##common.pageHeaderLogo.altText##

Review article: Biomedical intelligence

Vol. 147 No. 2728 (2017)

Invasive haemodynamic evaluation of the pulmonary circulation in pulmonary hypertension

Cite this as:
Swiss Med Wkly. 2017;147:w14445
Published
13.07.2017

Summary

The term pulmonary hypertension refers to a serious condition characterised by high pulmonary vascular pressure, mainly as a consequence of various cardiac and respiratory diseases. Current clinical classification of pulmonary hypertension considers five distinct groups. Transthoracic echocardiography represents the first and most important noninvasive screening tool for estimating the probability of pulmonary hypertension. The diagnostic approach to pulmonary hypertension is supported by a proposed algorithm, which identifies the underlying cause. The definitive diagnosis and classification of pulmonary hypertension requires invasive confirmation of an elevated pulmonary artery mean pressure during a right heart catheterisation at rest. Pulmonary artery wedge pressure assessment has a pivotal role in differentiating precapillary from postcapillary pulmonary hypertension. The correct acquisition and interpretation of invasive pulmonary haemodynamic variables play a central role, not only in confirming the diagnosis but also in prognostication and treatment decision-making. During right heart catheterisation correct zero levelling of the external pressure transducer and pressure tracing readings at end-expiration should be assured. Obese patients and patients with obstructive lung diseases require special attention, given that spontaneous positive end-expiratory intrathoracic pressures are frequently observed. Because pressure and flow determinations with a fluid-filled flow-directed thermodilution catheter are potentially insufficiently precise, it is recommended to average at least three measurements. Acute vasoreactivity testing is indicated only in selected patients. Recent data suggest that invasive pulmonary haemodynamic measurement during exercise may be more sensitive than resting haemodynamics for early diagnosis, for treatment response assessment and for prognostic purposes.

