Download Association of Coronary Sinus Diameter with Pulmonary Hypertension

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C 2008, Wiley Periodicals, Inc.
Journal compilation DOI: 10.1111/j.1540-8175.2008.00718.x
ORIGINAL INVESTIGATIONS
Association of Coronary Sinus Diameter
with Pulmonary Hypertension
Yilmaz Gunes, M.D., Unal Guntekin, M.D., Mustafa Tuncer, M.D., Yuksel Kaya, M.D.,
and Aytac Akyol, M.D.
Cardiology Department, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
Background: Impaired venous drainage secondary to increased right atrial pressure (RAP) may result
in coronary sinus (CS) dilatation. Methods: Two hundred fifteen patients referred for transthoracic
echocardiography were included in the study. CS diameters were measured from apical four-chamber
view with the transducer being slightly tilted posteriorly to the level of the dorsum of the heart.
Pulmonary artery systolic pressure (PASP) is estimated by measurement of tricuspid regurgitation
velocity (v) and estimate RAP based on size and collapsibility of inferior vena cava (VCI) with the
formula PASP: 4v2 +RAP. Patients with PASP >35 mmHg were considered to have pulmonary hypertension (PH). Results: CS diameter was measured in 80.3% of the patients with normal PASP (8.1 ±
2.4 mm) and 93.1% of the patients having PH (12.3 ± 2.5 mm). PASP was significantly correlated
with CS diameter (r = 0.647, P < 0.001), RA volume index (r = 0.631, P < 0.001), RV volume index
(r = 0.475, P < 0.001), VCI diameter (r = 0.365, P < 0.001), and left ventricular ejection fraction
(LVEF) (r = –0.270, P < 0.001). CS diameter was also correlated significantly with estimated RAP
(r = 0.557, P < 0.001), RA volume index (r = 0.520, P < 0.001), RV volume index (r = 0.386, P <
0.001), LVEF (r = –0.327, P < 0.001), and VCI diameter (r = 0.313, P < 0.001). Multivariate analyses,
testing for independent predictive information of CS size, VCI diameter, RA and RV volume indexes,
and estimated RAP for the presence of PH revealed that estimated RAP (beta = 0.465, P < 0.001)
and CS size (beta = 0.402, P = 0.003) were the significant predictors. Conclusions: Coronary sinus
is dilated in patients with pulmonary hypertension. Coronary sinus diameter significantly correlates
with PASP, RAP, right heart chamber volumes, LVEF, and VCI diameter. (ECHOCARDIOGRAPHY,
Volume 25, October 2008)
coronary sinus, pulmonary hypertension, right atrial pressure, vena cava inferior
The estimation of pulmonary artery systolic
pressure (PASP) with Doppler echocardiography is a simple and reliable noninvasive method
for the detection of pulmonary hypertension
(PH).1,2
In daily practice, PASP is estimated from
adding the mean right atrial pressure (RAP) of
a floating constant of 5, 10, or 20 mmHg (depending on the size of right atrium and appearance of the inferior vena cava [VCI]) to right
ventricular (RV) to right atrial (RA) pressure
gradient derived from incorporation of peak tricuspid regurgitation (TR) velocity into modified
Bernoulli equation. This method appears to result in satisfactory estimation of intercardiac
pressure.2–4 However, discrepancy between estimated RAP (either assumption of a constant
value or estimation by the pattern of VCI) and
measured RAP by right heart catheterization
has been reported.5–7 Venous system drains into
coronary sinus (CS) and opens to right atrium.
Therefore, we thought that CS size may be associated with RAP. Although, CS is often visualized on echocardiography in patients with rightsided heart disease relevance of this finding is
undefined.
In this study, we aimed to search the association of CS size with PASP, RAP, right heart
chambers, and VCI diameter.
Methods
Address for correspondence and reprint requests: Yilmaz
Gunes, M.D., Cardiology Department, Faculty of Medicine,
Yuzuncu Yil University, Van, Turkey. Fax: +904322168352; E-mail: [email protected]
Vol. 25, No. 9, 2008
A total of 215 patients referred for transthoracic echocardiography were included in the
study. Patients having severe valvular heart
ECHOCARDIOGRAPHY: A Jrnl. of CV Ultrasound & Allied Tech.
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GUNES, ET AL.
disease and unsatisfactory imaging of CS
and/or VCI were excluded from the study.
