Noninvasive model including right ventricular speckle tracking for the evaluation of pulmonary hypertension.
OBJECTIVE
To find parameters from transthorathic echocardiography (TTE) including speckle-tracking (ST) analysis of the right ventricle (RV) to identify precapillary pulmonary hypertension (PH).


METHODS
Forty-four patients with suspected PH undergoing right heart catheterization (RHC) were consecutively included (mean age 63.1 ± 14 years, 61% male gender). All patients underwent standardized TTE including ST analysis of the RV. Based on the subsequent TTE-derived measurements, the presence of PH was assessed: Left ventricular ejection fraction (LVEF) was calculated by Simpsons rule from 4Ch. Systolic pulmonary artery pressure (sPAP) was assessed with continuous wave Doppler of systolic tricuspid regurgitant velocity and regarded raised with values ≥ 30 mmHg as a surrogate parameter for RA pressure. A concomitantly elevated PCWP was considered a means to discriminate between the precapillary and postcapillary form of PH. PCWP was considered elevated when the E/e' ratio was > 12 as a surrogate for LV diastolic pressure. E/e' ratio was measured by gauging systolic and diastolic velocities of the lateral and septal mitral valve annulus using TDI mode. The results were then averaged with conventional measurement of mitral valve inflow. Furthermore, functional testing with six minutes walking distance (6MWD), ECG-RV stress signs, NT pro-BNP and other laboratory values were assessed.


RESULTS
PH was confirmed in 34 patients (precapillary PH, n = 15, postcapillary PH, n = 19). TTE showed significant differences in E/e' ratio (precapillary PH: 12.3 ± 4.4, postcapillary PH: 17.3 ± 10.3, no PH: 12.1 ± 4.5, P = 0.02), LV volumes (ESV: 25.0 ± 15.0 mL, 49.9 ± 29.5 mL, 32.2 ± 13.6 mL, P = 0.027; EDV: 73.6 ± 24.0 mL, 110.6 ± 31.8 mL, 87.8 ± 33.0 mL, P = 0.021) and systolic pulmonary arterial pressure (sPAP: 61.2 ± 22.3 mmHg, 53.6 ± 20.1 mmHg, 31.2 ± 24.6 mmHg, P = 0.001). STRV analysis showed significant differences for apical RV longitudinal strain (RVAS: -7.5% ± 5.6%, -13.3% ± 4.3%, -14.3% ± 6.3%, P = 0.03). NT pro-BNP was higher in patients with postcapillary PH (4677.0 ± 7764.1 pg/mL, precapillary PH: 1980.3 ± 3432.1 pg/mL, no PH: 367.5 ± 420.4 pg/mL, P = 0.03). Patients with precapillary PH presented significantly more often with ECG RV-stress signs (P = 0.001). Receiver operating characteristics curve analyses displayed the most significant area under the curve (AUC) for RVAS (cut-off < -6.5%, AUC 0.91, P < 0.001), sPAP (cut-off > 33 mmHg, AUC 0.86, P < 0.001) and ECG RV stress signs (AUC 0.83, P < 0.001). The combination of these parameters had a sensitivity of 82.8% and a specificity of 17.2% to detect precapillary PH.


CONCLUSIONS
The combination of non-invasive measurements allows feasible assessment of PH and seems beneficial for the differentiation between the pre- and postcapillary form of this disease.
Yossra Mahran, Robert Schueler, Marcel Weber, Carmen Pizarro, Georg Nickenig, Dirk Skowasch, Christoph Hammerstingl, Department of Internal Medicine, Cardiology, Pneumology and Angiology, Heart Centre Bonn, University of Bonn, 53105 Bonn, Germany.
Yossra
Y
Mahran
Yossra Mahran, Robert Schueler, Marcel Weber, Carmen Pizarro, Georg Nickenig, Dirk Skowasch, Christoph Hammerstingl, Department of Internal Medicine, Cardiology, Pneumology and Angiology, Heart Centre Bonn, University of Bonn, 53105 Bonn, Germany.
Robert
R
Schueler
Yossra Mahran, Robert Schueler, Marcel Weber, Carmen Pizarro, Georg Nickenig, Dirk Skowasch, Christoph Hammerstingl, Department of Internal Medicine, Cardiology, Pneumology and Angiology, Heart Centre Bonn, University of Bonn, 53105 Bonn, Germany.
Marcel
M
Weber
Yossra Mahran, Robert Schueler, Marcel Weber, Carmen Pizarro, Georg Nickenig, Dirk Skowasch, Christoph Hammerstingl, Department of Internal Medicine, Cardiology, Pneumology and Angiology, Heart Centre Bonn, University of Bonn, 53105 Bonn, Germany.
Carmen
C
Pizarro
Yossra Mahran, Robert Schueler, Marcel Weber, Carmen Pizarro, Georg Nickenig, Dirk Skowasch, Christoph Hammerstingl, Department of Internal Medicine, Cardiology, Pneumology and Angiology, Heart Centre Bonn, University of Bonn, 53105 Bonn, Germany.
Georg
G
Nickenig
Yossra Mahran, Robert Schueler, Marcel Weber, Carmen Pizarro, Georg Nickenig, Dirk Skowasch, Christoph Hammerstingl, Department of Internal Medicine, Cardiology, Pneumology and Angiology, Heart Centre Bonn, University of Bonn, 53105 Bonn, Germany.
Dirk
D
Skowasch
Yossra Mahran, Robert Schueler, Marcel Weber, Carmen Pizarro, Georg Nickenig, Dirk Skowasch, Christoph Hammerstingl, Department of Internal Medicine, Cardiology, Pneumology and Angiology, Heart Centre Bonn, University of Bonn, 53105 Bonn, Germany.
Christoph
C
Hammerstingl
Echocardiography; Pulmonary arterial hypertension; Right ventricle function