Echocardiographic Predictors of Adverse Outcomes in Primary Pulmonary Hypertension. - ECHO in PPH
To relate clinical outcome of patients with severe primary pulmonary hypertension (PPH) to echocardiographic and clinical findings.
Clinical and echocardiographic data were analyzed in 81 patients with PPH (NYHA Class III or IV). Echocardiographic variables included right atrial and right ventricular size, left ventricular ecentricity index, presence of pericardial effusion (PEF), and severity of tricuspid regurgitation (TR).
Patients were followed for 36.9 + 15.4 months; 20 patients died and 21 required lung transplantation. Noninvasive predictors of mortality included PEF (p = 0.003) and RA area indexed to height (p = 0.005). These 2 findings plus septal shift in diastole (p = 0.004) were predictors of death or transplant. Six minute walk distance, and mixed venous oxygen also predicted of an adverse outcome.
Among patients with severe PPH, there is an association between adverse outcomes and the presence of pericardial effusion, RA dilation and septal displacement. This multi-center study of a relatively large number of patients with PPH confirms findings suggested by a number of smaller single center studies. The relationship of outcome to parameters suggesting advanced right heart pathology probably relates to a worsened outcome due to right heart failure. The presence of pericardial effusion probably represents right heart pathology impeding pericardial fluid drainage and does not relate to a hemodynamic effect of the effusion. These patients were evaluated as part of a randomized trial of prostacyclin versus conventional treatment, after which the majority of patients received continuous prostacyclin. Early randomization to prostacyclin was also associated with a better outcome, however the data are not further broken down by echocardiographic variables in the early versus delayed prostacyclin therapy groups. Inspection of the survival curves suggests that there was substantial early mortality in these patients, however the relationship of therapy to outcome cannot be elucidated from the data as presented. This study certainly would support the contention that patients with greater degrees of right heart pathology represent a high-risk subset of PPH patients for whom referral to specialized centers should be considered.
Raymond RJ, Hinderliter AL, Willis PW, et al for the Primary Pulmonary Hypertension Study Group. Echocardiographic Predictors of Adverse Outcomes in Primary Pulmonary Hypertension. J Am Coll Cardiol 2002;39:1214-9.
Clinical Topics: Dyslipidemia, Heart Failure and Cardiomyopathies, Pericardial Disease, Pulmonary Hypertension and Venous Thromboembolism, Lipid Metabolism, Acute Heart Failure, Pulmonary Hypertension
Keywords: Lung Transplantation, Tricuspid Valve Insufficiency, Drainage, Hypertension, Pulmonary, Heart Failure, Prostaglandins I, Oxygen, Diastole, Pericardial Effusion
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