Transthoracic echocardiography was performed in accordance with the combined
ASE/ESC guidelines8 using commercially available device (Vivid 3, General Electric, Chicago,
IL, USA) with a 3 MHz transducer and with digital image storage. Volumes of the right heart
chambers were measured from apical four- and
two-chamber views and indexed for body surface area. From the four-chamber view plane,
the transducer was slightly tilted posteriorly
to the level of the dorsal wall of the heart. At
this level, both ventricles, right atrium, right
atrioventricular valve, and the floor of the left
atrium could still be visualized. In the posterior aspect of the left atrioventricular junction,
it was possible to identify the CS in its entire
length from the most lateral aspect of the heart
to its entry into the RA, just above the septal leaflet of the tricuspid valve (Fig. 1). Maximal and minimal CS diameters were measured
at the proximity of atrial junction and percent
contraction of CS diameter was calculated by
dividing minimum diameter to maximum diameter. Right ventricular to right atrial pressure gradient was calculated from velocity of
tricuspid insufficiency flow (v) in the parasternal short-axis and apical four-chamber view,
and the highest tricuspid regurgitation velocity
was taken as study sample. RAP was gauged by
measuring the size of VCI diameter adjacent to
the RA and the percent reduction in its diameter during inspiration in the subcostal view. A
diameter <1.5 cm estimated RAP 0–5 mmHg;
a normal diameter (1.5–2.5 cm) with inspira-
tory collapse >50% estimated RAP 5–10 mmHg;
a normal diameter with 50%< collapse estimated RAP 10–15 mmHg; dilatation with 50%<
collapse estimated RAP 15–20 mmHg and dilatation without inspiratory collapse estimated
RAP >20 mmHg.9,10 PASP is estimated with
the formula PASP: 4v2 +RAP.1,9 Patients with
PASP >35 mmHg were considered to have PH.
In the case of a large CS contrast injection of
a bolus of saline was performed in a left arm
peripheral vein to exclude the possibility of left
persistent superior vena cava (filling of CS with
bubbles before RA). Measurements were obtained by two experienced echocardiographers
blinded to clinical information and averaged.
The acquired images were reanalyzed independently to obtain the inter- and intraobserver
variabilities. The study was approved by the
ethics committee of the local institution and patients’ consents were obtained.
Statistics
Quantitative variables are expressed as
mean ± standard deviation (SD), and qualitative variables as numbers and percentages. Differences between independent groups
were assessed by Student’s t-test for normally
distributed quantitative variables and MannWhitney’s U-test for variables without normal
distribution of variances and Chi-square test
for qualitative variables. Pearson correlation
analysis was used to assess the correlations
for PASP, RAP, and the maximum CS diameter. Multivariate linear regression analysis was
used to analyze the value of different baseline characteristics as independent predictors
of PH. All tests were performed in the SPSS
for Windows, version 10.0 (SPSS, Chicago, IL,
USA). All results were considered statistically
significant at the level of P < 0.05.
Results
Figure 1. Coronary sinus (arrows) draining into right
atrium.
936
Eight patients having PH and 26 patients
with normal PASP were excluded from the
study due to unsatisfactory imaging of CS.
Therefore, CS diameter was measurable in
80.3% of the patients with normal PASP and
93.1% of the patients having PH. Intra- and interobserver variabilities for all measurements
were less than 5% and nonsignificant. No patient was suspected of left persistent superior
vena cava. Clinical and echocardiographic characteristics of the study group are seen in Table I.
Patients with PH were older, had larger right
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CORONARY SINUS IN PULMONARY HYPERTENSION
TABLE I
Characteristics of the Study Population
Age (years)
Male
Body mass index
Diabetes mellitus
Hypertension
Smoking
COPD
Atrial fibrillation
Coronary artery disease
LVEF
Maximum CS diameter (mm)
Minimum CS diameter (mm)
CS contraction (%)
VCI diameter (mm)
RA volume (cm3 )
RA volume index (cm10−4 )
RV volume (cm3 )
RV volume index (cm10−4 )
Pulmonary Hypertension
(N = 109)
Normal PASP
(N = 106)
P-Value
60.7 ± 1.3
51 (46.8%)
25.3 ± 4.7
20 (18.3%)
43 (39.4%)
34 (31.2%)
36 (33.0%)
34 (31.2%)
30 (27.5%)
52.7 ± 13.9
12.3 ± 2.5
9.3 ± 2.5
75.2 ± 8.3
23.6 ± 4.8
81.5 ± 55.0
45.5 ± 31.8
53.4 ± 35.9
30.1 ± 22.2
44.4 ± 15.7
63 (59,4%)
25.9 ± 3.8
5 (4.7%)
22 (20.7%)
30 (28.3%)
4 (3.8%)
1 (0.9%)
20 (18.8%)
60.2 ± 7.7
8.1 ± 2.4
5.5 ± 2.1
66.8 ± 11.2
20.8 ± 3.4
36.5 ± 14.3
19.9 ± 7.1
32.1 ± 11.2
17.5 ± 5.8
<0.001
0.076
0.307
0.002
0.003
0.658
<0.001
<0.001
0.148
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
PASP = pulmonary artery systolic pressure; COPD = chronic obstructive pulmonary disease; LVEF =
left ventricular ejection fraction; VCI = inferior vena cava; RA = right atrium; RV = right ventricle.
