Diagnostic value of right heart and pulmo­­nary artery catheterization in patients with suspected pulmonary hypertension. Part 1. Methodology of the procedure, nosology of the diseases and vasoreactivity testing

Main Article Content

Yu. M. Sirenko
I. O. Zhyvylo
G. D. Radchenko

Abstract

The aim – critical review of our own experience, its compliance with current recommendations and data from international registries, as also assessment of pulmonary and systemic hemodynamics obtained in patients with pulmonary arterial hypertension (PAH) in Ukraine.
Materials and methods. 220 procedures of the right heart and pulmonary artery catheterization were performed in 195 patients with medium or high probability of PAH according to echocardiography in compliance with current recommendations. All patients were hospitalized at National Scientific Center “M.D. Strazhesko Institute of Cardiology” of NAMS of Ukraine with suspected PAH (primary) or with worsening of the disease course (repeatedly) or in order to confirm the status of vasoreactivity (repeated).
Results and discussion. 220 successful catheterization procedures were performed. Primary (diagnostic) right heart catheterization was performed in 195 patients, and repeated – in 25. A diagnosis of pulmonary hypertension was confirmed in 178 patients. In 17 patients, according to the results of catheterization, the diagnosis of PAH was excluded: the mean pressure in the pulmonary artery was less than 20 mm Hg. The structure of nosology in patients who underwent right heart catheterization was as follows: idiopathic PAH was fixed in 68 (38 %) patients, of which 11 (6 %) were vasoreactive; PAH associated with connective tissue diseases – in 21 (12 %) patients; PAH associated with HIV infection in – 4 (2 %) patients; PAH associated with portal hypertension – in 4 (2 %) patients; PAH associated with congenital heart disease – in 26 (15 %) patients; chronic thromboembolic pulmonary hypertension – in 50 (28 %) patients. Vasoreactivity testing was performed in 33 patients with idiopathic PAH. In 11 of them it was positive (33 %). In patients with a positive vasoreactivity testing, the mean pulmonary artery pressure decreased by an average of 21.8 mm Hg to the level of 26.5 mm Hg (p<0.0001), while the cardiac index increased by 31 % and reached 3.8 l · min · m–2 (p<0.1). Pulmonary vascular resistance decreased by 6.4 Wood units to the level of 2.7 Wood units (p<0.0001). In patients with a negative vasoreactivity testing, the decrease in mean pulmonary artery pressure and pulmonary vascular resistance was not statistically significant (p>0.05), and no changes in the cardiac index were detected.
Conclusions. Based on the experience of our center, hemodynamic assessment using catheterization is safe and remains the diagnostic standard for PAH. Catheterization is necessary to clarify 4 parameters that are critical for the clinical profile of patients with pulmonary hypertension: right atrium pressure, pulmonary vascular resistance, cardiac output, pulmonary wedge pressure. Patients with idiopathic PAH also need to have vasoreactivity evaluated in order to predict sensitivity to calcium channel blockers therapy, the presence of which is associated with better treatment and survival outcomes.

Article Details

Keywords:

pulmonary hypertension, right heart catheterization, pulmonary artery, pulmonary artery pressure, vasoreactivity testing, cardiac index

References

Митрофанова Л.Б., Аминева Х.К. Макроскопический и органометрический анализ сердца в патологии: пособие для врачей / Под ред. Г.Б. Ковальского.– Санкт-Петер­­бург: ГПАБ, 1998.– 60 с.

Сіренко Ю.М., Радченко Г.Д., Живило І.О. та ін. Досвід катетеризації правих відділів серця та легеневої артерії у хворих на легеневу гіпертензію // Серце і судини.– 2016.– № 4.– С. 23–29.

Chatterjee K. Swan-Ganz catheters: past, present, and future: a viewpoint // Circulation.– 2009.– Vol. 119.– P. 147–152. doi: https://doi.org/10.1161/circulationaha.108.811141.

Frost A., Badesch D., Gibbs J.S.R. et al. Diagnosis of pulmonary hypertension // Eur. Respir. J.– 2019.– Vol. 53.– P. 1801904. https://doi.org/10.1183/13993003.01904-2018

Gaine S.P., Naeije R., Peacock A.J. The Right Heart. – London: Springer-Verlag, 2014. – 323 p. doi: https://doi.org/10.1007/978-1-4471-2398-9.

