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Comparison of Provocative Maneuvers During Right Heart Catheterization to Identify “Occult” Post-Capillary Pulmonary Hypertension
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A5703 - Comparison of Provocative Maneuvers During Right Heart Catheterization to Identify “Occult” Post-Capillary Pulmonary Hypertension
Author Block: A. Arunachalam, A. Bhattacharyya, R. Khan, F. Qadir, N. F. Chaisson, A. R. Tonelli; Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States.
1. Rationale:
Distinguishing pre- from post-capillary pulmonary hypertension (PH) has significant prognostic and treatment implications. This differentiation may be obscured by the use of diuretics and dietary changes just before right heart catheterization (RHC). Provocative maneuvers during RHC are critical tools to characterize these patients better. Prior studies have suggested the use of a fluid challenge to uncover post-capillary PH, but volume loading may cause undesirable effects. Therefore, we sought to determine whether submaximal graded supine exercise or passive leg raise (PLR) would yield similar hemodynamic changes as volume loading.
2. Methods:
We included adult patients who underwent RHC for evaluation of dyspnea. Based on prior studies, we defined “occult” post-capillary PH as a pulmonary artery wedge pressure (PAWP) at baseline rest between 11- 15 mmHg that increased to ≥ 20 mmHg with submaximal exercise and ≥ 18 mmHg with fluids or PLR. After obtaining baseline hemodynamics data, each patient underwent provocative maneuvers which included PLR (45-degree angle for 1 minute), submaximal graded exercise (up to 40 Watts) and fluid challenge (500 mL of normal saline over 5 minutes). We utilized counts and percentages for summary statistics.
3. Results:
Eighteen patients were included in the study (age 62±8 years, 55% female). All patients had a normal left ventricular function as assessed by echocardiogram. Baseline hemodynamics showed a mean pulmonary artery pressure (mPAP) of 27±7 mmHg, PAWP of 12.72± 1.27mmHg, cardiac index (CI) of 2.73±0.53 L/min/m2 and a PVR of 2.94±1.74 Wood units. With PLR the PAWP increased by 2.22±1.96 mmHg, and 16% of the patients met criteria for “occult” post-capillary PH. Using graded exercise, the PAWP increased by 7.12±5.29mmHg, and 55% patients met criteria for “occult” post-capillary PH. During a fluid challenge, the PAWP increased by 3.44±5.64mmHg, and 38% patients met criteria for occult post-capillary PH.
4. Conclusion:
In our cohort, submaximal graded exercise appeared to have better sensitivity to detect “occult” PH than fluid challenge and PLR. Future research should focus on comparative performance and predictive accuracy of these maneuvers to accurately diagnose pre- and post-capillary pulmonary hypertension.
Author Block: A. Arunachalam, A. Bhattacharyya, R. Khan, F. Qadir, N. F. Chaisson, A. R. Tonelli; Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States.
1. Rationale:
Distinguishing pre- from post-capillary pulmonary hypertension (PH) has significant prognostic and treatment implications. This differentiation may be obscured by the use of diuretics and dietary changes just before right heart catheterization (RHC). Provocative maneuvers during RHC are critical tools to characterize these patients better. Prior studies have suggested the use of a fluid challenge to uncover post-capillary PH, but volume loading may cause undesirable effects. Therefore, we sought to determine whether submaximal graded supine exercise or passive leg raise (PLR) would yield similar hemodynamic changes as volume loading.
2. Methods:
We included adult patients who underwent RHC for evaluation of dyspnea. Based on prior studies, we defined “occult” post-capillary PH as a pulmonary artery wedge pressure (PAWP) at baseline rest between 11- 15 mmHg that increased to ≥ 20 mmHg with submaximal exercise and ≥ 18 mmHg with fluids or PLR. After obtaining baseline hemodynamics data, each patient underwent provocative maneuvers which included PLR (45-degree angle for 1 minute), submaximal graded exercise (up to 40 Watts) and fluid challenge (500 mL of normal saline over 5 minutes). We utilized counts and percentages for summary statistics.
3. Results:
Eighteen patients were included in the study (age 62±8 years, 55% female). All patients had a normal left ventricular function as assessed by echocardiogram. Baseline hemodynamics showed a mean pulmonary artery pressure (mPAP) of 27±7 mmHg, PAWP of 12.72± 1.27mmHg, cardiac index (CI) of 2.73±0.53 L/min/m2 and a PVR of 2.94±1.74 Wood units. With PLR the PAWP increased by 2.22±1.96 mmHg, and 16% of the patients met criteria for “occult” post-capillary PH. Using graded exercise, the PAWP increased by 7.12±5.29mmHg, and 55% patients met criteria for “occult” post-capillary PH. During a fluid challenge, the PAWP increased by 3.44±5.64mmHg, and 38% patients met criteria for occult post-capillary PH.
4. Conclusion:
In our cohort, submaximal graded exercise appeared to have better sensitivity to detect “occult” PH than fluid challenge and PLR. Future research should focus on comparative performance and predictive accuracy of these maneuvers to accurately diagnose pre- and post-capillary pulmonary hypertension.
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