Association between Preoperative Dynamic Measures of Vascular Load and Postoperative Hemodynamics in Patients with Chronic Thromboembolic Pulmonary Hypertension after Pulmonary Thromboendarterectomy

Contijoch, Francisco; Wong, Darrin; Igata, Sachiyo; Mizzell, Anna McDivit; Auger, William R.; DeMaria, Anthony N.; Blanchard, Daniel G.; Waheed, Anam; Bachman, Timothy N.; Simon, Marc A.; Pinsky, Michael R.; Madani, Michael M.

doi:10.1513/annalsats.202006-685rl

Cited by 4 publications

(3 citation statements)

References 14 publications

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“…Presumably, this reflects the fact that with a normotensive RV there is continued ejection well beyond the point of peak RVSP due to the high capacitance and low resistance pulmonary circulation 14 resulting in ESP being reached later in the cardiac cycle. Overall, study results highlight previous reports 8 that although mPAP is correlated with RV ESP and has been frequently used as a surrogate [3][4][5][6] , it progressively underestimates ESP as RVP rises (Figure 1). Across all methods, a significant relationship between both pooled and individual SB and MB Ees/Ea data was evident only for ESPtve and adjusted mPAP.…”

Section: Discussionsupporting

confidence: 85%

“…An alternative approach to determining Ees/Ea is the "single beat" (SB) method that incorporates a prediction of Pmax (the theoretical pressure generated by the RV during an isovolumic beat), an estimate of ESP, and a measurement of SV 2 . A common assumption of the SB method has been that mean PA pressure (mPAP) [3][4][5][6] or peak RV systolic pressure (RVSP) 7 represent adequate surrogates for ESP. However, in a hypertensive RV, the mPAP frequently underestimates the ESP 8 while in a normotensive RV, the peak RVSP tends to overestimate ESP.…”

Section: Introductionmentioning

confidence: 99%

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Defining end-systolic pressure for single-beat estimation of right ventricle–pulmonary artery coupling: simple… but not really

et al. 2021

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Functional adaptation of the right ventricle (RV) to its afterload plays an important prognostic role in pulmonary hypertension (PH) [1]. The preferred “multibeat” (MB) method for assessing RV–pulmonary vascular interaction involves the measurement of end-systolic elastance ( E es ), the slope of the end-systolic pressure (ESP) to end-systolic volume over sequential heart beats with varying preload. The E es value is then matched to simultaneous pulmonary arterial (PA) elastance at end systole ( E a ), calculated as ESP pressure divided by stroke volume (SV). The ratio of E es to E a ( E es / E a ) is termed RV–PA coupling, preservation of which indicates maintenance RV functioning in the face of increasing afterload [1]. However, while the MB method is generally regarded as the reference standard, it requires continuous, accurate measurement of RV volume and is therefore not readily applicable in most clinical settings.

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Section: Discussionsupporting

confidence: 85%

Section: Introductionmentioning

confidence: 99%

Defining end-systolic pressure for single-beat estimation of right ventricle–pulmonary artery coupling: simple… but not really

et al. 2021

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“…Alternatively, 'single beat' method using RV pressure waveforms and stroke volume (SV) can be applied to data recorded during RHC for quantification of contractility and afterload as independent entities. [4][5][6][7][8][9] Within this construct, contractility is measured as end-systolic ventricular elastance (Ees, in mmHg/mL) and afterload as arterial elastance (Ea, in mmHg/mL). With both expressed in a common term, the ratio Ees/Ea can be used to summarize changes in RV contractility/afterload balance (RV:PA coupling) over time or in response to acute interventions.…”

