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Goldstein BH, O’Byrne ML, Petit CJ, Qureshi AM, Dai D, Griffis HM, France A, Kelleman MS, McCracken CE, Mascio CE, Shashidharan S, Ligon RA, Whiteside W, Wallen WJ, Agrawal H, Aggarwal V, Glatz AC. Differences in Cost of Care by Palliation Strategy for Infants With Ductal-Dependent Pulmonary Blood Flow. Circ Cardiovasc Interv 2019; 12:e007232. [PMID: 30998390 PMCID: PMC6546294 DOI: 10.1161/circinterventions.118.007232] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In infants with ductal-dependent pulmonary blood flow, initial palliation with patent ductus arteriosus (PDA) stent or modified Blalock-Taussig (BT) shunt have comparable mortality but discrepant length of stay, procedural complication rates and reintervention burdens, which may influence cost. The relative economic impact of these palliation strategies is unknown. METHODS AND RESULTS Retrospective study of infants with ductal-dependent pulmonary blood flow palliated with PDA stent (n=104) or BT shunt (n=251) from 2008 to 2015 at 4 centers of the Congenital Catheterization Research Collaborative. Inflation-adjusted inpatient hospital costs were calculated for first year of life using Pediatric Health Information System data. Costs derived from outpatient catheterizations not in Pediatric Health Information System were imputed. Costs were compared using propensity score-adjusted multivariable models, to account for baseline differences between groups. After propensity score adjustment, first year of life costs were significantly lower in PDA stent ($215 825 [190 644-244 333]) than BT shunt ($249 855 [230 693-270 609]) patients ( P=0.05). After addition of imputed costs, first year of life costs were not significantly different between PDA stent ($226 403 [200 274-255 941]) and BT shunt ($252 072 [232 955-272 759]) groups ( P=0.15). Patient characteristics associated with higher costs included: younger gestational age, genetic syndrome, noncardiac diagnoses, procedural complications, extracorporeal membrane oxygenation, duration of ventilation, intensive care unit and hospital length of stay and reintervention ( P≤0.02 for all). CONCLUSIONS In this first multicenter comparative cost study of PDA stent or BT shunt as palliation for infants with ductal-dependent pulmonary blood flow, adjusted for baseline differences, PDA stent was associated with lower to equivalent costs over the first year of life. Combined with previous evidence suggesting clinical noninferiority, these findings suggest that PDA stent provides competitive health care value.
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Affiliation(s)
| | - Michael L. O’Byrne
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | | | - Athar M. Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Dingwei Dai
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Heather M. Griffis
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Ashton France
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | | | | | - Christopher E. Mascio
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
| | - Subi Shashidharan
- Children’s Healthcare of Atlanta, Emory University School of Medicine
| | - R. Allen Ligon
- Children’s Healthcare of Atlanta, Emory University School of Medicine
| | - Wendy Whiteside
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | - W. Jack Wallen
- The Heart Institute, Cincinnati Children’s Hospital Medical Center
| | - Hitesh Agrawal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Varun Aggarwal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine
| | - Andrew C. Glatz
- The Cardiac Center at the Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine
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152
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Zablah JE, Fry R, Eilers D, Morgan G, Wilson N, Ross M. The Length Versus Diameter Relationship and Radial Force Properties of the Amplatzer™ Vascular Plug Type IV: Observations for Oversizing. Cardiovasc Eng Technol 2019; 10:271-276. [PMID: 30903455 DOI: 10.1007/s13239-019-00409-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/14/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND In palliated single ventricle patients aortopulmonary collateralization is a cause for significant loss of cardiovascular efficiency. In larger vessels, device occlusion becomes an alternative to embolization with multiple coils. The physical characteristics of the Amplatzer ™ Vascular Plug Type IV (AVPIV) are potentially conducive to oversizing the device allowing coverage of a longer portion of vessel. Despite the widespread use of the AVPIV, little published data exists describing the behavior of the device as it is constrained in different vessel sizes. METHODS 4-8 mm AVPIV devices were measured in glass tubing in diameters ranging from 1 to 8 mm internal diameter. Radial force was measured by constraining the devices to the desire diameters from 1 to 7 mm and measuring the force the device exerted to one of the constraining walls. This force vs. diameter relationship was evaluated for each device and compared across different devices. RESULTS The devices range in length from 12.36 to 31.24 mm. The 4 mm device lengthened 3.44 mm from unconstrained to 1 mm diameter (12.36 to 15.80 mm), while the 8 mm AVP IV lengthened 14.74 mm from unconstrained to 1 mm diameter constraint (16.50-31.24 mm, 89% lengthening). The highest overall radial force (1.38 N), radial force at 50% compression (1.25 N), and average stiffness (0.95 N/mm) was found in the 5 mm diameter device. CONCLUSIONS The AVP IV device has a reliable length for diameter relationship. A counterintuitive property of the AVP IV with regards to radial force for device size was found. The 5 mm AVPIV was found to exert the highest radial force and stiffness compared to the other devices. The 7 and 8 mm AVPIV devices were consistently found to exert less radial force. This property suggests that oversizing an AVP IV could be safe and effective, potentially decreasing total devices used, cost, and overall procedure time.
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Affiliation(s)
- Jenny E Zablah
- School of Medicine/Children's Hospital of Colorado, University of Colorado, 13123 East 16th Avenue, Box 100, Aurora, CO, 80045, USA.
