Echokardiographie und Rechtsherzkatheterisierung bei pulmonaler Hypertonie

 

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Zusammenfassung

Hintergrund und Fragestellung: Da die pulmonalen Hypertonie hämodynamisch mit einem pulmonal-arteriellen Mitteldruck (mPAP) von mindestens 25 mmHg definiert ist, ist die Rechtsherzkatheterisierung zur Diagnosesicherung unabdingbar. Unklar ist, ob die Echokardiographie die PH immer erfasst und wie echokardiographische und Rechtsherzkatheter-Messparameter korrelieren. Daher wurde bei Patienten an einem PH-Zentrum zunächst die Häufigkeit rechtsseitiger Klappeninsuffizienzen als Voraussetzung für die nicht-invasive Druckabschätzung ermittelt; anschließend wurden Korrelationen des nicht-invasiv abgeschätzten rechtsventrikulären systolischen Drucks (RVSP) mit dem invasiv gemessenem mPAP sowie von Echokardiographie-Parametern mit invasiv gemessenem Herzzeitvolumen (HZV) und pulmonal-vaskulärem Widerstand (PVR) bestimmt.

Methode: Retrospektive Analyse von echokardiographischen und mittels Rechtsherzkatheter bestimmten Parametern bei 74 konsekutiven Patienten mit unklarer Dyspnoe und Verdacht auf PH.

Ergebnisse: Bei gesicherter PH fand sich in 10 % keine Trikuspidalklappeninsuffizienz (TI), in 61,3 % keine messbare Pulmonalklappeninsuffizienz (PI). Der invasiv gemessene mPAP korrelierte am höchsten mit dem nicht-invasiv über eine TI über RVSP abgeschätzten mPAP (R = 0,80; p < 0,0001). Der über eine PI abgeschätzte mPAP (R = 0,72; p < 0,001) und der über die Akzelerationszeit im RVOT abgeschätzte mPAP (R = 0,54, p < 0,0001) korrelierten schwächer mit dem invasiv bestimmten mPAP. LVEI und TDI-TVA korrelierten mit dem PVR, während TAPSE mit PVR und dem HZV korreliert, RIMP jedoch nur mit dem HZV.

Folgerung: Eine PH kann bei alleiniger Beurteilung des RVSP über eine TI der Echokardiographie in 10 % entgehen. Auch andere Zeichen der Rechtsherzbelastung sollten bei Verdacht auf PH die weitere Abklärung veranlassen. Die echokardiographische Abschätzbarkeit des mPAP ist mäßig. Echokardiographie-Parameter können qualitative Informationen über HZV und PVR geben, den Rechtsherzkatheter aber nicht ersetzen.

Abstract

Background and objective: Since pulmonary hypertension is defined haemodynamically with a mean pulmonary artery pressure (mPAP) of at least 25 mmHg, right heart catheterization is mandatory for diagnosis of PH. However, it remains unclear if echocardiography can always detect a PH and to what extent echocardiographic and invasive parameters correlate. We aimed to determine the frequency of right heart valve insufficiencies, the correlation of mPAP measured invasively and estimated by echocardiography and the correlation of other echocardiographic parameters with invasively measured cardiac output (CO) and pulmonary vascular resistance (PVR) in patients who presented at our center for pulmonary hypertension.

Methods: Retrospective analysis of echocardiographic and invasively measured parameters in consecutive patients who presented with dyspnea and suspected PH.

Results: 10 % of the patients with invasively confirmed PH had no tricuspid valve insufficiency, 61.3 % had no pulmonary valve insufficiency. The highest correlation of invasively measured mPAP was found for mPAP estimated non-invasively via RVSP (R = 0.80; < 0.0001). Correlation of non-invasively estimated mPAP by the pulmonary valve regurgitation (R = 0,72, p < 0,004) and mPAP measured by the right ventricular outflow tract flow acceleration time (R = 0,54, p < 0.0001) with invasively measured mPAP were inferior. Left ventricular eccentricity index and systolic tissue Doppler velocity of tricuspid annulus correlated highly significant with PVR, TAPSE correlated with PVR and CO. Right ventricular myocardial performance index correlated with CO.

Conclusion: In 10 % of invasively proven PH, the diagnosis can be missed by estimation of RVSP by echocardiography alone, due to a lack of tricuspid valve insufficiency. Echocardiographic assessment of mPAP remains difficult. Echocardiography can deliver qualitative information about CO and PVR. Right heart catheterization remains mandatory to confirm or to rule out PH.

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