Anatomical, Functional, and Hemodynamic Determinants of Increased Pulmonary Capillary Wedge Pressure V-Wave Amplitude

IntroductionIncreased pulmonary capillary wedge pressure (PCWP) V-wave amplitude has been traditionally associated with significant mitral regurgitation (MR). However, increased PCWP V-waves may also occur in patients with elevated left ventricular end-diastolic pressure (LVEDP) or with dilated left atrium (LA). Interactions between MR, increased LVEDP, and LA dilatation in the genesis of increased PCWP V-waves were not well investigated. Material and MethodsIt was a single-center cohort study of 153 consecutive hemodynamically stable patients referred for invasive hemodynamic evaluation of dyspnea. Patients with significant valvular disease other than MR, acute coronary syndromes (ACS), hemodynamic instability, pericardial disease, and mechanical ventilation or mechanical LV support were excluded. ResultsStudy cohort included 41% males, 68.4+/-11.9 years old, 60% were on beta-adrenergic antagonists and 69.3% were on afterload reduction therapy. PCWP V-wave amplitude was significantly increased in patients with moderate or more severe MR (p<0.001), dilated LA (p=0.002), with a trend towards increased V-wave amplitude in elevated >12 mmHg LVEDP (p=0.117). There were no significant differences in age, gender, prevalence of LV dysfunction, other co-morbidities, and/or E/e ratio according to the MR degree, LA volume, and LVEDP. In patients categorized according to moderate or more severe MR, dilated LA, and increased >12 mmHg LVEDP - the presence of any two of these abnormal parameters was associated with 50-65% prevalence of elevated V-waves and reached 100% when all three were parameters were abnormal (p<0.002). ConclusionsIn euvolemic patients undergoing elective invasive hemodynamic evaluation of dyspnea, elevated PCWP V-waves are determined by three major pathophysiological parameters: moderate or more severe MV regurgitation, LA dilatation, and elevated LVEDP.