic value of echocardiography in the diagnosis of pulmonary hypertension

Correlation Between Tissue Doppler Imaging Method (E/e') and Invasive Measurements of Left Ventricular Filling Pressures: A Systematic Review, Meta-Analysis, and Meta-Regression

OBJECTIVES

Evaluation of pulmonary capillary wedge pressure (PCWP) through right heart catheterization can indirectly provide an estimation of the filling pressure of the left ventricle. Echocardiography can estimate left ventricular compliance using mitral annular tissue Doppler imaging (TDI). The E/e' ratio refers to the correlation between the peak mitral inflow (E-wave) velocity and early diastolic tissue Doppler mitral annular velocity (e'). The main purpose of this systematic review was to establish the correlation between echocardiographic E/e' ratio and PCWP. The correlation between E/e' and left ventricular end-diastolic pressure (LVEDP) was evaluated as a secondary objective.

DESIGN

A systematic review and meta-analysis of observational studies was conducted. The search was based on Medline (PubMed), Scopus, and Web of Science.

SETTING

Intensive care unit or cardiac intensive care unit.

PARTICIPANTS

Adult patients.

INTERVENTIONS

Any study comparing the left ventricular filling pressure obtained by cardiac catheterization (reference) and echocardiographic evaluation, in particular TDI analysis (intervention), were included.

MEASUREMENTS AND MAIN RESULTS

The pooled analysis included 94 studies from the initially identified 7,304 records. The correlation was 0.48 (95% CI 0.42-0.54, Q = 420.52, I2 = 84.8%) for PCWP and 0.50 (95% CI 0.38-0.60, Q = 210.91, I2 = 89.1%) for LVEDP.

CONCLUSIONS

The E/e' ratio moderately correlated with PCWP/LVEDP. The correlation was stable irrespective of the sites where e' was measured, but each site has its own limitations for specific patient subpopulations. The correlation was weak in patients with heart failure with a preserved ejection fraction.

Liver stiffness is associated with right heart dysfunction, cardiohepatic syndrome, and prognosis in pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) can lead to congestive hepatopathy, known as cardiohepatic syndrome (CHS). Hepatic congestion is associated with increased liver stiffness, which can be quantified using shear wave elastography. We aimed to investigate whether hepatic shear wave elastography detects patients at risk in the early stages of PH.

METHODS

Sixty-three prospectively enrolled patients undergoing right heart catheterization (52 diagnosed with PH and 11 with invasive exclusion of PH) and 52 healthy volunteers underwent assessments including echocardiography and hepatic shear wave elastography. CHS was defined as increased levels of ≥2 of the following: gamma-glutamyl transferase, alkaline phosphatase, and bilirubin. Liver stiffness was defined as normal (≤5.0 kPa) or high (>5.0 kPa).

RESULTS

Compared with normal liver stiffness, high liver stiffness was associated with impaired right ventricular (RV) and right atrial (RA) function (median [interquartile range] RV ejection fraction: 54 [49; 57]% vs 45 [34; 51]%, p < 0.001; RA reservoir strain: 49 [41; 54]% vs 33 [22; 41]%, p < 0.001), more severe tricuspid insufficiency (p < 0.001), and higher prevalence of hepatovenous backflow (2% vs 29%, p < 0.001) and CHS (2% vs 10%, p = 0.038). In the patient subgroup with precapillary PH (n = 48), CHS and high liver stiffness were associated with increased European Society of Cardiology/European Respiratory Society 2022 risk scores (p = 0.003).

CONCLUSIONS

Shear wave liver elastography yields important information regarding right heart function and may complement risk assessment in patients with (suspected) PH.

Traditional and Advanced Echocardiographic Evaluation in Chronic Obstructive Pulmonary Disease: The Forgotten Relation

Chronic obstructive pulmonary disease (COPD) is a significant preventable and treatable clinical disorder defined by a persistent, typically progressive airflow obstruction. This disease has a significant negative impact on mortality and morbidity worldwide. However, the complex interaction between the heart and lungs is usually underestimated, necessitating more attention to improve clinical outcomes and prognosis. Indeed, COPD significantly impacts ventricular function, right and left chamber architecture, tricuspid valve functionality, and pulmonary blood vessels. Accordingly, more emphasis should be paid to their diagnosis since cardiac alterations may occur very early before COPD progresses and generate pulmonary hypertension (PH). Echocardiography enables a quick, noninvasive, portable, and accurate assessment of such changes. Indeed, recent advancements in imaging technology have improved the characterization of the heart chambers and made it possible to investigate the association between a few cardiac function indexes and clinical and functional aspects of COPD. This review aims to describe the intricate relation between COPD and heart changes and provide basic and advanced echocardiographic methods to detect early right ventricular and left ventricular morphologic alterations and early systolic and diastolic dysfunction. In addition, it is crucial to comprehend the clinical and prognostic significance of functional tricuspid regurgitation in COPD and PH and the currently available transcatheter therapeutic approaches for its treatment. Moreover, it is also essential to assess noninvasively PH and pulmonary resistance in patients with COPD by applying new echocardiographic parameters. In conclusion, echocardiography should be used more frequently in assessing patients with COPD because it may aid in discovering previously unrecognized heart abnormalities and selecting the most appropriate treatment to improve the patient's symptoms, quality of life, and survival.

