State-of-the-Art Review: Echocardiography in Pulmonary Hypertension

Assessment of right ventricle-to-pulmonary artery coupling by three-dimensional echocardiography in pre-capillary pulmonary hypertension: comparison with tricuspid annular plane systolic excursion /systolic pulmonary artery pressure ratio

BACKGROUND

The tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio (TAPSE/sPAP) has limitations in evaluating right ventricle-to-pulmonary artery (RV-PA) coupling, particularly when pulmonary artery pressure cannot be accurately estimated by tricuspid regurgitation or when TAPSE cannot accurately reflect right ventricular systolic function in certain scenarios. Therefore, this study aimed to explore the value of three-dimensional echocardiography (3DE) coupling parameters in assessing RV-PA coupling in patients with pre-capillary pulmonary hypertension (PH).

METHODS

Fifty-nine patients with pre-capillary PH were retrospectively recruited. The surrogate "gold standard" of RV-PA coupling was derived from right heart catheterization (RHC) and cardiac magnetic resonance imaging (CMR). The relationships between echocardiographic RV-PA coupling parameters and RHC-CMR coupling standard were analyzed by Pearson's test and Bland‒Altman test. Additionally, 24 chronic thromboembolic pulmonary hypertension (CTEPH) patients were enrolled to explore the changes in echocardiographic RV-PA coupling parameters before and after PEA. Multivariate ordinal regression analysis was performed to identify echocardiographic parameters associated with prognostic risk stratification in pre-capillary PH patients.

RESULTS

3DE coupling parameters demonstrated strong correlation and good agreement with the RHC-CMR coupling standard. In contrast, TAPSE/sPAP was moderately correlated to the RHC-CMR coupling standard, but showed poor consistency, with a significant bias of 0.44 (95% CI: 0.374, 0.511). Before and after PEA, stroke volume/end-systolic volume (SV/ESV) derived by 3DE remained moderately correlated with pulmonary vascular resistance (PVR) and mean pulmonary artery pressure (mPAP) (r =-0.614, -0.655, P < 0.001), whereas TAPSE/sPAP was only associated with PVR and mPAP in CTEPH patients before PEA (r=-0.605, -0.758, P < 0.001). Multivariate regression analysis revealed TAPSE/sPAP as the strongest predictor of prognostic risk.

CONCLUSIONS

3DE-derived coupling parameters offer a noninvasive and reliable approach for assessing RV-PA coupling in patients with pre-capillary PH, especially for patients who cannot accurately estimate pulmonary artery pressure or have undergone cardiac surgery. 3DE SV/ESV is superior to TAPSE/sPAP for assessing postoperative RV-PA coupling in CTEPH patients, TAPSE/sPAP remains a valuable parameter for prognostic risk stratification in pre-capillary PH patients. Echocardiography can provide valuable information for assessing RV-PA coupling and prognosis in patients with pre-capillary PH. However, the application of echocardiographic coupling parameters should be determined based on the specific clinical context.

The Role OF 3D echocardiography in prediction of pulmonary vascular resistance and its reversibility in simple congenital heart disease with secondary pulmonary hypertension

BACKGROUND

Pulmonary hypertension is a progressive and often fatal disease that frequently presents with the non-specific symptom of dyspnea on exertion.

AIM

To determine non-Invasive Predictors of Pulmonary vascular resistance severity and reversibility in simple Congenital Heart Disease Patients Using 3D Echocardiography.

PATIENTS AND METHODS

This was a Prospective cohort study conducted on 40 patients selected from attendees of Cardiology clinics of Ain Shams University Hospitals over a period of 2 years.

RESULTS

There was a statistically significant positive correlation between PVR and its reversibility and right ventricular parameters (EDV/ESV/SVI), tricuspid valvular parameters (Coaptation height/Tenting volume/Annulus perimeter/Major axis/Minor axis) measured by 3D echocardiography (P < 0.05). On the other hand, no statistically significant correlation was found between PVR or its reversibility and ejection fraction, and annulus area (P < 0.05). All echocardiographic parameters are either excellent or good predictors for reversibility of PVR except for EF, FAC, and S'.

CONCLUSION

We conclude that EDV, ESV, SVI, CoH, tenting volume, and annulus perimeter were the most important variables to predict the PVR and found that all echocardiographic parameters were either excellent or good predictors for reversibility of PVR except for EF, FAC, and S'.

Right Heart Failure in the Intensive Care Unit: Etiology, Pathogenesis, Diagnosis, and Treatment

Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.

The Prognostic Value of Right Ventricular End-Diastolic Basal Diameter Index by Echocardiography in Connective Tissue Diseases Associated With Pulmonary Artery Hypertension

BACKGROUND

Right ventricular (RV) failure is a well-recognized pivotal prognostic factor of adverse outcomes in pulmonary artery hypertension (PAH), while RV dilation provides significant implications for adaptive or maladaptive changes. PAH is a predominant cause of mortality among patients with connective tissue disease (CTD). This study aims to elucidate the prognostic significance of RV morphology, as assessed by echocardiography (ECHO), in with CTD associated with PAH (CTD-PAH).

