Diastolic Pressure Difference to Classify Pulmonary Hypertension in the Assessment of Heart Transplant Candidates.

Published on Sep 1, 2017in Circulation-heart Failure6.033
· DOI :10.1161/CIRCHEARTFAILURE.117.004077
Stephen P. Wright12
Estimated H-index: 12
(UHN: University Health Network),
Yasbanoo Moayedi5
Estimated H-index: 5
(UHN: University Health Network)
+ 5 AuthorsSusanna Mak20
Estimated H-index: 20
(UHN: University Health Network)
Sources
Abstract
Background: The diastolic pressure difference (DPD) is recommended to differentiate between isolated postcapillary and combined pre-/postcapillary pulmonary hypertension (Cpc-PH) in left heart disease (PH-LHD). However, in usual practice, negative DPD values are commonly calculated, potentially related to the use of mean pulmonary artery wedge pressure (PAWP). We used the ECG to gate late-diastolic PAWP measurements. We examined the method’s impact on calculated DPD, PH-LHD subclassification, hemodynamic profiles, and mortality. Methods and Results: We studied patients with advanced heart failure undergoing right heart catheterization to assess cardiac transplantation candidacy (N=141). Pressure tracings were analyzed offline over 8 to 10 beat intervals. Diastolic pulmonary artery pressure and mean PAWP were measured to calculate the DPD as per usual practice (diastolic pulmonary artery pressure–mean PAWP). Within the same intervals, PAWP was measured gated to the ECG QRS complex to calculate the QRS-gated DPD (diastolic pulmonary artery pressure–QRS-gated PAWP). Outcomes occurring within 1 year were collected retrospectively from chart review. Overall, 72 of 141 cases demonstrated PH-LHD. Within PH-LHD, the QRS-gated DPD yielded higher calculated DPD values (3 [−1 to 6] versus 0 [−4 to 3] mm Hg; P P P Conclusions: The DPD calculated in usual practice is underestimated in PH-LHD, which may classify Cpc-PH patients as isolated postcapillary pulmonary hypertension. The QRS-gated DPD reclassifies a subset of PH-LHD patients from isolated postcapillary pulmonary hypertension to Cpc-PH, which is characterized by an adverse hemodynamic profile.
📖 Papers frequently viewed together
201623.60Circulation
8 Authors (Stephen P. Wright, ..., Susanna Mak)
92 Citations
References36
Newest
#1Emmanouil Tampakakis (Johns Hopkins University)H-Index: 15
#2Ryan J. Tedford (Johns Hopkins University)H-Index: 29
9 CitationsSource
#1Anikó Ilona Nagy (Semmelweis University)H-Index: 12
#2Ashwin Venkateshvaran (KTH: Royal Institute of Technology)H-Index: 6
Last. Aristomenis Manouras (Karolinska University Hospital)H-Index: 12
view all 5 authors...
Aims The diastolic pulmonary pressure gradient (DPG) has recently been introduced as a specific marker of combined pre-capillary pulmonary hypertension (Cpc-PH) in left heart disease (LHD). However, its diagnostic and prognostic superiority compared with traditional haemodynamic indices has been challenged lately. Current recommendations explicitly denote that in the normal heart, DPG values are greater than zero, with DPG ≥7 mmHg indicating Cpc-PH. However, clinicians are perplexed by the frequ...
35 CitationsSource
#1Tufik R. Assad (Vandy: Vanderbilt University)H-Index: 13
#2Anna R. Hemnes (Vandy: Vanderbilt University)H-Index: 43
Last. Evan L. Brittain (Vandy: Vanderbilt University)H-Index: 23
view all 12 authors...
Abstract Background Pulmonary hypertension (PH) is a common and morbid complication of left heart disease with 2 subtypes: isolated post-capillary pulmonary hypertension (Ipc-PH) and combined post-capillary and pre-capillary pulmonary hypertension (Cpc-PH). Little is known about the clinical or physiological characteristics that distinguish these 2 subphenotypes or if Cpc-PH shares molecular similarities to pulmonary arterial hypertension (PAH). Objectives The goal of this study was to test the ...
92 CitationsSource
#1Thomas S. Metkus (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 14
#2Christopher J. Mullin (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 3
Last. Ryan J. Tedford (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 29
view all 12 authors...
Background The effect of heart rate (HR) and body surface area (BSA) on pulmonary RC time and right ventricular (RV) load is unknown. Methods To determine the association of HR and BSA with the pulmonary RC time and measures of RV load, we studied three large patient cohorts including subjects with 1) known or suspected pulmonary arterial hypertension (PAH) (n = 1008), 2) pulmonary hypertension due to left heart disease (n = 468), and 3) end-stage heart failure with reduced ejection fraction (n ...
