As a result, patients are misclassified within pulmonary hypertension groups. 6 In fact, self-report of perceived inadequacies in ability to interpret RHC data are strikingly high with studies revealing surveys in which 50% of critical care trained attendings queried could not correctly identify PCWP from a clear chart recording. 5 Arguably most common, however, and of substantial consequence to patients, is the misinterpretation of RHC tracing data, specifically estimates of PCWP. 3, 4 Despite the facility of experienced operators at institutions specializing in the care of patients with pulmonary vascular disease, complications ranging from pneumothorax during vascular access to hypotension as a result of vasoreactivity testing to death as a result of pulmonary artery (PA) rupture do occur, albeit at low frequencies (1–5%). It is estimated that at least 1–2 million RHCs are performed each year. Invasive monitoring with assessment of PCWP is also useful in patients with acute heart failure, particularly for those with refractory hypotension or in whom renal function worsens despite standard therapy. 1 This classification not only determines the therapeutic options available to patients, as most therapeutics are only approved for group 1 disease, but also determines feasibility of patient inclusion in clinical trials. As defined by the World Health Organization (WHO), both PCWP ≤ 15 mmHg and pulmonary vascular resistance (PVR) ≥ 3 Wood units are necessary to differentiate PAH from patients with group 2 disease. Obtained during right heart catheterization (RHC), PCWPs are required to differentiate between patients with pre-capillary, group 1 pulmonary arterial hypertension (PAH), and post-capillary, group 2 pulmonary hypertension, due to left heart failure. Additional tools to ensure accuracy of pulmonary capillary wedge pressure reporting are reviewed.Īccurate pulmonary capillary wedge pressure (PCWP) measurements are critical in the evaluation of patients with pulmonary and cardiac pathology. As wedge pressures often drive diagnosis and treatment decisions for patients with cardiac and pulmonary pathology, operators should be attuned to balloon deflation as a time when alternative pulmonary capillary wedge pressures may be identified as they are likely more reflective of left ventricular end-diastolic pressure. In conclusion, inadvertently obtained, but likely more accurate, alternative pulmonary capillary wedge pressures were identified in almost 15% of procedures reviewed from a busy academic institution. For the eight patients for whom left heart catheterization data were available, left ventricular end-diastolic pressure aligned with the alternative pulmonary capillary wedge pressure. Eleven of these alternative pulmonary capillary wedge pressures were ≤15 mmHg with a calculated pulmonary vascular resistance ≥3 Wood units in 10 patients, re-classifying the etiology of pulmonary hypertension from post-capillary to pre-capillary in 38.5% of cases. Results showed that, of the 182 tracings reviewed, an alternative pulmonary capillary wedge pressure was identified in 26 or 14.3% of cases. Inter-rater reliability of tracing reviewers was also evaluated. Alternative pulmonary capillary wedge pressures were defined as a pulmonary capillary wedge pressure trace during balloon deflation ≥3 mmHg lower than the reported pulmonary capillary wedge pressure. We conducted a retrospective study of patients undergoing right heart catheterization or right heart catheterization and left heart catheterization with computer-generated pulmonary capillary wedge pressure ≥20 from January 2015 to June 2017. We hypothesized that this phenomenon can be identified on retrospective review of right heart catheterization tracings, which occurs commonly and goes unrecognized by operators. Balloon deflation prior to catheter retraction may result in catheter advancement into smaller branch vessels, yielding an inadvertent but more accurate alternative pulmonary capillary wedge pressure. Failure to completely occlude pulmonary artery branch vessels during balloon inflation can lead to falsely elevated, “incomplete” pulmonary capillary wedge pressures. To describe the frequency with which pulmonary capillary wedge pressure measurements, obtained during right heart catheterization, are falsely elevated and to educate operators on techniques to improve accuracy of pulmonary capillary wedge pressure reporting.
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