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Relationship of pulmonary artery diastolic and pulmonary artery wedge pressures in mitral stenosis
onary artery diastolic dge pressures in
be re!ationshi
etween pulmonary artery and mean pulmonary artery normal man has been reported various investigators. Is2The diastolic pressure dients across the pulmonary vascular bed in ital heart disease with left-to-right shunt, heart disease, and in corohave also been studied.3,4 Ensq5 in reviewing the literature, noted a few observations on the pulmonary artery diastolic and pulmonary artery wedge ressures in patients with mitral stenosis. Howrrelation between these two pressures ted in these patients. Herein, we reservations on the relationship between these two essures at rest and during exercise in patie with mitral stenosis and ulmonary vascular resistance.
aerodynamic studies performed in 33 patients with mitra stenosis in normal sinus rhythm with norm 1 pulmonary vascular resistance form the basis of this report. A pressure gradient of 5 mm. Hg or less between pulmonary artery diastolic and mean pulmonary artery pressures at rest was taken as normal puly vascular resistance. The subjects com14 men and 19 women, aged 9 to 42 years, the average being 26 years. Frmm the Department ofCardiobgy, ences, New Delhi, India. Received
for publication
May
All India
Manjuran
ofMedicalSci-
2, 1974.
Reprint requests: Dr. J. B. Agarwal, dia Inst,itute of Medical Sciences, ‘Present address: O., Kerala, India..
Institute
House,
Department New Delhi,
of Cardiology, 110016, India.
St. Germanes
All In-
Rd., N. Parvar
P.
the second costa
ex~r~jse for five rose above 30 mm.
racing. The inherent secutive rewording in
The
relation
ressures at r-es
between
fakiacy of con-
~~~~~o~ary artery
artery wedge
Manjuran,
Agarwal,
and Roy
Table 1. Pulmonary
artery
and pulmonary Pulmonary
No.
Name
Age
Sex
1.
PP
18
M
2.
RS
12
M
3.
RS
24
M
4.
UG
20
F
5.
VD
42
F
6.
SB
30
F
7.
M
19
F
8.
AKS
14
M
9.
AG
26
M
10.
s
35
F
11.
PK
33
M
12.
JSJ
36
M
13.
s
9
M
14.
SCG
23
M
15.
KLN
27
M
16.
BD
24
F
PAW (Rec.) = mean pulmonary E = exercise.
Systolic R E R E R E R E R E R E R E R E R E R E R E R E R E R E R E R E artery
artery
wedge pressures
artery pressure (mm. Hg) Diastolic
39 67 40 56 28 60 40 60 39 48 48 55 21 48 40 50 34 77 25 43 30 68 30 64 62 96 35 52 32 58 35 81 wedge pressure
20 34 20 37 12 30 24 34 20 24 24 27 10 25 21 25 19 48 11 16 17 40 17 43 23 44 15 29 15 32 15 41 (recorded);
stenosis
Mean
PAW (Rec.) (mm. Hg)
PA W-PAD (Rec.) (mm. Hgj
23 39 27 43 18 42 30 42 28 35 31 35 14 34 28 35 26 59 16 24 22 51 22 50 36 60 25 41 22 41 23 58
20 32 19 37 14 32 25 36 15 20 20 22 13 31 24 30 22 50 14 21 17 40 17 43 18 32 13 22 18 35 19 46
0 -2 -1 0 +2 +2 +1 +2 -5 -4 -4 -5 +3 +6 +3 +5 +3 +2 +3 +5 0 0 0 0 -5 -12 -2 -7 +3 +3 +4 +5
PAW (Pred.) = mean pulmonary