Pulmonary Hypertension in Left Ventricular Valvular Diseases: A Comprehensive Review on Pathophysiology and Prognostic Value

Left ventricular (LV) valvular diseases, make up one of the most common etiologies for pulmonary hypertension (PH), and it is not well understood how and at which degree it affects prognosis. The aim of the present study was a comprehensive review of the pathophysiologic mechanism of PH in patients with LV valvular diseases and the prognostic value of baseline and post-intervention PH in patients undergoing interventional treatment. The pathophysiology of PH in patients with LV valvular diseases involves gradual elevation of left ventricular filling pressure and left atrial pressure, which are passively transmitted to the pulmonary circulation and raise pulmonary artery systolic pressure (PASP). A long-lasting exposure to elevated PASP progressively leads to initially functional and thereafter irreversible structural changes in the pulmonary vasculature, leading up to high pulmonary vascular resistance. Surgical treatment of severe LV valvular diseases is highly effective in patients without resting PH or those with exercise-induced PH (EIPH) before intervention. In the case of pre-operative PH, successful interventional therapy decreases PASP, but the post-operative cardiac and all-cause mortality remain higher compared to patients without pre-operative PH. Hence, it is of paramount importance to detect patients with severe LV valvulopathies before the development of PH, since they will get greater benefits from early intervention.

Use of machine learning models to predict prognosis of combined pulmonary fibrosis and emphysema in a Chinese population

Background

Combined pulmonary fibrosis and emphysema (CPFE) is a novel clinical entity with a poor prognosis. This study aimed to develop a clinical nomogram model to predict the 1-, 2- and 3-year mortality of patients with CPFE by using the machine learning approach, and to validate the predictive ability of the interstitial lung disease-gender-age-lung physiology (ILD-GAP) model in CPFE.

Methods

The data of CPFE patients from January 2015 to October 2021 who met the inclusion criteria were retrospectively collected. We utilized LASSO regression and multivariable Cox regression analysis to identify the variables associated with the prognosis of CPFE and generate a nomogram. The Harrell's C index, the calibration curve and the area under the receiver operating characteristic (ROC) curve (AUC) were used to evaluate the performance of the nomogram. Then, we performed likelihood ratio test, net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA) to compare the performance of the nomogram with that of the ILD-GAP model.

Results

A total of 184 patients with CPFE were enrolled. During the follow-up, 90 patients died. After screening out, diffusing lung capacity for carbon monoxide (DLCO), right ventricular diameter (RVD), C-reactive protein (CRP), and globulin were found to be associated with the prognosis of CPFE. The nomogram was then developed by incorporating the above five variables, and it showed a good performance, with a Harrell's C index of 0.757 and an AUC of 0.800 (95% CI 0.736–0.863). Moreover, the calibration plot of the nomogram showed good concordance between the prediction probabilities and the actual observations. The nomogram also improved the discrimination ability of the ILD-GAP model compared to that of the ILD-GAP model alone, and this was substantiated by the likelihood ratio test, NRI and IDI. The significant clinical utility of the nomogram was demonstrated by DCA.

Conclusion

Age, DLCO, RVD, CRP and globulin were identified as being significantly associated with the prognosis of CPFE in our cohort. The nomogram incorporating the 5 variables showed good performance in predicting the mortality of CPFE. In addition, although the nomogram was superior to the ILD-GAP model in the present cohort, further validation is needed to determine the clinical utility of the nomogram.

Left atrial acceleration factor as a magnetic resonance 4D flow measure of mean pulmonary artery wedge pressure in pulmonary hypertension

Background

Mean pulmonary artery wedge pressure (PAWP) represents a right heart catheter (RHC) surrogate measure for mean left atrial (LA) pressure and is crucial for the clinical classification of pulmonary hypertension (PH). Hypothesizing that PAWP is related to acceleration of blood throughout the LA, we investigated whether an adequately introduced LA acceleration factor derived from magnetic resonance (MR) four-dimensional (4D) flow imaging could provide an estimate of PAWP in patients with known or suspected PH.

Methods

LA 4D flow data of 62 patients with known or suspected PH who underwent RHC and near-term 1.5 T cardiac MR (ClinicalTrials.gov identifier: NCT00575692) were retrospectively analyzed. Early diastolic LA peak outflow velocity (v_E) as well as systolic (v_S) and early diastolic (v_D) LA peak inflow velocities were determined with prototype software to calculate the LA acceleration factor (α) defined as α = v_E/[(v_S + v_D)/2]. Correlation, regression and Bland-Altman analysis were employed to investigate the relationship between α and PAWP, α-based diagnosis of elevated PAWP (>15 mmHg) was analyzed by receiver operating characteristic curve analysis.

Results

α correlated very strongly with PAWP (r = 0.94). Standard deviation of differences between RHC-derived PAWP and PAWP estimated from linear regression model (α = 0.61 + 0.10·PAWP) was 2.0 mmHg. Employing the linear-regression-derived cut-off α = 2.10, the α-based diagnosis of elevated PAWP revealed the area under the curve 0.97 with sensitivity/specificity 93%/92%.

Conclusions

The very close relationship between the LA acceleration factor α and RHC-derived PAWP suggests α as potential non-invasive parameter for the estimation of PAWP and the distinction between pre- and post-capillary PH.

A framework of deep learning networks provides expert-level accuracy for the detection and prognostication of pulmonary arterial hypertension

AIMS

To test the hypothesis that deep learning (DL) networks reliably detect pulmonary arterial hypertension (PAH) and provide prognostic information.