| | - Rachel Fry
- School of Medicine/Children's Hospital of Colorado, University of Colorado, 13123 East 16th Avenue, Box 100, Aurora, CO, 80045, USA
| | - Derek Eilers
- School of Medicine/Children's Hospital of Colorado, University of Colorado, 13123 East 16th Avenue, Box 100, Aurora, CO, 80045, USA
| | - Gareth Morgan
- School of Medicine/Children's Hospital of Colorado, University of Colorado, 13123 East 16th Avenue, Box 100, Aurora, CO, 80045, USA
| | - Neil Wilson
- School of Medicine/Children's Hospital of Colorado, University of Colorado, 13123 East 16th Avenue, Box 100, Aurora, CO, 80045, USA
| | - Michael Ross
- School of Medicine/Children's Hospital of Colorado, University of Colorado, 13123 East 16th Avenue, Box 100, Aurora, CO, 80045, USA
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153
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Hascoët S, Borrhomée S, Tahhan N, Petit J, Boet A, Houyel L, Lebret E, Ly M, Roussin R, Belli E, Lambert V, Laux D. Transcatheter pulmonary valvuloplasty in neonates with pulmonary atresia and intact ventricular septum. Arch Cardiovasc Dis 2019; 112:323-333. [PMID: 30797733 DOI: 10.1016/j.acvd.2018.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/20/2018] [Accepted: 11/21/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transcatheter pulmonary valvuloplasty in neonates with pulmonary atresia and intact ventricular septum (PA-IVS) or duct-dependent pulmonary valve stenosis (DD-PVS) has become a reasonable alternative to surgical right ventricle decompression. AIM To investigate mid-term outcomes following pulmonary valvuloplasty. METHODS Sixty-five neonates with PA-IVS (n=29) or DD-PVS (n=36) (median age 4 days; mean weight 3.0kg) undergoing pulmonary valvuloplasty were reviewed retrospectively. Procedural data and clinical outcomes were assessed. RESULTS Pulmonary valvuloplasty was successful in 59 patients (90.8%). Preterm birth, larger tricuspid valve annulus diameter and PA-IVS correlated with procedural failure. Eleven patients (18.6%) required a Blalock-Taussig shunt during early follow-up, despite valvuloplasty. These neonates had smaller tricuspid and pulmonary valve annulus Z-scores (-1.9 vs. -0.8 [p=0.04] and -2.5 vs. -0.9 [P=0.005], respectively) and a higher incidence of "bipartite" right ventricle (P=0.02). Mean follow-up was 5.4±3.3 years. Mortality after successful valvuloplasty was 8.5% (n=5). Among the 54 survivors, biventricular repair was achieved in 52 patients (96.3%), including nine with a previous Blalock-Taussig shunt. The cumulative rate of subsequent surgery (excluding Blalock-Taussig shunt) was 13.7% (95% confidence interval 6.8-26.7%) and 16.4% (95% confidence interval 8.5-30.4%) at 2 and 4 years, respectively. Secondary surgery was significantly more frequent in PA-IVS compared with DD-PVS, and in neonates with a Blalock-Taussig shunt (P=0.003 and 0.01, respectively). CONCLUSIONS Selected neonates with DD-PVS or PA-IVS managed by transcatheter pulmonary valvuloplasty had a good mid-term outcome. In neonates with a borderline small right ventricle, a hybrid strategy with a supplementary source of pulmonary blood flow can be efficient to achieve biventricular repair.
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Affiliation(s)
- Sébastien Hascoët
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France.
| | - Suzanne Borrhomée
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Nabil Tahhan
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Jérôme Petit
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Angele Boet
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Lucile Houyel
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Emmanuel Lebret
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Mohammed Ly
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Régine Roussin
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Emre Belli
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Virginie Lambert
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
| | - Daniela Laux
- Pôle des cardiopathies congénitales de l'enfant et de l'adulte, centre de référence malformations cardiaques congénitales complexes (M3C), hôpital Marie-Lannelongue, université Paris-Sud, université Paris-Saclay, 133, avenue de la Résistance, 92350 Le Plessis-Robinson, France
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154
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Lawson KL, Wong V, Finn JP, Fishbein GA. Intraesophageal aortopulmonary collateral artery occlusion in an infant with Tetralogy of Fallot and flow-dependent major aortopulmonary collateral arteries. Cardiovasc Pathol 2019; 39:74-76. [PMID: 30731330 DOI: 10.1016/j.carpath.2018.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 12/14/2018] [Accepted: 12/27/2018] [Indexed: 11/15/2022] Open
Abstract
Patients with flow-dependent aortopulmonary collateral arteries often exhibit tenuous clinical statuses. Here we present an infant with Tetralogy of Fallot with pulmonary atresia (TOF-PA) and major aortopulmonary collateral arteries (MAPCAs) who experienced clinically significant oxygen desaturations during feedings. These frequent episodes were attributed to gastroesophageal reflux. In preparation for possible surgical correction of her complex congenital heart condition, she was intubated for a cardiac catheterization to better characterize her anatomy, but terminally decompensated shortly after extubation and restarting feeding. On autopsy, very mild evidence of esophageal reflux was present; instead, one of her four aortopulmonary collateral arteries was unexpectedly discovered traversing through the muscular layer of her esophageal wall. This finding was confirmed microscopically with significant intimal hyperplasia compared to uninvolved collateral arteries. The remainder of the autopsy findings, including her myocardium, lungs, and esophagus, were unremarkable. Given the feeding-associated oxygen desaturations present in life and the aberrant collateral artery's comparative stenosis at death, we speculate that the repetitive trauma of esophageal peristalsis was not only significant enough to temporarily impact oxygenation but, over time, led to near-occlusion of the intraesophageal collateral artery, which may have contributed to the terminal decompensation of this already tenuous patient.
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155
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Ziener CH, Kampf T, Kurz FT, Schlemmer HP, Buschle LR. Pseudo-diffusion effects in lung MRI. J Magn Reson 2019; 299:1-11. [PMID: 30529849 DOI: 10.1016/j.jmr.2018.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/27/2018] [Accepted: 11/28/2018] [Indexed: 06/09/2023]
Abstract
Magnetic resonance imaging of lung tissue is strongly influenced by susceptibility effects between spin-bearing water molecules and air-filled alveoli. The measured lineshape, however, also depends on the interplay between susceptibility effects and blood-flow around alveoli that can be approximated as pseudo-diffusion. Both effects are quantitatively described by the Bloch-Torrey-equation, which was so far only solved for dephasing on the alveolar surface. In this work, we extend this model to the whole range of physiological relevant air volume fractions. The results agree very well with in vivo measurements in human lung tissue.
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Affiliation(s)
- C H Ziener
- German Cancer Research Center - DKFZ, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - T Kampf
- University of Würzburg, Department of Experimental Physics 5, Am Hubland, 97074 Würzburg, Germany; Würzburg University Hospital, Department of Neuroradiology, Josef-Schneider-Straße 11, 97080 Würzburg, Germany
| | - F T Kurz
- German Cancer Research Center - DKFZ, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - H P Schlemmer
- German Cancer Research Center - DKFZ, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - L R Buschle
- German Cancer Research Center - DKFZ, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg University, Faculty of Physics and Astronomy, Im Neuenheimer Feld 227, 69120 Heidelberg, Germany.