Exercise data. The relation between pulmonary artery diastolic and mean pulmonary artery wedge pressure during exercise is shown in Fig. 2. The pulmonary artery diastolic pressures varied from 16 to 48 (32.85 f 7.45) mm. Hg and the pulmonary artery wedge pressures ranged from 20 to 50 (32.45 5 7.70) mm. Hg. The correlation coefficient (i-1 between these two pressures was 0.8670. The difference between pulmonary artery wedge pressure and pulmonary artery diastolic pressure during exercise (PAW-PAD) was from -12 to +6 (-0.39 -t 3.91) mm. Hg. Relationship of PA W-PAD in exercise and resting states. The difference between the pressure gradients of PAW and PAD during exercise and at rest [(PAW-PAD,) - (PAW-PAD,)] varied
208
in mitral
artery
PAW (Pred.) (mm. Hgj
PA W-PAW (Rec.) 0’red.i (mm. Hg)
34
-2
36
+1
32
0
35
+1
19
+1
23
-1
28
+3
28
i-2
51
-1
19
+2
40
0
43
0
39
-7
27
-5
35
0
45
wedge pressure (predicted);
+1 R = resting;
and
from -4 to +7 (+0.15 + 2.46) mm. Hg. The correlation coefficient between the (PAW-PAD,) and (PAW-PAD,) was 0.7995 (Fig. 31. Discussion It is apparent from this study there is a close correlation between the pulmonary artery diastolic and mean pulmonary artery wedge pressures at rest and during exercise in patients with mitral stenosis and normal pulmonary vascular resistances. Yu and co-workers,7 reported good correlation between PAW and PAD pressures at rest (r = 0.825) in 32 patients with mitral stenosis, but no exercise study was done by these workers. The correlation of these pressures, at rest, was very high, as expected,
February,
1975,
Vol.
89, NO. 2
17.
PD
28
18.
s
9
19
RR
17
20.
MG
32
21.
MB%
21
22.
ts
11
23.
ABK
24
24.
LW
42
25.
BB
25
26.
NS
40
27.
DD
28
28.
s
31
29.
MD
19
30.
P&G
24
31.
5%
15
32.
PB
30
33.
TM
40
68 88 63 73 28 40 37 68 44 70 34 52 20 36 38 75 32 60 36 68 33 42 31 63 36 50 23 35 40 57 26 54 22 60
31 40 32 36 16 26 22 36 25 40 15 30 10 24 19 44 20 40 14 30 18 26 18 34 20 28 14 23 26 37 16 31 10 30
becahse of the nature of selection of patient5 (r = 0 ‘7). However, during exercise, a close carrel existed between the two pressures in nt study Cr = 0.8670). elatiouship between (PAW-PAD,) and AD,) had a correlation coefficient (r) of .a995 which is highly significant. The mean e between these two measurements was “15 -t- 2.46 mm. Hg. It was, therefore, hat if the exercise PAD was corrected ence (PAW-PAD) at rest, it might be x of PAW during exercise. The correlation between the predicted exercise PAW (PA r& calculated by the equation: J + (PAW-PAD511
49 62 44 55 21 34 29 50 33 52 20 35 15 30 27 58 26 48 24 42 24 32 24 47 27 37 17 30 30 44 19 42 15 40
27 37 28 34 16 25 24 42 23 41 15 30 10 24 18 40 18 36 15 25 17 23 17 35 20 28 13 22 26 36 16 32 10 32
36 32 26 38 38 30 24 43 38 31 25 33 28 22 37 31 30
etweermthe me
an increase in mean ma1 subjects. ls2 Alth~~gb ~~~5~a~~ artery we ary artery and ing exercise in mitral ~~e~os~s has been observed by ~x~~~~~s w~r~~~~s,~,~only a few patients with normal ~~1~~~~~~~ ~~~c~~~.r resistances were re~Qrte~. No ~~~~~~~~~~~ was at-
Manjuran, Agarwal, and Roy
i-r0.9017
.. . .
r-07995
.
.
R c
.
5 E
.
-4
.
iI 5
IO
I5
20
25
PA DIP, STOLIC
30
(mm OF
3.5
-S
H 1 ?
-10
Fig. 1. Relation between mean pulmonary arterial wedge (PAW) and pulmonary artery diastolic pressure (PAD) at rest.
. .
.
1.
. .
. . :
:
:
.
.
.
.
. 8 5
. .
l
.
