Hemodynamic Phenotyping of Pulmonary Hypertension in Left Heart Failure

Abstract

ABSTRACT:Increased pulmonary venous pressure secondary to left heart disease is the most common cause of pulmonary hypertension (PH). The diagnosis of PH due to left heart disease relies on a clinical probability assessment followed by the invasive measurements of a mean pulmonary artery pressure (PAP) ≥25 mm Hg and mean wedged PAP (PAWP) >15 mm Hg. A combination of mean PAP and mean PAWP defines postcapillary PH. Postcapillary PH is generally associated with a diastolic pulmonary pressure gradient (diastolic PAP minus mean PAWP) <7 mm Hg, a transpulmonary pressure gradient (mean PAP minus mean PAWP) <12 mm Hg, and pulmonary vascular resistance ≤3 Wood units (WU). This combination of criteria defines isolated postcapillary PH. Postcapillary PH with elevated vascular gradients and pulmonary vascular resistance defines combined post-and precapillary PH (Cpc-PH). Postcapillary PH is associated with a decreased survival in proportion to increased pulmonary vascular gradients, decreased pulmonary arterial compliance, and reduced right ventricular function. The Cpc-PH subcategory occurs in 12% to 13% of patients with PH due to left heart disease. Patients with Cpc-PH have severe PH, with higher diastolic pulmonary pressure gradient, transpulmonary pressure gradient, and pulmonary vascular resistance and more pronounced ventilatory responses to exercise, lower pulmonary arterial compliance, depressed right ventricular ejection fraction, and shorter life expectancy than isolated postcapillary PH. Cpc-PH bears similarities to pulmonary arterial hypertension. Whether Cpc-PH is amenable to therapies targeting the pulmonary circulation remains to be tested by properly designed randomized controlled trials.

Haemodynamic mechanisms and long‐term prognostic impact of pulmonary hypertension in patients with severe aortic stenosis undergoing valve replacement

“…Studies in patients with heart failure (HF) not related to AS [i.e. patients with HF with reduced or preserved left ventricular ejection fraction (LVEF)] have revealed two different haemodynamic patterns of PH with significantly different prognosis . The most common form is isolated post‐capillary PH (IpcPH), i.e.…”

“…PH solely driven by elevated left‐sided filling pressures and defined by an elevated mean pulmonary artery wedge pressure (mPAWP) but a normal pulmonary vascular resistance (PVR) and diastolic pressure gradient (DPG) . Ten to 15% of patients, however, have combined pre‐ and post‐capillary PH (CpcPH), which is characterized by high filling pressures in combination with a pulmonary vascular component of PH and is defined by the combination of elevated mPAWP and PVR and/or DPG . This form of PH shares similarities with pulmonary arterial hypertension (PAH) and is associated with poor prognosis …”

Estimated Pulmonary Artery Systolic Pressure and Mortality in Older‐Elderly Heart Failure Patients

“…PVR is variable in individuals with LV dysfunction, and previous studies have reported such variability to be independent of LVEF, which further complicates the pathophysiology of pulmonary hypertension in LV dysfunction. Although previous studies have reported that pulmonary hypertension is an important predictor of mortality in HF, the contribution of high ePASP to mortality may differ with age. The present study suggests that the prognostic value of high ePASP in individuals with HF increases with age.…”

Baseline diastolic pressure gradient and pressure reduction in chronic heart failure patients implanted with the CardioMEMS™ HF sensor

“…No consideration is given to concomitant Ipc‐PH or Cpc‐PH, and given worse outcomes in the Cpc‐PH16 subgroup, we felt it important to explore the magnitude of pressure response. Furthermore, a priori knowledge of anticipated pressure reduction based on phenotype may assist in daily management and how best to titrate medical therapy.…”