Proximal pulmonary emboli modify right ventricular ejection pattern

Abstract

Proximal pulmonary emboli modify right ventricular ejection pattern. A. Torbicki, M. Kurzyna, M. Ciurzynski, P. Pruszczyk, R. Pacho, A. Kuch-Wocial, M. Szulc. #ERS Journals Ltd 1999. ABSTRACT: Analysis of the systolic flow velocity curve (SFVC) in the right ventricular outflow tract is considered as an alternative to the tricuspid valve pressure gradient (TVPG) method for echo-Doppler assessment of pulmonary arterial pressure (Ppa). The present study checked whether or not SFVC is affected by the cause of pulmonary hypertension.Doppler recordings of 86 patients (39 female, aged 55.515.2 yrs) with acute (AP-PE) or chronic (CP-PE) proximal pulmonary embolism, chronic obstructive pulmonary disase (COPD) or primary pulmonary hypertension (PPH) were retrospectively analysed by two observers unaware of the purpose of the study.Despite having the lowest TVPG (4813 mmHg), patients with AP-PE had the shortest acceleration time (tacc; 5615 ms) and time to midsystolic deceleration (tmsd; 10516 ms). tacc <60 ms in patients with TVPG <60 mmHg had 98% specificity and 48% sensitivity for AP-PE. In PPH, SFVC was less abnormal (tacc 6414 ms, tmsd 12525 ms, both p<0.03) despite having a TVPG twice as high (9212 mmHg, p< 0.001). In contrast to tacc, TVPG showed strong correlation with direct Ppa measurements whenever performed (r=-0.43, p=0.02, versus r=0.80, p<0.001; n=30). There was no correlation between tacc and TVPG in a pooled study group and SFVC seemed strongly affected by the presence of both AP-PE and CP-PE.While potentially useful for evaluation of the true right ventricular afterload during pulsatile flow conditions, the systolic flow velocity curve does not provide a reliable estimate of pulmonary arterial pressure. Eur Respir J 1999; 13: 616±621. The method of choice for noninvasive estimation of pulmonary arterial pressure (Ppa) is based on continuous wave Doppler measurement of the peak velocity of the regurgitant jet across the tricuspid valve (tricuspid valve pressure gradient; TVPG). This method, based on the simplified Bernoulli equation and a straightforward pathophysiological concept, proved highly reliable in a wide spectrum of cardiovascular disease [1±4].However, the pulsed wave Doppler-derived pattern of the systolic flow velocity curve (SFVC) in the right ventricular (RV) outflow tract is also believed to reflect the level of Ppa [5±9]. Using SFVC is appealing because, in contrast to TVPG, it can be recorded in almost every patient, including those with lung hyperinflation [10]. Coexistence of short acceleration time (tacc) and midsystolic deceleration (tmsd; which has a "notched" pattern) is considered diagnostic of severe pulmonary hypertension [5]. However, such patterns have also been observed in the setting of acute pulmonary embolism [11] and similar changes have been induced experimentally by proximal constriction of the proximal pulmonary arteries in dogs [12]. In both these situations, marked SFVC changes were found in the presence of acute but relatively mild elevation of Ppa limited by the per...

Echocardiography Can Identify Patients With Increased Pulmonary Vascular Resistance by Assessing Pressure Reflection in the Pulmonary Circulation

“…Characteristic changes of the flow profile in the PA due to pressure reflection with a notch after peak velocity (see Figure 2) have been described in patients with pulmonary embolism. 8,9 In the presence of a notch, we should suspect increased PVR, but absence of the notch has a low predictive value. In patients with PAH, we have shown in a recent study that PVR can be calculated with a strong correlation (Rϭ0.93) between catheter and Doppler methods.…”

“…This phenomenon has been studied invasively and by Doppler echocardiography in patients with pulmonary embolism. 8,9 However, to the best of our knowledge, there are no studies that have used Doppler echocardiography for a comprehensive description of pressure reflection, the effects of pressure reflection on PA flow, and the right ventricle pressure profile. In the present study, we hypothesize that pressure reflection and its effect on the right ventricle pressure profile can be described noninvasively by Doppler echocardiography.…”

Magnetic Resonance–Derived 3-Dimensional Blood Flow Patterns in the Main Pulmonary Artery as a Marker of Pulmonary Hypertension and a Measure of Elevated Mean Pulmonary Arterial Pressure

“…2,3,[7][8][9][10][11] However, the overall applicability and accuracy of the above-described methods are controversial. [12][13][14][15][16] Additionally, various authors 10,11,17,18 have observed spatially highly inhomogeneous cross-sectional flow profiles and fractions of retrograde flow during systole and diastole in the main pulmonary artery in patients with PH. This was not observed in normal subjects.…”

The role of echocardiography in the diagnosis and management of patients with pulmonary hypertension

“…In addition, AcT tended to be shorter with more distal Doppler sample volume positions [13,14] in individuals with body surface area .2.0 m 2 and in adults .30 yrs old [15]. Due to these limitations, the measurement of time intervals with pulsed wave Doppler as a method of estimation of Ppa was practically eliminated from clinical practice, while their potential role in assessment of components of pulsatile haemodynamics still remain largely unexplored [16,17].…”