.
l
PAW
IS
5
IO
15
20
%*ST0LIC
25
30
35
40
45
50
< m m OF H%,
Fig. 2. Relation between mean pulmonary arterial (PAW) and pulmonary artery diastolic pressure (PAD) exercise.
pulmonary diastolic
in such patients, the exercise pulmonary artery diastolic pressure itself can give a good estimate of the mean pulmonary artery wedge pressure. However, a closer value can be obtained by modifying the exercise pulmonary artery diastolic pressure by the equation:
l *
-12
.
.
l
.
Fig. 3. Relation between difference of the mean arterial wedge (PAW) and pulmonary artery pressure (PAW-PAD) at rest and during exercise.
r = 0.6670
.
. -6
I 40
01
exercise
= PAD exercise (PAW-PAD)
+ Resting
This may be of practical importance in those circumstances where the reliable recording of the pulmonary artery wedge pressure pulse during exercise is not possible. j Summary
wedge during
tempted between pulmonary artery diastolic and mean pulmonary artery wedge pressures at rest and during exercise in these studies. The findings indicate that the pulmonary circulation in patients with mitral stenosis with normal pulmonary vascular resistance behaves like that in normal subjects during exercise, and
210
. .
.
5
Resting and exercise hemodynamic studies were performed in 33 patients with mitral stenosis (14 men and 19 women; average age, 25 years) in normal sinus rhythm with normal pulmonary vascular resistances. A normal pulmonary vascular resistance was assumed when the resting pressure gradient between the pulmonary artery diastolic and mean pulmonary artery wedge pressures was 5 mm. Hg or less. A satisfactory correlation existed between the pulmonary
February, 1975, Vol. 89, No. 2
lit pressure can be modified tuted for mean p pressure if the restin nary artery w stolic pressure
r.Q.9561
X X x I
X xxx
x x
x
it
x
x
CES
xx X
x
I x X x xx
x X
x X
I
20
25
30 PREDICTED
Fig. 4. Relation wedge (PAW) pressure during
35 (mm
40 OF
between recorded mean and predicted pulmonary exercise.
45 H
B
50
55
1
pulmonary artery
artery wedge
ge and ~~Im~~ary artery diastolic pressures at rest Cr = 0.9017) and during exercise (I = 0.8 A method of predicting pulmonary artery e pressure from pulmonary artery iastolic pressure during exercise was formulated. The correlation between the predicted an measured exercise pulmonary artery wedge pressures was very close (r = 0.9561). It is suggested that during exercise the pulmonary arter.y
American
Near-t
Journal
& tia’sove
Bevegard, S., Molmgren, A., and donsson, B.. Circulatory studies in well-trained athletes at rest and during heavy exercise with special reference to stroke vohrme and influence of body position, Acta Physiol. &and. 1963. Granath, A., and Strandell, T.: Relatio.r&ips between cardiac output, stroke volume, and intracardiac s at rest and during exercise in the supine posisome anthropometric data in healthy old men, Acta Med. Scand. 176:411, 1964 almborg; R. 0.: A clinical and barn~~~a~~c analysis of factors limiting the cardiac performance in patients with coronary heart disease, Acta Med. Stand. 177:CSuppl.M26, 1965. Kaltman, A. J., Herbert, W. Ei., Conroy, R. 3., and Kossman, C. E.: The gradient in pressure across the nary vascular bed during diastole: Circulation 1966. Harvey, R. M., and Enson, Y.: Pnlnmnary vascular resistance, Adv. Intern. Med. t Roy, 9. B., Gadboys, H. L., and left-heart catheterization, AM. WEART J. Uu, P. N. G., Simpson, J. H., Lovejay, F. W., Jr., Joos: 14. A., and Nye, R. E., Jr.: Studies of pakmona:q hypertension. IV. Pulmonary circulatory dynam’ with mitral stenosis at rest, AM. EXAM 3. Gorlin, R., Sawyer, C. G., Haynes, P. W4, and Dexter, L.: Effects of exercise on circulatory dynamics in mitral stenosis, AM. NsABT J. 41:192,1951. Lukas, D. S., and Dotter, C. T.: ~~o~~~cat~o~s of tbe pmmonzry circulation in mitral stenosis, Am. Y, Med. 12:639, 1952.
