Boilson B A, Pislaru S V, McGregor C G A
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
Minerva Cardioangiol. 2012 Jun;60(3):257-65.
Chronic thromboembolic pulmonary hypertension (CTEPH) results from chronic thrombotic occlusion of the pulmonary arterial circulation and may be potentially cured by pulmonary thromboendarterectomy. Echocardiography is the most practical modality for the assessment of right ventricular function and right heart pressures before and after surgery. However, there is scant data on how these estimates compare with the "gold standards" of invasive right heart catheterization and CT and MR scanning.
The records of 100 consecutive patients with CTEPH who subsequently underwent pulmonary thromboendarterectomy at our institution were studied. Right atrial (RA) and right ventricular (RV) systolic pressure estimated at preoperative echocardiography were compared with measurements at preoperative cardiac catheterization. In addition, preoperative echocardiographic estimates of RV systolic function by visual assessment and by calculation of RV index of myocardial performance were compared with preoperative measurements of RV ejection fraction (EF) by computed tomography (CT) or magnetic resonance (MR) scanning.
Although estimates of RA and PA systolic pressures by echocardiography correlated significantly with those at cardiac catheterization (p<0.0001) in patients with CTEPH, Bland-Altman analysis demonstrated significant variation in these measurements compared with cardiac catheterization. Cohen's Kappa analysis demonstrated that agreement between echo and cath derived values was slight (κ=0.1). RVEF assessed by CT or MR scanning correlated with echocardiographic visual assessment of RV systolic function (P<0.0001), and with RIMP (P=0.001), but actual measurements of right ventricular ejection fraction at a given assessment of right ventricular function by RIMP or visual assessment varied widely
Caution is warranted in over-reliance on echo derived measurements of right heart hemodynamics and function in the setting of pulmonary hypertension, and where the clinical scenario calls the data into question, a low threshold should be maintained for proceeding to more advanced and invasive modalities of evaluation.
慢性血栓栓塞性肺动脉高压（CTEPH）由肺动脉循环的慢性血栓性阻塞引起，肺动脉血栓内膜剥脱术有可能治愈该病。超声心动图是评估手术前后右心室功能和右心压力最实用的方法。然而，关于这些评估与有创右心导管检查及CT和MR扫描这些“金标准”相比情况的数据却很少。
对在我们机构随后接受肺动脉血栓内膜剥脱术的100例连续CTEPH患者的记录进行研究。将术前超声心动图估计的右心房（RA）和右心室（RV）收缩压与术前心脏导管检查测量值进行比较。此外，将术前通过视觉评估和计算右心室心肌性能指数对RV收缩功能进行的超声心动图估计与术前通过计算机断层扫描（CT）或磁共振（MR）扫描测量的RV射血分数（EF）进行比较。
虽然在CTEPH患者中，超声心动图对RA和肺动脉收缩压的估计与心脏导管检查的结果显著相关（p<0.0001），但Bland-Altman分析表明，与心脏导管检查相比，这些测量存在显著差异。Cohen's Kappa分析表明，超声心动图和导管检查得出的值之间的一致性较差（κ=0.1）。通过CT或MR扫描评估的RVEF与超声心动图对RV收缩功能的视觉评估相关（P<0.0001），与RIMP相关（P=0.001），但在通过RIMP或视觉评估对右心室功能进行特定评估时，右心室射血分数的实际测量值差异很大。
在肺动脉高压情况下过度依赖超声心动图得出的右心血流动力学和功能测量结果时应谨慎，并且在临床情况对数据提出质疑时，应保持较低阈值以便采用更先进的有创评估方法。
