Accuracy of echocardiographic estimations of right heart pressures in adult heart transplant recipients.

BACKGROUND: Accurate assessment of right atrial pressure (RAP) and pulmonary artery systolic pressure (PASP) is critical in the management of heart transplant recipients. The accuracy of echocardiography in estimating these pressures has been debated. OBJECTIVE: To assess the correlation and agreement between echocardiographic estimations of right heart pressures with those of respective invasive hemodynamic measurements by right heart catheterization (RHC) in adult heart transplant recipients. METHODS: This is a prospective evaluation of 84 unique measurements from heart transplant recipients who underwent RHC followed by standard echocardiographic evaluation within 159 ± 64 min with no intervening medication changes. The relationship between noninvasive pressure estimations and invasive hemodynamic measurements was examined. RESULTS: Mean RAP was 7 ± 5 mmHg and mean PASP was 33 ± 8 mmHg by RHC. There was no significant correlation between echocardiographic estimation of RAP and invasive RAP (Spearman's rho = -0.05, p = .7), and no significant agreement between these two variables (weighted kappa = -0.1). There was a modest correlation between echocardiographic estimation of PASP and invasive PASP (r = .39, p = .002). Bland-Altman analysis showed a mean bias of 2.1 ± 9 mmHg (limits of agreement = -15 to 20 mmHg). CONCLUSION: In heart transplant recipients, there is no significant correlation or agreement between echocardiographic RAP estimation and invasively determined RAP. Noninvasive PASP estimation correlates significantly but modestly with invasively measured PASP. Further refinement of echocardiographic methods for assessment of RAP is warranted in this unique patient population.

3D echocardiography to evaluate right atrial pressure in acutely decompensated heart failure correlation with invasive hemodynamics.

OBJECTIVES: This study examined the utility of 3-dimensional right atrial volume index (3D-RAVi), combined with 2-dimensional echocardiographic (2DE) parameters, for the identification of elevated right atrial pressure (RAP) in patients with heart failure. BACKGROUND: Accurate noninvasive determination of RAP is clinically important for the management of patients with heart failure. Although 2DE methods have been used to noninvasively estimate RAP, the accuracy of these parameters has limitations when estimating RAP in an individual patient. Three-dimensional echocardiography (3DE) provides tomographic imaging of right atrial volume that may be helpful in refining the noninvasive assessment of hemodynamics in patients with heart failure. METHODS: 2DE and 3DE studies were examined in 40 initial patients who were admitted for acutely decompensated heart failure. Simultaneous pulmonary artery catheter monitoring was performed. The relationship between echocardiographic parameters and RAP was examined in this derivation group. The findings from the derivation group were then prospectively tested in a validation group of 40 additional patients. RESULTS: Mean RAP was 11 ± 5 mm Hg (range 2 to 22 mm Hg). 3D-RAVi correlated with RAP (r = 0.51, p < 0.001), whereas 2-dimensional right atrial volume index did not. Inferior vena cava (IVC) diameter ≥2 cm and IVC respirophasic collapse <40% also correlated with RAP (p < 0.001 and p = 0.028, respectively). Based on receiver-operator characteristic curve analysis, 3D-RAVi ≥35 ml/m(2) was the optimal 3D-RAVi cutpoint for identifying RAP >10 mm Hg. The value of 3D-RAVi ≥35 ml/m(2), combined with IVC measures, for predicting RAP >10 mm Hg was prospectively tested in the validation group. 3D-RAVi ≥35 ml/m(2) in combination with IVC ≥2 cm had a high accuracy (88%) for identifying RAP >10 mm Hg and had a higher accuracy than the combination of IVC ≥2 cm and IVC collapse <40% (accuracy: 68%, p = 0.038). CONCLUSIONS: In patients with heart failure, 3D-RAVi in conjunction with IVC parameters has a high accuracy for detection of elevated RAP. The addition of 3D-RAVi to 2DE methods may be helpful in the noninvasive estimation of right atrial pressure.

A cost-saving strategy for inpatient management of advanced decompensated heart failure patients: the Cardiomyopathy Unit.

BACKGROUND: This article analyzes the relative costs and revenues of the Tufts Medical Center Cardiomyopathy Unit (CMU), a recent innovation for grouping and managing advanced decompensated heart failure patients. METHODS AND RESULTS: We selected a retrospective sample of all patients with the primary diagnosis of heart failure, primary procedure of pulmonary artery catheterization, and with no other hospitalization procedures, admitted to Tufts Medical Center between 2000 and 2006. Regression models were used to estimate the cost for the intervention group and controls. Propensity analysis was used to test for selection bias in the comparison groups. We identified 114 hospitalizations meeting these criteria. Patients in the CMU group were well-balanced compared with controls with respect to demographic and clinical variables. Estimated direct medical costs for CMU and control groups were $11,817 (95% CI $7678-$16,106) and $17,236 (95% CI $11,199-$23,493), respectively. A similar pattern of cost differentials was displayed among propensity-matched sample groups. Net revenue was $12,609 (95% CI $9578-$16,845) and $15,627 (95% CI $11,871-$20,877) in the CMU and control groups, respectively. CONCLUSIONS: The inpatient CMU may offer a lower cost and higher contribution margin alternative for the management of advanced heart failure patients requiring hemodynamic monitoring without other major inpatient procedures.