be re!ationshi
etween pulmonary artery and mean pulmonary artery normal man has been reported various investigators. Is2The diastolic pressure dients across the pulmonary vascular bed in ital heart disease with left-to-right shunt, heart disease, and in corohave also been studied.3,4 Ensq5 in reviewing the literature, noted a few observations on the pulmonary artery diastolic and pulmonary artery wedge ressures in patients with mitral stenosis. Howrrelation between these two pressures ted in these patients. Herein, we reservations on the relationship between these two essures at rest and during exercise in patie with mitral stenosis and ulmonary vascular resistance.
aerodynamic studies performed in 33 patients with mitra stenosis in normal sinus rhythm with norm 1 pulmonary vascular resistance form the basis of this report. A pressure gradient of 5 mm. Hg or less between pulmonary artery diastolic and mean pulmonary artery pressures at rest was taken as normal puly vascular resistance. The subjects com14 men and 19 women, aged 9 to 42 years, the average being 26 years. Frmm the Department ofCardiobgy, ences, New Delhi, India. Received
for publication
May
All India
Manjuran
ofMedicalSci-
2, 1974.
Reprint requests: Dr. J. B. Agarwal, dia Inst,itute of Medical Sciences, ‘Present address: O., Kerala, India..
Institute
House,
Department New Delhi,
of Cardiology, 110016, India.
St. Germanes
All In-
Rd., N. Parvar
P.
the second costa
ex~r~jse for five rose above 30 mm.
racing. The inherent secutive rewording in
The
relation
ressures at r-es
between
fakiacy of con-
~~~~~o~ary artery
artery wedge
Manjuran,
Agarwal,
and Roy
Table 1. Pulmonary
artery
and pulmonary Pulmonary
No.
Name
Age
Sex
1.
PP
18
M
2.
RS
12
M
3.
RS
24
M
4.
UG
20
F
5.
VD
42
F
6.
SB
30
F
7.
M
19
F
8.
AKS
14
M
9.
AG
26
M
10.
s
35
F
11.
PK
33
M
12.
JSJ
36
M
13.
s
9
M
14.
SCG
23
M
15.
KLN
27
M
16.
BD
24
F
PAW (Rec.) = mean pulmonary E = exercise.
Systolic R E R E R E R E R E R E R E R E R E R E R E R E R E R E R E R E artery
artery
wedge pressures
artery pressure (mm. Hg) Diastolic
39 67 40 56 28 60 40 60 39 48 48 55 21 48 40 50 34 77 25 43 30 68 30 64 62 96 35 52 32 58 35 81 wedge pressure
20 34 20 37 12 30 24 34 20 24 24 27 10 25 21 25 19 48 11 16 17 40 17 43 23 44 15 29 15 32 15 41 (recorded);
stenosis
Mean
PAW (Rec.) (mm. Hg)
PA W-PAD (Rec.) (mm. Hgj
23 39 27 43 18 42 30 42 28 35 31 35 14 34 28 35 26 59 16 24 22 51 22 50 36 60 25 41 22 41 23 58
20 32 19 37 14 32 25 36 15 20 20 22 13 31 24 30 22 50 14 21 17 40 17 43 18 32 13 22 18 35 19 46
0 -2 -1 0 +2 +2 +1 +2 -5 -4 -4 -5 +3 +6 +3 +5 +3 +2 +3 +5 0 0 0 0 -5 -12 -2 -7 +3 +3 +4 +5
PAW (Pred.) = mean pulmonary
