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Lawrence G. Rudski, MD
Author and Funding Information

From the Division of Cardiology, Department of Medicine, Jewish General Hospital, McGill University.

Correspondence to: Lawrence G. Rudski, MD, Jewish General Hospital, Room E 206, 3755 Côte-Sainte-Catherine Rd, Montreal, QC H3T 1E2, Canada; e-mail: lrudski@jgh.McGill.ca


Financial/nonfinancial disclosures: The author has reported to CHEST the following conflict of interest: Dr Rudski has a minor GE stock holding outside of a managed portfolio. GE manufactures echocardiography and cardiac catheterization equipment.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(4):1426-1427. doi:10.1378/chest.13-1631
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To the Editor:

I thank Dr Nobre et al for their insightful comments related to this important clinical issue that was debated.1 I agree that attention to detail is critical if echocardiography is to be used to estimate pulmonary artery pressures (PAPs). The American Society of Echocardiography right heart guidelines stipulate that it is better to avoid reporting a PAP from a weak and incomplete tricuspid regurgitant (TR) jet than to provide an unreliable value.2 Agitated saline, air-blood-saline, and Levovist (Bayer Healthcare Pharmaceuticals) contrast agents have been demonstrated to enhance the TR signal, resulting in a much higher feasibility of obtaining a complete Doppler envelope and usually yielding higher values of PAP by simplified Bernoulli equation.3,4

It is challenging, however, to recommend that contrast be used routinely when a strong TR signal with optimal alignment is already present. Similarly, it would be premature to recommend Levovist as opposed to agitated saline or air-blood-saline contrast without comparative data, particularly when considering cost. Jeon et al3 demonstrated an excellent correlation with agitated air-blood-saline mix compared with invasively measured PAPs. What appears concerning in the consistent increase in PAP estimation with contrast is that when considering the Bland-Altman plots of Fisher et al5 and Rich et al,6 there is similar overestimation and underestimation of systolic PAP by echocardiography. If the addition of Levovist consistently raised the PAP estimate, it is unclear how the echocardiography-catheterization relationship would be altered. Accordingly, validation studies would have to be repeated with simultaneous echocardiographic and invasive hemodynamic measures to evaluate the accuracy and clinical utility of echocardiographic contrast agents.

It is evident that the noninvasive measurement of systolic PAP is critical in evaluating patients with dyspnea. The basis of this remains an expert, comprehensive transthoracic echocardiogram that uses all available tools (including contrast when needed) to ensure the most accurate and reproducible PAP estimate.

References

Rudski LG. Point: can Doppler echocardiography estimates of pulmonary artery systolic pressures be relied upon to accurately make the diagnosis of pulmonary hypertension? Yes. Chest. 2013;143(6):1533-1536. [CrossRef] [PubMed]
 
Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713. [CrossRef] [PubMed]
 
Jeon DS, Luo H, Iwami T, et al. The usefulness of a 10% air-10% blood-80% saline mixture for contrast echocardiography: Doppler measurement of pulmonary artery systolic pressure. J Am Coll Cardiol. 2002;39(1):124-129. [CrossRef] [PubMed]
 
Cabello B, Borrás X, Carreras F, Thomas B, Leta R, Pons-Lladó G. Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease [in Spanish]. Med Intensiva. 2010;34(8):506-512. [CrossRef] [PubMed]
 
Fisher MR, Forfia PR, Chamera E, et al. Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. Am J Respir Crit Care Med. 2009;179(7):615-621. [CrossRef] [PubMed]
 
Rich JD, Shah SJ, Swamy RS, Kamp A, Rich S. Inaccuracy of Doppler echocardiographic estimates of pulmonary artery pressures in patients with pulmonary hypertension: implications for clinical practice. Chest. 2011;139(5):988-993. [CrossRef] [PubMed]
 

Figures

Tables

References

Rudski LG. Point: can Doppler echocardiography estimates of pulmonary artery systolic pressures be relied upon to accurately make the diagnosis of pulmonary hypertension? Yes. Chest. 2013;143(6):1533-1536. [CrossRef] [PubMed]
 
Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713. [CrossRef] [PubMed]
 
Jeon DS, Luo H, Iwami T, et al. The usefulness of a 10% air-10% blood-80% saline mixture for contrast echocardiography: Doppler measurement of pulmonary artery systolic pressure. J Am Coll Cardiol. 2002;39(1):124-129. [CrossRef] [PubMed]
 
Cabello B, Borrás X, Carreras F, Thomas B, Leta R, Pons-Lladó G. Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease [in Spanish]. Med Intensiva. 2010;34(8):506-512. [CrossRef] [PubMed]
 
Fisher MR, Forfia PR, Chamera E, et al. Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. Am J Respir Crit Care Med. 2009;179(7):615-621. [CrossRef] [PubMed]
 
Rich JD, Shah SJ, Swamy RS, Kamp A, Rich S. Inaccuracy of Doppler echocardiographic estimates of pulmonary artery pressures in patients with pulmonary hypertension: implications for clinical practice. Chest. 2011;139(5):988-993. [CrossRef] [PubMed]
 
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