Open AccessCritical appraisal of the instantaneous end‐diastolic pulmonary arterial wedge pressures
Author(s) -
Manouras Aristomenis,
Lund Lars H.,
Gellér László,
Nagy Anikó Ilona,
Johnson Jonas
Publication year - 2020
Publication title -
esc heart failure
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.787
H-Index - 25
ISSN - 2055-5822
DOI - 10.1002/ehf2.13057
Subject(s) - cardiology , pulmonary wedge pressure , medicine , qrs complex , atrial fibrillation , pulmonary hypertension , heart failure
Aims A substantial shift in the field of pulmonary hypertension (PH) is ongoing, as the previous practice of mean pulmonary arterial wedge pressure (PAWP M ) is no longer supported. Instead, aiming for a better estimate of end‐diastolic pressures (EDP), instantaneous PAWP at mid‐A‐wave (PAWP mid‐A ) or, in the absence of an A‐wave, at 130–160 ms following QRS onset has recently been recommended. Electrocardiogram‐gated PAWP (PAWP QRS ) has also been proposed. The quantitative differences as well as the diagnostic and prognostic utility of these novel PAWP measurements have not been evaluated. We set out to address these issues. Methods and results Pressure tracings of 141 patients with PH due to left heart disease (PH‐LHD) and 43 with primary pulmonary arterial hypertension (PAH) were analysed. PAWP was measured as follows: (i) mean pressure (PAWP M ); (ii) per the latest consensus approach [PAWP mid‐A , or in atrial fibrillation 130, 140, 150, and 160 ms following QRS onset (PAWP 130–160 )]; (iii) at QRS onset (PAWP QRS ); and (iv) Z‐point (PAWP Z ). For each PAWP, the corresponding pulmonary vascular resistance (PVR) and diastolic pressure gradient were calculated. The cohort comprised 45% female. Mean age was 66 ± 15. PAWP mid‐A was in good agreement with PAWP Z (17.3 [14.5 to 21.2] vs. 17.6 [14.2 to 21.6] mmHg, P = 0.63), whereas PAWP QRS provided significantly lower values (15.3 [12.5 to 19.2] mmHg, P < 0.001). In atrial fibrillation, PAWP 130 and PAWP QRS yielded the optimal temporal and quantitative analyses of EDPs. The ability to differentiate PAH from PH‐LHD was similar for the various PAWP measurements [PAWP M : area under the curve (AUC) 0.98, confidence interval (CI) 0.96–0.99; PAWP mid‐A/130 : AUC 0.94, CI 0.91–0.98; PAWP QRS : AUC 0.96, CI 0.94–0.99, P < 0.001 for all]. PVR based on instantaneous PAWP measurements failed to provide superior prognostic information in PH‐LHD as compared with conventional PVR. Conclusions Although instantaneous PAWP measurement might better represent EDP, they nevertheless fail to yield incremental diagnostic or prognostic information in PH‐LHD as compared with conventional measurements.