Exercise data. The relation between pulmonary artery diastolic and mean pulmonary artery wedge pressure during exercise is shown in Fig. 2. The pulmonary artery diastolic pressures varied from 16 to 48 (32.85 f 7.45) mm. Hg and the pulmonary artery wedge pressures ranged from 20 to 50 (32.45 5 7.70) mm. Hg. The correlation coefficient (i-1 between these two pressures was 0.8670. The difference between pulmonary artery wedge pressure and pulmonary artery diastolic pressure during exercise (PAW-PAD) was from -12 to +6 (-0.39 -t 3.91) mm. Hg. Relationship of PA W-PAD in exercise and resting states. The difference between the pressure gradients of PAW and PAD during exercise and at rest [(PAW-PAD,) - (PAW-PAD,)] varied
208
in mitral
artery
PAW (Pred.) (mm. Hgj
PA W-PAW (Rec.) 0’red.i (mm. Hg)
34
-2
36
+1
32
0
35
+1
19
+1
23
-1
28
+3
28
i-2
51
-1
19
+2
40
0
43
0
39
-7
27
-5
35
0
45
wedge pressure (predicted);
+1 R = resting;
and
from -4 to +7 (+0.15 + 2.46) mm. Hg. The correlation coefficient between the (PAW-PAD,) and (PAW-PAD,) was 0.7995 (Fig. 31. Discussion It is apparent from this study there is a close correlation between the pulmonary artery diastolic and mean pulmonary artery wedge pressures at rest and during exercise in patients with mitral stenosis and normal pulmonary vascular resistances. Yu and co-workers,7 reported good correlation between PAW and PAD pressures at rest (r = 0.825) in 32 patients with mitral stenosis, but no exercise study was done by these workers. The correlation of these pressures, at rest, was very high, as expected,
February,
1975,
Vol.
89, NO. 2
17.
PD
28
18.
s
9
19
RR
17
20.
MG
32
21.
MB%
21
22.
ts
11
23.
ABK
24
24.
LW
42
25.
BB
25
26.
NS
40
27.
DD
28
28.
s
31
29.
MD
19
30.
P&G
24
31.
5%
15
32.
PB
30
33.
TM
40
68 88 63 73 28 40 37 68 44 70 34 52 20 36 38 75 32 60 36 68 33 42 31 63 36 50 23 35 40 57 26 54 22 60
31 40 32 36 16 26 22 36 25 40 15 30 10 24 19 44 20 40 14 30 18 26 18 34 20 28 14 23 26 37 16 31 10 30
becahse of the nature of selection of patient5 (r = 0 ‘7). However, during exercise, a close carrel existed between the two pressures in nt study Cr = 0.8670). elatiouship between (PAW-PAD,) and AD,) had a correlation coefficient (r) of .a995 which is highly significant. The mean e between these two measurements was “15 -t- 2.46 mm. Hg. It was, therefore, hat if the exercise PAD was corrected ence (PAW-PAD) at rest, it might be x of PAW during exercise. The correlation between the predicted exercise PAW (PA r& calculated by the equation: J + (PAW-PAD511
49 62 44 55 21 34 29 50 33 52 20 35 15 30 27 58 26 48 24 42 24 32 24 47 27 37 17 30 30 44 19 42 15 40
27 37 28 34 16 25 24 42 23 41 15 30 10 24 18 40 18 36 15 25 17 23 17 35 20 28 13 22 26 36 16 32 10 32
36 32 26 38 38 30 24 43 38 31 25 33 28 22 37 31 30
etweermthe me
an increase in mean ma1 subjects. ls2 Alth~~gb ~~~5~a~~ artery we ary artery and ing exercise in mitral ~~e~os~s has been observed by ~x~~~~~s w~r~~~~s,~,~only a few patients with normal ~~1~~~~~~~ ~~~c~~~.r resistances were re~Qrte~. No ~~~~~~~~~~~ was at-
Manjuran, Agarwal, and Roy
i-r0.9017
.. . .
r-07995
.
.
R c
.
5 E
.
-4
.
iI 5
IO
I5
20
25
PA DIP, STOLIC
30
(mm OF
3.5
-S
H 1 ?
-10
Fig. 1. Relation between mean pulmonary arterial wedge (PAW) and pulmonary artery diastolic pressure (PAD) at rest.
. .
.
1.
. .
. . :
:
:
.
.
.
.
. 8 5
. .
l
.