References

  1. Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint 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: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67–119. https://doi.org/10.1093/eurheartj/ehv317
  2. Hatano S, Strasser T. Primary Pulmonary Hypertension, Report on a WHO Meeting. October 15-17, 1973, Geneva: World Health Organization, 1975
  3. Fishman AP. Clinical classification of pulmonary hypertension. Clin Chest Med. 2001;22(3):385–91, vii. https://doi.org/10.1016/S0272-5231(05)70278-1
  4. Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25, Suppl):D34–41. https://doi.org/10.1016/j.jacc.2013.10.029
  5. Vachiéry JL, Adir Y, Barberà JA, Champion H, Coghlan JG, Cottin V, et al. Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol. 2013;62(25, Suppl):D100–8. https://doi.org/10.1016/j.jacc.2013.10.033
  6. Rich JD, Rich S. Clinical diagnosis of pulmonary hypertension. Circulation. 2014;130(20):1820–30. https://doi.org/10.1161/CIRCULATIONAHA.114.006971
  7. Guazzi M, Borlaug BA. Pulmonary hypertension due to left heart disease. Circulation. 2012;126(8):975–90. https://doi.org/10.1161/CIRCULATIONAHA.111.085761
  8. Guazzi M. Pulmonary hypertension in heart failure preserved ejection fraction: prevalence, pathophysiology, and clinical perspectives. Circ Heart Fail. 2014;7(2):367–77. https://doi.org/10.1161/CIRCHEARTFAILURE.113.000823
  9. Ghio S, Gavazzi A, Campana C, Inserra C, Klersy C, Sebastiani R, et al. Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure. J Am Coll Cardiol. 2001;37(1):183–8. https://doi.org/10.1016/S0735-1097(00)01102-5
  10. Seeger W, Adir Y, Barberà JA, Champion H, Coghlan JG, Cottin V, et al. Pulmonary hypertension in chronic lung diseases. J Am Coll Cardiol. 2013;62(25, Suppl):D109–16. https://doi.org/10.1016/j.jacc.2013.10.036
  11. Oswald-Mammosser M, Weitzenblum E, Quoix E, Moser G, Chaouat A, Charpentier C, et al. Prognostic factors in COPD patients receiving long-term oxygen therapy. Importance of pulmonary artery pressure. Chest. 1995;107(5):1193–8. https://doi.org/10.1378/chest.107.5.1193
  12. Shorr AF, Wainright JL, Cors CS, Lettieri CJ, Nathan SD. Pulmonary hypertension in patients with pulmonary fibrosis awaiting lung transplant. Eur Respir J. 2007;30(4):715–21. https://doi.org/10.1183/09031936.00107206
  13. Cottin V, Le Pavec J, Prévot G, Mal H, Humbert M, Simonneau G, et al.; GERM“O”P. Pulmonary hypertension in patients with combined pulmonary fibrosis and emphysema syndrome. Eur Respir J. 2010;35(1):105–11. https://doi.org/10.1183/09031936.00038709
  14. Lang IM, Madani M. Update on chronic thromboembolic pulmonary hypertension. Circulation. 2014;130(6):508–18. https://doi.org/10.1161/CIRCULATIONAHA.114.009309
  15. McGoon MD, Benza RL, Escribano-Subias P, Jiang X, Miller DP, Peacock AJ, et al. Pulmonary arterial hypertension: epidemiology and registries. J Am Coll Cardiol. 2013;62(25, Suppl):D51–9. https://doi.org/10.1016/j.jacc.2013.10.023
  16. Hoeper MM, Bogaard HJ, Condliffe R, Frantz R, Khanna D, Kurzyna M, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25, Suppl):D42–50. https://doi.org/10.1016/j.jacc.2013.10.032
  17. Kovacs G, Berghold A, Scheidl S, Olschewski H. Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review. Eur Respir J. 2009;34(4):888–94. https://doi.org/10.1183/09031936.00145608
  18. Lau EMT, Godinas L, Sitbon O, Montani D, Savale L, Jaïs X, et al. Resting pulmonary artery pressure of 21-24 mmHg predicts abnormal exercise haemodynamics. Eur Respir J. 2016;47(5):1436–44. https://doi.org/10.1183/13993003.01684-2015
  19. Hervé P, Lau EM, Sitbon O, Savale L, Montani D, Godinas L, et al. Criteria for diagnosis of exercise pulmonary hypertension. Eur Respir J. 2015;46(3):728–37. https://doi.org/10.1183/09031936.00021915
  20. Brown LM, Chen H, Halpern S, Taichman D, McGoon MD, Farber HW, et al. Delay in recognition of pulmonary arterial hypertension: factors identified from the REVEAL Registry. Chest. 2011;140(1):19–26. https://doi.org/10.1378/chest.10-1166
  21. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, 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 Echocardiogr. 2010;23(7):685–713, quiz 786–8. https://doi.org/10.1016/j.echo.2010.05.010
  22. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(3):233–70. https://doi.org/10.1093/ehjci/jev014