18 CitationsSource
#1Nazzareno Galiè (UNIBO: University of Bologna)H-Index: 98
#2Alessandra Manes (UNIBO: University of Bologna)H-Index: 33
Last. Massimiliano Palazzini (UNIBO: University of Bologna)H-Index: 18
view all 3 authors...
Definition and diagnosis of pulmonary vascular disease in heart failure: still an unclear rebus http://ow.ly/qp1L300x6yY
7 CitationsSource
#1Robert Naeije (Free University of Brussels)H-Index: 92
#2Michele D'Alto (Seconda Università degli Studi di Napoli)H-Index: 30
Abstract Pulmonary hypertension (PH) secondary to left heart diseases associated with an increased pulmonary venous pressure is the second of a total of five groups recognized in the classification of PH. Group 2 PH is the commonest form of PH, and is associated with high morbidity and mortality. The diagnosis of group 2 PH relies on a clinical probability assessment in which echocardiography plays a major role, eventually followed by the invasive measurements of a mean pulmonary artery pressure...
10 CitationsSource
#1Stephan Rosenkranz (University of Cologne)H-Index: 63
#2J. Simon R. Gibbs (NIH: National Institutes of Health)H-Index: 51
Last. Jean-Luc Vachiery (ULB: Université libre de Bruxelles)H-Index: 54
view all 6 authors...
In patients with left ventricular heart failure (HF), the development of pulmonary hypertension (PH) and right ventricular (RV) dysfunction are frequent and have important impact on disease progression, morbidity, and mortality, and therefore warrant clinical attention. Pulmonary hypertension related to left heart disease (LHD) by far represents the most common form of PH, accounting for 65–80% of cases. The proper distinction between pulmonary arterial hypertension and PH-LHD may be challenging...
250 CitationsSource
#1Nazzareno GalièH-Index: 98
#2Marc HumbertH-Index: 163
Last. Marius M. HoeperH-Index: 99
view all 21 authors...
ALAT : alanine aminotransferase ASAT : aspartate aminotransferase APAH : associated pulmonary arterial hypertension BAS : balloon atrial septostomy BMPR2 : bone morphogenetic protein receptor 2 BNP : brain natriuretic peptide BPA : balloon pulmonary angioplasty BREATHE : Bosentan
3,375 CitationsSource
Mandeep R. Mehra, MD (Chair), Charles E. Canter, MD, Margaret M. Hannan, MD, Marc J. Semigran, MD, Patricia A. Uber, PharmD, David A. Baran, MD, Lara Danziger-Isakov, MD, MPH, James K. Kirklin, MD, Richard Kirk, MD, Sudhir S. Kushwaha, MD, Lars H. Lund, MD, PhD, Luciano Potena, MD, PhD, Heather J. Ross, MD, David O. Taylor, MD, Erik A.M. Verschuuren, MD, PhD, Andreas Zuckermann, MD and on behalf of the International Society for Heart Lung Transplantation (ISHLT) Infectious Diseases, Pediatric an...
531 CitationsSource
#1Evan L. BrittainH-Index: 23
#2Tufik R. AssadH-Index: 13
Last. John H. NewmanH-Index: 69
view all 4 authors...
We read with interest the report by Al-Naamani et al. [(1)][1] and the editorial by Borlaug [(2)][2] on the prognostic value of the diastolic pressure gradient (DPG) in heart failure patients with preserved ejection fraction. The DPG did not predict mortality, which is in agreement with results
13 CitationsSource
Cited By18
Newest
#1Edo Y. Birati (UPenn: University of Pennsylvania)H-Index: 19
#2Jeremy A. Mazurek (UPenn: University of Pennsylvania)H-Index: 13
Source
#1Elena Pfeuffer-Jovic (University of Würzburg)
#2Simon Weiner (University of Würzburg)
Last. Matthias Held (University of Würzburg)H-Index: 8
view all 6 authors...
Abstract Background The World Symposium on Pulmonary Hypertension (WSPH) in 2018 recommended new definitions of pulmonary hypertension (PH). We investigated the impact of the updated definition on prevalence of PH due to left heart disease (PH-LHD). Methods The data of right heart catheterizations in patients with suspected PH-LHD between January 2008 and July 2015 was retrospectively analyzed applying different definitions. The number of patients diagnosed by the updated WSPH hemodynamic criter...
Source
#1Stephen P. Wright (UBC: University of British Columbia)H-Index: 1
#1Stephen P. Wright (UBC: University of British Columbia)H-Index: 1
Last. Susanna Mak (U of T: University of Toronto)H-Index: 20
view all 6 authors...
With each heartbeat, the right ventricle (RV) inputs blood into the pulmonary vascular (PV) compartment which conducts blood through the lungs at low pressure and concurrently fills the left atrium (LA) for output to the systemic circulation. This overall hemodynamic function of the integrated RV-PV-LA unit is determined by complex interactions between the components that vary over the cardiac cycle but are often assessed in terms of mean pressure and flow. Exercise challenges these hemodynamic ...