METHODS

In this ambispective cohort study, 143 CTD-PAH patients diagnosed by right-sided heart catheterization (RHC) from 2013 to 2023 were enrolled. Clinical characteristics, laboratory data, echocardiographic parameters (right ventricular end-diastolic basal diameter index (RVDDI), tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP)) and therapy were recorded. The primary endpoint was defined as clinical worsening within a five-year timeframe. Analytical methods included Kaplan-Meier survival analyses, the log-rank test, and multivariable Cox proportional hazards regression to evaluate prognostic factors.

RESULTS

The study enrolled a total of 143 patients with CTD-PAH, with a notable female predominance (95.1%) and a median age of 41.67 years; SLE-PAH (49%) and pSS-PAH (34%) were the most common subtypes, and 94% of the participants were in WHO-FC II-III. Among the participants, 34 (23.8%) patients experienced clinical worsening during a median follow-up period of 21 months. After adjusting for confounders such as age and sex, RVDDI, as determined by ECHO was correlated with clinical worsening (HR 1.090; 95% CI: 1.019-1.166; p = 0.012). RVDDI > 25.81 mm/m2 predicts higher incidence of clinical worsening in CTD-PAH. In the subgroup of TAPSE/PASP > 0.19 mm/mmHg, patients with RVDDI > 25.81 mm/m2 had a higher incidence of clinical worsening. The estimated event-free survival rates at 1 and 3 years were 93.5% and 53.7%, respectively.

CONCLUSION

The study demonstrates that RVDDI, as evaluated by ECHO, is a significant prognostic indicator for clinical worsening in CTD-PAH. Its inclusion in the assessment of RV function and risk stratification may provide valuable incremental prognostic information for this CTD-PAH population.

Echocardiographic estimation of pulmonary arterial and right atrial pressures in children with congenital heart disease: a comprehensive prospective study and introduction of novel equations

BACKGROUND

Pediatric pulmonary hypertension (PH) is characterized by a mean pulmonary arterial pressure exceeding 20 mmHg. There is limited research on the suitability of adult-based methods for estimating PH in pediatric populations. Using established formulas for adults, this study aimed to evaluate the correlation between echocardiographic estimates of systolic, diastolic, and mean pulmonary arterial pressures, and mean right atrial pressures in children with congenital heart disease (CHD).

METHODS

A prospective study was conducted involving children with CHD undergoing cardiac catheterization without prior cardiac surgery. We used echocardiography to estimate pulmonary and right atrial pressures and compared these with invasively measured values. Four reliable regression equations were developed to estimate systolic, diastolic, and mean pulmonary arterial pressures, and mean right atrial pressures. Cutoff values were determined to predict the occurrence of PH. Linear regression, Bland-Altman analysis, and receiver operating characteristic curve analysis were performed to assess the accuracy of echocardiography and establish diagnostic thresholds for PH.

RESULTS

The study involved 55 children (23 with normal pulmonary arterial pressure and 32 with PH) with acyanotic CHD aged 1 to 192 months. Four equations were developed to detect high pulmonary arterial pressures, with cutoff values of 32.9 for systolic pulmonary arterial pressure, 14.95 for diastolic pulmonary arterial pressure, and 20.7 for mean pulmonary arterial pressure. The results showed high sensitivity and moderate specificity but a tendency to underestimate systolic and mean pulmonary arterial pressures at higher pressures.

CONCLUSIONS

The study provides valuable insights into the use of adult-based echocardiographic formulas for estimating PH in pediatric patients with acyanotic CHD.

Lung water density is increased in patients at risk of heart failure and is largely independent of conventional cardiovascular magnetic resonance measures

Aims

Non-invasive methods to quantify pulmonary congestion are lacking in clinical practice. Cardiovascular magnetic resonance (CMR) lung water density (LWD) mapping is accurate and reproducible and has prognostic value. However, it is not known whether LWD is associated with routinely acquired CMR parameters.

Methods and results

This was an observational cohort including healthy controls and patients at risk of heart failure. LWD was measured using CMR with a free-breathing short echo time 3D Cartesian gradient-echo sequence with a respiratory navigator at 1.5 T. Associations were assessed between LWD, lung water volume and cardiac volumes, left ventricular (LV) mass and function, myocardial native T1, and extracellular volume fraction. In patients at risk for heart failure (n = 155), LWD was greater than in healthy controls (n = 15) (30.4 ± 5.0 vs. 27.2 ± 4.3%, P = 0.02). Using receiver operating characteristic analysis, the optimal cut-off for LWD was 27.6% to detect at-risk patients (sensitivity 72%, specificity 73%, positive likelihood ratio 2.7, and inverse negative likelihood ratio 2.6). LWD was univariably associated with body mass index (BMI), hypertension, right atrial area, and LV mass. In multivariable linear regression, only BMI remained associated with LWD (R 2 = 0.32, P < 0.001).

