Left Ventricular Filling Pressure in Chronic Thromboembolic Pulmonary Hypertension

• Published in: Journal of the American College of Cardiology Vol. 81; no. 7; pp. 653 - 664
• Main Authors: Gerges, Christian, Pistritto, Anna-Maria, Gerges, Mario, Friewald, Richard, Hartig, Valerie, Hofbauer, Thomas M., Reil, Benedikt, Engel, Leon, Dannenberg, Varius, Kastl, Stefan P., Skoro-Sajer, Nika, Moser, Bernhard, Taghavi, Shahrokh, Klepetko, Walter, Lang, Irene M.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 21.02.2023
• Subjects: Atrial Fibrillation; Cardiovascular; chronic thromboembolic pulmonary hypertension; Humans; Hypertension; Hypertension, Pulmonary - diagnosis; Hypertension, Pulmonary - epidemiology; Hypertension, Pulmonary - etiology; left atrial volume; left ventricular end-diastolic pressure; left ventricular filling pressure; mean pulmonary arterial wedge pressure; Mitral Valve Insufficiency; Mitral Valve Stenosis; Pulmonary Wedge Pressure; Ventricular Function, Left; Ventricular Pressure; mPAP; RV; mRAP; LV; PVR; AUC; LVEDP; mPAWP; sPAP; WU; left atrial volume; ROC; left ventricular end-diastolic pressure; TAPSE; PEA; left ventricular filling pressure; PAWP; chronic thromboembolic pulmonary hypertension; mean pulmonary arterial wedge pressure; BPA; dPAP; LA; LVFP; PH; ICU; CTEPH; mean pulmonary artery pressure; pulmonary arterial wedge pressure; pulmonary hypertension; systolic pulmonary artery pressure; right ventricle/ventricular; receiver-operating characteristic; intensive care unit; left ventricle/ventricular; left atrium; mean right atrial pressure; area under the curve; Wood units; tricuspid annular plane systolic excursion; pulmonary endarterectomy; balloon pulmonary angioplasty; pulmonary vascular resistance; diastolic pulmonary artery pressure
• DOI: 10.1016/j.jacc.2022.11.049
• ISSN: 0735-1097; 1558-3597

Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by obstruction of major pulmonary arteries with organized thrombi. Clinical risk factors for pulmonary hypertension due to left heart disease including metabolic syndrome, left-sided valvular heart disease, and ischemic heart disease are common in CTEPH patients. The authors sought to investigate prevalence and prognostic implications of elevated left ventricular filling pressures (LVFP) in CTEPH. A total of 593 consecutive CTEPH patients undergoing a first diagnostic right and left heart catheterization were included in this study. Mean pulmonary arterial wedge pressure (mPAWP) and left ventricular end-diastolic pressure (LVEDP) were utilized for assessment of LVFP. Two cutoffs were applied to identify patients with elevated LVFP: 1) for the primary analysis mPAWP and/or LVEDP >15 mm Hg, as recommended by the current pulmonary hypertension guidelines; and 2) for the secondary analysis mPAWP and/or LVEDP >11 mm Hg, representing the upper limit of normal. Clinical and echocardiographic features, and long-term mortality were assessed. LVFP was >15 mm Hg in 63 (10.6%) and >11 mm Hg in 222 patients (37.4%). Univariable logistic regression analysis identified age, systemic hypertension, diabetes, atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume as significant predictors of elevated LVFP. Atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume remained independent determinants of LVFP in adjusted analysis. At follow-up, higher LVFPs were measured in patients who had meanwhile undergone pulmonary endarterectomy (P = 0.002). LVFP >15 mm Hg (P = 0.021) and >11 mm Hg (P = 0.006) were both associated with worse long-term survival. Elevated LVFP is common, appears to be due to comorbid left heart disease, and predicts prognosis in CTEPH. [Display omitted]