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Comparison of Pulmonary Artery and Pulmonary Venous Wedge Pressure in Congenital Heart Disease

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Comparison of Pulmonary Artery and Pulmonary Venous Wedge Pressure in Congenital Heart Disease Br Heart J: first published as 10.1136/hrt.35.4.386 on 1 April 1973. Downloaded from British Heart_Journal, I973, 35, 386-39I. Comparison of pulmonary artery and pulmonary venous wedge pressure in congenital heart disease Richard E. Hawker' and John M. Celermajer From The Adolph Basser Institute of Cardiology, Royal Alexandra Hospitalfor Children, Sydney, Australia A statistical comparison ofpulmonary artery andpulmonary vein wedge pressures has been made by the corre- lation coefficient method, in patients with congenital heart disease. The correlation was poor (r = o066) in patients with a pulmonary artery mean pressure in the normal range, but good (r= o.86) in patients with mild to moderate pulmonary hypertension. An analysis of patients in whom catheterization of the pulmonary artery may not always be possible, showed a good correlation in transposition of the great arteries (r= o084) and ventricular septal defect, with banding of the mainpulmonary artery (r=o093), but not as good in tetralogy ofFallot andpulmonary stenosis. Despite the poor statistical correlation in the overallgroup, it wasfound that patients with pulmonary vein wedge mean pressure below the upper limits of normal had a pulmonary artery mean pressure below this level in 8I of87 cases and minimally raised pulmonary artery mean pressure in the remaining 6. Likewise, a raised pulmonary artery pressure was found in 33 out of 34 cases with high pulmonary vein wedge mean pressure. Therefore it is concluded that (i) if the pulmonary artery is not entered, a pulmonary vein wedge pressure within the normal range makes it very unlikely that the pulmonary artery pressure is raised; (2) if the pul- http://heart.bmj.com/ monary vein wedge pressure is raised, the pulmonary artery pressure is almost certainly raised. However, this rise cannot be quantitatedfrom the pulmonary vein wedge trace; and (3) the pulmonary vein wedge mean pres- sure is a useful indication ofpulmonary artery mean pressure in selected cases of congenital heart disease. The pulmonary vein wedge pressure is sometimes the systolic or diastolic pressure was selected for used as an indirect measurement of pulmonary statistical analysis as it was thought that the correla- artery pressure in cases of congenital heart disease tion of mean pressures would be more meaningful when catheterization of the pulmonary artery is because it might be less affected by the damping on September 29, 2021 by guest. Protected copyright. unsuccessful. A recent publication (Rao and Siss- effect on the pressure wave transmitted through the man, I97I) examined the relation of pulmonary pulmonary vascular bed. Moreover, the mean pul- venous wedge to pulmonary arterial pressures. How- monary arterial pressure is used in the calculations ever, a statistical correlation of pulmonary vein of pulmonary vascular resistance and resistance wedge and pulmonary artery pressures in congenital ratios, and so in the assessment of pulmonary vascu- heart disease has not to our knowledge been pub- lar disease. lished, though it is known that the correlation is poor inthe presence ofpulmonary hypertension (Zimmer- Subjects and methods man, I966). It is the purpose ofthis paper to present The reports of cardiac catheterizations performed be- a statistical correlation between mean pulmonary tween February I968 and September 1970 in the Car- vein wedge and mean pulmonary artery pressures ob- diac Department of the Royal Alexandra Hospital for tained at routine and emergency cardiac catheteriza- Children were reviewed. In I87 of these, a pulmonary tion of infants and children with congenital heart vein wedge pressure was recorded and in 135 both pul- disease, and to assess the usefulness of pulmonary monary artery and pulmonary vein wedge pressures records. The mean rather than were available. The pulmonary vein wedge pressure vein wedge pressure recording was considered adequate only if there was a Received 7 July 1972. recognizable arterial type wave form present and if 1 Present address: The Johns Hopkins Hospital, Baltimore, there was the expected wave form change on with- Maryland, U.S.A. drawal of the catheter from the wedge position to the Br Heart J: first published as 10.1136/hrt.35.4.386 on 1 April 1973. Downloaded from Pulmonary artery and pulmonary venous wedge pressures 387 pulmonary vein in cases where a withdrawal trace was Comparisons were also made of the pulmonary artery recorded. Cases known to have peripheral pulmonary and pulmonary vein wedge mean pressure in (i) trans- artery stenosis were excluded since it could not be deter- position of the great arteries, (2) pulmonary stenosis and mined