Echocardiographic estimation of pulmonary pressure in patients with severe tricuspid regurgitation

OBJECTIVES

The estimation of systolic pulmonary artery pressure (sPAP) by transthoracic echocardiography (TTE) is challenging in patients with severe tricuspid regurgitation (TR). The study aimed to determine the reliability of the assessment of sPAP by TTE in this population.

METHODS

This study was a single-centre analysis of consecutive patients at the University Hospital of Rennes with right heart catheterisation and TTE, performed with a maximum delay of 48 hours. Lin's concordance coefficient (LCC) and Bland-Altman analysis were used to compare the values.

RESULTS

After applying the exclusion criteria, 236 patients were included in the analysis (age 71±11.5 years old; male 56%). The two principal indications were TR (34.3%) and mitral regurgitation (32.2%). The correlation between the two procedures was good in the total population (LCC=0.80; 95% limits of agreement (LOA): 0.74, 0.84), but weaker in the 78 patients (33%) with severe TR (LCC=0.67; 95% LOA: 0.49, 0.80), with a propensity to an underestimation by TTE. An elevated right atrial pressure (RAP) was associated with an underestimation by TTE of about 8 mmHg. The presence of a 'V-wave cut-off' sign on continuous-wave Doppler (OR=3.74; 95% CI 1.48, 9.30; p<0.01), found exclusively in patients with severe TR, was an independent predictor of sPAP misestimation by TTE.

CONCLUSION

The reliability of the estimation of sPAP in patients with severe TR could be altered by high RAP which cannot be estimated with current thresholds.

Conductive disturbances in the transcatheter aortic valve implantation setting: An appraisal of current knowledge and unmet needs

New-onset conduction disturbances, including left bundle branch block and permanent pacemaker implantation, remain a major issue after transcatheter aortic valve implantation. Preprocedural risk assessment in current practice is most often limited to evaluation of the baseline electrocardiogram, whereas it may benefit from a multimodal approach, including ambulatory electrocardiogram monitoring and multidetector computed tomography. Physicians may encounter equivocal situations during the hospital phase, and the management of follow-up is not fully defined, despite the publication of several expert consensuses and the inclusion of recommendations regarding the role of electrophysiology studies and postprocedural monitoring in recent guidelines. This review provides an overview of current knowledge and future perspectives regarding the management of new-onset conduction disturbances in the setting of transcatheter aortic valve implantation, from the preprocedural phase to long-term follow-up.

Reliability of echocardiographic estimation of pulmonary artery pressure in patients with severe tricuspid regurgitation

Background

Transthoracic Echocardiography (TTE) seems to be mistaken for the estimation of systolic Pulmonary Artery Pressure (sPAP) especially in patients with severe Tricuspid Regurgitation (TR). This study aimed to determine the reliability of the assessment of sPAP by TTE in this population.

Methods

This is a monocentric analysis of 236 consecutive patients with concomitant Right Heart Catheterization (RHC) and TTE performed in the assessment of an heart failure syndrome. Lin's Concordance Coefficient (LCC) and Bland-Altman Analysis (BAA) were used to compare the values of RHC and TTE.

Results

The correlation between the two procedures was good in the total population (LCC = 0.80; 95% limits of agreement (LOA): 0.74; 0.84), but weaker in the 78 patients (33%) with severe TR (LCC = 0.67; 95% LOA: 0.49; 0.80), with a propensity to an underestimation by TTE. Altered Right Ventricular (RV) – Pulmonary Artery (AP) coupling did not lead to a misestimation, contrary to an elevated Right Atrial Pressure (RAP), which was associated with an underestimation by TTE of about 8 mmHg. The presence of “C-V waves” sign on the RAP curves (Odds-Ratio (OR) = 3.32; 95% Confidence Interval (CI): 1.02; 10.9; p=0.04) and invasive sPAP ≥50 mmHg (OR = 2.63; 95% CI: 1.35; 5.16; p&lt;0.01) were two independent predictors of a misestimation of sPAP by TTE.

Conclusion

Severe TR led to an underestimation by TTE, especially if the RAP curve shows a “C-V waves” sign, and in the case of high invasive sPAP.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): CHU Rennes Pontchaillou