Mardi Gomberg-Maitland, MD, MSc, on Right Heart Catheterization in the Management of Patients With PH
In this podcast, Mardi Gomberg-Maitland, MD, MSc, speaks about the reasons she believes right heart catheterization is necessary in the follow-up management of patients with pulmonary hypertension, including the risks and benefits of having a right heart catheterization.
- Sitbon O, Gomberg-Maitland M, Granton J, et al. Clinical trial design and new therapies for pulmonary arterial hypertension. Eur Respir J. 2019;53(1). https://doi.org/10.1183/13993003.01908-2018
Mardi Gomberg-Maitland, MD, is a cardiologist and a Professor of Medicine at George Washington University School of Medicine and Health Sciences in Washington, DC.
Jessica Bard: Hello, everyone. Welcome to another installment of "Podcasts360," your go‑to resource for medical news and clinical updates. I'm your moderator Jessica Bard with Consultant360 Specialty Network.
Right‑heart catheterization is used for confirming the diagnosis of pulmonary arterial hypertension and can be used in the follow‑up management of patients with PAH. However, reasons for not performing a right‑heart cath in follow‑up might include cost or the risk associated with the invasive procedure.
Dr Mardi Gomberg‑Maitland is here to speak with us about that today. She's a cardiologist and a professor of medicine at George Washington University in Washington, DC.
Dr Gomberg‑Maitland, you'll be speaking at the session "Clinical Controversies in Pulmonary Hypertension ‑‑ A Pro/Con Debate" at ATS 2021 annual meeting. Do you believe that right‑heart catheterization is necessary in the follow‑up management of PAH?
Dr Mardi Gomberg‑Maitland: Obviously, the answer is yes. I believe that right‑heart catheterization is important in follow‑up of pulmonary hypertension. My colleague, not sure if you're interviewing as well. If you are, he's going to sound a lot better because he has a nice English accent and probably thinks he'll win the debate.
The reality is pulmonary hypertension is high pressure in the lungs. It's defined by the heart catheterization. Wouldn't it make sense to do a follow‑up catheterization in order to assess improvement?
We do that with regular blood pressure, systemic blood pressure. We should be doing that with pulmonary blood pressure. Unfortunately, a lot of our imaging right now, it's a good screen, but it's not diagnostic. Especially early on in follow‑up, it's important to know where we stand.
Jessica: What are the risks and benefits of having a right‑heart catheterization? Is it safe in the follow‑up management of all patients with PAH?
Dr Gomberg‑Maitland: If the patient is really sick, that's going to be a risk regardless. Obviously, imaging would be a safer option because it's non‑invasive.
Catheterization's been going on for at least 50 years. It's been a long time, and we've gotten better at it. We even go through the arm now, and they go home within an hour. It's a lot less risk than it used to be. It's still a very low‑risk procedure. It's the sedation, you're not on a ventilator. Folks at the conference know that it's not a high risk and we do it all the time.
The community would prefer non‑invasive imaging because it's easier and it's less on the patient and it isn't an invasive procedure, but it's not accurate enough. The benefit is knowing exactly what the resistance is in the lungs or the amount of work that the lungs do versus guessing it.
There's only a few centers where they spend enough time doing the imaging study and getting the right results. In fact, sometimes it might be more of a risk to go for an MRI. That's an hour procedure down in the basement, with breathing that you have to synchronize. In order to get the images could be harder than doing the heart cath.
There's always going to be exceptions, and some patients will be better off with one test or the other. If we want to know where the patients at and what their pressures are and their resistance, you have to do a heart catheterization.
Jessica: Do you believe that in the future imaging will be able to be utilized instead of right‑heart cath?
Dr Gomberg‑Maitland: We're getting closer all the time. It's a really good question. We all hoped that MRI would be able to take over. It's not small enough. It's not feasible across the world. This is an international conference. It's not just the US. Even here in the US, we can't get it reimbursed because it's not standard of care.
Imaging has played more of a role in understanding the physiology and for research purposes versus I need to know exactly what the hemodynamics are. That still is the right‑heart cath. We all see that iPhones have advanced so rapidly that it's only a matter of time till the imaging gets to the point where we won't need the right‑heart cath, but we're not there yet.
Jessica: What are the overall key take‑home messages for our audience from your session and your position?
Dr Gomberg‑Maitland: The key take‑home is that we need to be doing more right‑heart caths and that patients can suffer from not having it.
If we just rely on echo imaging and if you're not even seeing the images, which happens sometimes, if you're a pulmonologist and you're referring to the cardiologist and you just get the reports, you might not appreciate that the right ventricular function is worse. If you have a heart catheterization, you're going to have the actual numbers and know what the pressure is.
For many patients, you really do need to do the heart cath. It's an understanding that there is a role for imaging and follow‑up. If patients aren't doing well or they need to be in a clinical trial because there's new therapies out there, the right‑heart cath is still the gold standard.
Jessica: Is there anything else that you'd like to add that you believe that we missed?
Dr Gomberg‑Maitland: I'm hoping that I won the debate.
Jessica: You've convinced me. [laughs] Thank you very much for your time. I appreciate it.
Dr Gomberg‑Maitland: Thank you.