if pulmonary artery pressures had been recorded tetralogy of Fallot, and (3) ventricular septal defect, beyond the obstruction. The pressure traces of all cases with banding of the main pulmonary artery, because in in which there was a greater than 20 per cent discrep- these conditions the pulmonary artery may be difficult ancy between pulmonary artery and pulmonary vein to catheterize. Eleven additional patients with these mal- wedge pressures were reviewed and I3 cases were rejec- formations were added to the number drawn from the ted on the basis of incomplete information or technically original series to increase the significance of the results. inadequate pulmonary vein wedge traces. Statistical comparison ofpairedobservations was made by The ages of the patients ranged from i8 hours to 13 using the regression equation and correlation coefficient years. Neonates were curarized, intubated, and ven- method. tilated during the procedure, while infants and older Finally, cases in which the pulmonary artery was not children were studied under local anaesthesia with pre- entered were examined to see if any significance could medication of omnopon and scopolamine except for be placed on the recorded pulmonary vein wedge those weighing less than 6 kg who were given morphine. pressures. A 5 or 6 French gauge endhole catheter' was used to record both pulmonary artery and pulmonary vein wedge Results pressure. The catheters were connected via Statham Group A: normal and subnormal mean pul- 23 De pressure transducers to a Sanborn 8-channel monary artery pressures (Fig. i) photographic recorder. The reference level for zero pressure was at the midchest position. There was a poor correlation in this group (correla- Comparison was made between the pulmonary artery tion coefficient r = o-66, standard error of the estim- and pulmonary vein wedge mean pressures except in ate (SE est.) = 2.49, slope = o-63). cases with banding of the main pulmonary artery in However, in only one case was the pulmonary vein which right or left pulmonary artery mean pressure and wedge mean pressure greater than 20 mmHg. The the pulmonary vein wedge mean pressure from the greatest discrepancy between mean pulmonary corresponding side was used. The paired results were artery and pulmonary vein wedge was 8 mmHg. The considered as follows. slope of the line being less than i indicates the over- Group A: 82 cases with mean pulmonary artery pressure all tendency for the pulmonary artery pressure to below and in the normal range of Kjellberg et al. (I955) be higher than the pulmonary vein wedge pressure. (i.e. 8 to I9 mmHg). http://heart.bmj.com/ Group B: I9 cases with mean pulmonary artery pressure Group B: mean pressure 20 to 39 mmHg (Fig. 2) between 20 and 39 mmHg. The = Group C: 21 cases with mean pulmonary artery pressure correlation was good in this group (r o-86, above 39 mmHg. SE est. = 2.53). The range of pulmonary vein wedge 1 U.S.C.I. Lehman. 35 on September 29, 2021 by guest. Protected copyright. 24 0 r=O- E c- E 25 E 0 0 0 . 0 p 0 2 i 62 !D . , 20 0 0 *0 3 *0 0 .# f *0. 15 0 . 0 00 0 >~ 8 & 0 0 a lo , 4, 0%W 0 4 8 12 16 20 24 28 32 0 5 10 15 20 25 30 35 40 Mean PA pressure (mmHg) Meon PA pressure (mmHg) FIG. I Statistical comparison of mean pulmonary FIG. 2 Statistical comparison of mean pulmonary artery and pulmonary vein wedge pressures: Group A artery and pulmonary vein wedge pressures: Group B (mean pulmonary artery pressure less than 20 mmHg). (mean pulmonary artery pressure 20-39 mmHg). Br Heart J: first published as 10.1136/hrt.35.4.386 on 1 April 1973. Downloaded from 388 Hawker and Celermajer pressure was I3 tO 35 mmHg, and the greatest dis- 60. crepancy between pulmonary artery and pulmonary vein wedge was 7 mmHg. o =E 50. C Group C: mean pulmonary artery pressures 1- greater than 39 mmHg (Fig. 3) a 40- I range This group showed a very poor correlation (r = 0 I34, SE est. = 7 78). However, in all cases the I50*0 * mean CL mean pulmonary vein wedge pressure was 20 mmHg c or greater. The slope of the regression line is nega- E0 20 tive, indicating that in this range the mean pulmon- ary vein wedge pressure actually becomes less the 10 higher the mean pulmonary artery pressure rises. x No mean pulmonary vein wedge pressure higher than 50 mmHg was recorded. 0 III <8 8-19 20-29 30-39 40-49 >50 Meon PA pressure (mmHg) 60 FIG. 4 Statistical comparison of mean pulmonary - 50- artery and pulmonary vein wedge pressures: the dis- CE crepancy between mean pulmonary artery and pul- 40- monary vein wedge pressures increases with increasing pulmonary artery pressure. ° 30- r.n 0-314 3: 20- >. 60 cxa I0 io. c, 50 http://heart.bmj.com/ I E 0 10 20 30 40 50 60 70 80 40 Mean PA pressure (mmHg) 6) 30Q FIG. 3 Statistical comparison of mean pulmonary 3. artery and pulmonary vein wedge pressures: Group C a> 20' (mean pulmonary artery pressure greater than 39 ac 0 mmHg).
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