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Koen Ameloot, Pieter-Jan Palmers, Alexander Vande Bruaene, Annelies Gerits, Werner Budts, Jens-Uwe Voigt, Marion Delcroix, Clinical value of echocardiographic Doppler-derived right ventricular dp/dt in patients with pulmonary arterial hypertension, European Heart Journal - Cardiovascular Imaging, Volume 15, Issue 12, December 2014, Pages 1411–1419, https://doi.org/10.1093/ehjci/jeu134
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Abstract
Right ventricular (RV) dp/dt is the instantaneous rate of RV pressure rise during early systole and is a surrogate marker of RV contractility. The main objective of this study was to evaluate the ability of echocardiographic Doppler obtained RV dp/dt to predict long-term survival in patients with pulmonary arterial hypertension (PAH) and chronic thrombo-embolic pulmonary hypertension (CTEPH).
Seventy-eight consecutive newly diagnosed untreated patients (64 ± 15 years, 71% female, 57% PAH, 43% inoperable CTEPH) were included in the study. At baseline, patients were assessed clinically [New York Heart Association (NYHA) and 6 minutes walking distance (6MWD)], by transthoracic cardiac ultrasound and by right heart catherization. RV dp/dt was assessed using spectral Doppler recordings from the tricuspid regurgitation signal at a sweep speed of 200 mm/s by measuring the time interval in which the regurgitant velocity increased from 0.5 to 2 m/s. During a mean follow-up period of 3.5 ± 1.7 years, 31 patients died and 3 received a lung transplant [study endpoint reached in 34/78 (44%) patients]. The optimal RV dp/dt cut-off was determined by receiver operating characteristic analysis at 3 years to be 410 mmHg/s (specificity 84%, positive-predictive value 55%, and negative-predictive value 83%). In univariate analysis, RV dp/dt <410 mmHg/s (hazard ratio 2.67, 95% CI 1.30–5.47, P = 0.007), tricuspid annulus plane systolic excursion (TAPSE) <15 mm, NYHA, 6MWD, and right atrial pressure were predictors of mortality. In a multivariate model with TAPSE, RV dp/dt remained an independent predictor of mortality (P = 0.01).
A reduced baseline RV dp/dt is a clear indicator of poor outcome independent of TAPSE in patients with PAH/CTEPH.
- tricuspid valve insufficiency
- echocardiography
- thromboembolic pulmonary hypertension
- lung transplantation
- transesophageal atrial pacing stress echocardiography
- pulmonary hypertension
- right atrial pressure
- follow-up
- heart ventricle
- roc curve
- systole
- heart
- mortality
- embolism
- pulmonary arterial hypertension
- right ventricular pressure
- surrogate markers
- right side of heart
- walking distance
- new york heart association classification
- tricuspid valve anulus
- 6-minute walk test
Comments
We would like to thank Drs Demirkol, Ozturk, Aparci, Unlu and Arslan for their interest and positive reaction on our paper entitled "Clinical value of echocardiographic Doppler-derived right ventricular dp/dt in patients with pulmonary arterial hypertension" that was recently published in EHJ CVI. Of course we agree with the writers of the letter to the editor that RV dp/dt values in healthy volunteers should not necesserily equal values obtained in a population of patients with PAH/CTEPH. We consider it as a strenght of the RV dp/dt parameter that the obtained values in healthy individuals (1016 +/- 421 mmHg/s) contrast with average values in patients with CTEPH/PAH (658+/-371 mmHg/s) and with our suggested cut-off for unfavorable outcome (<410 mmHg/s). Finally, we also agree with the authors that a second comparable validation study in another PH population (diastolic left heart failure?) would further increase the value of RV dp/dt.
Conflict of Interest:
None declared
Dear Editor,
It was with great interest that we read the recent article (1) by Ameloot K. et al entitled "Clinical value of echocardiographic Doppler- derived right ventricular dp/dt in patients with pulmonary arterial hypertension" published in European Heart Journal Cardiovascular Imaging. They aimed to evaluate the ability of echocardiographic Doppler obtained RV dp/dt to predict long-term survival in patients with pulmonary arterial hypertension (PAH) and chronic thrombo-embolic pulmonary hypertension (CTEPH). They concluded that a reduced baseline RV dp/dt was a clear indicator of poor outcome independent of TAPSE in patients with PAH/CTEPH. We believe that these findings will act as a guide for further studies regarding echocardiographic evaluation of right ventricular functions in patients with PAH/CTEPH. Thanks to the authors for their valuable contribution.
Contrary to common belief, the right ventricle is not a passive chamber. Echocardiographic assessment of the right ventricle has been largely qualitative, because of the difficulty with estimating RV volume and function with two-dimensional echocardiography because of its unusual shape (2). Right ventricular dP/dt is a tool for measuring right ventricular function but there is a few data hindering its widespread use in decision making process. We tried to help solve this problem by determining the mean of RV dP/dt (0.5-2) and RV dP/dt (1-2) in healthy population. We found that the mean of RV dP/dt (0.5-2) and RV dP/dt (1-2) was 1016 +/- 421 mmHg/s (95% CI, 891-1142) and 1524 +/- 573 mmHg/s (95% CI, 1354-1694), respectively (3). Ameloot K. et al in their article indicated that this results contrast with their presented RV dp/dt cut-off (<410 mmHg/s) and with the mean RV dp/dt in their study cohort (658+/- 371 mmHg/s) (1). I think this is not a contrast that their population consisted of patients with PAH/CTEPH whereas our patients were healthy individuals with trivial tricuspid regurgitation. There are limited data in both normal subjects and pathologic conditions, we think that it might be helpful if these results have been confirmed with further large scale studies in both groups.
REFERENCES
1. Ameloot K, Palmers PJ, Vande Bruaene A, Gerits A, Budts W, Voigt JU, Delcroix M. Clinical value of echocardiographic Doppler-derived right ventricular dp/dt in patients with pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging. 2014 Sep 8. [Epub ahead of print]
2. Jurcut R, Giusca S, La Gerche A, Vasile S, Ginghina C, Voigt JU. The echocardiographic assessment of the right ventricle: what to do in 2010? Eur J Echocardiogr 2010;11:81-96.
3. Demirkol S, Unlu M, Arslan Z, Baysan O, Balta S, Kurt IH, Kucuk U, Celik T. Assessment of right ventricular systolic function with dP/dt in healthy subjects: an observational study. Anadolu Kardiyol Derg. 2013 Mar;13(2):103-7.
Conflict of Interest:
None declared