Search

Systolic deceleration or "notching" of the right ventricular outflow tract Doppler flow velocity envelope (FVE(RVOT)) relates to pathologic wave reflection in the setting of elevated pulmonary artery impedance.We investigated whether simple visual assessment of FVE(RVOT) morphology aids in hemodynamic differentiation and detection of pulmonary vascular disease among a referral pulmonary hypertension (PH) cohort.We reviewed hemodynamics, echocardiography, and clinical data for 88 patients referred for PH and 32 subjects with systolic heart failure and PH. The FVE(RVOT) was categorized as normal (no notch [NN]); late systolic notch (LSN); or midsystolic notch (MSN).The pulmonary vascular resistance (PVR) was highest in the MSN group (9.2 ± 3.5 Wood's units [WU]; P0.001) versus the LSN (5.7 ± 3.1 WU) and NN (3.3 ± 2.4 WU) groups. The ratio of stroke volume to pulse pressure (compliance) also differed by FVE(RVOT) morphology (MSN = 1.2 ± 0.5; LSN = 1.7 ± 0.8; NN = 2.6 ± 1.7; P = 0.001 and 0.04, respectively, vs. NN). MSN was 96% specific and 71% sensitive for a PVR5 WU (positive predictive value, 98%). The MSN group had severe right ventricular dysfunction (tricuspid annular plane systolic excursion 1.6 ± 0.5 cm) relative to the LSN and NN groups (tricuspid annular plane systolic excursion 1.9 ± 0.6 vs. 2.2 ± 0.6 cm; both P0.05). In the PH cohort, any FVE(RVOT) notching (MSN or LSN) was highly associated with PVR3 WU (odds ratio, 22.3; 95% confidence interval, 5.2-96.4), whereas the NN pattern predicted a PVR less than or equal to 3WU and pulmonary artery wedge pressure greater than 15 mm Hg (odds ratio, 30.2; 95% confidence interval, 6.3-144.9).Visual inspection of the shape of the FVE(RVOT) provides insight into the hemodynamic basis of PH in a referral PH cohort. MSN is associated with the most severe pulmonary vascular disease and right heart dysfunction.

Transthoracic Doppler echocardiography is recommended for screening for the presence of pulmonary hypertension (PH). However, some recent studies have suggested that Doppler echocardiographic pulmonary artery pressure estimates may frequently be inaccurate.Evaluate the accuracy of Doppler echocardiography for estimating pulmonary artery pressure and cardiac output.We conducted a prospective study on patients with various forms of PH who underwent comprehensive Doppler echocardiography within 1 hour of a clinically indicated right-heart catheterization to compare noninvasive hemodynamic estimates with invasively measured values.A total of 65 patients completed the study protocol. Using Bland-Altman analytic methods, the bias for the echocardiographic estimates of the pulmonary artery systolic pressure was -0.6 mm Hg with 95% limits of agreement ranging from +38.8 to -40.0 mm Hg. Doppler echocardiography was inaccurate (defined as being greater than +/-10 mm Hg of the invasive measurement) in 48% of cases. Overestimation and underestimation of pulmonary artery systolic pressure by Doppler echocardiography occurred with a similar frequency (16 vs. 15 instances, respectively). The magnitude of pressure underestimation was greater than overestimation (-30 +/- 16 vs. +19 +/- 11 mm Hg; P = 0.03); underestimates by Doppler also led more often to misclassification of the severity of the PH. For cardiac output measurement, the bias was -0.1 L/min with 95% limits of agreement ranging from +2.2 to -2.4 L/min.Doppler echocardiography may frequently be inaccurate in estimating pulmonary artery pressure and cardiac output in patients being evaluated for PH.

Rationale: Hyponatremia is associated with decompensated heart failure and poor prognosis in patients with left ventricular systolic dysfunction. Objectives: We sought to determine if hyponatremia is associated with right heart failure and worse prognosis in patients with pulmonary arterial hypertension (PAH). Methods: We prospectively followed 40 patients with PAH and examined the relationship between serum sodium and right heart function as well as survival. Measurements and Main Results: Subjects with hyponatremia (Na < 136 mEq/L) were more symptomatic (11/13 World Health Organization [WHO] class III/IV vs. 12/27 WHO class III/IV; P 5 0.02), had more peripheral edema (69 vs. 26%; P 5 0.009), and had higher hospitalization rates (85 vs. 41%; P 5 0.009) than normonatremic subjects. Hyponatremic subjects had higher right atrial pressure (14 66vs.9 63mmHg;P ,0.001),lowerstrokevolumeindex(21 67 vs. 32 6 10 ml/m2; P , 0.01), larger right ventricular:left ventricular area ratio (1.8 6 0.4 vs. 1.3 6 0.4; P , 0.001), and lower tricuspid annular plane systolic excursion (1.4 6 0.3 vs. 2.0 6 0.6 cm; P 5 0.001), despite similar mean pulmonary artery pressure (49 6 10 vs. 47 612 mm Hg;P 50.60). The 1- and 2-year survival estimates were 93% (95% confidence interval [CI], 73‐98%) and 85% (95% CI, 65‐ 94%), and 38% (95% CI, 14‐63%) and 15% (95% CI, 2‐39%) for normonatremic and hyponatremic subjects, respectively (log-rank x2 525.19,P ,0.001).Theunadjustedriskofdeath(hazardratio)in hyponatremic compared with normonatremic subjects was 10.16 (95% CI, 3.42‐30.10, P , 0.001). Hyponatremia predicted outcome after adjusting for WHO class, diuretic use, as well as right atrial pressure and cardiac index. Conclusions: Hyponatremia is strongly associated with right heart failure and poor survival in PAH.

Right ventricular (RV) function is an important determinant of prognosis in pulmonary hypertension. However, noninvasive assessment of the RV function is often limited by complex geometry and poor endocardial definition.To test whether the degree of tricuspid annular displacement (tricuspid annular plane systolic excursion [TAPSE]) is a useful echo-derived measure of RV function with prognostic significance in pulmonary hypertension.We prospectively studied 63 consecutive patients with pulmonary hypertension who were referred for a clinically indicated right heart catheterization. Patients underwent right heart catheterization immediately followed by transthoracic echocardiogram and TAPSE measurement.In the overall cohort, a TAPSE of less than 1.8 cm was associated with greater RV systolic dysfunction (cardiac index, 1.9 vs. 2.7 L/min/m2; RV % area change, 24 vs. 33%), right heart remodeling (right atrial area index, 17.0 vs. 12.1 cm(2)/m), and RV-left ventricular (LV) disproportion (RV/LV diastolic area, 1.7 vs. 1.2; all p0.001), versus a TAPSE of 1.8 cm or greater. In patients with pulmonary arterial hypertension (PAH; n = 47), survival estimates at 1 and 2 yr were 94 and 88%, respectively, in those with a TAPSE of 1.8 cm or greater versus 60 and 50%, respectively, in subjects with a TAPSE less than 1.8 cm. The unadjusted risk of death (hazard ratio) in patients with a TAPSE less than 1.8 versus 1.8 cm or greater was 5.7 (95% confidence interval, 1.3-24.9; p = 0.02) for the PAH cohort. For every 1-mm decrease in TAPSE, the unadjusted risk of death increased by 17% (hazard ratio, 1.17; 95% confidence interval, 1.05-1.30; p = 0.006), which persisted after adjusting for other echocardiographic and hemodynamic variables and baseline treatment status.TAPSE powerfully reflects RV function and prognosis in PAH.