Echokardiographie und Rechtsherzkatheterisierung bei pulmonaler Hypertonie

Zusammenfassung

Hintergrund und Fragestellung: Da die pulmonalen Hypertonie hämodynamisch mit einem pulmonal-arteriellen Mitteldruck (mPAP) von mindestens 25 mmHg definiert ist, ist die Rechtsherzkatheterisierung zur Diagnosesicherung unabdingbar. Unklar ist, ob die Echokardiographie die PH immer erfasst und wie echokardiographische und Rechtsherzkatheter-Messparameter korrelieren. Daher wurde bei Patienten an einem PH-Zentrum zunächst die Häufigkeit rechtsseitiger Klappeninsuffizienzen als Voraussetzung für die nicht-invasive Druckabschätzung ermittelt; anschließend wurden Korrelationen des nicht-invasiv abgeschätzten rechtsventrikulären systolischen Drucks (RVSP) mit dem invasiv gemessenem mPAP sowie von Echokardiographie-Parametern mit invasiv gemessenem Herzzeitvolumen (HZV) und pulmonal-vaskulärem Widerstand (PVR) bestimmt.

Methode: Retrospektive Analyse von echokardiographischen und mittels Rechtsherzkatheter bestimmten Parametern bei 74 konsekutiven Patienten mit unklarer Dyspnoe und Verdacht auf PH.

Ergebnisse: Bei gesicherter PH fand sich in 10 % keine Trikuspidalklappeninsuffizienz (TI), in 61,3 % keine messbare Pulmonalklappeninsuffizienz (PI). Der invasiv gemessene mPAP korrelierte am höchsten mit dem nicht-invasiv über eine TI über RVSP abgeschätzten mPAP (R = 0,80; p < 0,0001). Der über eine PI abgeschätzte mPAP (R = 0,72; p < 0,001) und der über die Akzelerationszeit im RVOT abgeschätzte mPAP (R = 0,54, p < 0,0001) korrelierten schwächer mit dem invasiv bestimmten mPAP. LVEI und TDI-TVA korrelierten mit dem PVR, während TAPSE mit PVR und dem HZV korreliert, RIMP jedoch nur mit dem HZV.

Folgerung: Eine PH kann bei alleiniger Beurteilung des RVSP über eine TI der Echokardiographie in 10 % entgehen. Auch andere Zeichen der Rechtsherzbelastung sollten bei Verdacht auf PH die weitere Abklärung veranlassen. Die echokardiographische Abschätzbarkeit des mPAP ist mäßig. Echokardiographie-Parameter können qualitative Informationen über HZV und PVR geben, den Rechtsherzkatheter aber nicht ersetzen.

Abstract

Background and objective: Since pulmonary hypertension is defined haemodynamically with a mean pulmonary artery pressure (mPAP) of at least 25 mmHg, right heart catheterization is mandatory for diagnosis of PH. However, it remains unclear if echocardiography can always detect a PH and to what extent echocardiographic and invasive parameters correlate. We aimed to determine the frequency of right heart valve insufficiencies, the correlation of mPAP measured invasively and estimated by echocardiography and the correlation of other echocardiographic parameters with invasively measured cardiac output (CO) and pulmonary vascular resistance (PVR) in patients who presented at our center for pulmonary hypertension.

Methods: Retrospective analysis of echocardiographic and invasively measured parameters in consecutive patients who presented with dyspnea and suspected PH.

Results: 10 % of the patients with invasively confirmed PH had no tricuspid valve insufficiency, 61.3 % had no pulmonary valve insufficiency. The highest correlation of invasively measured mPAP was found for mPAP estimated non-invasively via RVSP (R = 0.80; < 0.0001). Correlation of non-invasively estimated mPAP by the pulmonary valve regurgitation (R = 0,72, p < 0,004) and mPAP measured by the right ventricular outflow tract flow acceleration time (R = 0,54, p < 0.0001) with invasively measured mPAP were inferior. Left ventricular eccentricity index and systolic tissue Doppler velocity of tricuspid annulus correlated highly significant with PVR, TAPSE correlated with PVR and CO. Right ventricular myocardial performance index correlated with CO.

Conclusion: In 10 % of invasively proven PH, the diagnosis can be missed by estimation of RVSP by echocardiography alone, due to a lack of tricuspid valve insufficiency. Echocardiographic assessment of mPAP remains difficult. Echocardiography can deliver qualitative information about CO and PVR. Right heart catheterization remains mandatory to confirm or to rule out PH.

Schlüsselwörter

pulmonale Hypertonie - mittlerer pulmonal-arterieller Druck - systolischer pulmonal-arterieller Druck - Echokardiographie - Rechtsherzkatheter

Keywords

pulmonary hypertension - mean pulmonary artery pressure - systolic pulmonary artery pressure - echocardiogryphy - right heart catheterization

