Cardiac catheterization in pediatric pulmonary hypertension: a systematic and practical approach

Abstract

Significant progress in the understanding of the etiology, epidemiology, pathobiology and prognosis of pulmonary hypertension (PH) has been made over the last years. Especially in the pediatric patient population the etiology of PH is very heterogeneous. Nevertheless, the most recent change of the definition of PH to a mean pulmonary artery pressure (mPAP) >20 mmHg has been accepted by pediatricians for uniformity and concordance with adult physicians. Based on the diverse underlying medical conditions leading to PH, a comprehensive and systematic approach for diagnosis and treatment is mandatory. Cardiac catheterization remains the gold standard for invasive assessment and acute vasoreactivity testing (AVT) additionally providing detailed information about nature of PH. In most patients repeat cardiac catheterization may be helpful for evaluation of response to targeted PH treatment, risk stratification and indication for lung transplantation. However, the information and results taken from cardiac catheterization should be interpreted by experienced investigators only who are familiar with confounding factors that may influence the results. Here we provide an overview of current recommendations for invasive hemodynamic evaluation in pediatric PH. We point out different patient scenarios and provide a structured approach for AVT and response interpretation.

Keywords: Cardiac catheterization; children; pulmonary hypertension (PH); vasoreactivity.

Figure 1

Suggestion of a protocol for right heart catheterization and acute vasoreactivity testing. * = in instable patients the protocol may be stopped at this point without proceeding to the next steps for testing. VR, vasoreactivity; iNO, inhaled nitric oxide; O₂, oxygen; RHC, right heart catheterization.