METHODS AND RESULTS

Consecutive patients with PAH, right ventricular (RV) dilation (without PAH), and normal controls were included. An ensemble of deep convolutional networks incorporating echocardiographic views and estimated RV systolic pressure (RVSP) was trained to detect (invasively confirmed) PAH. In addition, DL-networks were trained to segment cardiac chambers and extracted geometric information throughout the cardiac cycle. The ability of DL parameters to predict all-cause mortality was assessed using Cox-proportional hazard analyses. Overall, 450 PAH patients, 308 patients with RV dilatation (201 with tetralogy of Fallot and 107 with atrial septal defects) and 67 normal controls were included. The DL algorithm achieved an accuracy and sensitivity of detecting PAH on a per patient basis of 97.6 and 100%, respectively. On univariable analysis, automatically determined right atrial area, RV area, RV fractional area change, RV inflow diameter and left ventricular eccentricity index (P < 0.001 for all) were significantly related to mortality. On multivariable analysis DL-based RV fractional area change (P < 0.001) and right atrial area (P = 0.003) emerged as independent predictors of outcome. Statistically, DL parameters were non-inferior to measures obtained manually by expert echocardiographers in predicting prognosis.

CONCLUSION

The study highlights the utility of DL algorithms in detecting PAH on routine echocardiograms irrespective of RV dilatation. The algorithms outperform conventional echocardiographic evaluation and provide prognostic information at expert-level. Therefore, DL methods may allow for improved screening and optimized management of PAH.

Arterial partial pressure of oxygen and procalcitonin levels correlate with pulmonary artery systolic pressure in patients with active pulmonary tuberculosis

OBJECT

We aimed to study whether arterial blood gas parameters, inflammatory markers, and coagulation indicators correlate with pulmonary artery systolic pressure (PASP) values in patients with active pulmonary tuberculosis (PTB).

METHODS

A total of 121 patients with PTB who had a measurement of PASP by Doppler echocardiography in the active phase of tuberculosis were included in this study. We carried out univariate and multivariate linear regression analyses to determine factors correlated with PASP values. We excluded patients with other diseases or conditions that might lead to increased PASP.

RESULTS

Univariate linear regression analysis revealed positive correlations of age, white blood cell count, neutrophils ratio, Log procalcitonin, erythrocyte sedimentation rate, Log C-reactive protein, fibrinogen, Log D-dimer with PASP and showed an inverse correlation of arterial partial pressure of oxygen (PaO₂) and arterial oxygen saturation (SaO₂) with PASP. Multiple linear regression analysis demonstrated that PaO₂ and Log procalcitonin remained correlated with PASP values.

CONCLUSION

PaO₂ and procalcitonin were strongly correlated with PASP values in patients with active PTB. The degree of hypoxia and severity of secondary respiratory bacterial infection may influence PASP value in active PTB.

Correlation of Echocardiographic and Right Heart Catheterization Estimations of Pulmonary Artery Systolic Pressure

Background

Pulmonary artery pressure (PAP) is one of the most important and valuable markers in cardiovascular disease, measured by right heart catheterization (RHC) as the gold standard diagnostic modality. However, due to several limitations, such as invasiveness, lack of repeatability, and high health costs, echocardiographic estimation of PAP has been used to substitute RHC for diagnosis and monitoring of this disease. This study aimed to evaluate the correlation of echocardiographic and RHC estimations of systolic PAP.

Materials and Methods

In this study, patients, who were referred to Masih Daneshvari Hospital in Tehran, Iran, evaluated by RHC and echocardiography, were selected. The median PAP (mPAP) and systolic PAP (sPAP) for each modality, time interval between the two modalities, sex, and age were extracted from the patients' records. The RHC mPAP data was used for categorization of patients as pulmonary hypertension, while the sPAP data of two modalities was used to assess correlations and define a cut-off point by the ROC analysis. Data analysis was performed using SPSS version 24, and the level of statistical significance was less than 0.05.

Results

Seventy-six patients, including 31 males (40.8%) and 45 females (59.2%) with the mean age of 45±14 years, were evaluated in this study. The mean sPAP was 71.98±30.22 mmHg when measured by RHC and 69.75±26.03 mmHg when measured by echocardiography (correlation coefficient=0.805; P<0.001). Agreement between the two measurements was 97%, and the accuracy of echocardiography was 43%. By considering 40 mmHg as the cutoff point, the sensitivity and specificity of echocardiography were estimated at 89.2% and 42.8%, respectively. Based on the ROC analysis, the highest sensitivity (86.7%) and specificity (87.5%) were achieved with an estimated sPAP of 57.5 mmHg.

Conclusion

Echocardiography showed a good correlation and agreement with RHC in estimating sPAP; therefore, it is appropriate for screening of patients because of high sensitivity. However, for diagnosis confirmation, monitoring, and follow-up of pulmonary hypertension via echocardiography, high specificity is needed, which can be achieved by considering sPAP of 57.5 mmHg as the cutoff value for pulmonary hypertension.