Conclusion

LWD is increased in patients at risk for heart failure compared with controls and is only weakly explained by conventional CMR measures. LWD provides diagnostic information that is largely independent of conventional CMR measures.

2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults

Transthoracic echocardiography (TTE) is the most widely available and utilised imaging modality for the screening, diagnosis, and serial monitoring of all abnormalities related to cardiac structure or function. The primary objectives of this document are to provide (1) a guiding framework for treating clinicians of the acceptable indications for the initial and serial TTE assessments of the commonly encountered cardiovascular conditions in adults, and (2) the minimum required standard for TTE examinations and reporting for imaging service providers. The main areas covered within this Position Statement pertain to the TTE assessment of the left and right ventricles, valvular heart diseases, pericardial diseases, aortic diseases, infective endocarditis, cardiac masses, pulmonary hypertension, and cardiovascular diseases associated with cancer treatments or cardio-oncology. Facilitating the optimal use and performance of high quality TTEs will prevent the over or under-utilisation of this resource and unnecessary downstream testing due to suboptimal or incomplete studies.

Effect of Macitentan in Pulmonary Arterial Hypertension and the Relationship Between Echocardiography and cMRI Variables: REPAIR Echocardiography Sub-study Results

INTRODUCTION

The aim of this sub-study was to evaluate the relationship between echocardiography (echo) and cardiac magnetic resonance imaging (cMRI) variables and to utilize echo to assess the effect of macitentan on right ventricle (RV) structure and function.

METHODS

REPAIR (NCT02310672) was a prospective, multicenter, single-arm, open-label, 52-week, phase 4 study in pulmonary arterial hypertension (PAH) patients, which investigated the effect of macitentan 10 mg as monotherapy, or in combination with a phosphodiesterase 5 inhibitor, on RV structure, function, and hemodynamics using cMRI and right heart catheterization. In this sub-study, patients were also assessed by echo at screening and at weeks 26 and/or 52. Post hoc correlation analyses between echo and cMRI variables were performed using Pearson's correlation coefficient, Spearman's correlation coefficient, and Bland-Altman analyses.

RESULTS

The Echo sub-study included 45 patients. Improvements in echo-assessed RV stroke volume (RVSV), left ventricular SV (LVSV), LV end-diastolic volume (LVEDV), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), and in 2D global longitudinal RV strain (2D GLRVS) were observed at weeks 26 and 52 compared to baseline. There was a strong correlation between echo (LVSV, 2D GLRVS, and LVEDV) and cMRI variables, with a moderate correlation for RVSV. Bland-Altman analyses showed a good agreement for LVSV measured by echo versus cMRI, whereas an overestimation in echo-assessed RVSV was observed compared to cMRI (bias of - 15 mL). Hemodynamic and functional variables, as well as safety, were comparable between the Echo sub-study and REPAIR.

CONCLUSIONS

A good relationship between relevant echo and cMRI parameters was shown. Improvements in RV structure and function with macitentan treatment was observed by echo, consistent with results observed by cMRI in the primary analysis of the REPAIR study. Echo is a valuable complementary method to cMRI, with the potential to non-invasively monitor treatment response at follow-up.

TRIAL REGISTRATION NUMBER

REPAIR NCT02310672.

What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension?

BACKGROUND

Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions.

OBJECTIVE

This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation.

DISCUSSION

The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic).

CONCLUSIONS

Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.

Automatic echocardiographic evaluation of the probability of pulmonary hypertension using machine learning

Echocardiography, a simple and noninvasive tool, is the first choice for screening pulmonary hypertension (PH). However, accurate assessment of PH, incorporating both the pulmonary artery pressures and additional signs for PH remained unsatisfied. Thus, this study aimed to develop a machine learning (ML) model that can automatically evaluate the probability of PH. This cohort included data from 346 (275 for training set and internal validation set and 71 for external validation set) patients with suspected PH patients and receiving right heart catheterization. Echocardiographic images on parasternal short axis-papillary muscle level (PSAX-PML) view from all patients were collected, labeled, and preprocessed. Local features from each image were extracted and subsequently integrated to build a ML model. By adjusting the parameters of the model, the model with the best prediction effect is finally constructed. We used receiver-operating characteristic analysis to evaluate model performance and compared the ML model with the traditional methods. The accuracy of the ML model for diagnosis of PH was significantly higher than the traditional method (0.945 vs. 0.892, p = 0.027 [area under the curve [AUC]]). Similar findings were observed in subgroup analysis and validated in the external validation set (AUC = 0.950 [95% CI: 0.897-1.000]). In summary, ML methods could automatically extract features from traditional PSAX-PML view and automatically assess the probability of PH, which were found to outperform traditional echocardiographic assessments.