Section: Introductionmentioning

confidence: 99%

Pressure‐based estimation of right ventricular ejection fraction

et al. 2022

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Aims A method for estimating right ventricular ejection fraction (RVEF) from RV pressure waveforms was recently validated in an experimental model. Currently, cardiac magnetic resonance imaging (MRI) is the clinical reference standard for measurement of RVEF in pulmonary arterial hypertension (PAH). The present study was designed to test the hypothesis that the pressure-based method can detect clinically significant reductions in RVEF as determined by cardiac MRI in patients with PAH. Methods and results RVEF estimates derived from analysis of RV pressure waveforms recorded during right heart catheterization (RHC) in 25 patients were compared with cardiac MRI measurements of RVEF obtained within 24 h. Three investigators blinded to cardiac MRI results independently performed pressure-based RVEF estimation with the mean of their results used for comparison. Linear regression was used to assess correlation, and a receiver operator characteristic (ROC) curve was derived to define ability of the pressure-based method to detect a maladaptive RV response, defined as RVEF <35% on cardiac MRI. In 23 patients, an automated adaptation of the pressure-based RVEF method was also applied as proof of concept for beat-to-beat RVEF monitoring. The study cohort was comprised of 16 female and 9 male PAH patients with an average age of 53 ± 13 years. RVEF measured by cardiac MRI ranged from 16% to 57% (mean 37.7 ± 11.6%), and estimated RVEF from 15% to 54% (mean 36.2 ± 11.2%; P = 0.6). Measured and estimated RVEF were significantly correlated (r 2 = 0.78; P < 0.0001). ROC curve analysis demonstrated an area under the curve of 0.94 ± 0.04 with a sensitivity of 81% and specificity of 85% for predicting a maladaptive RV response. As a secondary outcome, with the recognized limitation of non-coincident measures, Bland-Altman analysis was performed and indicated minimal bias for estimated RVEF (À1.5%) with limits of agreement of ± 10.9%. Adaptation of the pressure-based estimation method to provide beat-to-beat RVEF also demonstrated significant correlation between the median beat-to-beat value over 10 s with cardiac MRI (r 2 = 0.66; P < 0.001), and an area under the ROC curve of 0.94 ± 0.04 (CI = 0.86 to 1.00) with sensitivity and specificity of 78% and 86%, respectively, for predicting a maladaptive RV response. Conclusions Pressure-based estimation of RVEF correlates with cardiac MRI and detects clinically significant reductions in RVEF. Study results support potential utility of pressure-based RVEF estimation for assessing the response to diagnostic or therapeutic interventions during RHC.

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Right ventricular–pulmonary artery coupling in chronic thromboembolic pulmonary hypertension

Bartnik

Pepke‐Zaba

Hoole

et al. 2022

Heart

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Chronic thromboembolic pulmonary hypertension occurs in a proportion of patients with prior acute pulmonary embolism and is characterised by breathlessness, persistently raised pulmonary pressures and right heart failure. Surgical pulmonary endarterectomy (PEA) offers significant prognostic and symptomatic benefits for patients with proximal disease distribution. For those with inoperable disease, management options include balloon pulmonary angioplasty (BPA) and medical therapy. Current clinical practice relies on the evaluation of pulmonary haemodynamics to assess disease severity, timing of and response to treatment. However, pulmonary haemodynamics correlate poorly with patient symptoms, which are influenced by right ventricular tolerance of the increased afterload. How best to manage symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension is not resolved.Right ventricular–pulmonary artery coupling (RV-PAC) describes the energy transfer within the whole cardiopulmonary unit. Thus, it can identify the earliest signs of decompensation even before pulmonary hypertension is overt. Invasive measurement of coupling using pressure volume loop technology is well established in research settings. The development of efficient and less invasive measurement methods has revived interest in coupling as a viable clinical tool. Significant improvement in RV-PAC has been demonstrated after both PEA and BPA. Further studies are required to understand its clinical utility and prognostic value, in particular, its potential to guide management in patients with CTEPD. Finally, given the reported differences in coupling between sexes in pulmonary arterial hypertension, further work is required to understand the applicability of proposed thresholds for decoupling in therapeutic decision making.

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Association between Preoperative Dynamic Measures of Vascular Load and Postoperative Hemodynamics in Patients with Chronic Thromboembolic Pulmonary Hypertension after Pulmonary Thromboendarterectomy

Cited by 4 publications

References 14 publications

Defining end-systolic pressure for single-beat estimation of right ventricle–pulmonary artery coupling: simple… but not really

Defining end-systolic pressure for single-beat estimation of right ventricle–pulmonary artery coupling: simple… but not really

Pressure‐based estimation of right ventricular ejection fraction

Right ventricular–pulmonary artery coupling in chronic thromboembolic pulmonary hypertension

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