Wright Stephen P, Moayedi Yasbanoo, Foroutan Farid, Agarwal Suhail, Paradero Geraldine, Alba Ana C, Baumwol Jay, Mak Susanna
From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.).
Circ Heart Fail. 2017 Sep;10(9). doi: 10.1161/CIRCHEARTFAILURE.117.004077.
The diastolic pressure difference (DPD) is recommended to differentiate between isolated postcapillary and combined pre-/postcapillary pulmonary hypertension (Cpc-PH) in left heart disease (PH-LHD). However, in usual practice, negative DPD values are commonly calculated, potentially related to the use of mean pulmonary artery wedge pressure (PAWP). We used the ECG to gate late-diastolic PAWP measurements. We examined the method's impact on calculated DPD, PH-LHD subclassification, hemodynamic profiles, and mortality.
We studied patients with advanced heart failure undergoing right heart catheterization to assess cardiac transplantation candidacy (N=141). Pressure tracings were analyzed offline over 8 to 10 beat intervals. Diastolic pulmonary artery pressure and mean PAWP were measured to calculate the DPD as per usual practice (diastolic pulmonary artery pressure-mean PAWP). Within the same intervals, PAWP was measured gated to the ECG QRS complex to calculate the QRS-gated DPD (diastolic pulmonary artery pressure-QRS-gated PAWP). Outcomes occurring within 1 year were collected retrospectively from chart review. Overall, 72 of 141 cases demonstrated PH-LHD. Within PH-LHD, the QRS-gated DPD yielded higher calculated DPD values (3 [-1 to 6] versus 0 [-4 to 3] mm Hg; <0.01) and a greater proportion of Cpc-PH (24% versus 8%; <0.01) versus the usual practice DPD. Cases reclassified as Cpc-PH based on QRS-gated DPD demonstrated higher pulmonary arterial pressures versus isolated postcapillary pulmonary hypertension (<0.05). One-year mortality was similar between PH-LHD groups.
The DPD calculated in usual practice is underestimated in PH-LHD, which may classify Cpc-PH patients as isolated postcapillary pulmonary hypertension. The QRS-gated DPD reclassifies a subset of PH-LHD patients from isolated postcapillary pulmonary hypertension to Cpc-PH, which is characterized by an adverse hemodynamic profile.
舒张压差值（DPD）被推荐用于鉴别左心疾病相关肺动脉高压（PH-LHD）中单纯毛细血管后性肺动脉高压与毛细血管前/后性肺动脉高压合并症（Cpc-PH）。然而，在实际操作中，常计算出DPD值为负，这可能与平均肺动脉楔压（PAWP）的使用有关。我们使用心电图来门控舒张末期PAWP测量。我们研究了该方法对计算出的DPD、PH-LHD亚分类、血流动力学特征和死亡率的影响。
我们研究了141例因晚期心力衰竭接受右心导管检查以评估心脏移植候选资格的患者。压力曲线在离线状态下以8至10个心动周期的间隔进行分析。按照常规方法测量舒张期肺动脉压和平均PAWP以计算DPD（舒张期肺动脉压-平均PAWP）。在相同的间隔内，门控心电图QRS波群测量PAWP以计算QRS门控DPD（舒张期肺动脉压-QRS门控PAWP）。通过回顾病历，回顾性收集1年内发生的结局。总体而言，141例患者中有72例表现为PH-LHD。在PH-LHD患者中，与常规DPD相比，QRS门控DPD得出的计算DPD值更高（3[-1至6]mmHg对0[-4至3]mmHg；<0.01），且Cpc-PH的比例更高（24%对8%；<0.01）。基于QRS门控DPD重新分类为Cpc-PH的病例与单纯毛细血管后性肺动脉高压相比，肺动脉压更高（<0.05）。PH-LHD组之间的1年死亡率相似。
在PH-LHD中，常规方法计算出的DPD被低估，这可能会将Cpc-PH患者归类为单纯毛细血管后性肺动脉高压。QRS门控DPD将一部分PH-LHD患者从单纯毛细血管后性肺动脉高压重新分类为Cpc-PH，其特征为不良的血流动力学特征。