Galie N., Humbert M., Vachiery J.L. et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT) // Eur. Respir. J.– 2015.– Vol. 46.– P. 903–975. doi: https://doi.org/10.1183/13993003.51032-2015.

Hemnes A.R., Zhao M., West J. et al. Critical genomic networks and vasoreactive variants in idiopathic pulmonary arterial hypertension // Am. J. Respir. Crit. Care. Med.– 2016.– Vol. 194.– P. 464–475. doi: https://doi.org/10.1164/rccm.201508-1678oc.

Hoeper M.M., Bogaard H.J., Condliffe R. et al. Definitions and diagnosis of pulmonary hypertension // J. Am. Coll. Cardiol.– 2013.– Vol. 62 (25).– P. 42–50. doi: https://doi.org/10.1016/j.jacc.2013.10.032.

Hoeper M.M., Lee S.H., Voswinckel R. et al. Complications of right heart catheterization procedures in patients with pulmonary hypertension in experienced centers // J. Am. Coll. Cardiol.– 2006.– Vol. 48.– P. 46–52. doi: https://doi.org/10.1016/s0734-3299(08)70488-x.

Jing Z.C., Jiang X., Han Z.Y. et al. Iloprost for pulmonary vasodilator testing in idiopathic pulmonary hypertension // Eur. Respir. J.– 2009.– Vol. 33 (6).– P. 1354–1360. doi: https://doi.org/10.1183/09031936.00169608.

Lang I.M. Measuring vasorectivity in pulmonary hypertension: a simple test, but do we understand it? // J. Heart Lung Transplant.– 2015.– Vol. 34 (3).– P. 306–307. doi: https://doi.org/10.1016/j.healun.2014.12.002.

Lang R.M., Badano L.P., Mor-Avi V. et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging // J. Am. Soc. Echocardiogr.– 2015.– Vol. 28 (1).– P. 1–39. doi: https://doi.org/10.1016/j.echo.2014.10.003.

McLaughlin V.V., Archer S.L., Badesch D.B. et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians, American Thoracic Society and the Pulmonary Hypertension Associa­tion // J. Am. Coll. Cardiol.– 2009.– Vol. 53 (17).– P. 1573–619. doi: https://doi.org/10.1016/j.jacc.2009.01.004.

Morris A.H., Chapman R.H., Gardner R.M. Frequency of technical problems encountered in the measurement of pulmonary artery wedge pressure // Crit. Care Med.– 1984.– Vol. 12 (3).– P. 164–170. doi: https://doi.org/10.1097/00003246-198403000-00003.

Nossaman B.D., Scruggs B.A., Nossaman V.E. et al. History of Right Heart Catheterization: 100 Years of Experimentation and Methodology Development // CARDIOL. REV.– 2010.– Vol. 18 (2).– P. 94–101. doi: https://doi.org/10.1097/crd.0b013e3181ceff67.

Rosenkranz S., Behr J., Ewert R. et al. Rechtsherzkatheter-Untersuchung bei pulmonaler Hypertonie [Right heart catheterization in pulmonary hypertension] // Dtsch. Med. Wochenschr.– 2011.– Vol. 136.– P. 2601–2616. doi: https://doi.org/10.1055/s-0031-1292858.

Simonneau G., Montani D., Celermajer D.S. et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension // Eur. Respir. J.– 2019.– Vol. 53.– P. 1801913. doi: https://doi.org/10.1183/13993003.01913-2018.

Sitbon O., Humbert M., Jaïs X. et al. Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension // Circulation.– 2005.– Vol. 111.– P. 3105–3111. doi: https://doi.org/10.1016/j.accreview.2005.09.056.

Tonelli A.R., Mubarak K.K., Li N. et al. Effect of Balloon Inflation Volume on Pulmonary Artery Occlusion Pressure in Patients With and Without Pulmonary Hypertension // CHEST.– 2011.– Vol. 139 (1).– P. 115–121. doi: https://doi.org/10.1378/chest.10-0981.

Volk K.W. The assessment of acute vasoreactivity during right heart catheterization for the evaluation of pulmonary arterial hypertension // Cath. Lab. Digest.– 2018.– Vol. 26 (May) – online (https://www.cathlabdigest.com/article/Assessment-Acute-Vasoreactivity-During-Right-Heart-Catheterizations-Evaluation-Pulmonary).