Echocardiographic assessment of estimated right atrial pressure and size predicts mortality in pulmonary arterial hypertension

Christopher Austin, Khadija Alassas, Charles Burger, Robert Safford, Ricardo Pagan, Katherine Duello, Preetham Kumar, Tonya Zeiger, Brian Shapiro, Christopher Austin, Khadija Alassas, Charles Burger, Robert Safford, Ricardo Pagan, Katherine Duello, Preetham Kumar, Tonya Zeiger, Brian Shapiro

Abstract

Background: Elevated mean right atrial pressure (RAP) measured by cardiac catheterization is an independent risk factor for mortality. Prior studies have demonstrated a modest correlation with invasive and noninvasive echocardiographic RAP, but the prognostic impact of estimated right atrial pressure (eRAP) has not been previously evaluated in patients with pulmonary arterial hypertension (PAH).

Methods: A retrospective analysis of 121 consecutive patients with PAH based on right-sided heart catheterization and echocardiography was performed. The eRAP was calculated by inferior vena cava diameter and collapse using 2005 and 2010 American Society of Echocardiography (ASE) definitions. Accuracy and correlation of eRAP to RAP was assessed. Kaplan-Meier survival analysis by eRAP, right atrial area, and Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL Registry) risk criteria as well as univariate and multivariate analysis of echocardiographic findings was performed.

Results: Elevation of eRAP was associated with decreased survival time compared with lower eRAP (P < .001, relative risk = 7.94 for eRAP > 15 mm Hg vs eRAP ≤ 5 mm Hg). Univariate analysis of echocardiographic parameters including eRAP > 15 mm Hg, right atrial area > 18 cm², presence of pericardial effusion, right ventricular fractional area change < 35%, and at least moderate tricuspid regurgitation was predictive of poor survival. However, multivariate analysis revealed that eRAP > 15 mm Hg was the only echocardiographic risk factor that was predictive of mortality (hazard ratio = 2.28, P = .037).

Conclusions: Elevation of eRAP by echocardiography at baseline assessment was strongly associated with increased risk of death or transplant in patients with PAH. This measurement may represent an important prognostic component in the comprehensive echocardiographic evaluation of PAH.

Figures

Figure 1 –
Figure 1 –
Estimated right atrial pressure by echocardiography. A-D, The inferior vena cava (IVC) (*) during normal respiration (A) and inspiratory sniff (B) in a patient with estimated right atrial pressure of 5 mm Hg. Conversely, the IVC in a patient with estimated right atrial pressure of 20 mm Hg is dilated during normal respiration (C) and does not collapse with inspiratory sniff (D).
Figure 2 –
Figure 2 –
Right atrial size by echocardiography. A-B, The right atria (*) can be measured by echocardiography with area ≤ 18 cm2 defined as normal (A) and > 18 cm2 considered enlarged (B).
Figure 3 –
Figure 3 –
Survival by estimated right atrial pressure (eRAP). The pulmonary arterial hypertension cohort was stratified by eRAP and survival was analyzed by Kaplan-Meier. A-B, Analysis was performed for the 2005 (A) and 2010 (B) American Society of Echocardiography-defined eRAP. The groups were significantly different, and stratification by eRAP was similar for 2005 and 2010 eRAP definitions. Right atrial pressure > 15 mm Hg was significantly associated with decreased transplant-free survival at 3 y after baseline echocardiography.
Figure 4 –
Figure 4 –
Survival by estimated right atrial area. Enlarged right atrial area (> 18 cm2) was associated with increased death or transplant at 3 y by Kaplan-Meier analysis.
Figure 5 –
Figure 5 –
Survival by Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management (REVEAL Registry) 1-y risk. The pulmonary arterial hypertension cohort was stratified by calculated REVEAL Registry 1-y risk and survival analyzed by Kaplan-Meier. Very high risk patients were significantly more likely to experience death or transplantation at 3 y.

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