  23. D’Alto M, Romeo E, Argiento P, D’Andrea A, Vanderpool R, Correra A, et al. Accuracy and precision of echocardiography versus right heart catheterization for the assessment of pulmonary hypertension. Int J Cardiol. 2013;168(4):4058–62. https://doi.org/10.1016/j.ijcard.2013.07.005
  24. Naeije R, D’Alto M, Forfia PR. Clinical and research measurement techniques of the pulmonary circulation: the present and the future. Prog Cardiovasc Dis. 2015;57(5):463–72. https://doi.org/10.1016/j.pcad.2014.12.003
  25. Hoeper MM, Lee SH, Voswinckel R, Palazzini M, Jais X, Marinelli A, et al. Complications of right heart catheterization procedures in patients with pulmonary hypertension in experienced centers. J Am Coll Cardiol. 2006;48(12):2546–52. https://doi.org/10.1016/j.jacc.2006.07.061
  26. Pagnamenta A, Vanderpool R, Brimioulle S, Naeije R. Proximal pulmonary arterial obstruction decreases the time constant of the pulmonary circulation and increases right ventricular afterload. J Appl Physiol (1985). 2013;114(11):1586–92. https://doi.org/10.1152/japplphysiol.00033.2013
  27. Gidwani UK, Mohanty B, Chatterjee K. The pulmonary artery catheter: a critical reappraisal. Cardiol Clin. 2013;31(4):545–65, viii. https://doi.org/10.1016/j.ccl.2013.07.008
  28. Rosenkranz S, Preston IR. Right heart catheterisation: best practice and pitfalls in pulmonary hypertension. Eur Respir Rev. 2015;24(138):642–52. https://doi.org/10.1183/16000617.0062-2015
  29. Halpern SD, Taichman DB. Misclassification of pulmonary hypertension due to reliance on pulmonary capillary wedge pressure rather than left ventricular end-diastolic pressure. Chest. 2009;136(1):37–43. https://doi.org/10.1378/chest.08-2784
  30. LeVarge BL, Pomerantsev E, Channick RN. Reliance on end-expiratory wedge pressure leads to misclassification of pulmonary hypertension. Eur Respir J. 2014;44(2):425–34. https://doi.org/10.1183/09031936.00209313
  31. Kovacs G, Avian A, Pienn M, Naeije R, Olschewski H. Reading pulmonary vascular pressure tracings. How to handle the problems of zero leveling and respiratory swings. Am J Respir Crit Care Med. 2014;190(3):252–7.
  32. Naeije R, Boerrigter BG. Pulmonary hypertension at exercise in COPD: does it matter? Eur Respir J. 2013;41(5):1002–4. https://doi.org/10.1183/09031936.00173512
  33. Prasad A, Hastings JL, Shibata S, Popovic ZB, Arbab-Zadeh A, Bhella PS, et al. Characterization of static and dynamic left ventricular diastolic function in patients with heart failure with a preserved ejection fraction. Circ Heart Fail. 2010;3(5):617–26. https://doi.org/10.1161/CIRCHEARTFAILURE.109.867044
  34. Lador F, Hervé P. A practical approach of pulmonary hypertension in the elderly. Semin Respir Crit Care Med. 2013;34(5):654–64. https://doi.org/10.1055/s-0033-1356549
  35. Robbins IM, Hemnes AR, Pugh ME, Brittain EL, Zhao DX, Piana RN, et al. High prevalence of occult pulmonary venous hypertension revealed by fluid challenge in pulmonary hypertension. Circ Heart Fail. 2014;7(1):116–22. https://doi.org/10.1161/CIRCHEARTFAILURE.113.000468
  36. Humbert M, Sitbon O, Yaïci A, Montani D, O’Callaghan DS, Jaïs X, et al.; French Pulmonary Arterial Hypertension Network. Survival in incident and prevalent cohorts of patients with pulmonary arterial hypertension. Eur Respir J. 2010;36(3):549–55. https://doi.org/10.1183/09031936.00057010
  37. Thenappan T, Shah SJ, Rich S, Tian L, Archer SL, Gomberg-Maitland M. Survival in pulmonary arterial hypertension: a reappraisal of the NIH risk stratification equation. Eur Respir J. 2010;35(5):1079–87. https://doi.org/10.1183/09031936.00072709
  38. Castelain V, Chemla D, Humbert M, Sitbon O, Simonneau G, Lecarpentier Y, et al. Pulmonary artery pressure-flow relations after prostacyclin in primary pulmonary hypertension. Am J Respir Crit Care Med. 2002;165(3):338–40. https://doi.org/10.1164/ajrccm.165.3.2106033
  39. Provencher S, Hervé P, Sitbon O, Humbert M, Simonneau G, Chemla D. Changes in exercise haemodynamics during treatment in pulmonary arterial hypertension. Eur Respir J. 2008;32(2):393–8. https://doi.org/10.1183/09031936.00009008
  40. Chaouat A, Sitbon O, Mercy M, Ponçot-Mongars R, Provencher S, Guillaumot A, et al. Prognostic value of exercise pulmonary haemodynamics in pulmonary arterial hypertension. Eur Respir J. 2014;44(3):704–13. https://doi.org/10.1183/09031936.00153613