heart chambers and wider CS (Fig. 2) and VCI
diameters. PASP was significantly correlated
with CS diameter (r = 0.647, P < 0.001), RA
volume index (r = 0.631, P < 0.001), RV vol-
ume index (r = 0.475, P < 0.001), VCI diameter
(r = 0.365, P < 0.001), and left ventricular ejection fraction (LVEF) (r = –0.270, P < 0.001). Estimated RAP was significantly correlated with
PASP (r = 0.710, P < 0.001), VCI diameter (r =
0.707, P < 0.001), RA volume index (r = 0.601,
P < 0.001), CS diameter (r = 0.557, P < 0.001),
RV volume index (r = 0.531, P < 0.001), and
LVEF (r = –0.295, P < 0.001). Maximum CS diameter was correlated significantly with PASP
(r = 0.647, P < 0.001), estimated RAP (r = 0.557,
P < 0.001), RA volume index (r = 0.520, P <
0.001), RV volume index (r = 0.386, P < 0.001),
LVEF (r = –0.327, P < 0.001), and VCI diameter
(r = 0.313, P < 0.001). Multivariate analyses,
testing for independent predictive information
of CS size, VCI diameter, RA and RV volume
indexes, and estimated RAP for the presence of
PH revealed that estimated RAP (beta = 0.465,
P < 0.001) and CS size (beta = 0.402, P = 0.003)
were the significant predictors.
Discussion
Figure 2. Error bar of coronary sinus by pulmonary hypertension.
Vol. 25, No. 9, 2008
In this study we evaluated size of CS and
found significant association with PASP, RAP,
VCI size, and right heart chambers.
In the parasternal long-axis view of the left
ventricle, the CS can be seen wedged into the
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GUNES, ET AL.
atrioventricular sulcus. Because the CS courses
around the posterior aspect of the left atrioventricular groove in a plane perpendicular to the
longitudinal plane of the heart, it is seen in its
short axis as a circular structure adjacent to the
posterior mitral valve. Except for a dilated CS,
this echocardiographic section does not always
provide a clear definition of the CS. The apical
position has been considered as the best section
for the visualization of the coronary sinus in a
normal heart.11
Transthoracic echocardiography (TTE) is an
excellent noninvasive method to detect PH.
TTE estimates PASP and provides additional
information about causes and consequences of
PH. PASP is equivalent to right ventricular systolic pressure (RVSP) in the absence of right
ventricular or pulmonary outflow obstruction.
RVSP is estimated by measurement of tricuspid regurgitation velocity (v) and estimate
RAP with the formula RVSP: 4v2 +RAP.1,9 The
echocardiographic studies with patients having diverse disorders showed that predictions
of RVSP correlated well with catheterization
values.2–4 RAP is either a standard value of 5–
15 mmHg or estimated value from characteristics of VCI or from the height of jugular venous
distension.12 Additional echocardiographic and
Doppler parameters, including right and left
ventricular dimensions and function, valvular
abnormalities, right ventricular ejection and
left ventricular filling characteristics, and VCI
dimensions, are for the diagnosis confirmation
and assessment of severity of PASP.1
Use of the size and inspiratory collapsibility
of the VCI is the most widely adopted method
for the estimation of RAP.9 Although, a number
of studies report a high correlation (0.57–0.93)
between TTE and right heart catheterization
measurements of PASP,1 discrepancies have
been observed between RAP estimated by the
pattern of VCI collapse and measured by right
heart catheterization.6,7,13,14 Vena cava measurements depend on the image being obtained
perpendicular to the vessel, and in addition,
there may be differences in the collapsibility
of the VCI based on variations in inspiratory
effort. Decreased respiratory effort, by causing
smaller swings of intrapleural pressure, can
simulate VCI plethora. Conversely, increased
respiratory effort, as may occur due to various
cardiac or respiratory causes, might prevent
VCI plethora from being manifest even when
the central venous pressure is high.15 Brennan et al.6 evaluated echocardiographic imag-
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ing of the VCI for estimation of RAP in 102
patients undergoing right heart catheterization
and found that traditional classification of RAP
into 5 mmHg ranges based on VCI size and
collapsibility performed poorly (43% accurate).