.
l
PAW
IS
5
IO
15
20
%*ST0LIC
25
30
35
40
45
50
< m m OF H%,
Fig. 2. Relation between mean pulmonary arterial (PAW) and pulmonary artery diastolic pressure (PAD) exercise.
pulmonary diastolic
in such patients, the exercise pulmonary artery diastolic pressure itself can give a good estimate of the mean pulmonary artery wedge pressure. However, a closer value can be obtained by modifying the exercise pulmonary artery diastolic pressure by the equation:
l *
-12
.
.
l
.
Fig. 3. Relation between difference of the mean arterial wedge (PAW) and pulmonary artery pressure (PAW-PAD) at rest and during exercise.
r = 0.6670
.
. -6
I 40
01
exercise
= PAD exercise (PAW-PAD)
+ Resting
This may be of practical importance in those circumstances where the reliable recording of the pulmonary artery wedge pressure pulse during exercise is not possible. j Summary
wedge during
tempted between pulmonary artery diastolic and mean pulmonary artery wedge pressures at rest and during exercise in these studies. The findings indicate that the pulmonary circulation in patients with mitral stenosis with normal pulmonary vascular resistance behaves like that in normal subjects during exercise, and
210
. .
.
5
Resting and exercise hemodynamic studies were performed in 33 patients with mitral stenosis (14 men and 19 women; average age, 25 years) in normal sinus rhythm with normal pulmonary vascular resistances. A normal pulmonary vascular resistance was assumed when the resting pressure gradient between the pulmonary artery diastolic and mean pulmonary artery wedge pressures was 5 mm. Hg or less. A satisfactory correlation existed between the pulmonary
February, 1975, Vol. 89, No. 2
lit pressure can be modified tuted for mean p pressure if the restin nary artery w stolic pressure
r.Q.9561
X X x I
X xxx
x x
x
it
x
x
CES
xx X
x
I x X x xx
x X
x X
I
20
25
30 PREDICTED
Fig. 4. Relation wedge (PAW) pressure during
35 (mm
40 OF
between recorded mean and predicted pulmonary exercise.
45 H
B
50
55
1
pulmonary artery
artery wedge
ge and ~~Im~~ary artery diastolic pressures at rest Cr = 0.9017) and during exercise (I = 0.8 A method of predicting pulmonary artery e pressure from pulmonary artery iastolic pressure during exercise was formulated. The correlation between the predicted an measured exercise pulmonary artery wedge pressures was very close (r = 0.9561). It is suggested that during exercise the pulmonary arter.y
American
Near-t
Journal
& tia’sove
Bevegard, S., Molmgren, A., and donsson, B.. Circulatory studies in well-trained athletes at rest and during heavy exercise with special reference to stroke vohrme and influence of body position, Acta Physiol. &and. 1963. Granath, A., and Strandell, T.: Relatio.r&ips between cardiac output, stroke volume, and intracardiac s at rest and during exercise in the supine posisome anthropometric data in healthy old men, Acta Med. Scand. 176:411, 1964 almborg; R. 0.: A clinical and barn~~~a~~c analysis of factors limiting the cardiac performance in patients with coronary heart disease, Acta Med. Stand. 177:CSuppl.M26, 1965. Kaltman, A. J., Herbert, W. Ei., Conroy, R. 3., and Kossman, C. E.: The gradient in pressure across the nary vascular bed during diastole: Circulation 1966. Harvey, R. M., and Enson, Y.: Pnlnmnary vascular resistance, Adv. Intern. Med. t Roy, 9. B., Gadboys, H. L., and left-heart catheterization, AM. WEART J. Uu, P. N. G., Simpson, J. H., Lovejay, F. W., Jr., Joos: 14. A., and Nye, R. E., Jr.: Studies of pakmona:q hypertension. IV. Pulmonary circulatory dynam’ with mitral stenosis at rest, AM. EXAM 3. Gorlin, R., Sawyer, C. G., Haynes, P. W4, and Dexter, L.: Effects of exercise on circulatory dynamics in mitral stenosis, AM. NsABT J. 41:192,1951. Lukas, D. S., and Dotter, C. T.: ~~o~~~cat~o~s of tbe pmmonzry circulation in mitral stenosis, Am. Y, Med. 12:639, 1952.