Left Atrial Pressure

Left atrial pressure, LAP, is becoming rapidly and important measurement to accurately treat patients in acute decompensated heart failure with congestion but also to rule out a component of pulmonary vascular congestion due to HfpEF.  Due to the dramatic decrease decline in use of pulmonary artery catheters, this is really the next best measurement we have for left ventricular filling/correlate to left ventricular end-diastolic pressure.

However in patients with moderate to severe ARDS that require proning due to severe hypoxemia, I still feel these patient's benefit from a pulmonary artery catheter.  Prior studies that  reviewed  the use of PA catheters was in all-comers in the MICU,  in a very inhomogeneous patient population, an Achilles heel in randomized control trials that limit any credibility regarding external validity.

Notable exception here is that a pulmonary artery catheter still remains a standard of care in post cardiac surgery patients, as well as stage IV class D for treatment decisions for in particular inotropic therapy with milrinone, heart failure patient and cardiogenic shock

I have posted earlier this year on diastolic function and a quick easy approach to assess intracardiac filling pressures.  This is a more complete article with the 2016 guidelines from ASE with attached PowerPoint presentation.

 Realize that most echocardiographic reports are quite inaccurate in determining the degree of diastolic dysfunction and are even more inaccurate in the determination of left atrial pressure. Tissue Doppler imaging from the lateral mitral annulus and medial mitral annulus has become a surrogate quick measure ( E/e' ratio)  for cardiologist and Intensivist ( by bedside US) to determine left atrial pressure. Nothing is farther from the truth : these numbers need to be correlated with additional markers and pressure measurements obtained by echocardiography to give an accurate value. This requires a comprehensive and somewhat time consuming procedure, particularly if done at the bedside.  In most patients on mechanical ventilation, it may not be possible to follow the guidelines to obtain all the measurements that go into the final determination of left atrial pressure/LAP