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156
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Wagner WW, Jaryszak EM, Peterson AJ, Doerschuk CM, Bohlen HG, King JAC, Tanner JA, Crockett ES, Glenny RW, Presson RG. A perpetual switching system in pulmonary capillaries. J Appl Physiol (1985) 2019; 126:494-501. [PMID: 30571293 PMCID: PMC6397411 DOI: 10.1152/japplphysiol.00507.2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 12/13/2022] Open
Abstract
Of the 300 billion capillaries in the human lung, a small fraction meet normal oxygen requirements at rest, with the remainder forming a large reserve. The maximum oxygen demands of the acute stress response require that the reserve capillaries are rapidly recruited. To remain primed for emergencies, the normal cardiac output must be parceled throughout the capillary bed to maintain low opening pressures. The flow-distributing system requires complex switching. Because the pulmonary microcirculation contains contractile machinery, one hypothesis posits an active switching system. The opposing hypothesis is based on passive switching that requires no regulation. Both hypotheses were tested ex vivo in canine lung lobes. The lobes were perfused first with autologous blood, and capillary switching patterns were recorded by videomicroscopy. Next, the vasculature of the lobes was saline flushed, fixed by glutaraldehyde perfusion, flushed again, and then reperfused with the original, unfixed blood. Flow patterns through the same capillaries were recorded again. The 16-min-long videos were divided into 4-s increments. Each capillary segment was recorded as being perfused if at least one red blood cell crossed the entire segment. Otherwise it was recorded as unperfused. These binary measurements were made manually for each segment during every 4 s throughout the 16-min recordings of the fresh and fixed capillaries (>60,000 measurements). Unexpectedly, the switching patterns did not change after fixation. We conclude that the pulmonary capillaries can remain primed for emergencies without requiring regulation: no detectors, no feedback loops, and no effectors-a rare system in biology. NEW & NOTEWORTHY The fluctuating flow patterns of red blood cells within the pulmonary capillary networks have been assumed to be actively controlled within the pulmonary microcirculation. Here we show that the capillary flow switching patterns in the same network are the same whether the lungs are fresh or fixed. This unexpected observation can be successfully explained by a new model of pulmonary capillary flow based on chaos theory and fractal mathematics.
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Affiliation(s)
- Wiltz W Wagner
- Department of Anesthesiology, Indiana University School of Medicine , Indianapolis, Indiana
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine , Indianapolis, Indiana
- Department of Molecular and Cellular Pharmacology, Department of Physiology and Cell Biology, Center for Lung Biology, University of South Alabama , Mobile, Alabama
| | - Eric M Jaryszak
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine , Indianapolis, Indiana
| | - Amanda J Peterson
- Department of Anesthesiology, Indiana University School of Medicine , Indianapolis, Indiana
| | - Claire M Doerschuk
- Center for Airways Disease, Department of Medicine, University of North Carolina , Chapel Hill, North Carolina
| | - H Glenn Bohlen
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine , Indianapolis, Indiana
| | - Judy A C King
- Department of Molecular and Cellular Pharmacology, Department of Physiology and Cell Biology, Center for Lung Biology, University of South Alabama , Mobile, Alabama
| | - Judith A Tanner
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine , Indianapolis, Indiana
| | - Edward S Crockett
- Department of Molecular and Cellular Pharmacology, Department of Physiology and Cell Biology, Center for Lung Biology, University of South Alabama , Mobile, Alabama
| | - Robb W Glenny
- Departments of Medicine and of Physiology and Biophysics, University of Washington , Seattle, Washington
| | - Robert G Presson
- Department of Anesthesiology, Indiana University School of Medicine , Indianapolis, Indiana
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157
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Alsaied T, Sleeper LA, Masci M, Ghelani SJ, Azcue N, Geva T, Powell AJ, Rathod RH. Maldistribution of pulmonary blood flow in patients after the Fontan operation is associated with worse exercise capacity. J Cardiovasc Magn Reson 2018; 20:85. [PMID: 30558626 PMCID: PMC6296022 DOI: 10.1186/s12968-018-0505-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/09/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Maldistribution of pulmonary artery blood flow (MPBF) is a potential complication in patients who have undergone single ventricle palliation culminating in the Fontan procedure. Cardiovascular magnetic resonance (CMR) is the best modality that can evaluate MPBF in this population. The purpose of this study is to identify the prevalence and associations of MPBF and to determine the impact of MPBF on exercise capacity after the Fontan operation. METHODS This retrospective single-center study included all patients after Fontan operation who had maximal cardiopulmonary exercise test (CPET) and CMR with flow measurements of the branch pulmonary arteries. MPBF was defined as > 20% difference in branch pulmonary artery flow. Exercise capacity was measured as percent of predicted oxygen consumption at peak exercise (% predicted VO2). Linear and logistic regression models were used to determine univariate and multivariable predictors of exercise capacity and correlates of MPBF, respectively. RESULTS A total of 147 patients who had CMR between 1999 and 2017 were included (median age at CMR 21.8 years [interquartile range (IQR) 16.5-30.6]) and the median time between CMR and CPET was 2.8 months [IQR 0-13.8]. Fifty-three patients (36%) had MPBF (95% CI 29-45%). The mean % predicted VO2 was 63 ± 16%. Patients with MPBF had lower mean % predicted VO2 compared to patients without MPBF (60 ± 14% versus 65 ± 16%, p = 0.04). On multivariable analysis, a lower % predicted VO2 was independently associated with longer time since Fontan, higher ventricular mass-to-volume ratio, and MPBF. On multivariable analysis, only compression of the branch pulmonary arteries by the ascending aorta or aortic root was associated with MPBF (OR 6.5, 95% CI 5.6-7.4, p < 0.001). CONCLUSION In patients after the Fontan operation, MPBF is common and is independently associated with lower exercise capacity. MPBF was most likely to be caused by pulmonary artery compression by the aortic root or the ascending aorta. This study identifies MPBF as an important risk factor and as a potential target for therapeutic interventions in this fragile patient population.