• Literatur

• 1 Champion HC, De Michelakis ED, Hassoun PM. Comprehensive and non-invasive approach to the right ventricular-pulmonary circulation. Circulation 2009; 120: 992-1007
• 2 Chemla D, Castelain V, Humbert M et al. New formula for predicting mean pulmonary artery pressure using systolic pulmonary artery pressure. Chest 2004; 126: 1313-1317
• 3 Coghlan GJ G, Denton CP, Grünig E et al. on behalf of the DETECT study group. Evidence-based detection of pulmonary arterial hypertension in systemic sclerosis. The DETECT study. Ann Rheum Dis 2013; May 18. [Epub ahead of print]
• 4 Dabestani A, Mahan G, Gardin JM et al. Evaluation of pulmonary artery pressure and resistance by pulsed Doppler echocardiography. Am J Cardiol 1987; 59: 662-668
• 5 Dokainish H, Zoghbi WA, Lakkis NM et al. Comparative accuracy of B-type natriuretic peptide and tissue Doppler echocardiography in the diagnosis of congestive heart failure. Am J Cardiol 2004; 93: 1130-1135
• 6 Er F, Ederer S, Nia AM et al. Accuracy of Doppler-echocardiographic mean pulmonary artery pressure for diagnosis of pulmonary hypertension. Plos One 2010; 5: e 15670
• 7 Fisher MR, Criner GJ, Fishman AP et al. NETT Research Group. Estimating pulmonary artery pressures by echocardiography in patients with emphysema. Eur Respir J 2007; 30: 914-921
• 8 Fisher MR, Forfia PR, Chamera E et al. Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. Am J Respir Crit Care Med 2009; 179: 615-621
• 9 Forfia PR, Fisher MR, Mathai SC et al. Tricuspid annular displacement predicts survivalin pulmonary hypertension. Am J Respir Crit Care Med 2006; 174: 1034-1041
• 10 Galiè N, Hoeper MM, Humbert M et al. ESC Commitee for Practice Guidelines (CPG). Guidelines for the diagnosis and treatment of pulmonary hypertension: the 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 the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30: 2493-2537
• 11 Grünig E, Barner A, Bell M et al. Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with updated Commentary of the Cologne Consensus Conference 2011. Int J Cardiol 2011; 152 (Suppl. 01) S3-S12
• 12 Held M, Grün M, Kaiser R et al. Cardiopulmonary exercise testing detects pulmonary hypertension in patients with suspected chronic thromboembolic pulmonary hypertension and normal echocardiography (ATS Poster). Am J Respir Crit Care Med 187 2013; A 3339
• 13 Hoeper MM, Lee SH, Voswinckel R et al. Complications of right heart catheterization procedures in patients with pulmonary hypertension in experienced centers. J Am Coll Cardiol 2006; 48: 2546-2552
• 14 Kaul S, Tei C, Hopkins JM et al. Assessment of right ventricular function using two-dimensional echocardiography. Am Heart J 1984; 107: 526-531
• 15 Kitabatake A, Inoue M, Asao M et al. Noninvasive evaluation of pulmonary hypertension by a pulsed Doppler technique. Circulation 1983; 68: 302-309
• 16 Lang RM, Bierig M, Devereux RB et al. Recommendations for chamber quantification. Eur J Echocardiography 2006; 7: 79-108
• 17 Mahan G, Dabestani A, Gardin J et al. Estimation of pulmonary artery pressure by pulsed Doppler echocardiography (abstr). Circulation 1984; 70 (Suppl. 02) II-363
• 18 Masuyama T, Kodama K et al. Continuous-wave Doppler echocardiographic detection of pulmonary regurgitation and its application to noninvasive estimation of pulmonary artery pressure. Circulation 1986; 74: 484-492
• 19 Meluzín J, Spinarová L, Dusek L et al. Prognostic importance of the right ventricular function assessed by Doppler tissue imaging. Eur J Echocardiogr 2003; 4: 262-271
• 20 Nickel N, Golpon H, Greer M et al. The prognostic impact of follow-up assesments in patients with idiopathic pulmonary arterial hypertension. Eur Resp J 2012; 39: 589-596
• 21 Olschewski H, Hoeper MM, Borst MM et al. Diagnostik und Therapie der chronischen pulmonalen Hypertonie. Pneumologie 2006; 60: 749-771
• 22 Opitz CF, Blindt R, Blumberg F et al. Pulmonary Hypertension: Hemodynamic evaluation. Updated Recommendations of the Cologne Conference 2011. Int J Cardiol 2001; 152: 13-19
• 23 Raymond RJ, Hinderliter AL, Willis PW et al. Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension. J Am Coll Cardiol 2002; 39: 1214-1219
• 24 Rosenkranz S, Bonderman D, Buerke M et al. Pulmonary hypertension due to left heart disease: updated Recommendations of the Cologne Consensus Conference 2011. Int J Cardiol 2011; 154 (Suppl. 01) 34-44
• 25 Rosenkranz S, Behr J, Ewert R et al. Rechtsherzkatheter-Untersuchung bei pulmonaler Hypertonie. Dtsch med Wochenschr 2011; 136: 2601-2620
• 26 Rudski LG, Lai WW, Afilalo J et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiography 2010; 23: 685-713
• 27 Spooner EW, Perry BL, Stern AM et al. Estimation of Pulmonary/Systemic Resistance Ratios from echocardiographic systolic time intervals in young patients with congenital or aquired heart disease. Am J Cardiol 1978; 42: 810-816
• 28 Yeo TC, Dujardin KS, Tei C et al. Value of a Doppler-derived index combining systolic and diastolic time intervals in predicting outcome in primary pulmonary hypertension. Am J Cardiol 1998; 81: 1157-1161