PDF(Pubmed)
Abstract：
Impaired respiratory variation of right atrial pressure (RAP) in severe pulmonary hypertension (PH) suggests difficulty tolerating increased preload during inspiration. Our study explores whether this impairment links to specific factors: right ventricular (RV) diastolic function, elevated RV afterload, systolic RV function, or RV-pulmonary arterial (PA) coupling. We retrospectively evaluated respiratory RAP variation in all participants enrolled in the EXERTION study. Impaired respiratory variation was defined as end-expiratory RAP - end-inspiratory RAP ≤ 2 mm Hg. RV function and afterload were evaluated using conductance catheterization. Impaired diastolic RV function was defined as end-diastolic elastance (Eed) ≥ median (0.19 mm Hg/mL). Seventy-five patients were included; PH was diagnosed in 57 patients and invasively excluded in 18 patients. Of the 75 patients, 31 (41%) had impaired RAP variation, which was linked with impaired RV systolic function and RV-PA coupling and increased tricuspid regurgitation and Eed as compared to patients with preserved RAP variation. In backward regression, RAP variation associated only with Eed. RAP variation but not simple RAP identified impaired diastolic RV function (area under the receiver operating characteristic curve [95% confidence interval]: 0.712 [0.592, 0.832] and 0.496 [0.358, 0.634], respectively). During exercise, patients with impaired RAP variation experienced greater RV dilatation and reduced diastolic reserve and cardiac output/index compared with patients with preserved RAP variation. Preserved RAP variation was associated with a better prognosis than impaired RAP variation based on the 2022 European Society of Cardiology/European Respiratory Society risk score (chi-square P = 0.025) and survival free from clinical worsening (91% vs 71% at 1 year and 79% vs 50% at 2 years [log-rank P = 0.020]; hazard ratio: 0.397 [95% confidence interval: 0.178, 0.884]). Subgroup analyses in patients with group 1 and group 4 PH demonstrated consistent findings with those observed in the overall study cohort. Respiratory RAP variations reflect RV diastolic function, are independent of RV-PA coupling or tricuspid regurgitation, are associated with exercise-induced haemodynamic changes, and are prognostic in PH.Trial registration. NCT04663217.
摘要：
严重肺动脉高压（PH）患者右心房压（RAP）的呼吸变化受损表明在吸气过程中难以忍受预负荷的增加。我们的研究探讨了这种损害是否与特定因素有关：右心室（RV）舒张功能，升高的RV后负荷，收缩性RV功能,或RV-肺动脉（PA）耦合。我们回顾性评估了参加EXERTION研究的所有参与者的呼吸RAP变异。呼吸变异受损定义为呼气末RAP-吸气末RAP≤2mmHg。使用电导导管检查评估RV功能和后负荷。右心室舒张功能受损定义为舒张末期弹性(Eed)≥中位数(0.19mmHg/mL)。纳入75例患者；57例患者被诊断为PH，18例患者被侵入性排除。在75名患者中，31（41%）的RAP变异受损，与保留RAP变异的患者相比，这与RV收缩功能和RV-PA偶联受损以及三尖瓣反流和Eed增加有关。在向后回归中，RAP变异仅与Eed相关。RAP变化，但不是简单的RAP识别的舒张性RV功能受损（接受者工作特征曲线下面积[95％置信区间]：0.712[0.592，0.832]和0.496[0.358，0.634]，分别)。在锻炼过程中,与保留RAP变异的患者相比,RAP变异受损的患者的RV扩张更大,舒张储备和心输出量/指数降低.根据2022年欧洲心脏病学会/欧洲呼吸学会风险评分（卡方P=0.025）和无临床恶化的生存率（1年为91％vs71％，2年为79％vs50％[log-rankP=0.020]；风险比：0.397[95％置信区间：0.178，0.884]），保留的RAP变异与受损的RAP变异的预后更好。第1组和第4组PH患者的亚组分析显示与整个研究队列中观察到的结果一致。呼吸RAP变化反映RV舒张功能，与RV-PA偶联或三尖瓣反流无关，与运动引起的血液动力学变化有关，并在PH中具有预后。试用登记。NCT04663217。