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Affiliation(s)
- Tarek Alsaied
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Marco Masci
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Sunil J. Ghelani
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Nina Azcue
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Tal Geva
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Andrew J. Powell
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Rahul H. Rathod
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
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158
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Reyes RV, Díaz M, Ebensperger G, Herrera EA, Quezada SA, Hernandez I, Sanhueza EM, Parer JT, Giussani DA, Llanos AJ. The role of nitric oxide in the cardiopulmonary response to hypoxia in highland and lowland newborn llamas. J Physiol 2018; 596:5907-5923. [PMID: 29369354 PMCID: PMC6265547 DOI: 10.1113/jp274340] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/17/2018] [Indexed: 01/19/2023] Open
Abstract
KEY POINTS Perinatal hypoxia causes pulmonary hypertension in neonates, including humans. However, in species adapted to hypoxia, such as the llama, there is protection against pulmonary hypertension. Nitric oxide (NO) is a vasodilatator with an established role in the cardiopulmonary system of many species, but its function in the hypoxic pulmonary vasoconstrictor response in the newborn llama is unknown. Therefore, we studied the role of NO in the cardiopulmonary responses to acute hypoxia in high- and lowland newborn llamas. We show that high- compared to lowland newborn llamas have a reduced pulmonary vasoconstrictor response to acute hypoxia. Protection against excessive pulmonary vasoconstriction in the highland llama is mediated via enhancement of NO pathways, including increased MYPT1 and reduced ROCK expression as well as Ca2+ desensitization. Blunting of pulmonary hypertensive responses to hypoxia through enhanced NO pathways may be an adaptive mechanism to withstand life at high altitude in the newborn llama. ABSTRACT Llamas are born in the Alto Andino with protection against pulmonary hypertension. The physiology underlying protection against pulmonary vasoconstrictor responses to acute hypoxia in highland species is unknown. We determined the role of nitric oxide (NO) in the cardiopulmonary responses to acute hypoxia in high- and lowland newborn llamas. The cardiopulmonary function of newborn llamas born at low (580 m) or high altitude (3600 m) was studied under acute hypoxia, with and without NO blockade. In pulmonary arteries, we measured the reactivity to potassium and sodium nitroprusside (SNP), and in lung we determined the content of cGMP and the expression of the NO-related proteins: BKCa, PDE5, PSer92-PDE5, PKG-1, ROCK1 and 2, MYPT1, PSer695-MYPT1, PThr696-MYPT1, MLC20 and PSer19-MLC20. Pulmonary vascular remodelling was evaluated by morphometry and based on α-actin expression. High- compared to lowland newborn llamas showed lower in vivo pulmonary arterial pressor responses to acute hypoxia. This protection involved enhanced NO function, as NO blockade reverted the effect and the pulmonary arterial dilatator response to SNP was significantly enhanced in highland neonates. The pulmonary expression of ROCK2 and the phosphorylation of MLC20 were lower in high-altitude llamas. Conversely, MYPT1 was up-regulated whilst PSer695-MYPT1 and PThr695-MYPT1 did not change. Enhanced NO-dependent mechanisms were insufficient to prevent pulmonary arterial remodelling. Combined, the data strongly support that in the highland newborn llama reduced ROCK, increased MYPT1 expression and Ca2+ desensitization in pulmonary tissue allow an enhanced NO biology to limit hypoxic pulmonary constrictor responses. Blunting of hypoxic pulmonary hypertensive responses may be an adaptive mechanism to life at high altitude.
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Affiliation(s)
- Roberto V. Reyes
- Laboratorio de Bioquímica y Biología Molecular de la Hipoxia, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de MedicinaUniversidad de ChileSantiagoChile
- International Center for Andean Studies (INCAS)Universidad de ChileSantiagoChile
| | - Marcela Díaz
- Departamento de Promoción de la Salud de la Mujer y el Recién Nacido, Facultad de MedicinaUniversidad de ChileSantiagoChile
- Laboratorio de Mecanismos de Stress y Adaptación Vascular, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de MedicinaUniversidad de ChileSantiagoChile
| | - Germán Ebensperger
- Laboratorio de Mecanismos de Stress y Adaptación Vascular, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de MedicinaUniversidad de ChileSantiagoChile
| | - Emilio A. Herrera
- International Center for Andean Studies (INCAS)Universidad de ChileSantiagoChile
- Laboratorio de Función y Reactividad Vascular, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de MedicinaUniversidad de ChileSantiagoChile
| | - Sebastián A. Quezada
- Laboratorio de Bioquímica y Biología Molecular de la Hipoxia, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de MedicinaUniversidad de ChileSantiagoChile
| | - Ismael Hernandez
- Laboratorio de Bioquímica y Biología Molecular de la Hipoxia, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de MedicinaUniversidad de ChileSantiagoChile
| | - Emilia M. Sanhueza
- Laboratorio de Fisiología y Fisiopatología del Desarrollo, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de MedicinaUniversidad de ChileSantiagoChile
| | - Julian T. Parer
- Department of Obstetrics, Gynecology and Reproductive SciencesUniversity of California San FranciscoCaliforniaUSA
| | - Dino A. Giussani
- Department of Physiology, Development and NeuroscienceUniversity of CambridgeUK
| | - Aníbal J. Llanos
- International Center for Andean Studies (INCAS)Universidad de ChileSantiagoChile
- Laboratorio de Fisiología y Fisiopatología del Desarrollo, Programa de Fisiopatología, Instituto de Ciencias Biomédicas, Facultad de MedicinaUniversidad de ChileSantiagoChile
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Henningsson M, Zahr RA, Dyer A, Greil GF, Burkhardt B, Tandon A, Hussain T. Feasibility of 3D black-blood variable refocusing angle fast spin echo cardiovascular magnetic resonance for visualization of the whole heart and great vessels in congenital heart disease. J Cardiovasc Magn Reson 2018; 20:76. [PMID: 30474554 PMCID: PMC6260764 DOI: 10.1186/s12968-018-0508-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/14/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Volumetric black-blood cardiovascular magnetic resonance (CMR) has been hampered by long scan times and flow sensitivity. The purpose of this study was to assess the feasibility of black-blood, electrocardiogram (ECG)-triggered and respiratory-navigated 3D fast spin echo (3D FSE) for the visualization of the whole heart and great vessels. METHODS The implemented 3D FSE technique used slice-selective excitation and non-selective refocusing pulses with variable flip angles to achieve constant echo signal for tissue with T1 (880 ms) and T2 (40 ms) similar to the vessel wall. Ten healthy subjects and 21 patients with congenital heart disease (CHD) underwent 3D FSE and conventional 3D balanced steady-state free precession (bSSFP). The sequences were compared in terms of ability to perform segmental assessment, local signal-to-noise ratio (SNRl) and local contrast-to-noise ratio (CNRl). RESULTS In both healthy subjects and patients with CHD, 3D FSE showed superior pulmonary vein but inferior coronary artery origin visualisation compared to 3D bSFFP. However, in patients with CHD the combination of 3D bSSFP and 3D FSE whole-heart imaging improves the success rate of cardiac morphological diagnosis to 100% compared to either technique in isolation (3D FSE, 23.8% success rate, 3D bSSFP, 5% success rate). In the healthy subjects SNRl for 3D bSSFP was greater than for 3D FSE (30.1 ± 7.3 vs 20.9 ± 5.3; P = 0.002) whereas the CNRl was comparable (17.3 ± 5.6 vs 17.4 ± 4.9; P = 0.91) between the two scans. CONCLUSIONS The feasibility of 3D FSE for whole-heart black-blood CMR imaging has been demonstrated. Due to their high success rate for segmental assessment, the combination of 3D bSSFP and 3D FSE may be an attractive alternative to gadolinium contrast enhanced morphological CMR in patients with CHD.