Role of functional echocardiographic parameters in the diagnosis of bronchopulmonary dysplasia-associated pulmonary hypertension

Echocardiogram (echo) is a commonly used noninvasive modality for the diagnosis of bronchopulmonary dysplasia associated pulmonary hypertension (BPD-PH). Though not considered the gold standard for the diagnosis of BPD-PH, it is an extremely valuable tool in the neonatal and pediatric population, especially when cardiac catheterization is not feasible. In addition to the traditional echo parameters that are used to assess the presence of BPD-PH, much attention has been recently placed on newer bedside echo measures, the so-called functional echo parameters, to aid and assist in the diagnosis. This review article provides a brief introduction to BPD-PH, describes the pitfalls of traditional echo parameters and details the newer echo modalities currently available for the diagnosis of neonatal PH.

Pulmonary Hypertension Registry of Kerala, India (PRO-KERALA): One-year outcomes

BACKGROUND

Short term outcomes of patients with pulmonary hypertension are not available from low and middle-income countries including India.

METHODS

We conducted a prospective study of 2003 patients with pulmonary hypertension, from 50 centres (PROKERALA) in Kerala, who were followed up for one year. Pulmonary hypertension (PH) was mainly diagnosed on the basis of Doppler echocardiography. The primary outcome was a composite end-point of all-cause death and hospital admission for heart failure. All cause hospitalisation events constituted the secondary outcome.

RESULTS

Mean age of study population was 56 ± 16 years. Group 1 and Group 2 PH categories constituted 21.2% and 59% of the study population, respectively. Nearly two-thirds (65%) of the study participants had functional class II symptoms. 31% of Group 1 PH patients were on specific vasodilator drugs.In total, 83 patients (4.1%) died during the one-year follow-up period. Further, 1235 re-hospitalisation events (61.7%) were reported. In the multivariate model, baseline NYHA class III/IV (OR 1.87, 95% C.I. 1.35-2.56), use of calcium channel blockers (OR 0.18, 95% C.I. 0.04-0.77), vasodilator therapy (OR 0.5, 95% C.I. 0.28-0.87) and antiplatelet agents (OR 1.80, 95% C.I. 1.29-2.51) were associated with primary composite outcome at one-year (p < 0.05).

CONCLUSION

In the PROKERALA registry, annual mortality rate was 4%. More than half of the patients reported re-hospitalisation events on follow up. Uptake of guideline directed therapies were suboptimal in the study population. Quality improvement programmes to improve guideline directed therapy may improve clinical outcomes of PH patients in India.

N-terminal pro-B-type-natriuretic peptide as a screening tool for pulmonary hypertension in the paediatric population

BACKGROUND

Although cardiac catheterisation (cath) is the diagnostic test for pulmonary hypertension, it is an invasive procedure. Echocardiography (echo) is commonly used for the non-invasive diagnosis of pulmonary hypertension but maybe limited by lack of adequate signals. Therefore, emphasis has been placed on biomarkers as a potential diagnostic tool. No prior paediatric studies have simultaneously compared N-terminal pro-B-type-natriuretic peptide (NTproBNP) with cath/echo as a potential diagnostic tool. The aim of this study was to determine if NTproBNP was a reliable diagnostic tool for pulmonary hypertension in this population.

METHODS

Patients were divided into Study (echo evidence/established diagnosis of pulmonary hypertension undergoing cath) and Control (cath for small atrial septal defect/patent ductus arteriosus and endomyocardial biopsy post cardiac transplant) groups. NTproBNP, cath/echo data were obtained.

RESULTS

Thirty-one patients met inclusion criteria (10 Study, 21 Control). Median NTproBNP was significantly higher in the Study group. Echo parameters including transannular plane systolic excursion z scores, pulmonary artery acceleration time and right ventricular fractional area change were lower in the Study group and correlated negatively with NTproBNP. Receiver operation characteristic curve analysis demonstrated NTproBNP > 389 pg/ml was 87% specific for the diagnosis of pulmonary hypertension with the addition of pulmonary artery acceleration time improving the specificity.

CONCLUSIONS

NTproBNP may be a valuable adjunctive diagnostic tool for pulmonary hypertension in the paediatric population. Echo measures of transannular plane systolic excursion z score, pulmonary artery acceleration time and right ventricular fractional area change had negative correlations with NTproBNP. The utility of NTproBNP as a screening tool for pulmonary hypertension requires validation in a population with unknown pulmonary hypertension status.

Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment

Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.

RETROSPECTIVE COMPUTER-ASSISTED IMAGE ANALYSIS OF DOPPLER ECHOCARDIOGRAPHY IN PULMONARY HYPERTENSION PATIENTS

Pulmonary hypertension (PH) is diagnosed invasively by right heart catheterization (RHC), which determines patient’s mean and systolic pulmonary artery pressure (mPAP, sPAP) and pulmonary vascular resistance (PVR). This study sought to identify non-invasive echocardiography parameters useful for screening PH. Patients ([Formula: see text]; 19 normotensive; 17 pre-capillary PH; 48 post-capillary PH) who had undergone transthoracic Doppler echocardiography and RHC within 60 days of each other were identified. Tricuspid regurgitant (TR) jet velocities, velocity spectral densities, average flow rates, and Fourier transforms (FFT) of velocity waveforms were calculated via an in-house MATLAB code. Correlations were found between the FFT magnitude at 0 Hz and sPAP and mPAP for normotensive patients; between the MATLAB-calculated TR jet and sPAP and PVR for all PH patients; and between the sum of FFT magnitudes [Formula: see text][Formula: see text]Hz and mPAP, sPAP, and PVR for post-capillary PH patients. Statistical difference was found between the FFT magnitudes at 2 Hz of pre- and post-capillary PH patients ([Formula: see text]). These results suggest non-invasive parameters with clinical utility for estimating RHC measurements and discriminating between PH types, offering a path forward for less invasive and more accessible PH screening protocol.