Severe Covid-19 and acute pulmonary hypertension: 24-month follow-up regarding mortality and relationship to initial echocardiographic findings and biomarkers

INTRODUCTION

Critically ill Covid-19 patients are likely to develop the sequence of acute pulmonary hypertension (aPH), right ventricular strain, and eventually right ventricular failure due to currently known pathophysiology (endothelial inflammation plus thrombo-embolism) that promotes increased pulmonary vascular resistance and pulmonary artery pressure. Furthermore, an in-hospital trans-thoracic echocardiography (TTE) diagnosis of aPH is associated with a substantially increased risk of early mortality. The aim of this retrospective observational follow-up study was to explore the mortality during the 1-24-month period following the TTE diagnosis of aPH in the intensive care unit (ICU).

METHODS

A previously reported cohort of 67 ICU-treated Covid-19 patients underwent an electronic medical chart-based follow-up 24 months after the ICU TTE. Apart from the influence of aPH versus non-aPH on mortality, several TTE parameters were analyzed by the Kaplan-Meier survival plot technique (K-M). The influence of biomarkers for heart failure (NTproBNP) and myocardial injury (Troponin-T), taken at the time of the ICU TTE investigation, was analyzed using receiver-operator characteristics curve (ROC) analysis.

RESULTS

The overall mortality at the 24-month follow-up was 61.5% and 12.8% in group aPH and group non-aPH, respectively. An increased relative mortality risk continued to be present in aPH patients (14.3%) compared to non-aPH patients (5.6%) during the 1-24-month period. The easily determined parameter of a tricuspid valve regurgitation, allowing a measurement of a systolic pulmonary artery pressure (regardless of magnitude), was associated with a similar K-M outcome as the generally accepted diagnostic criteria for aPH (systolic pulmonary artery pressure >35 mmHg). The biomarker values of NTproBNP and Troponin-T at the time of the TTE did not result in any clinically useful ROC analysis data.

CONCLUSION

The mortality risk was increased up to 24 months after the initial examination in ICU-treated Covid-19 patients with a TTE diagnosis of aPH, compared to non-aPH patients. Certain individual TTE parameters were able to discriminate 24-month risk of morality.

The prevalence of pulmonary hypertension after successful tuberculosis treatment in a community sample of adult patients

There are an estimated 155 million survivors of tuberculosis (TB). Clinical experience suggests that post tuberculosis lung disease (PTLD) is an important cause of Group 3 pulmonary hypertension (PH). However, TB is not listed as a cause of PH in most guidelines. A cross-sectional, community-based study was conducted in nonhealthcare seeking adults who had successfully completed TB treatment. Subjects underwent questionnaires, spirometry, a 6-min walk distance test (6MWD) and transthoracic echocardiography (TTE). Screen probable PH was defined on TTE as an estimated pulmonary artery peak systolic pressure (PASP) of ≥40 mmHg. One hundred adults (71 males) were enrolled, with a mean age of 42 years (SD 13.8 years) and a median of one TB episode (interquartile range: 1-2). Co-morbidities included hypertension (21%), diabetes (16%), human immunodeficiency virus (10%) and asthma/COPD (5%). Only 25% had no residual symptoms after TB. Probable PH was found in 9%, while 7% had borderline raised PASP values (PASP 35-40 mmHg). An association was found between PH and the number of previous TB episodes, with each additional episode of TB increasing the odds of PH-postTB 2.13-fold (confidence interval [CI]: 1.17-3.88; p = 0.013). All of those found to have PH were smokers or ex-smokers yielding an unadjusted odds ratio for PH-postTB of 3.67 (95% CI: 0.77-17.46). There was no statistical difference in spirometry or 6MWD, between those with and without PH. Neither symptoms nor co-morbidities demonstrated significant association with PH. PH after TB was a common finding in this community-based population. Further research is needed to confirm and determine the significance of these findings.

Pulmonary hypertension in remote and disadvantaged population: overcoming unique challenges for improved outcomes

Pulmonary hypertension (PH) is a common and debilitating medical condition with high mortality. PH research has traditionally focused on pulmonary arterial hypertension and its management in expert PH centres. Other forms of PH such as PH associated with cardiac or respiratory disease are more common, less well-understood and associated with higher mortality. Epidemiology of PH in disadvantaged, remote and rural regions, remains largely undocumented. In this review, we discuss the unique challenges in identifying PH in rural and disadvantaged populations using the Top End region of the Northern Territory of Australia as an example. We propose a simple diagnostic approach, ideally suited to regions where resource allocation is scarce, using clinical skills, echocardiography, and an escalation algorithm. The brief history, epidemiology and current literature on PH are summarised to inform the busy clinicians. We highlight two case examples from the Top End to illustrate the challenges and potential solutions.