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Affiliation(s)
- Markus Henningsson
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Riad Abou Zahr
- Departments of Pediatrics and Radiology, University of Texas Southwestern/Children’s Health, Dallas, TX USA
| | - Adrian Dyer
- Departments of Pediatrics and Radiology, University of Texas Southwestern/Children’s Health, Dallas, TX USA
| | - Gerald F. Greil
- Departments of Pediatrics and Radiology, University of Texas Southwestern/Children’s Health, Dallas, TX USA
| | - Barbara Burkhardt
- Departments of Pediatrics and Radiology, University of Texas Southwestern/Children’s Health, Dallas, TX USA
| | - Animesh Tandon
- Departments of Pediatrics and Radiology, University of Texas Southwestern/Children’s Health, Dallas, TX USA
| | - Tarique Hussain
- Departments of Pediatrics and Radiology, University of Texas Southwestern/Children’s Health, Dallas, TX USA
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Abstract
Pulmonary arteriovenous malformation, a condition most commonly associated with hereditary hemorrhagic telangiectasia, is an abnormal communication between the pulmonary artery and pulmonary vein without an intervening capillary communication. Although asymptomatic in ~ 50% individuals, it can present with the dreaded complications of stroke or intracranial abscess in high-risk individuals including pregnant women, if untreated. The mainstay of treatment is now endovascular embolization of the feeding artery which can alleviate the symptoms and prevent these complications. In this review, we describe the pathophysiology, methods of screening, diagnostic workup and treatment of these vascular lesions with a particular focus on the currently used embolization techniques and their outcomes.
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Affiliation(s)
- Sreeshma Tellapuri
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Harold S Park
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Kriechbaum SD, Wiedenroth CB, Keller T, Wolter JS, Ajnwojner R, Peters K, Haas MA, Roller FC, Breithecker A, Rieth AJ, Guth S, Rolf A, Bandorski D, Hamm CW, Mayer E, Liebetrau C. Dynamics of high-sensitivity cardiac troponin T during therapy with balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. PLoS One 2018; 13:e0204683. [PMID: 30252896 PMCID: PMC6155553 DOI: 10.1371/journal.pone.0204683] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/12/2018] [Indexed: 01/05/2023] Open
Abstract
Aims Balloon pulmonary angioplasty (BPA) is an interventional treatment modality for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Therapy monitoring, based on non-invasive biomarkers, is a clinical challenge. This post-hoc study aimed to assess dynamics of high-sensitivity cardiac troponin T (hs-cTnT) as a marker for myocardial damage and its relation to N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels as a marker for cardiac wall stress. Methods and results This study included 51 consecutive patients who underwent BPA treatment and completed a 6-month follow-up (6-MFU) between 3/2014 and 3/2017. Biomarker measurement was performed consecutively prior to each BPA and at 6-MFU. In total, the 51 patients underwent an average of 5 BPA procedures. The 6-month survival rate was 96.1%. The baseline (BL) meanPAP (39.5±12.1mmHg) and PVR (515.8±219.2dyn×sec×cm-5) decreased significantly within the 6-MFU (meanPAP: 32.6±12.6mmHg, P<0.001; PVR: 396.9±182.6dyn×sec×cm-5, P<0.001). At BL, the median hs-cTnT level was 11 (IQR 6–16) ng/L and the median NT-proBNP level was 820 (IQR 153–1872) ng/L. The levels of both biomarkers decreased steadily after every BPA, showing the first significant difference after the first procedure. Within the 6-MFU, hs-cTnT levels (7 [IQR 5–12] ng/L; P<0.001) and NT-proBNP levels (159 [IQR 84–464] ng/l; P<0.001) continued to decrease. The hs-cTnT levels correlated with the PVR (rrs = 0.42; p = 0.005), the meanPAP (rrs = 0.32; p = 0.029) and the NT-proBNP (rrs = 0.51; p<0.001) levels at BL. Conclusion Non-invasive biomarker measurement provides valuable evidence for the decreasing impairment of myocardial function and structure during BPA therapy. Changes in hs-cTNT levels are suggestive for a reduction in ongoing myocardial damage.