Pulmonary Hypertension

Pulmonary hypertension (PH) is a chronic and progressive disease that presents like many other lung diseases, often leading to a delay in diagnosis, and therefore a delay in optimal therapy. This article provides a review of PH for internists, covering clinical presentation, diagnostic algorithm, different types of PH, and overview of treatments. In addition, it emphasizes the importance of early referral to, and partnership between, PH specialists and physicians on the front lines to improve early diagnosis and optimize management of these complex patients.

Combined automated 3D volumetry by pulmonary CT angiography and echocardiography for detection of pulmonary hypertension

OBJECTIVES

To assess the diagnostic accuracy of automated 3D volumetry of central pulmonary arteries using computed tomography pulmonary angiography (CTPA) for suspected pulmonary hypertension alone and in combination with echocardiography.

METHODS

This retrospective diagnostic accuracy study included 70 patients (mean age 66.7, 48 female) assessed for pulmonary hypertension by CTPA and transthoracic echocardiography with estimation of the pulmonary arterial systolic pressure (PASP). Gold standard right heart catheterisation with measurement of the invasive mean pulmonary arterial pressure (invasive mPAP) served as the reference. Volumes of the main, right and left pulmonary arteries (MPA, RPA and LPA) were computed using automated 3D segmentation. For comparison, axial dimensions were manually measured. A linear regression model was established for prediction of mPAP (predicted mPAP).

RESULTS

MPA, RPA and LPA volumes were significantly increased in patients with vs. without pulmonary hypertension (all p < 0.001). Of all measures, MPA volume demonstrated the strongest correlation with invasive mPAP (r = 0.76, p < 0.001). Predicted mPAP using MPA volume and echocardiographic PASP as covariates showed excellent correlation with invasive mPAP (r = 0.89, p < 0.001). Area under the curves for predicting pulmonary hypertension were 0.94 for predicted mPAP, compared to 0.90 for MPA volume and 0.92 for echocardiographic PASP alone. A predicted mPAP > 25.8 mmHg identified pulmonary hypertension with sensitivity, specificity, positive and negative predictive values of 86%, 93%, 95% and 81%, respectively.

CONCLUSIONS

Automated 3D volumetry of central pulmonary arteries based on CTPA may be used in conjunction with echocardiographic pressure estimates to noninvasively predict mPAP and pulmonary hypertension as confirmed by gold standard right heart catheterisation with higher diagnostic accuracy than either test alone.

KEY POINTS

• This diagnostic accuracy study derived a regression model for noninvasive prediction of invasively measured mean pulmonary arterial pressure as assessed by gold standard right heart catheterisation. • This regression model using automated 3D volumetry of the central pulmonary arteries based on CT pulmonary angiography in conjunction with the echocardiographic pressure estimate predicted pulmonary arterial pressure and the presence of pulmonary hypertension with good diagnostic accuracy. • The combination of automated 3D volumetry and echocardiographic pressure estimate in the regression model provided superior diagnostic accuracy compared to each parameter alone.

Echocardiographic evaluation of diastolic function in the setting of pulmonary hypertension

Heart failure due to diastolic dysfunction and pulmonary hypertension are frequent comorbid conditions with significant morbidity and mortality. Identifying the presence and etiology of diastolic dysfunction in the setting of pulmonary hypertension remains challenging despite profound therapeutic and prognostic implications. Additionally, there is little guidance in identifying and parsing etiology of diastolic dysfunction in patients found to have pulmonary hypertension. This review discusses the complex interplay between left ventricular diastolic dysfunction and pulmonary hypertension. With an explicit focus on the use of echocardiography for determination of diastolic dysfunction and etiology of pulmonary hypertension, this review also provides a comprehensive review of the literature and provides a framework by which to assess diastolic dysfunction echocardiographically in the setting of pulmonary hypertension.

Usefulness of Echocardiography/Doppler to Reliably Predict Elevated Left Ventricular End-Diastolic Pressure in Patients With Pulmonary Hypertension

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.

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 (sPAP) was assessed with continuous wave Doppler of systolic tricuspid regurgitant velocity and regarded raised with values ≥ 30 mmHg 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 mL, 32.2 ± 13.6 mL, 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 (sPAP: 61.2 ± 22.3 mmHg, 53.6 ± 20.1 mmHg, 31.2 ± 24.6 mmHg, 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/mL, 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 mmHg, 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.

Transthoracic echocardiography for the evaluation of children and adolescents with suspected or confirmed pulmonary hypertension. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and D6PK

Transthoracic echocardiography (TTE) is a useful method for non-invasive screening of patients at risk of pulmonary hypertension (PH). Since TTE often serves as the initial study before invasive cardiac catheterisation, misinterpretation of TTE variables may lead to missed or delayed diagnosis with devastating consequences for the patients, or unnecessary invasive diagnostics that have inheriting risks. Due to the heterogeneous anatomy in congenital heart disease, particularly the assessment of myocardial function in children with PH is challenging. Here, we present recommendations on the use of TTE in the screening, diagnosis and follow-up of patients with PH, and discuss the limitations of this non-invasive imaging technique. This expert consensus statement focuses on key TTE variables used to determine the pressure in the pulmonary artery, myocardial contractility and systolic and diastolic function of the RV and LV. A particular focus is on the TTE assessment of RV function and geometry. According to the published data on the application of TTE in PH in childhood, we suggest a structured approach for non-invasive assessment of pulmonary artery pressure and myocardial function that may help to identify patients with early ventricular deterioration and their response to advanced pharmacotherapy. In addition to clinical and biochemical markers, serial examination of patients with PH using a standardised TTE approach, determining conventional and several more novel echocardiographic variables may allow early diagnosis and treatment, better recognition of disease progression and guide tailored therapy.

