Pressure reflection in the pulmonary circulation by echocardiography in patients with left heart disease indicates reactive pulmonary hypertension
Pressure reflection in the pulmonary circulation by echocardiography in patients with left heart disease indicates reactive pulmonary hypertension
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DOI：
10.1093/eurheartj/eht310.p5743
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发表时间：
2013-08
影响因子：
39.3
通讯作者：
O. Bech-Hanssen;B. Fadel;W. Al-Habeeb;J. Al-Buraiki;N. Selimovic
中科院分区：
文献类型：
--
作者：
O. Bech-Hanssen;B. Fadel;W. Al-Habeeb;J. Al-Buraiki;N. Selimovic
背景和目的：左心病 (LHD) 合并肺动脉高压 (PH) 的两种血流动力学特征，即肺静脉压升高的被动 PH 和肺血管阻力 (PVR) 增加的反应性 PH，无法以非侵入方式区分。我们假设肺循环中压力反射 (PR) 的超声心动图征象可用于诊断反应性 PH。方法：该研究纳入 122 名患者，分为三组：无 PH 患者（无 PH，n=61）、有 PH 患者（肺动脉平均压，PAMP≥25 mmHg）和正常 PVR 患者（被动 PH，n=29）和 PVR 增加患者（反应性 PH，n=32）。超声心动图和右心导管插入术 (RHC) 在 24 小时内进行。选择三个 PR 变量：右心室流出道 (RVOT) 的加速时间、RVOT 峰值速度与三尖瓣返流峰值速度之间的时间间隔以及 RVOT 峰值速度后右心室压力增加。使用接受者操作特征 (ROC) 曲线研究了指示 PVR>3WU 的高可能性（主要标准）或低可能性（次要标准）的单独截止值。结果：平均±标准差年龄为50±14岁，男性比例为63%。 68 名患者 (56%) 因已知或疑似 LHD 接受 RHC，其中 23 名患者患有扩张型心肌病。 31 名患者（25%）为心脏移植受者，8 名患者（7%）患有心脏淀粉样变性，15 名患者（12%）为其他患者。研究中没有患者因左心室功能障碍以外的其他原因出现 PH 或 PVR 增加。 66% 的反应性 PH 患者患有轻度至中度 PH (PAMP 25-40 mmHg)。肺毛细血管楔压>15 mmHg的患者比例，无PH患者为14%，被动PH患者为97%，反应性PH患者为74%。 PR 变量的 ROC 曲线下面积为 0.82 至 0.89。存在三个主要标准时，PVR>3 WU 的可能性增加 27.3 倍（阳性似然比），而缺少次要标准则使可能性降低 8.3 倍（阴性似然比）。结论：LHD 患者 PR 的超声心动图评估可用于识别或排除反应性 PH。反应性PH患者通常有轻度至中度PH，而不是重度PH。
Background and aims: The two hemodynamic profiles in Left Heart Disease (LHD) with Pulmonary Hypertension (PH), passive PH with increased pulmonary venous pressure and reactive PH with increased Pulmonary Vascular Resistance (PVR), cannot be distinguished non-invasively. We hypothesized that echocardiographic signs of Pressure Reflection (PR) in the pulmonary circulation can be used to diagnose reactive PH. Methods: The study comprised 122 patients that were divided into three groups: patients without PH (No PH, n=61), patients with PH (pulmonary artery mean pressure, PAMP≥25 mmHg) and normal PVR (Passive PH, n=29) and patients with increased PVR (Reactive PH, n=32). Echocardiography and Right Heart Catheterization (RHC) was performed within 24 hours. Three PR variables were selected: the acceleration time in the Right Ventricular Outflow Tract (RVOT), the time interval between RVOT peak velocity and peak tricuspid regurgitant velocity and the right ventricular pressure increase after peak RVOT velocity. Separate cutoff values indicating either high likelihood (major criteria) or low likelihood (minor criteria) for PVR>3WU were investigated using Receiver Operator Characteristic (ROC) curves. Results: The mean±SD age was 50±14 years, and the percentage of males was 63%. Sixty-eight patients (56%) underwent RHC due to known or suspected LHD whereof 23 patients had dilated cardiomyopathy. Thirty-one patients (25%) were heart transplant recipients, 8 patients (7%) had cardiac amyloidosis and 15 patients (12%) were miscellaneous. No patient included in the study had PH or increased PVR due to other causes than left ventricular dysfunction. Sixty-six percent of patients with Reactive PH had mild to moderate PH (PAMP 25-40 mmHg). The proportion of patients with pulmonary capillary wedge pressure>15 mmHg was 14% in No PH, 97% in Passive PH and 74% in Reactive PH. The area under the ROC curve for PR variables was 0.82 to 0.89. With three major criteria present the likelihood of PVR>3 WU increases 27.3 fold (positive likelihood ratio) and absence of minor criteria decreases the likelihood 8.3 fold (negative likelihood ratio). Conclusions: Echocardiographic assessment of PR in patients with LHD can be used to identify or exclude reactive PH. Patients with reactive PH often have mild to moderate rather than severe PH.