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Affiliation(s)
- Steffen D. Kriechbaum
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- * E-mail:
| | | | - Till Keller
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Jan Sebastian Wolter
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Ruth Ajnwojner
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Karina Peters
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Moritz A. Haas
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Fritz C. Roller
- Justus Liebig University Giessen, Department of Radiology, Giessen, Germany
| | | | - Andreas J. Rieth
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Stefan Guth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Andreas Rolf
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Dirk Bandorski
- Justus Liebig University of Giessen, Department of Internal Medicine, Division of Pulmonology, Giessen, Germany
| | - Christian W. Hamm
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Eckhard Mayer
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
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Ho AK, Ho AMH, Mizubuti GB. Blockage of the tracheal bronchus: effects on blood oxygen content, partial pressure of oxygen, and intrapulmonary shunt. Adv Physiol Educ 2018; 42:383-386. [PMID: 29761713 DOI: 10.1152/advan.00017.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Adrienne K Ho
- Department of Oncology, The Christie NHS Foundation Trust , Manchester , United Kingdom
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University , Kingston, Ontario , Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University , Kingston, Ontario , Canada
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McCabe C, Oliveira RKF, Rahaghi F, Faria-Urbina M, Howard L, Axell RG, Priest AN, Waxman AB, Systrom DM. Right ventriculo-arterial uncoupling and impaired contractile reserve in obese patients with unexplained exercise intolerance. Eur J Appl Physiol 2018; 118:1415-1426. [PMID: 29713818 PMCID: PMC6028899 DOI: 10.1007/s00421-018-3873-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/23/2018] [Indexed: 02/01/2023]
Abstract
Background Right ventricular (RV) dysfunction and heart failure with preserved ejection fraction may contribute to exercise intolerance in obesity. To further define RV exercise responses, we investigated RV–arterial coupling in obesity with and without development of exercise pulmonary venous hypertension (ePVH). Methods RV–arterial coupling defined as RV end-systolic elastance/pulmonary artery elastance (Ees/Ea) was calculated from invasive cardiopulmonary exercise test data in 6 controls, 8 obese patients without ePVH (Obese−ePVH) and 8 obese patients with ePVH (Obese+ePVH) within a larger series. ePVH was defined as a resting pulmonary arterial wedge pressure < 15 mmHg but ≥ 20 mmHg on exercise. Exercise haemodynamics were further evaluated in 18 controls, 20 Obese−ePVH and 17 Obese+ePVH patients. Results Both Obese−ePVH and Obese+ePVH groups developed exercise RV–arterial uncoupling (peak Ees/Ea = 1.45 ± 0.26 vs 0.67 ± 0.18 vs 0.56 ± 0.11, p < 0.001, controls vs Obese−ePVH vs Obese+ePVH respectively) with higher peak afterload (peak Ea = 0.31 ± 0.07 vs 0.75 ± 0.32 vs 0.88 ± 0.62 mL/mmHg, p = 0.043) and similar peak contractility (peak Ees = 0.50 ± 0.16 vs 0.45 ± 0.22 vs 0.48 ± 0.17 mL/mmHg, p = 0.89). RV contractile reserve was highest in controls (ΔEes = 224 ± 80 vs 154 ± 39 vs 141 ± 34% of baseline respectively, p < 0.001). Peak Ees/Ea correlated with peak pulmonary vascular compliance (PVC, r = 0.53, p = 0.02) but not peak pulmonary vascular resistance (PVR, r = − 0.20, p = 0.46). In the larger cohort, Obese+ePVH patients on exercise demonstrated higher right atrial pressure, lower cardiac output and steeper pressure-flow responses. BMI correlated with peak PVC (r = − 0.35, p = 0.04) but not with peak PVR (r = 0.24, p = 0.25). Conclusions Exercise RV–arterial uncoupling and reduced RV contractile reserve further characterise obesity-related exercise intolerance. RV dysfunction in obesity may develop independent of exercise LV filling pressures.
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Affiliation(s)
- Colm McCabe
- Division of Cardiology, Royal Brompton Hospital, London, SW3 6NP, UK.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA.
| | - Rudolf K F Oliveira
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
- Division of Respiratory Diseases, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Farbod Rahaghi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - Mariana Faria-Urbina
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | | | | | | | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
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Nishine H, Muraoka H, Inoue T, Miyazawa T, Mineshita M. Pulmonary Perfusion Using Intrabronchial Capnography in Pulmonary Artery Stenosis. Respiration 2018; 95:465-468. [PMID: 29680830 DOI: 10.1159/000487712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 02/12/2018] [Indexed: 11/19/2022] Open
Abstract
Stenting at the flow-limiting segment can improve the ventilation-perfusion ratio in patients with central airway stenosis. However, there is no quantitative examination for assessing the perfusion status during interventional bronchoscopy. Intrabronchial capnography can estimate regional gas exchange by measuring carbon dioxide concentration. We herein report a case of bilateral bronchial stenosis where stenting was able to improve ventilation-perfusion ratio using intrabronchial capnography. A 44-year-old man was admitted to our institution with orthopnea. Chest computed tomography showed an extrinsic compression at the bilateral main bronchus and right pulmonary artery due to a mediastinal mass. After introduction of general anesthesia, arterial oxygen tension suddenly decreased in the supine position. After initial stenting, an increase was seen in ventilation at the right lung; however, a ventilation-perfusion mismatch occurred due to an increase in dead-space ventilation at the right pulmonary artery stenosis. Intrabronchial capnography was an effective modality to confirm the regional perfusion status during interventional bronchoscopy in real time.
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165
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Tan C, Rossiter HB, Porszasz J, Bowen TS, Witte KK, Stringer WW, Casaburi R, Hansen JE. Reliability and Physiological Interpretation of Pulmonary Gas Exchange by "Circulatory Equivalents" in Chronic Heart Failure. J Am Heart Assoc 2018; 7:e008072. [PMID: 29588313 PMCID: PMC5907590 DOI: 10.1161/jaha.117.008072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/26/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peak ratios of pulmonary gas-exchange to ventilation during exercise (V˙O2/V˙E and V˙CO2/V˙E, termed "circulatory equivalents") are sensitive to heart failure (HF) severity, likely reflecting low and/or poorly distributed pulmonary perfusion. We tested whether peak V˙O2/V˙E and V˙CO2/V˙E would: (1) distinguish HF patients from controls; (2) be independent of incremental exercise protocol; and (3) correlate with lactate threshold (LT) and ventilatory compensation point (VCP), respectively. METHODS AND RESULTS Twenty-four HF patients (61±11 years) with reduced ejection fraction (31±8%) and 11 controls (63±7 years) performed ramp-incremental cycle ergometry. Eighteen HF patients also performed slow (5±1 W/min), medium (9±4 W/min), and fast (19±6 W/min) ramps. Peak V˙O2/V˙E and V˙CO2/V˙E from X-Y plot, and LT and VCP from 9-panel plot, were determined by 2 independent, blinded, assessors. Peak V˙O2/V˙E (31.2±4.4 versus 41.8±4.8 mL/L; P<0.0001) and V˙CO2/V˙E (29.3±3.0 versus 36.9±4.0 mL/L; P<0.0001) were lower in HF than controls. Within individuals, there was no difference across 3 ramp rates in peak V˙O2/V˙E (P=0.62) or V˙CO2/V˙E (P=0.97). Coefficient of variation (CV) in peak V˙O2/V˙E was lower than for LT (5.1±2.1% versus 8.2±3.7%; P=0.014), and coefficient of variation in peak V˙CO2/V˙E was lower than for VCP (3.3±1.8% versus 8.7±4.2%; P<0.001). In all participants, peak V˙O2/V˙E was correlated with, but occurred earlier than, LT (r2=0.94; mean bias, -0.11 L/min), and peak V˙CO2/V˙E was correlated with, but occurred earlier than, VCP (r2=0.98; mean bias -0.08 L/min). CONCLUSIONS Peak circulatory equivalents during exercise are strongly associated with (but not identical to) LT and VCP. Peak circulatory equivalents are reliable, objective, effort-independent indices of gas-exchange abnormality in HF.
