Echocardiographic Score To Predict Hemodynamic Typing In Patients With Pulmonary Hypertension Due To Left Heart Disease

Objective:A simplified echocardiographic score system to predict the hemodynamics typing in patients with pulmonary hypertension due to left heart disease(PH-LDH).Methods:A retrospective analysis of 85 patients with PH-LHD diagnosed as post-capillary pulmonary hypertension(post-PH)by right heart catheter(RHC)from August 2015 to July 2018 was performed in the Department of Pulmonary Circulation,Shanghai Pulmonary Hospital.According to the diastolic pressure gradient(DPG),patients was divided into group isolated post-capillary pulmonary hypertension(Icp-PH)by DPG<7 mmHg and group combined post-capillary and pre-capillary pulmonary hypertension(Cpc-PH)by DPG>7 mmHg.And 65 patients with pulmonary arterial hypertension(PAH),who were diagnosed as pre-capillary pulmonary hypertension(pre-PH)by RHC at the same time,were randomly selected.The clinical data,echocardiography and hemodynamic data of all the patients were collected.The difference of echocardiographic parameters was analyzed and the echocardiographic score to predict hemodynamic typing of PH-LDH was established by Logistic regression analysis.Results:1.A total of 150 patients were enrolled in the study,with an average age of 55.7±16.9 years,62 males and 88 females,65 patients with PAH and 85 patients with PH-LDH,in the latter,Ipc-PH was found in 72 and Cpc-PH in 13.2.In the RHC,there was a significant difference in the superior vena cava pressure(SVCP)(3.4±2.9 vs 10.6±7 mmHg,P<0.001),mean right atrial pressure(mRAP)(3.6±2.9 vs 10.6±6.7 mmHg,P<0.001),mean right ventricular pressure(mRVP)(7.3±4.3 vs14.8±9.5 mmHg,P<0.001),pulmonary artery diastolic pressure(dPAP)(28±12 vs 21.4±7.5 mmHg,P=0.013),mean pulmonary artery pressure(mPAP)(48.1±14.5 vs 37.9±13 mmHg,P<0.001),mean pulmonary artery wedge pressure(mPAWP)(5.5±2.8 vs 21.1±6.3 mmHg,P<0.001),DPG(22.6±11.9 vs 0.3±6.4 mmHg,P<0.001),pulmonary vascular resistance(PVR)(9.8±4.5 vs 3.8±3.2 WU,P<0.001),total pulmonary resistance(TPR)(11±4.7 vs 8.5±4.6 WU,P=0.001)between group pre-PH and group post-PH.3.In echocardiography,there was difference in the aortic root diameter(AO)(23.8±4.8 vs 28.3±4.8 mm,P<0.001),left atrial diameter(LA)(30.9±4.1vs 45.6±9 mm,P<0.001),left ventricular end diastolic diameter(LVEDd)(39.2±5.7 vs 49.4±9.1 mm,P<0.001),left ventricular end systolic diameter(LVEDs)(21.5±4.8 vs 31.9 ± 9.2 mm,P<0.001),interventricular septum diastolic thickness(IVSd)(7.5±1.6 vs 9.4±2.4 mm,P<0.001),diastolic left ventricular posterior wall thickness(LVPWd)(8.1±1.7 vs 9.5±1.9 mm,P<0.001),pulmonary artery systolic pressure(PASP)(78.6±20.3 vs 57.4±17 mmHg,P<0.001),right atrial systolic longitudinal diamete(RAIDs)(50.1±7.2 vs 56.3±10.4 mm,P<0.001),right ventricular diastolic diameter(RVDd)(40.3±6.6 vs 35.2±6.2 mm,P<0.001),mitral valve E wave(59.4±20.4 vs 106.9±42.5 cm/s,P<0.001),tricuspid valve E wave(50.5±15.8 vs 64.6±21.8 cm/s,P<0.001),maximum flow velocity on the aortic valve(93±18.7 vs 110.6±40.8 cm/s,P=0.002),left ventricular ejection fraction(LV EF)(75.9±7.7 vs 62.1±12.1%,P<0.001),left ventricular fractional shortening(LV FS)(44.6±7.3 vs 35.1±8.4%,P<0.001),right atrial pressure(RAP)(6.4±2.3 vs 8.7±3.7 mmHg,P<0.001),mitral valve Sm(9.9±2.4 vs 7.6±2 cm/s,P<0.001),mitral valve Em(9.8±3 vs 8.6±3 cm/s,P=0.017)and E/Em(6.7±3.4 vs 14.4±10,P<0.001)between group pre-PH and post-PH.4.Univariate logistic regression analysis showed that the parameters above can predict post-PH;multivariate logistic regression analysis showed that the LA(OR 1.53,95%CI 1.26-1.85,P<0.001),LVEDs(OR 1.23,95%CI 1.06-1.43,P=0.006),RAP(OR 1.38,95%CI 1.02-1.85,P=0.034),E/Em(OR 1.28,95%CI 1.08-1.51,P=0.005)were independent predictors for the diagnosis of post-PH.A scoring system was established(2 for LA>38.5 mm,l for LVEDs>28.5 mm,l for RAP>8 mmHg and 1 for E/Em>8.6).The sensitivity and specificity of the score>2 for predicting post-PH was 95.3%and 89.2%,respectively(aera under the cruve 0.969).5.In RHC,the Cpc-PH group had higher dPAP(19.9±5.7 vs 30±10.2 mmHg,P<0.001),mPAP(35.5 ± 9.8 vs 51.5±19.6 mmHg,P=0.012),PVR(3.0 ± 1.6 vs 8.5±5.3 WU,P=0.003)and TPR(7.6±3.0 vs 13.5±7.9 WU,P=0.019)than the Ipc-PH group.6.In echocardiography,there was difference in the main pulmonary artery diameter(MPA)(28.1±5.3 vs 32±4.2 mm,P=0.015),PASP(54±13.9 vs 75.9±21 mmHg,P<0.001),right ventricular free wall systolic diameter(RVWDd)(6.6±1.4 vs 7.8±1.4 mm,P=0.005),right atrial systolic diamete(RADs)(44.7±7.7 vs 50.1±8.3 mm,P=0.025),RAIDs(55.2±9.8 vs 62.1±12.4 mm,P=0.028)and RVDd(34.4±5.9 vs 39.5±6.7 mm,P=0.006)btween group Ipc-PH and Cpc-PH.7.Univariate logistic regression analysis showed that the parameters above can predict Cpc-PH;multivariate logistic regression analysis showed that the PASP(OR 1.09,95%CI 1.04-1.14,P=0.001)and RVDd(OR 1.18,95%CI 1.03-1.35,P=0.015)were independent predictors for the diagnosis of Cpc-PH,and the combination of the two(PASP>62.5 mmHg and RVDd?35.6 mm)to predict the Cpc-PH was with an area under curve of 0.874,the sensitivity and specificity was 84.6%and 77.8%,respectively.Conclusion:Establishing a simplified scoring system based on echocardiographic parameters such as LA,LVEDs,RAP and E/Em is helpful to predict post-PH.In addition,the combination of echocardiographic parameters of PASP and RVDd can further identify Icp-PH and Cpc-PH.