ACR Appropriateness Criteria® Suspected Pulmonary Hypertension: 2022 Update

Pulmonary hypertension may be idiopathic or related to a large variety of diseases. Various imaging examinations may be helpful in diagnosing and determining the etiology of pulmonary hypertension. Imaging examinations discussed in this document include chest radiography, ultrasound echocardiography, ventilation/perfusion scintigraphy, CT, MRI, right heart catheterization, and pulmonary angiography. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Right ventricular outflow tract Doppler flow analysis and pulmonary arterial coupling by transthoracic echocardiography in sepsis: a retrospective exploratory study

INTRODUCTION

Right ventricular (RV) and pulmonary vascular dysfunction appear to be common in sepsis. RV performance is frequently assessed in isolation, yet its close relationship to afterload means combined analysis with right ventricular outflow tract (RVOT) Doppler and RV-pulmonary arterial (RV-PA) coupling may be more informative than standard assessment techniques. Data on feasibility and utility of these parameters in sepsis are lacking and were explored in this study.

METHODS

This is a retrospective study over a 3-year period of one-hundred and thirty-one patients admitted to ICU with sepsis who underwent transthoracic echocardiography (TTE) with RVOT pulsed wave Doppler. RVOT Doppler flow and RV-PA coupling was evaluated alongside standard measurements of RV systolic function and pulmonary pressures. RVOT Doppler analysis included assessment of pulmonary artery acceleration time (PAAT), velocity time integral and presence of notching. RV-PA coupling was assessed using tricuspid annular planar systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio.

RESULTS

PAAT was measurable in 106 (81%) patients, and TAPSE/PASP was measurable in 77 (73%). Seventy-three (69%) patients had a PAAT of ≤ 100 ms suggesting raised pulmonary vascular resistance (PVR) is common. RVOT flow notching occurred in 15 (14%) of patients. TRV was unable to be assessed in 24 (23%) patients where measurement of PAAT was possible. RV dysfunction (RVD) was present in 28 (26%), 26 (25%) and 36 (34%) patients if subjective assessment, TAPSE < 17 mm and RV dilatation definitions were used, respectively. There was a trend towards shorter PAAT with increasing severity of RVD. RV-PA uncoupling defined as a TAPSE/PASP < 0.31 mm/mmHg was present in 15 (19%) patients. As RV dilatation increased the RV-PA coupling ratio decreased independent of LV systolic function, whereas TAPSE appeared to be more susceptible to changes in LV systolic function.

CONCLUSION

Raised PVR and RV-PA uncoupling is seen in a significant proportion of patients with sepsis. Non-invasive assessment with TTE is feasible. The role of these parameters in assisting improved definitions of RVD, as well as their therapeutic and prognostic utility against standard parameters, deserves further investigation.

A novel method for measuring pulmonary artery pressure by high-frequency ultrasound-guided transthoracic puncture in rats

Objectives

The success of the rat model of pulmonary hypertension (PH) is primarily dependent on the measurement of pulmonary artery pressure. We herein demonstrate a novel method for measuring pulmonary artery pressure through a high-frequency ultrasound-guided transthoracic puncture in rats. The efficacy and time of this novel method are also discussed.

Methods

A single subcutaneous injection of monocrotaline (MCT) was used to establish a rat model of PH. Through the heat shaping method, the tip of that puncture cannula was maintained at a certain angle after the needle core was removed. In-plane real-time guided trocar puncture of the right ventricular outflow tract was performed in the short-axis section of the parasternal aorta. The external pressure sensor was used to record the real-time waveform of right ventricular systolic pressure, pulmonary artery systolic pressure, and diastolic pressure.

Results

The success rates of which using this novel method in the model group and the control group were 88.5 and 86.7%, respectively. The time of puncture pressure measurement was 164 ± 31 and 235 ± 50 s, respectively. The right ventricular systolic blood pressure, pulmonary systolic blood pressure, and diastolic blood pressure of the model group were higher than those of the control group.

Conclusion

The modified method for trocar is helpful for accurately positioning pulmonary artery manometry. The method described in this paper has a high success rate and short operation time. It can simultaneously measure systolic blood pressure, diastolic blood pressure, and mean pressure of the right ventricle and pulmonary artery. It has a broad application prospect in verifying the rat PH model and pulmonary artery pressure monitoring.

A framework of deep learning networks provides expert-level accuracy for the detection and prognostication of pulmonary arterial hypertension

AIMS

To test the hypothesis that deep learning (DL) networks reliably detect pulmonary arterial hypertension (PAH) and provide prognostic information.