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Affiliation(s)
- Chunting Tan
- Department of Respiratory Medicine, Beijing Friendship Hospital Capital Medical University, Beijing, China
- Division of Respiratory and Critical Care Physiology and Medicine, Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Harry B Rossiter
- Division of Respiratory and Critical Care Physiology and Medicine, Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
- Faculty of Biological Sciences, University of Leeds, United Kingdom
| | - Janos Porszasz
- Division of Respiratory and Critical Care Physiology and Medicine, Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - T Scott Bowen
- Faculty of Biological Sciences, University of Leeds, United Kingdom
| | - Klaus K Witte
- Faculty of Medicine, University of Leeds, United Kingdom
| | - William W Stringer
- Division of Respiratory and Critical Care Physiology and Medicine, Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Richard Casaburi
- Division of Respiratory and Critical Care Physiology and Medicine, Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - James E Hansen
- Division of Respiratory and Critical Care Physiology and Medicine, Rehabilitation Clinical Trials Center, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
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Chatterjee A, Jackson AE, Acharya D, Law MA. Transcatheter Closure of Pulmonary Arteriovenous Malformation to Facilitate Treatment of Pulmonary Arterial Hypertension. JACC Cardiovasc Interv 2018; 11:e45-e46. [PMID: 29501545 DOI: 10.1016/j.jcin.2017.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/15/2017] [Accepted: 12/19/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Arka Chatterjee
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Ashley E Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Deepak Acharya
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark A Law
- Department of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
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Pudasaini B, Yang GL, Yang C, Guo J, Yuan P, Wen-lan Y, Zhang R, Wang L, Zhao QH, Gong SG, Jiang R, Chen TX, Wei X, Liu JM. Characteristics of exercise capacity in female systemic lupus erythematosus associated pulmonary arterial hypertension patients. BMC Cardiovasc Disord 2018; 18:56. [PMID: 29566672 PMCID: PMC5865350 DOI: 10.1186/s12872-018-0783-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 02/26/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND To study the oxygen uptake efficiency and determine usefulness of submaximal parameters of oxygen uptake in systemic lupus erythematosus associated pulmonary arterial hypertension (SLE PAH) on performing a cardiopulmonary exercise test (CPET). METHODS CPET was performed in 21 SLE PAH patients, equal number of idiopathic pulmonary arterial hypertension (IPAH) patients and controls. Peak VO2, anaerobic threshold (AT), oxygen uptake efficiency slope (OUES) and oxygen uptake efficiency plateau (OUEP) and other CPET parameters were examined. All subjects had pulmonary function test (PFT) at rest, which included FEV1, FVC, FEV1/FVC, DLCO measurements. Right heart catheterization (RHC) was also done in SLE PAH and IPAH patients. CPET parameters were compared with RHC parameters to determine potential correlations. RESULTS Peak VO2, PETCO2 and peak O2 pulse were lower in SLE PAH than IPAH and controls with OUE being lower during all stages of exercise in SLE PAH. DLCO and FVC values were significantly lower in SLE PAH (p < 0.05). Peak O2 pulse and VO2@AT in SLE PAH and IPAH was low (p < 0.05) and significant difference between SLE PAH and IPAH was seen (p < 0.05). PVR correlated with the lowest VE/VCO2, O2 pulse, peak PETCO2 and OUE in SLE PAH patients (all p < 0.05). CONCLUSIONS SLE PAH patients have cardiopulmonary exercise limitation with reduced oxygen uptake efficiency. VO2@ at AT, peak O2 pulse and O2 pulse at AT were significantly reduced (p < 0.05). Key CPET parameters correlated with elevated pulmonary vascular resistance (PVR). Submaximal parameters of oxygen uptake are equally useful in SLE PAH.
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Affiliation(s)
- Bigyan Pudasaini
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Guo-ling Yang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Chen Yang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Ping Yuan
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Yang Wen-lan
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Rui Zhang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Lan Wang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Qin-Hua Zhao
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Su-Gang Gong
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Rong Jiang
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Tian-Xiang Chen
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Xiong Wei
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
| | - Jin-Ming Liu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
- Department of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200433 China
- Shanghai Pulmonary Hospital, Tongji University, School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433 China
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Buggeskov KB. Pulmonary artery perfusion versus no pulmonary per-fusion during cardiopulmonary bypass. Dan Med J 2018; 65:B5473. [PMID: 29510817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
During conventional cardiopulmonary bypass (CPB) there is no active perfusion of the pulmonary circulation and the mechanical ventilation is ceased leaving the lungs exposed to warm ischemia.
Pulmonary dysfunction is seen in varying degrees after major surgery, but more severe in cardiac surgery patients probably due to the effects of CPB. The evidence for effect and safety are limited, but active pulmonary artery perfusion during CPB could be beneficial for the patients' postoperative oxygenation.
Our aim was in a randomised clinical trial to assess primarily the effect of pulmonary artery perfusion during CPB on postoperative oxygenation in patients diagnosed with chronic obstructive pulmonary disease (COPD), secondarily to assess other possible benefits and harms. Furthermore, we wanted in a systematic review with meta-analyses of all randomised clinical trials to investigate the pooled effects of pulmonary artery perfusion during CPB.
We planned and conducted a randomised, partly blinded, clinical trial assigning cardiac surgery patients diagnosed with COPD to receive pulmonary artery perfusion with oxygenated blood or histidine-tryptophan-ketoglutarate (HTK) solution compared to no pulmonary perfusion during CPB. The primary outcome was the oxygenation index measured during and after surgery. Secondary outcomes were intubation time, serious adverse events, days alive outside the intensive care unit and outside the hospital, 30- and 90-days mortality.
Secondly, we conducted a systematic review of randomised clinical trials comparing benefits and harms of using pulmonary artery perfusion versus no pulmonary perfusion during CPB pooling results in meta-analyses and trial sequential analyses (TSA).
Of the 90 randomised patients 89 were included in analysis of the primary outcome, the inverse oxygenation index, measured at a single time point 21 hours after CPB start and longitudinally 1, 3, 5, 7, and 21 hours after CPB start. At 21 hours, patients randomised to pulmonary artery perfusion with oxygenated blood had a higher inverse oxygenation index compared to patients randomised to no pulmonary perfusion during CPB (mean difference (MD) 0.94; 95% confidence interval (CI), 0.05 to 1.83; P=0.04). The inverse oxygenation index was also significantly higher at 21 hours after CPB start (MD 0.99; CI, 0.29 to 1.69; P=0.007), and longitudinally (P=0.009), for patients receiving pulmonary artery perfusion with oxygenated blood compared to pulmonary artery perfusion with HTK solution. This corresponds to a PaO2 difference of 23 mmHg with a median FiO2 of 0.32. We found no additional significant differences for the remaining comparisons of the inverse oxygenation index neither for any of the secondary outcomes.
