Author + information
- Islam Abdelkarim, MSc, MD,
- Andrew D. Althouse, PhD,
- Floyd W. Thoma, BA,
- Joon S. Lee, MD,
- John T. Schindler, MD,
- Thomas G. Gleason, MD and
- João L. Cavalcante, MD∗ ()
- ↵∗Department of Medicine, Division of Cardiology, Heart & Vascular Institute, University of Pittsburgh/UPMC, 200 Lothrop St, Scaife Hall, S-558, Pittsburgh, Pennsylvania 15213
The recent American College of Cardiology expert consensus for transcatheter aortic valve replacement (TAVR) decision pathway mentions pulmonary hypertension (PH) as a major cardiovascular comorbidity (1). The consensus does not specify the method of assessment, only suggesting that PH may be evaluated by echocardiography; however, right heart catheterization (RHC) is the gold standard for PH assessment. We retrospectively evaluated consecutive patients that had transthoracic echocardiogram (TTE) and RHC performed within 3 days of one another as part of their routine clinical care before TAVR at the University of Pittsburgh Medical Center. We sought to determine the agreement between pulmonary artery systolic pressure (PASP) measured by TTE and RHC in these patients.
According to the guidelines, PASP was calculated using the maximal tricuspid regurgitation jet velocity obtained from continuous-wave Doppler using multiple windows and integrated into the modified Bernoulli equation plus the estimated right atrial pressure. RHC was performed with a standard pulmonary artery catheter. PH severity was categorically classified as none (PASP <35 mm Hg), mild (35 to 45 mm Hg), moderate (46 to 59 mm Hg), and severe (≥60 mm Hg). Bland-Altman plots and linear regression correlated PASP between the 2 methods.
Our study included 86 patients with severe AS with a mean age of 84 ± 6 years, indexed AV area 0.33 ± 0.1 cm2/m2, LVEF 51 ± 15%, and PASP 45 ± 20 mm Hg. Correlation of PASP measurement by RHC and TTE was modest with wide variability (Figures 1A and 1B). Twenty-seven patients were classified as having no PH by TTE; of these, 8 (30%) were reclassified to ≥ moderate PH by RHC with 4 (15%) patients as severe PH by RHC. TTE was very specific for severe PH (96%; 95% confidence interval [CI]: 87% to 99%), but not adequately sensitive (47%; 95% CI: 29% to 65%).
In conclusion, we found substantial variability between TTE versus RHC assessment of PH severity in patients undergoing TAVR evaluation. TTE was highly specific, but not adequately sensitive. Up to 30% of patients with no PH by TTE were reclassified to moderate or severe PH by RHC. Our data support that RHC should be the gold standard method for accurate PH assessment in patients being evaluated for TAVR procedure because presence and severity of PH impacts TAVR outcomes.
Please note: Dr. Schindler is on the advisory board of Boston Scientific; and has received grant support from Edwards Lifesciences. Dr. Gleason has received a research grant from Medtronic, Inc.; and is a steering committee member for Medtronic, Inc. and Boston Scientific. Dr. Cavalcante has received investigator-initiated research grant support from Medtronic Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
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