METHODS AND RESULTS

Consecutive patients with PAH, right ventricular (RV) dilation (without PAH), and normal controls were included. An ensemble of deep convolutional networks incorporating echocardiographic views and estimated RV systolic pressure (RVSP) was trained to detect (invasively confirmed) PAH. In addition, DL-networks were trained to segment cardiac chambers and extracted geometric information throughout the cardiac cycle. The ability of DL parameters to predict all-cause mortality was assessed using Cox-proportional hazard analyses. Overall, 450 PAH patients, 308 patients with RV dilatation (201 with tetralogy of Fallot and 107 with atrial septal defects) and 67 normal controls were included. The DL algorithm achieved an accuracy and sensitivity of detecting PAH on a per patient basis of 97.6 and 100%, respectively. On univariable analysis, automatically determined right atrial area, RV area, RV fractional area change, RV inflow diameter and left ventricular eccentricity index (P < 0.001 for all) were significantly related to mortality. On multivariable analysis DL-based RV fractional area change (P < 0.001) and right atrial area (P = 0.003) emerged as independent predictors of outcome. Statistically, DL parameters were non-inferior to measures obtained manually by expert echocardiographers in predicting prognosis.

CONCLUSION

The study highlights the utility of DL algorithms in detecting PAH on routine echocardiograms irrespective of RV dilatation. The algorithms outperform conventional echocardiographic evaluation and provide prognostic information at expert-level. Therefore, DL methods may allow for improved screening and optimized management of PAH.

Echocardiographic estimation of pulmonary hypertension in COVID-19 patients

Introduction

Coronavirus disease 2019 (COVID-19) is the cause of a devastating global pandemic and is not likely to be fully resolved in the near future. In most cases COVID-19 presents with mild symptoms, but in a minority of patients respiratory and multi-organ failure may ensue. Previous research has focused on the correlation between COVID-19 and a variety of cardiovascular complications. However, the effect of COVID-19 on pulmonary hypertension (PH) and correlated cardiovascular parameters has not been evaluated extensively.

Methods

This study was designed as a single-centre, semi-quantitative analysis. PH was considered to be present if echocardiographic measurements estimated right ventricular systolic pressure at rest to be 36 mm Hg or higher in combination with indirect indicators of right ventricular overload.

Results

In total, 101 patients (67.3% male) were included in this study, with a mean age of 66 years (range 23–98 years). PH was diagnosed by echocardiographic estimation in 30 patients (29.7%). Echocardiographically estimated PH (eePH) was not correlated with a diagnosis of heart failure or pulmonary embolism. Mortality was significantly higher among COVID-19 patients with eePH (p = 0.015). In all 10 of 20 surviving eePH patients in whom echocardiographic follow-up was obtained, echocardiographic estimations of pulmonary pressures showed a significant decrease after a median of 144 ± 72 days.

Conclusion

eePH is frequently observed in COVID-19 patients and is correlated with increased mortality. COVID-19-related eePH appears to be reversible after recovery. Vigilant attention and a low threshold for performance of echocardiography in COVID-19 patients seems warranted, as eePH may be applicable as a prognostic risk factor.

Interstitial Pneumonia with Autoimmune Features: What the Rheumatologist Needs to Know

PURPOSE OF REVIEW

This narrative review will focus on the role of the rheumatologist in evaluating patients with interstitial lung disease (ILD) without a defined rheumatic disease and will outline the current classification criteria for interstitial pneumonia with autoimmune features (IPAF) and describe what is known regarding IPAF pathobiology, natural history, prognosis, and treatment. Lastly, knowledge gaps and opportunities for future research will be discussed.

RECENT FINDINGS

IPAF is a recently defined classification of ILD patients who have features suggesting an autoimmune-mediated process, but do not fulfill current rheumatic disease criteria. The goal of the IPAF criteria is to provide a uniform case definition for the study of autoimmune ILD patients who do not currently fit within standard ILD diagnostic categories, ultimately improving diagnosis and therapy. Many of these patients are referred for rheumatologic evaluation to aid the diagnostic process. The care of the IPAF patient is complex and is multidisciplinary with pulmonology, rheumatology, pathology, radiology, physical therapy, primary care, pulmonary transplant providers all serving vital roles. The rheumatologist has several roles which include classification, disease monitoring, and management.

Echocardiographic Estimated Pulmonary Systolic Pressure and Outcome After Noncardiac-Obstetrics Surgery in Postcapillary Pulmonary Hypertensive Patients

Pulmonary hypertension is associated with increased postoperative risk. This study analyzed the relation between the preoperative echocardiographic estimated blood pressure (estimated pulmonary arterial systolic pressure [ePASP]) of noncardiac patients and postoperative cardiac outcome and tried to identify a clinically meaningful threshold for ePASP in postcapillary pulmonary hypertensive patients. This was a single-center retrospective cohort study with propensity score analysis based on patients who underwent elective noncardiac surgery from June 2012 to December 31, 2018. We evaluated the relation between ePASP and the development of postoperative major adverse cardiac events (MACEs). Multivariate logistic regression models and generalized additive models were used, and the minimum p value approach was used to identify the threshold of ePASP that independently indicated the risk of MACEs. Finally, propensity score matching was used for patients with ePASP above or below the threshold, and the exposure effect was evaluated. Of the 16,210 surgeries, 7.0% experienced postoperative MACEs. The threshold for the ePASP was 47 mm Hg. Adjusted odds ratios for MACEs before and after propensity score matching were 2.03 (1.22 to 2.83) and 1.62 (1.01 to 2.23), respectively. In conclusion, the incidence of postoperative MACEs was 7.0% in patients who underwent elective noncardiac surgery. An ePASP ≥47 mm Hg was significantly associated with an increased risk of postoperative MACEs in postcapillary pulmonary hypertensive patients.