Transthoracic echocardiography in the evaluation of pediatric pulmonary hypertension and ventricular dysfunction

Transthoracic echocardiography (TTE) is the most accessible noninvasive diagnostic procedure for the initial assessment of pediatric pulmonary hypertension (PH). This review focuses on principles and use of TTE to determine morphologic and functional parameters that are also useful for follow-up investigations in pediatric PH patients. A basic echocardiographic study of a patient with PH commonly includes the hemodynamic calculation of the systolic pulmonary artery pressure (PAP), the mean and diastolic PAP, the pulmonary artery acceleration time, and the presence of a pericardial effusion. A more detailed TTE investigation of the right ventricle (RV) includes assessment of its size and function. RV function can be evaluated by RV longitudinal systolic performance (e.g., tricuspid annular plane systolic excursion), the tricuspid regurgitation velocity/right ventricular outflow tract velocity time integral ratio, the fractional area change, tissue Doppler imaging-derived parameters, strain measurements, the systolic-to-diastolic duration ratio, the myocardial performance (Tei) index, the RV/left ventricle (LV) diameter ratio, the LV eccentricity index, determination of an enlarged right atrium and RV size, and RV volume determination by 3-dimensional echocardiography. Here, we discuss the potential use and limitations of TTE techniques in children with PH and/or ventricular dysfunction. We suggest a protocol for TTE assessment of PH and myocardial function that helps to identify PH patients and their response to pharmacotherapy. The outlined protocol focuses on the detailed assessment of the hypertensive RV; RV-LV crosstalk must be analyzed separately in the evaluation of different pathologies that account for pediatric PH.

Tuberculosis associated pulmonary hypertension: The revelation of a clinical observation

Background:

Pulmonary tuberculosis is not listed as a cause of pulmonary hypertension (PH). Scanty information is available in the literature regarding this issue.

Methods:

A group of patients with a history of pulmonary tuberculosis were diagnosed to have PH on the basis of a novel clinico-radio-echocardiographic criteria. Subdivided into two groups on the basis of the history of smoking, we looked for their demographic, spirometric, radiological characteristics along with the quality of life assessment.

Results:

A total of 40 patients (21 smokers and 19 nonsmokers) were found to have PH with history of pulmonary tuberculosis. The two groups were similar radiologically including the extent of fibrosis. The nonsmoker group had lower age range (52.16 ± 14.81 vs. 63.1 ± 10.05, P = 0.01), worse chronic obstructive pulmonary disease (COPD) assessment test score (16.11 ± 6.24 vs. 13.9 ± 5.6, P = 0.25) and higher pulmonary artery (PA) pressure (46.39 ± 7.44 vs. 44.55 ± 8.04, P = 0.46) compared to the smokers. Overall and for the smoker group, in particular, the spirometric pictures were favoring obstruction without reversibility as in COPD (forced expiratory volume in 1 second [FEV₁] % as 64.26 ± 18.38 and 58.85 ± 14.61 with % of predicted FEV₁ being 43.74 ± 17.26 and 42.38 ± 16.64 respectively). However, those with no history of smoking had restrictive changes as in diffuse parenchymal lung disease (DPLD) in their spirometry (FEV₁/forced vital capacity [FVC] of 79.33 ± 19.93 and FVC as 49.67 ± 11.54% of predicted). The smoker group had far more obvious involvement of the small airways in terms of change in FEF_25-75 compared to nonsmokers (FEF_25-75 = 22.85 ± 19.68 vs. 63.83 ± 48.61).

Conclusion:

PH appears associated with the history of pulmonary tuberculosis. With or without a history of smoking, they pose two distinct phenotypes in spirometry as COPD and DPLD. The DPLD phenotype had worse quality of life.

[Pulmonary hypertension in hemodialysis patients: Prevalence and associated factors]

BACKGROUND AND OBJECTIVE

Pulmonary hypertension (PH) is a progressive disorder that can be caused by several underlying conditions or an intrinsic alteration of the pulmonary vasculature. Chronic increased pressure in the pulmonary vasculature leads to changes in the architecture of the vessels that can perpetuate PH and produce right ventricular dysfunction. These structural and functional alterations can decrease survival and quality of life of patients on hemodialysis; however, there is a lack of evidence about this problem in this population. The aim of this study is to establish the prevalence of PH in patients on hemodialysis and its association with specific factors related to this patient population.

MATERIAL AND METHODS

We included 202 prevalent patients on hemodialysis for at least 6 months and who were clinically stable. We collected demographic data, routine laboratory parameters and data of 2D Doppler-echocardiography. PH was defined as a systolic pulmonary artery pressure (SPAP) estimated by Doppler ultrasound above 35mmHg. Hydration status was assessed by determining the plasma concentration of N-terminal pro brain natriuretic peptide (Nt-proBNP).

