Echocardiographic evaluation of right ventricular diastolic function in pulmonary hypertension

Athiththan Yogeswaran; Zvonimir A Rako; Selin Yildiz; Hossein Ardeschir Ghofrani; Werner Seeger; Bruno Brito da Rocha; Henning Gall; Nils C Kremer; Philipp Douschan; Silvia Papa; Carmine Dario Vizza; Domenico Filomena; Ryan J Tedford; Robert Naeije; Manuel J Richter; Roberto Badagliacca; Khodr Tello

doi:10.1183/23120541.00226-2023

Echocardiographic evaluation of right ventricular diastolic function in pulmonary hypertension

ERJ Open Res. 2023 Sep 18;9(5):00226-2023. doi: 10.1183/23120541.00226-2023. eCollection 2023 Sep.

Authors

Athiththan Yogeswaran^{1

2}, Zvonimir A Rako^{1

2}, Selin Yildiz¹, Hossein Ardeschir Ghofrani¹, Werner Seeger¹, Bruno Brito da Rocha¹, Henning Gall¹, Nils C Kremer¹, Philipp Douschan^{1

3

4}, Silvia Papa⁵, Carmine Dario Vizza⁵, Domenico Filomena⁵, Ryan J Tedford⁶, Robert Naeije⁷, Manuel J Richter¹, Roberto Badagliacca^{5

2}, Khodr Tello^{1

2}

Affiliations

¹ Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.
² These authors contributed equally to this work.
³ Department of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria.
⁴ Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria.
⁵ Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
⁶ Division of Cardiology, Department of Medicine, Medical University of South Carolina, South Carolina, USA.
⁷ Free University of Brussels, Brussels, Belgium.

Abstract

Background: Right ventricular (RV) diastolic dysfunction may be prognostic in pulmonary hypertension (PH). However, its assessment is complex and relies on conductance catheterisation. We aimed to evaluate echocardiography-based parameters as surrogates of RV diastolic function, provide validation against the gold standard, end-diastolic elastance (Eed), and define the prognostic impact of echocardiography-derived RV diastolic dysfunction.

Methods: Patients with suspected PH who underwent right heart catheterisation including conductance catheterisation were prospectively recruited. In this study population, an echocardiography-based RV diastolic function surrogate was derived. Survival analyses were performed in patients with precapillary PH in the Giessen PH Registry, with external validation in patients with pulmonary arterial hypertension at Sapienza University (Rome).

Results: In the derivation cohort (n=61), the early/late diastolic tricuspid inflow velocity ratio (E/A) and early tricuspid inflow velocity/early diastolic tricuspid annular velocity ratio (E/e') did not correlate with Eed (p>0.05). Receiver operating characteristic analysis revealed a large area under the curve (AUC) for the peak lateral tricuspid annulus systolic velocity/right atrial area index ratio (S'/RAAi) to detect elevated Eed (AUC 0.913, 95% confidence interval (CI) 0.839-0.986) and elevated end-diastolic pressure (AUC 0.848, 95% CI 0.699-0.998) with an optimal threshold of 0.81 m²·s^-1·cm^-1. Subgroup analyses demonstrated a large AUC in patients with preserved RV systolic function (AUC 0.963, 95% CI 0.882-1.000). Survival analyses confirmed the prognostic relevance of S'/RAAi in the Giessen PH Registry (n=225) and the external validation cohort (n=106).

Conclusions: Our study demonstrates the usefulness of echocardiography-derived S'/RAAi for noninvasive assessment of RV diastolic function and prognosis in PH.