A prediction model of simple echocardiographic variables to screen for potentially correctable shunts in adult patients with pulmonary arterial hypertension associated with atrial septal defects: a cross-sectional study


During the routine follow-up of adult patients with pulmonary arterial hypertension associated with atrial septal defects (ASD-PAH), the suitability of shunt closure depends on the invasive right heart catheterization (RHC). It is difficult to grasp the timing of RHC shunt closure for moderate-severe PAH. This retrospective cross-sectional study was designed to investigate which echocardiographic variables are related to pulmonary vascular resistance (PVR) in adult ASD-PAH patients and propose a method using echocardiographic variables to screen for patients where shunt closure is suitable. A total of 139 adult ASD-PAH patients with a PASP ≥ 60 mmHg measured by transthoracic echocardiogram (TTE) were included in this study. All RHCs were performed within a week after TTE. The Correctable shunt was defined as PVR ≤ 4.6 wood units (WU). Multivariate regressions were performed with echocardiographic variables. The nomogram of prediction model was constructed by the predictors of PVR ≤ 4.6 WU by multivariate logistic regression analysis. Multivariate linear regression revealed that TAPSE (tricuspid annular plane systolic excursion)/pulmonary artery systolic pressure (PASP) measured by TTE was negatively associated with PVR (β per SD: − 1.84, 95%CI − 2.62, − 1.06). Multivariate logistic regression showed that TAPSE/PASP and pulmonary valve (PV) peak velocity were positively associated with a potentially correctable shunt (PVR ≤ 4.6 WU) (OR per SD: 2.38, 95%CI 1.34, 4.25, and OR per SD: 2.67, 95%CI 1.26, 5.64, respectively). In receiver operating characteristic analysis, the TAPSE/PASP + PV peak velocity combined model achieved the best performance (AUC: 0.8584, sensitivity: 83.33%, specificity: 72.16%). Internal verification showed stable performance (AUC: 0.8591, sensitivity: 88.10%, specificity: 68.04%). The net benefit of this model was greater than other models when it came to a wide range probability threshold in decision curve analysis. TAPSE/PASP + PV the peak velocity model may have great value in predicting adult ASD-PAH patients with operability potential, which could help clinicians make the treatment decision for follow-up patients.

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Availability of data and materials

The data that support the findings of this study are available on request. The data are not publicly available due to the containing information that could compromise the privacy of research participants.

Code availability

Not applicable.



Atrial septal defect


Pulmonary arterial systolic pressure


Pulmonary arterial hypertension


Pulmonary valve


Pulmonary vascular resistance


Right heart catheterization


Right ventricular outflow tract diameter


Tricuspid annular plane systolic excursion


Peak velocity of tricuspid regurgitation

TV s’:

Systolic annular tissue velocity of the lateral tricuspid annulus


Velocity–time integral


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This work was supported by Guangdong Provincial People's Hospital Hospital Science and Technology Special Project (No. 2017zh04); Guangzhou Science and Technology Key Project [201904010448], National key Research and Development Program of China [2018YFC1002600], the Natural Science Foundation of Guangdong Province [2018A030313785, 2018A030313764], the Science and Technology Planning Project of Guangdong Province, China [No.2017A070701013, 2017B090904034, 2017B030314109, 2018B090944002, 2019B020230003], and Guangdong Peak Project [DFJH201802].

Author information




Mingqi Li, Yu Wang and Hezhi Li collected echocardiographic data, performed the statistical analysis and drafted the manuscript under the supervision of Hongwen Fei and Caojin Zhang. Yigao Huang, Tao Huang and Caojin Zhang helped to collect the data of right heart catheterization. All authors read and approved the final manuscript.

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Correspondence to Caojin Zhang or Hongwen Fei.

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This study was approved by the Research Ethics Committee of Guangdong General Hospital, Guangdong, China on 24 July 2015 (No. GDREC2015254H(R1)). We further confirm that any aspect of the data collection covered in this manuscript that has involved our patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript.

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Li, M., Wang, Y., Li, H. et al. A prediction model of simple echocardiographic variables to screen for potentially correctable shunts in adult patients with pulmonary arterial hypertension associated with atrial septal defects: a cross-sectional study. Int J Cardiovasc Imaging (2021). https://doi.org/10.1007/s10554-020-02128-5

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  • Pulmonary arterial hypertension
  • Atrial septal defect
  • Echocardiography
  • Pulmonary vascular resistance