The VCI size cutoff with optimum predictive use
for RAP above or below 10 mmHg was 2.0 cm
(sensitivity 73% and specificity 85%) and the
optimal VCI collapsibility cutoff was 40% (sensitivity 73% and specificity 84%). Therefore, assessment of additional criteria like right heart
chamber volumes and CS diameter may be useful for the prediction of RAP. Machraouni et al.13
found a good correlation between pulmonary
artery mean pressure and the area index of
the two right heart cavities (r = 0.83) and between RAP and RA area index (r = 0.64). In
the study of Raymond et al.,16 RA area index
was also closely correlated with RAP (r = 0.72,
P < 0.001). In the present study, we found that
patients with PH had larger right heart chambers and wider CS and VCI diameters and there
were significant correlations between PASP, estimated RAP, right heart chamber volume indexes, VCI diameter, and CS diameter. Therefore, assessment of all of these parameters may
be useful during evaluation of PH on echocardiographic examination.
Andrade et al.11 studied 400 patients of 5 to
80 years of age and defined CS diameter as 0.4–
0.8 cm. Kronzon et al.17 were able to measure
CS diameter at the right atrial communication
by TTE in 16 of 40, and in all patients by transesophageal echocardiography (maximal diameter 6 to 14 mm, mean 9 ± 2). Dilated CS
can result from increased blood flow due to
abnormal venous drainage found in persistent
left superior vena cava, total anomalous intracardiac pulmonary venous drainage, impaired
right ventricular function, severe tricuspid regurgitation, unroofed left atrium, CS diverticulum, or coronary artery to CS fistula.11,18,19 In
the absence of primary abnormalities of the tricuspid valve, right atrial enlargement is generally a manifestation of high RAP due to functional tricuspid regurgitation or elevated right
ventricular diastolic pressure. A previous study
demonstrated that pericardial effusion size is
correlated with RAP in patients with PH20 and
a likely mechanism of pericardial effusion observed in patients with primary PH was explained to be impaired venous and lymphatic
drainage resulting from elevated RAP.16,18 Accordingly, impaired venous drainage secondary
to increased RAP may result in CS dilatation.
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CORONARY SINUS IN PULMONARY HYPERTENSION
Patients with poor left ventricular systolic function show mild CS dilatation21 and attenuation of CS contraction has been described
in patients with congestive heart failure with
marked venous congestion.22 In the present
study, there was a moderate but significant correlation between CS diameter and LVEF and
CS contraction was attenuated in patients with
PH. This attenuation may be an echocardiographic sign of elevated right heart pressures
and central venous pressure. Ehtisham et al.23
visualized CS in 81% of 43 patients who underwent right heart catheterization for the evaluation of PH. Coronary sinus size correlated significantly with RA size (r = 0.60, P < 0.001)
and RA pressure (r = 0.59, P < 0.001) but
not with RV size, degree of tricuspid regurgitation, right ventricular pressure, mean pulmonary artery pressure, or pulmonary vascular
resistance. Lee et al.24 assessed the anatomical
changes of the CS with coronary venography
in patients with LV dysfunction having moderate or severe mitral regurgitation. They found
significant positive correlation between the CS
perimeter and the PASP and magnitude of mitral regurgitation. No other significant correlations were observed between CS dimensions
and left ventricular diameters, mitral annulus
diameter, left atrial diameter, and right heart
filling pressures. We were able to measure CS
diameter in 80.3% of the patients with normal
PASP (8.1 ± 2.4 mm) and 93.1% of the patients
having PH (12.3 ± 2.5 mm). We found that
CS size was significantly correlated with PASP,
RAP, RA, and RV volumes, LVEF and VCI diameter and a dilated CS is a significant predictor
of PH.
Limitations
The gold standard for determination of PASP
is right heart catheterization. Right heart
catheterization is not performed due to ethical concerns and is the major limitation of the
study. As exact pressures are not measured by
catheterization, evaluation of accuracy and cutoff values of echocardiographic findings to predict PASP and RAP were not possible. However,
because this procedure is invasive, expensive,
and potentially risky, determining PASP noninvasively has been a current matter for years. Although, PASP cannot be determined by echocardiography in some patients it is an inexpensive
and reliable method allowing serial measurements and is the most commonly used noninvasive tool to determine PASP.1,9
Vol. 25, No. 9, 2008
Conclusions
Our findings show that coronary sinus is dilated in patients with PH. Coronary sinus diameter significantly correlates with PASP, RAP,
right heart chamber volumes, LVEF, and VCI
diameter. Therefore, echocardiographic evaluation of CS may be considered an integral component of the assessment of PH on echocardiographic examination.
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