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AimsThe current guidelines on pulmonary hypertension (PH) recommend the use of invasive examination for differentiating between left-sided heart disease-related (post-capillary) and pre-capillary PH. However, atrial sizes are considered markers of ventricular filling pressures. Therefore, we aimed to test the clinical applicability of atrial volumes measured by transthoracic three-dimensional echocardiography (3DE) in differentiating between pre-capillary and post-capillary PH. Methods and results Seventy-five consecutive patients with PH were prospectively examined with transthoracic 3DE. After less than 24 h, the patients underwent right heart catheterization and 3DE and were classified as pre-capillary or post-capillary PH according to the recommendations of the ESC guidelines. The atrial volumes were measured offline with dedicated commercial software. Thirty-eight patients (13 men, age 65 ± 18 year) had pre-capillary PH, and 37 (23 men, age 62 ± year) had post-capillary PH. The mean pulmonary artery pressures were similar in patients with pre-capillary and post-capillary PH (38 [IQR 26, 54] mmHg vs. 41 [IQR 33, 48] mmHg, respectively, P = 0.49). The left atrial indexed maximum (LAVi max) and minimum (LAVi min) volumes were significantly larger in the post-capillary PH patient group than in the pre-capillary PH patient group (LAVi max: 64 ± 32 mL/m 2 vs. 41 ± 25 mL/m 2 , P = 0.001; LAVi min: 50 ± 22 mL/m 2 vs. 26 ± 24 mL/m 2 , P < 0.0001). The indexed right atrial minimum volume (RAVi min) was also higher in patients with post-capillary PH (51 ± 27 mL/m 2 vs. 38 ± 26 mL/m 2 ; P = 0.02). Both the left atrial (LA) and right atrial (RA) volumes, especially the LA minimum volume, correlated with the pulmonary artery wedge pressure (PAWP) (r = 0.62 (P < 0.0001) for LAV min vs. r = 0.49 (P < 0.0001) for LAV max; r = 0.32 (P = 0.005) for RAV min vs. r = 0.24 (P = 0.04) for RAV max). Multivariate logistic regression analysis showed that LAVi min was an independent predictor of post-capillary PH. In the receiver operating characteristic (ROC) curves of parameters predicting the post-capillary PH, the areas under the curve (AUC) for LAVi min, LAVi max, and RAVi min were 0.86 (95% CI, 0.76-0.95), 0.78 (95% CI, 0.67-0.89), and 0.66 (0.53-0.78), respectively. Concerning the performance of the atrial volume ratio for differentiating post-capillary PH, the AUC of the atrial volume ratio was significantly lower [AUC: 0.66 (95% CI, 0.53-0.78)]. The ROC analysis indicated a possible cutoff value of 27.7 mL/m 2 for LAVi min to predict post-capillary PH (AUC = 0.86; sensitivity = 86%, specificity = 76%). Conclusions The BSA-indexed left atrial minimum volume measured by transthoracic 3DE is a useful parameter for differentiating pre-capillary from post-capillary pulmonary hypertension.

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Background Right ventricular (RV) pacing may worsen left ventricular (LV) systolic function causing heart failure, but the exact mechanism of the LV dysfunction is unknown. The purpose of this study was to examine the right ventricle by three-dimensional echocardiography in patients with LV dysfunction accompanied by long-term RV pacing. Methods We analysed consecutive patients receiving permanent pacemaker (PPM) due to atrioventricular block from 2015 January to 2017 March (n = 335). During the mean follow-up period (27 months) 4 patients were selected with at least 5% decrease in the LV ejection fraction measured by two-dimensional echocardiography (B group). Control (K) group contains 4 age-, sex-, concomitant disease matched patients without the sign of LV dysfunction from the same time interval. Right ventricle function was assessed by 3D echocardiography. Results In both groups, there were 3 men, and the mean age was similar (B: 68 ± 6 y vs. K: 66 ± 10 y; p = 0.65). Right ventricular ejection fraction (EF) was significantly higher in controls compared to patients (K: 49 ± 7.8% vs. B: 36 ± 3.1%; p = 0.02), while the right ventricular volumes [end-systolic (K: 79 ± 47 ml vs. B: 71 ± 7 ml; p = 0.77), end-diastolic (K: 151 ± 73 ml vs. B: 111 ± 11 ml; p = 0.36) and stroke volumes (K: 58 ± 44 ml vs. B: 40 ± 6 ml; p = 0.5)] did not differ significantly. We did not find any important differences between the groups regarding the permanent right ventricle pace rate (K: 93 ± 5.6% vs. B: 84 ± 19.5%; p = 0.5), systolic pulmonary pressure (K: 34 ± 6 mmHg vs. B: 35 ± 18 mmHg; p = 0.92), or the severity of tricuspid regurgitation. Conclusion The left ventricular dysfunction after permanent right ventricular pacing results in right ventricular systolic dysfunction. The decrease of RV ejection fraction is not associated with RV enlargement or increase of pulmonary pressure.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hungarian Government Research Fund, Szív- és érkutatási kiválóságközpont (IRONHEART) Aims Atrial sizes are considered markers of ventricular filling pressures. The studies focused on left atrial (LA) maximum volume (LAV max), however during diastole the left ventricular (LV) diastolic pressure affects the LA minimum volume (LAV min) instead. Therefore, we aimed to test the clinical applicability of atrial volumes measured by transthoracic three-dimensional echocardiography (3DE) in predicting elevated LV filling pressure. Methods Eighty-eight consecutive patients with and without left-sided heart disease were prospectively examined with transthoracic 3DE who underwent right heart catheterization because of clinical indication. Elevated LV filling pressure was determined as the pulmonary artery wedge pressure was higher than 15 mm Hg. The atrial volumes were measured offline with dedicated commercial software. Results Thirty-eight patients (24 males, age 62 ± 8 y) had left-sided heart disease (group A) and 50 (20 males, age 62 ± 15 y) had pulmonary hypertension because of lung disease (Group B). The left atrial indexed maximum (LAVi max) and minimum (LAVi min) volumes were significantly larger in group A than in group B (LAVi max: 64 ± 31 ml/m² vs. 40 ± 22 ml/m², p = 0.001; LAVi min: 51 ± 22 ml/m² vs. 25 ± 21 ml/m², p &lt; 0.0001). The LA minimum volume correlated with the pulmonary artery wedge pressure [r = 0.6 (p &lt; 0.0001) for LAV min vs. r = 0.47 (p &lt; 0.0001) for LAV max]. In the receiver operating characteristic (ROC) curves of parameters predicting the elevated LV filling pressure, the areas under the curve (AUC) for LAVi min and LAVi max were 0.86 (95% CI, 0.79-0.94), 0.79 (95% CI, 0.70-0.89), respectively. The ROC analysis indicated a possible cutoff value of 28 ml/m² for LAVi min to elevated LV filling pressure (AUC = 0.86; sensitivity = 87%, specificity = 74%). Conclusion The left atrial minimum volume measured by transthoracic 3DE is a useful parameter for predicting elevated left ventricular filling pressure.