Source
#1William R. Miranda (Mayo Clinic)H-Index: 14
#2C. Charles Jain (Mayo Clinic)H-Index: 4
Last. Donald J. Hagler (Mayo Clinic)H-Index: 88
view all 7 authors...
Objective To assess the prevalence of elevated systemic right ventricular (sRV) end-diastolic pressure and pulmonary arterial hypertension in adults with transposition of the great arteries (TGA) who have undergone atrial switch operation. Methods Forty-two adults (aged ≥18 years) with complete TGA and atrial switch palliation undergoing cardiac catheterisation between 2004 and 2018 at Mayo Clinic, MN, were identified. Clinical, echocardiographic and invasive haemodynamic data were abstracted fr...
Source
#1Aristomenis Manouras (KI: Karolinska Institutet)H-Index: 12
#2Lars H. Lund (KI: Karolinska Institutet)H-Index: 43
Last. Jonas Johnson (Karolinska University Hospital)H-Index: 6
view all 5 authors...
AIMS A substantial shift in the field of pulmonary hypertension (PH) is ongoing, as the previous practice of mean pulmonary arterial wedge pressure (PAWPM ) is no longer supported. Instead, aiming for a better estimate of end-diastolic pressures (EDP), instantaneous PAWP at mid-A-wave (PAWPmid-A ) or, in the absence of an A-wave, at 130-160 ms following QRS onset has recently been recommended. Electrocardiogram-gated PAWP (PAWPQRS ) has also been proposed. The quantitative differences as well as...
Source
#1Claudia Frankfurter (U of T: University of Toronto)H-Index: 7
#2Micaela Molinero (UHN: University Health Network)H-Index: 1
Last. Ana C. Alba (UHN: University Health Network)H-Index: 19
view all 9 authors...
BACKGROUND Right ventricular failure (RVF) is a cause of major morbidity and mortality after left ventricular assist device (LVAD) implantation. It is, therefore, integral to identify patients who may benefit from biventricular support early post-LVAD implantation. Our objective was to explore the performance of risk prediction models for RVF in adult patients undergoing LVAD implantation. METHODS A systematic search was performed on Medline, Embase, Cochrane Central Register of Controlled Trial...
1 CitationsSource
#1Aristomenis Manouras (KI: Karolinska Institutet)H-Index: 12
#2Jonas Johnson (Karolinska University Hospital)H-Index: 6
Last. Anikó Ilona Nagy (KI: Karolinska Institutet)
view all 4 authors...
AIMS: The diastolic pressure gradient (DPG) has been proposed as a marker pulmonary vascular disease in the setting of left heart failure (HF). However, its diagnostic utility is compromised by the high prevalence of physiologically incompatible negative values (DPGNEG) and the contradictory evidence on its prognostic value. Pressure pulsatility impacts on DPG measurements, thus conceivably, pulmonary artery wedge pressure (PAWP) measurements insusceptible to the oscillatory effect of the V-wave...
1 CitationsSource
#1Koichi Sugimoto (Fukushima Medical University)H-Index: 23
#2Akiomi Yoshihisa (Fukushima Medical University)H-Index: 23
Last. Yasuchika Takeishi (Fukushima Medical University)H-Index: 53
view all 11 authors...
: Pulmonary hypertension (PH) caused by left-sided heart disease (LHD-PH) is classified into 2 types: isolated post-capillary PH (Ipc-PH) and combined pre- and post-capillary PH (Cpc-PH). However, the impact of pulmonary vascular resistance (PVR) or diastolic pressure gradient (DPG) on the prognosis of LHD-PH has varied among previous studies. Thus, we verified the significance of PVR or DPG on the prognosis of LHD-PH in our series.We analyzed 243 consecutive LHD-PH patients. The patients were d...
Source
#1Stephen P. Wright (UHN: University Health Network)H-Index: 12
#2Leah A. Groves (UWO: University of Western Ontario)H-Index: 2
Last. Susanna Mak (UHN: University Health Network)
view all 7 authors...
BACKGROUND The objectives of this study were to describe right ventricular-pulmonary arterial elastance coupling hemodynamic phenotypes and their frequency in patients with advanced heart failure and to evaluate the association of elastance-based indices with all-cause mortality, cardiac transplantation, and left ventricular assist device therapy. METHODS This study included 175 patients with heart failure undergoing right heart catheterization to evaluate candidacy for advanced therapies and 21...
6 CitationsSource
#1Eric L. Bonno (MUSC: Medical University of South Carolina)H-Index: 2
#2Michael C. Viray (MUSC: Medical University of South Carolina)H-Index: 3
Last. Ryan J. Tedford (MUSC: Medical University of South Carolina)H-Index: 29
view all 5 authors...
Source