Acute pulmonary hypertension and short-term outcomes in severe Covid-19 patients needing intensive care

Introduction

Critically ill Covid‐19 pneumonia patients are likely to develop the sequence of acute pulmonary hypertension, right ventricular (RV) strain, and eventually RV failure due to known pathophysiology (endothelial inflammation plus thrombo‐embolism) that promotes increased pulmonary vascular resistance and pulmonary artery pressure. This study aimed to investigate the occurrence of acute pulmonary hypertension (aPH) as per established trans‐thoracic echocardiography (TTE) criteria in Covid‐19 patients receiving intensive care and to explore whether short‐term outcomes are affected by the presence of aPH.

Methods

Medical records were reviewed for patients treated in the intensive care units at a tertiary university hospital over a month. The presence of aPH on the TTE was noted, and plasma NTproBNP and troponin were measured as markers of cardiac failure and myocardial injury, respectively. Follow‐up data were collected 21 d after the performance of TTE.

Results

In total, 26 of 67 patients (39%) had an assessed systolic pulmonary artery pressure of > 35 mmHg (group aPH), meeting the TTE definition of aPH. NTproBNP levels (median [range]: 1430 [102‐30 300] vs. 470 [45‐29 600] ng L⁻¹; P = .0007), troponin T levels (63 [22‐352] vs. 15 [5‐407] ng L⁻¹; P = .0002), and the 21‐d mortality rate (46% vs. 7%; P < .001) were substantially higher in patients with aPH compared to patients not meeting aPH criteria.

Conclusion

TTE‐defined acute pulmonary hypertension was frequently observed in severely ill Covid‐19 patients. Furthermore, aPH was linked to biomarker‐defined myocardial injury and cardiac failure, as well as an almost sevenfold increase in 21‐d mortality.

Differences in the microcirculation disturbance in the right and left ventricles of neonatal rats with hypoxic pulmonary hypertension

Microcirculation disturbance is a crucial pathological basis of heart damage; however, microcirculation alterations induced by hypoxic pulmonary hypertension (HPH) remain unknown, and the left ventricle (LV) in HPH is conventionally ignored. Herein, we investigated the changes in the cardiac structure, function and microcirculation after HPH and further compared the differences between the right ventricle (RV) and LV. Using a neonatal rat model of HPH, we found RV myocardial hypertrophy, dysfunction and poor myocardial perfusion in HPH rats. Additionally, RV microcirculation disturbance manifested as the abnormal expression of endothelin-1/eNOS and increased expression of intercellular cell adhesion molecule-1 (ICAM-1) or E-selectin 3 days after hypoxia, followed by vascular inflammation, coronary arterial remodeling and microvascular sparseness. Impairment in LV vasodilation was detected in rats after 3 days of hypoxia; however, no obvious microvascular rarefaction or inflammatory reaction was observed in the LV. In conclusion, our results suggest that HPH mainly triggers RV microcirculation disturbances, causing low myocardial perfusion damage and cardiac dysfunction. Despite the differences in the RV and LV, their impaired microvascular function, mediated by endothelial cells, occurs almost simultaneously after HPH, earlier than cardiac functional or structural abnormalities.

Right-heart contrast echocardiography reveals missed patent ductus arteriosus in a postpartum woman with pulmonary embolism: A case report

BACKGROUND

As an established, simple, inexpensive, and surprisingly effective diagnostic tool, right-heart contrast echocardiography (RHCE) might help in solving a vexing diagnostic problem. If performed appropriately and interpreted logically, RHCE allows for differentiation of various usual and unusual right-to-left shunts based on the site of injection and the sequence of microbubble appearance in the heart.

CASE SUMMARY

A 31-year-old woman was readmitted to hospital with a 2-mo history of worsening palpitation and chest distress. Two years prior, she had been diagnosed with postpartum pulmonary embolism by conventional echocardiography and computed tomography angiography. While the latter showed no sign of pulmonary artery embolism, the former showed pulmonary artery hypertension, moderate insufficiency, and mild stenosis of the aortic valve. RHCE showed microbubbles appearing in the left ventricle, slightly delayed after right-heart filling with microbubbles; no microbubbles appeared in the left atrium and microbubbles’ appearance in the descending aorta occurred nearly simultaneous to right pulmonary artery filling with microbubbles. Conventional echocardiography was re-performed, and an arterial horizontal bidirectional shunt was found according to Doppler enhancement effects caused by microbubbles. The original computed tomography angiography findings were reviewed and found to show a patent ductus arteriosus.

