Does pulmonary artery pulsatility index predict mortality in pulmonary arterial hypertension?

Abstract

Aims Pulmonary artery pulsatility index (PAPi), defined as [(pulmonary artery systolic pressure À diastolic pulmonary artery pressure)/mean right atrial pressure], is a novel haemodynamic index that predicts right ventricular failure after myocardial infarction and left ventricular assist device implantation. We analysed if a low PAPi is associated with death in our 14 -year pulmonary arterial hypertension (PAH) registry. Methods Consecutive patients with newly diagnosed PAH and complete haemodynamic data were prospectively enrolled into our standing registry between January 2003 and December 2016. PAPi was calculated from baseline invasive right heart catheterization data. A prognostic cut-off value was determined with a decision tree. Baseline characteristics of 'high' and 'low' PAPi groups based on this cut-off were compared, as well as odds of death and time-to-death. Results One hundred and two patients were included. Mean age was 53 years, and 77% were women. Our multi-ethnic cohort was 64% Chinese, 23% Malay, and 10% Indian. The aetiologies were idiopathic (33%), connective tissue disease (31%), congenital heart disease (24%), and others (12%). The low PAPi group (<5.3) had a greater age (56 years vs. 49 years), lower pulmonary artery systolic pressure (71 mmHg vs. 85 mmHg), and higher mean right atrial pressure (14 mmHg vs. 6 mmHg). Mortality risk was higher in the low PAPi group (adjusted odds ratio: 2.98 and adjusted hazard ratio: 2.23). Mean right atrial pressure was the strongest predictor (hazard ratio 1.114, P = 0.009) when components of PAPi were analysed. Conclusions Pulmonary artery pulsatility index was found to be predictive of mortality in PAH and may be a valuable marker for risk stratification. Its prognostic strength may be driven by mean right atrial pressure.

Prognostic Value of Pulmonary Artery Pulsatility Index in Right Ventricle Failure-Related Mortality in Inoperable Chronic Thromboembolic Pulmonary Hypertension

“…To the best of our knowledge, this is the first study to evaluate the prognostic utility of PAPI in a cohort of patients with inoperable CTEPH. The idea of using PAPI as a predictor for RV failure and mortality in inoperable CTEPH seems attractive due to simplicity of estimation and proven utility in other disease entities, such as acute inferior wall myocardial infarction, end-stage left heart failure, or pulmonary arterial hypertension (PAH) [ 17 , 18 , 19 , 24 ]. The numerator of the PAPI is defined as PA pulse pressure (PAPP), which reflects the combined of RV contractile function and pulmonary artery capacitance [ 24 ].…”

“…Following left ventricular assist device implantation, the optimal cut-off value for RVF development variers between studies from 1.85 through 2.0 up to 3.33 [ 18 , 25 , 26 , 27 ]. However, in PAH population (group I of PH according to ESC classification), a prognostic cut-off value was established between 3.7 and 5.3 [ 19 , 24 ]. In our inoperable CTEPH population, the derived PAPI cut-off value for mortality prediction is 3.9.…”

“…PAC is negatively correlated with PVR. Hence, an increase of stroke volume and PVR raises pulmonary artery pulse pressure [ 19 , 28 ]. The pathophysiology of a disease needs to be taken into consideration in PAPI interpretation.…”

“…Differences between continuous variables were tested with the Student’s t -test, the Mann−Whitney test, or Wilcoxon test as appropriate. PAPI calculated from hemodynamic data was categorized into “low” and “high” groups with the chi-square automated interactions detector algorithm as described previously [ 19 , 23 ]. This is a multi-way splitting decision tree used for identifying the predictors or explaining an outcome based on the adjusted Bonferroni testing or determining the optimal cut-off values for the predictors.…”

“…The pulmonary artery pulsatility index (PAPI) is a novel hemodynamic parameter designed to assess the ability of the right ventricle (RV) to generate a pressure gradient and is defined as difference between systolic pulmonary arterial pressure (sPAP) and diastolic pulmonary arterial pressure (dPAP) in the nominator divided by mean right atrial pressure (mRAP) in the denominator ((sPAP-dPAP)/mRAP) [ 17 ]. Some previous studies revealed that PAPI predict RVF development in patients with acute inferior myocardial infarction and after left ventricular assist device implantation in end-stage left heart failure [ 17 , 18 , 19 ]. We hypothesized that PAPI might be also predictive marker in inoperable CTEPH patients.…”