Left Ventricular Filling Pressure in Chronic Thromboembolic Pulmonary Hypertension

doi:10.1016/j.jacc.2022.11.049

Journal of the American College of Cardiology

Volume 81, Issue 7, 21 February 2023, Pages 653-664

https://doi.org/10.1016/j.jacc.2022.11.049 Get rights and content

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Abstract

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by obstruction of major pulmonary arteries with organized thrombi. Clinical risk factors for pulmonary hypertension due to left heart disease including metabolic syndrome, left-sided valvular heart disease, and ischemic heart disease are common in CTEPH patients.

Objectives

The authors sought to investigate prevalence and prognostic implications of elevated left ventricular filling pressures (LVFP) in CTEPH.

Methods

A total of 593 consecutive CTEPH patients undergoing a first diagnostic right and left heart catheterization were included in this study. Mean pulmonary arterial wedge pressure (mPAWP) and left ventricular end-diastolic pressure (LVEDP) were utilized for assessment of LVFP. Two cutoffs were applied to identify patients with elevated LVFP: 1) for the primary analysis mPAWP and/or LVEDP >15 mm Hg, as recommended by the current pulmonary hypertension guidelines; and 2) for the secondary analysis mPAWP and/or LVEDP >11 mm Hg, representing the upper limit of normal. Clinical and echocardiographic features, and long-term mortality were assessed.

Results

LVFP was >15 mm Hg in 63 (10.6%) and >11 mm Hg in 222 patients (37.4%). Univariable logistic regression analysis identified age, systemic hypertension, diabetes, atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume as significant predictors of elevated LVFP. Atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume remained independent determinants of LVFP in adjusted analysis. At follow-up, higher LVFPs were measured in patients who had meanwhile undergone pulmonary endarterectomy (P = 0.002). LVFP >15 mm Hg (P = 0.021) and >11 mm Hg (P = 0.006) were both associated with worse long-term survival.

Conclusions

Elevated LVFP is common, appears to be due to comorbid left heart disease, and predicts prognosis in CTEPH.

Central Illustration

Key words

chronic thromboembolic pulmonary hypertension

left atrial volume

left ventricular end-diastolic pressure

left ventricular filling pressure

mean pulmonary arterial wedge pressure

Abbreviations and Acronyms

AUC

area under the curve

BPA

balloon pulmonary angioplasty

CTEPH

chronic thromboembolic pulmonary hypertension

dPAP

diastolic pulmonary artery pressure

ICU

intensive care unit

left atrium

left ventricle/ventricular

LVEDP

left ventricular end-diastolic pressure

LVFP

left ventricular filling pressure

mPAP

mean pulmonary artery pressure

mPAWP

mean pulmonary arterial wedge pressure

mRAP

mean right atrial pressure

PAWP

pulmonary arterial wedge pressure

PEA

pulmonary endarterectomy

pulmonary hypertension

PVR

pulmonary vascular resistance

ROC

receiver-operating characteristic

right ventricle/ventricular

sPAP

systolic pulmonary artery pressure

TAPSE

tricuspid annular plane systolic excursion

Wood units

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