CONCLUSION

RHCE shows a special imaging sequence for unexplained pulmonary artery hypertension with aortic valve insufficiency and simultaneous patent ductus arteriosus.

Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young

While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.

Right Heart Size and Right Ventricular Reserve in Pulmonary Hypertension: Impact on Management and Prognosis

Various parameters reflecting right heart size, right ventricular function and capacitance have been shown to be prognostically important in patients with pulmonary hypertension (PH). In the advanced disease, patients suffer from right heart failure, which is a main reason for an impaired prognosis. Right heart size has shown to be associated with right ventricular function and reserve and is correlated with prognosis in patients with PH. Right ventricular reserve, defined as the ability of the ventricle to adjust to exercise or pharmacologic stress, is expressed by various parameters, which may be determined invasively by right heart catheterization or by stress-Doppler-echocardiography as a noninvasive approach. As the term "right ventricular contractile reserve" may be misleading, "right ventricular output reserve" seems desirable as a preferred term of increase in cardiac output during exercise. Both right heart size and right ventricular reserve have been shown to be of prognostic importance and may therefore be useful for risk assessment in patients with pulmonary hypertension. In this article we aim to display different aspects of right heart size and right ventricular reserve and their prognostic role in PH.

Update on noninvasive imaging of right ventricle dysfunction in pulmonary hypertension

Pulmonary hypertension (PH) is a progressive disease affecting patients across the life span. The pathophysiology primarily involves the pulmonary vasculature and right ventricle (RV), but eventually affects the left ventricular (LV) function as well. Safe, accurate imaging modalities are critical for diagnosis, serial monitoring, and tailored therapy. While cardiac catheterization remains the conventional modality for establishing diagnosis and serial monitoring, noninvasive imaging has gained considerable momentum in providing accurate assessment of the entire RV-pulmonary axis. In this state-of-the-art review, we will discuss the most recent developments in echocardiography, magnetic resonance imaging, and computed tomography in PH evaluation from pediatric to adult population.

Pulmonary Hypertension: A Brief Guide for Clinicians

Pulmonary hypertension (PH) is classified into 5 clinical subgroups: pulmonary arterial hypertension (PAH), PH due to left-sided heart disease, PH due to chronic lung disease, chronic thromboembolic PH (CTEPH), and PH with an unclear and/or multifactorial mechanisms. A range of underlying conditions can lead to these disorders. Overall, PH affects approximately 1% of the global population, and over half of patients with heart failure may be affected. Cardiologists are therefore likely to encounter PH in their practice. Routine tests in patients with symptoms and physical findings suggestive of PH include electrocardiography, chest radiography, and pulmonary function tests. Transthoracic echocardiography is used to estimate the probability of PH. All patients with suspected or confirmed PH, without confirmed left-sided heart or lung diseases, should have a ventilation-perfusion scan to exclude CTEPH. Right-sided heart catheterization is essential for accurate diagnosis and classification. All patients with PAH or CTEPH must be referred to a specialist center. Surgical pulmonary endarterectomy is the treatment of choice for eligible patients with CTEPH. Targeted treatments (phosphodiesterase type 5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, prostacyclin analogues, and prostacyclin receptor agonists) are licensed for patients with PAH. The soluble guanylate cyclase stimulator riociguat is the only licensed targeted therapy for patients with inoperable or persistent/recurrent CTEPH. Management of PH resulting from left-sided heart disease primarily involves treatment of the underlying condition.

The usefulness of subxiphoid view in the evaluation of acceleration time and pulmonary hypertension in ICU patients

BACKGROUND

Pulmonary hypertension (PHT) is very frequent in ICUs. Estimation of systolic pulmonary artery pressure (PASP) by using tricuspid regurgitation velocity (TRV) is impossible in 25% of patients. However, it may be possible to estimate PHT in these patients by obtaining subxiphoid imaging of short axis (SX-SAX) and measuring pulmonary artery diameter (PAD) and right ventricular outflow tract (RVOT) acceleration time (AT). We first aimed to compare the values of AT and PAD measured at the parasternal short axis view (PSAX) and SX-SAX and then to compare AT measurements obtained in the RVOT and pulmonary artery (PA) in ICU patients.

METHODS

This prospective observational study was conducted in a 7-bed ICU of a tertiary academic teaching hospital. Measurements of TRV, PAD, and AT in parasternal and subxiphoid SAX were obtained. AT was measured in RVOT and PA locations. We measured other echocardiographic signs of PHT to assess the probability of PHT in addition to TRV measurements.

RESULTS

The study consisted of 61 patients. TRV was measured in 85% of the patients, and SX-SAX was visualized in 78%. The probability of PHT was high (49%) in this study population. There were agreement and no proportional bias between the measurements of PAD and AT at both SX-SAX and PSAX. Measurements of AT in the RVOT and PA were similar, as well.

CONCLUSION

These results suggested that measurements of AT in the PSAX and SX-SAX and RVOT and PA were similar in the ICU patients.