RESULTS

PH prevalence was 37.1% (75 patients). The average SPAP in the entire study population was 32±12mmHg and in the group with PH it was 45±11mmHg. We found a direct and statistically significant correlation between the presence of PH and age (P=.001), time on renal replacement therapy (P=.04), the presence of systolic dysfunction (P=.007), diastolic dysfunction (P= 01), mitral valve disease (P=.01) and double mitral and aortic disease (P=.007). Volume overload was closely associated with PH, as demonstrated by the correlation between the SPAP and Nt-proBNP levels (P=.001).

CONCLUSION

We conclude that prevalence of PH in hemodialysis patients is high. And one of the most important associated factors is volume overload. More studies are needed to establish the impact of PH on morbidity and mortality of patients and to assess whether a better volume control improves PH.

The Role of Echocardiography in the Evaluation of Pulmonary Arterial Hypertension

The evaluation of pulmonary arterial hypertension (PAH) requires a multimodality approach that combines invasive and noninvasive imaging studies to ensure accurate diagnosis and classification. Given the complexity of the hemodynamic relationships between the left heart, pulmonary circulation, and right heart, the diagnosis of PAH is often a challenging task. Right heart catheterization is the gold standard for diagnosis, providing the hemodynamic information that defines the disease. Nonetheless, echocardiography continues to be a valuable tool in the approach to the patient with suspected PAH. Echocardiographic assessment generates a wealth of information about the response of the right heart to elevated pulmonary pressures and provides essential diagnostic and prognostic data to the clinician. Numerous measurements can be used to identify alterations in right heart morphology, pressure, and function; although each variable in isolation may have little utility, meaningful information is revealed when multiple parameters are considered together. In this article, we will review the echocardiographic measurements employed in assessment of the right heart and seek to clarify the role of echocardiography in the diagnostic workup of PAH.

Impact of endoscopic lung volume reduction on right ventricular myocardial function

Introduction

Endoscopic lung volume reduction (ELVR) provides a minimally invasive therapy for patients with severe lung emphysema. As its impact on right ventricular (R_tV) function is undefined, we examined the extent of R_tV functional changes following ELVR, as assessed by use of speckle tracking-based R_tV deformation analysis.

Methods

We enrolled 32 patients with severe emphysematous COPD scheduled for bronchoscopic LVR using endobronchial valves (Zephyr, PulmonX, Inc.), comprising 16 matched clinical responders and 16 non-responders. Echocardiography was conducted one day prior to ELVR and at an eight-week postprocedural interval.

Results

Patients were predominantly of late middle-age (65.8±8.7yrs), male (62.5%) and presented advanced COPD emphysema (means FEV1 and RV: 32.6% and 239.1% of predicted, respectively). After ELVR, R_tV apical longitudinal strain improved significantly in the total study cohort (-7.96±7.02% vs. -13.35±11.48%, p=0.04), whereas there were no significant changes in other parameters of R_tV function such as R_tV global longitudinal strain, TAPSE or pulmonary arterial systolic pressure. In responding patients, 6MWT-improvement correlated with a decrease in NT-proBNP (Pearson´s r: -0.53, p=0.03). However, clinical non-responders did not exhibit any R_tV functional improvement.

Discussion

ELVR beneficially impacts R_tV functional parameters. Speckle tracking-based R_tV apical longitudinal strain analysis allows early determination of R_tV contractile gain and identification of clinical responsiveness.

Three-dimensional echocardiography and 2D-3D speckle-tracking imaging in chronic pulmonary hypertension: diagnostic accuracy in detecting hemodynamic signs of right ventricular (RV) failure

BACKGROUND

Our aim was to compare three-dimensional (3D) and 2D and 3D speckle-tracking (2D-STE, 3D-STE) echocardiographic parameters with conventional right ventricular (RV) indexes in patients with chronic pulmonary hypertension (PH), and investigate whether these techniques could result in better correlation with hemodynamic variables indicative of heart failure.

METHODS AND RESULTS

Seventy-three adult patients (mean age, 53±13 years; 44% male) with chronic PH of different etiologies were studied by echocardiography and cardiac catheterization (25 precapillary PH from pulmonary arterial hypertension, 23 obstructive pulmonary heart disease, and 23 postcapillary PH from mitral regurgitation). Thirty healthy subjects (mean age, 54±15 years; 43% male) served as controls. Standard 2D measurements (RV-fractional area change-tricuspid annular plane systolic excursion) and mitral and tricuspid tissue Doppler annular velocities were obtained. RV 3D volumes and global and regional ejection fraction (3D-RVEF) were determined. RV strains were calculated by 2D-STE and 3D-STE. RV 3D global-free-wall longitudinal strain (3DGFW-RVLS), 2D global-free-wall longitudinal strain (GFW-RVLS), apical-free-wall longitudinal strain, basal-free-wall longitudinal strain, and 3D-RVEF were lower in patients with precapillary PH (P<0.0001) and postcapillary PH (P<0.01) compared to controls. 3DGFW-RVLS (hazard ratio 4.6, 95% CI 2.79 to 8.38, P=0.004) and 3D-RVEF (hazard ratio 5.3, 95% CI 2.85 to 9.89, P=0.002) were independent predictors of mortality. Receiver operating characteristic curves showed that the thresholds offering an adequate compromise between sensitivity and specificity for detecting hemodynamic signs of RV failure were 39% for 3D-RVEF (AUC 0.89), -17% for 3DGFW-RVLS (AUC 0.88), -18% for GFW-RVLS (AUC 0.88), -16% for apical-free-wall longitudinal strain (AUC 0.85), 16 mm for tricuspid annular plane systolic excursion (AUC 0.67), and 38% for RV-FAC (AUC 0.62).

