Pulmonary Congestion by Conventional Chest Radiography: Relationship With Hemodynamics and Mortality in Patients With Severe Aortic Stenosis

Background The relationship between chest radiography (CXR) findings of pulmonary congestion and invasive hemodynamics and clinical outcomes in patients with cardiac diseases is unclear. We assessed the correlation between a CXR-based congestion score (RxCS) and the mean pulmonary artery wedge pressure (mPAWP) and the prognostic impact of RxCS and mPAWP in severe aortic stenosis (AS). Methods In 471 severe AS patients undergoing right heart catheterization and upright CXR, the RxCS was calculated (six items, maximum score: 10 points) independently by two radiologists (average value taken) blinded to clinical data. Congestion was defined as RxCS >1. Four patterns were defined based on presence/absence of congestion (C+ or C-) and elevated (>15 mmHg)/normal mPAWP (P+ or P-). Results The median (interquartile range) RxCS was 1 (0-2). Patients with an RxCS >1 (n=207) had a higher mean right atrial pressure, mean pulmonary artery pressure (mPAP), mPAWP, and pulmonary vascular resistance than patients with an RxCS ≤1 (n=264). However, the correlation between the RxCS and mPAWP was moderate only (r=0.45). Patients with a C+/P+ pattern had the worst hemodynamics, while C-/P- patients had the most favourable constellation. After a median post-valve replacement follow-up of 1361 days mortality was higher in patients with RxCs >1 versus ≤1 as well as mPAWP >15 mmHg versus ≤15 mmHg. Mortality was highest in C+/P+ patients and lowest in C-/P-, while it was intermediate in C-/P+ and C+/P- patients. Conclusions In AS patients, there is a significant but moderate correlation between RxCS and mPAWP. Both RxCS and mPAWP provide prognostic information.