CONCLUSIONS

In chronic PH, 3D, 2D-STE and 3D-STE parameters indicate global and regional RV dysfunction that is associated with RV failure hemodynamics better than conventional echo indices.

Pulmonary arterial hypertension: the key role of echocardiography

Echocardiography is a key screening tool in the diagnostic algorithm of pulmonary arterial hypertension (PAH). It provides an estimate of right ventricular function and pulmonary artery pressure, either at rest or during exercise, and is useful in ruling out secondary causes of pulmonary hypertension (PH) such as left heart disease or congenital heart disease. Several studies have showed that echocardiography is insufficiently precise as single tool for the ultimate diagnosis of PH respect to the right heart catheterization, considered the gold standard technique. Echocardiography is valuable in assessing prognosis and treatment options, monitoring the efficacy of specific therapeutic interventions, and detecting the preclinical stages of disease. The ideal imaging modality for accurate noninvasive assessment of the right heart should be accurate and precise, not influenced by loading conditions, routinely practicable and easily repeatable. For all such reasons and considering that PAH is a rare and severe condition, a complete noninvasive assessment of right heart function requires a deep knowledge of the disease and a multimodality approach.

Development of left ventricular longitudinal speckle tracking echocardiography in very low birth weight infants with and without bronchopulmonary dysplasia during the neonatal period

Objectives

In preterm infants, postnatal myocardial adaptation may be complicated by bronchopulmonary dysplasia (BPD). We aimed to describe the development of left ventricular function by serial 2D, Doppler, and speckle tracking echocardiography (2D-STE) in infants with and without BPD during the neonatal period and compare these to anthropometric and conventional hemodynamic parameters.

Study Design

Prospective echocardiography on day of life (DOL) 1, 7, 14, and 28 in 119 preterm infants <1500 g birth weight of whom 36 developed BPD (need for oxygen supplementation at 36 weeks gestational age). Non-BPD and BPD infants differed significantly in median (IQR) gestational age (25.5(24–26.5) weeks vs. 29(27–30) weeks, p<0.001) and birth weight (661(552–871) g vs. 1100(890–1290) g, p<0.001).

Results

The intra- and inter-observer variability of the 2D-STE parameters measured did not depend on time of measurement, although there were significant differences in the reproducibility of the parameters. Low intra- and inter-observer variability was seen for longitudinal systolic strain and strain rate mid septum with a median CV (coefficient of variation) of <4.6%. Much higher CVs (>10%) were seen for the apical segment. While anthropometric parameters show rapid development during the first 4 weeks of life, the speckle tracking parameters did not differ statistically significantly during the neonatal period. Infants with and without BPD differed significantly (p<0.001) in the development of anthropometric parameters, conventional hemodynamic parameters except for heart rate, and 2D-STE parameters: global longitudinal systolic strain rate (GLSSR) and longitudinal systolic strain for the mid left wall (LSSR). The largest differences were seen at DOL 1 and 7 in GLSSR (p<0.001) and in LSSR (p<0.01).

Conclusions

Reproducible 2D-STE measurements are possible in preterm infants <1500 g. Cardiac deformation reveals early (DOL 1 and 7) ventricular changes (GLSSR and LSSR) in very low birth weight infants who develop BPD.

Pulmonary Hypertension and Right Heart Failure in Chronic Kidney Disease: New Challenge for 21st-Century Cardionephrologists

Pulmonary hypertension is defined as an increased systolic pulmonary pressure of >30 mm Hg, and it shows a 40% prevalence in hemodialysis patients due to vascular access (both central venous catheter and arteriovenous fistula). Secondary pulmonary hypertension in chronic kidney disease patients is strictly related to pulmonary circulation impairment together with chronic volume overload and increased levels of cytokines and growth factors, such as FGF, PDGF, and TGF-β, leading to fibrosis. Endothelial dysfunction, together with lower activation of NOS, increased levels of serum endothelin and fibrin storages, involves an extensive growth of endothelial cells leading to complete obliteration of pulmonary vessels. Pulmonary hypertension has no pathognomonic and distinctive symptoms and signs; standard transthoracic echocardiography allows easy assessment of compliance of the right heart chambers. The therapeutic approach is based on traditional drugs such as digitalis-derived drugs, vasodilatory agents (calcium channel blockers), and oral anticoagulants. New pharmacological agents are under investigation, such as prostaglandin analogues, endothelin receptor blockers, and phosphodiesterase-5 inhibitors.

Pulmonary hypertension in parenchymal lung disease

Idiopathic pulmonary arterial hypertension (IPAH) has been extensively investigated, although it represents a less common form of the pulmonary hypertension (PH) family, as shown by international registries. Interestingly, in types of PH that are encountered in parenchymal lung diseases such as interstitial lung diseases (ILDs), chronic obstructive pulmonary disease (COPD), and many other diffuse parenchymal lung diseases, some of which are very common, the available data is limited. In this paper, we try to browse in the latest available data regarding the occurrence, pathogenesis, and treatment of PH in chronic parenchymal lung diseases.