The systematic review identified 4 trials with a total of 210 patients. In meta-analyses pulmonary artery perfusion with blood versus no pulmonary perfusion during CPB was not associated with relative risk of death (1.7; 95% CI, 0.4 to 6.9; 210 patients in three trials with high and one trial with low risk of bias), serious adverse events (1.2; 95% CI, 0.8 to 1.8; 180 patients in two trials with high and one trial with low risk of bias) or intubation time (-0.4 hours; 95% CI, -1.1 to 0.4; 176 patients in three trials with high and one trial with low risk of bias). TSA on mortality, serious adverse events, and PaO2/FiO2 ratio showed that required information sizes have not been reached, but pulmonary artery perfusion with blood was associated with a higher PaO2/FiO2 ratio (27.8 mmHg; 95% CI, 5.7 to 50.0 mmHg; 119 patients in two trials with high and one trial with low risk of bias). TSA on intubation time showed that the boundary for lack of superiority (futility) was crossed refuting a shorten intubation time of 1.5 hours or more.
Our trial provided additional knowledge about the use of pulmonary artery perfusion during CPB in cardiac surgery patients with COPD, and improved oxygenation for patients receiving pulmonary artery perfusion with oxygenated blood. Pulmonary artery perfusion with HTK solution did not result in an improved oxygenation. In line with this, the systematic review including data from additional trials showed a possible association between pulmonary artery perfusion with blood and improved oxygenation, but no significant associations with mortality, serious adverse events or intubation time. However, all data are too sparse to be conclusive.
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Dogan M, Efe TH, Cimen T, Ozisler C, Felekoglu MA, Ertem AG, Erat M, Yiginer O, Tulmac M. Pulmonary Arterial Hemodynamic Assessment by a Novel Index in Systemic Sclerosis Patients: Pulmonary Pulse Transit Time. Lung 2018; 196:173-178. [PMID: 29445936 DOI: 10.1007/s00408-018-0098-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 02/07/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Systemic sclerosis (SSc) is a chronic, inflammatory, and autoimmune connective tissue disease that is associated with vascular lesions, and fibrosis of the skin and visceral organs. Cardiac complications may occur as a secondary effect of SSc as a result of pulmonary arterial hypertension and interstitial lung disease. The objective of this study was to assess whether the pulmonary pulse transit time (pPTT) could serve as a diagnostic marker for pulmonary arterial alterations in patients with SSc, prior to development of pulmonary hypertension. METHODS Twenty-five SSc patients as a study group and 25 age- and sex-matched healthy volunteers for the control group were recruited to the study. Right ventricle function parameters, such as tricuspid annular plane systolic excursion (TAPSE), estimated pulmonary artery systolic pressure (ePASP), right ventricular dimensions, right ventricle fractional area changes, and myocardial perfusion index (MPI) were measured and calculated. Pulmonary pulse transit time was defined as the time interval between the R-wave peak in the ECG and the corresponding peak late systolic pulmonary vein flow velocity. RESULTS Right ventricle myocardial performance index (RVMPI) and eSPAP were significantly higher in the SSc group than the controls (p = 0.032, p = 0.012, respectively). Pulmonary pulse transit time and TAPSE was shorter in the patients with SSc (p = 0.006, p = 0.015, respectively). In correlation analysis, pPTT was inversely correlated with RVMPI (r = - 0.435, p = 0.003), eSPAP (r = - 0.434, p = 0.003), and disease duration (r = - 0.595, p = 0.003). Conversely, it positively correlated with TAPSE (r = 0.345, p = 0.022). CONCLUSION pPTT was found to be shorter in SSc patients. pPTT might serve as a surrogate marker of pulmonary hemodynamics in patients with SSc, even prior to the development of pulmonary hypertension.
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Affiliation(s)
- Mehmet Dogan
- Department of Cardiology, Medipol University Hospital, Istanbul, Turkey.
| | - Tolga Han Efe
- Department of Cardiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Tolga Cimen
- Department of Cardiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Cem Ozisler
- Department of Rheumatology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Mehmet Ali Felekoglu
- Department of Cardiology, Dr. Ersin Aslan Training and Research Hospital, Gaziantep, Turkey
| | - Ahmet Goktug Ertem
- Department of Cardiology, Türkiye Yüksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Mehmet Erat
- Department of Cardiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Omer Yiginer
- Department of Cardiology, Bahcesehir University Hospital, Istanbul, Turkey
| | - Murat Tulmac
- Department of Cardiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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Meyer GMB, Spilimbergo FB, Altmayer S, Pacini GS, Zanon M, Watte G, Marchiori E, Hochhegger B. Multiparametric Magnetic Resonance Imaging in the Assessment of Pulmonary Hypertension: Initial Experience of a One-Stop Study. Lung 2018; 196:165-171. [PMID: 29435739 DOI: 10.1007/s00408-018-0097-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/05/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Our goal was to assess the diagnostic performance of magnetic resonance imaging (MRI) as a single method to diagnose pulmonary hypertension (PH) compared to right heart catheterization (RHC), computed tomography (CT), and ventilation/perfusion (V/Q) scintigraphy. METHODS We identified 35 patients diagnosed with PH by RHC in our institution who have also undergone a CT, a scintigraphy, and an MRI within a month. All cases were discussed in multidisciplinary meetings. We performed correlations between the MRI-derived hemodynamic parameters and those from RHC. The sensitivity and specificity of MRI were determined to identify its diagnostic performance to identify chronic thromboembolic pulmonary hypertension (CTEPH) and interstitial lung disease PH. The gold standard reference for the diagnosis of CTEPH and ILD was based on a review of multimodality imaging (V/Q scintigraphy and CT scan) and clinical findings. RESULTS Our results showed a good correlation between the hemodynamic parameters of cardiac MRI and RHC. Pulmonary vascular resistance had the best correlation between both methods (r = 0.923). The sensitivity and specificity of MRI to diagnose CTEPH was 100 and 96.8%, respectively. For the ILD-related PH, the MRI yielded a sensitivity of 60.0% and a specificity of 100%. Additionally, cardiac MRI was able to confirm all cases of PAH due to congenital heart disease initially detected by echocardiography. CONCLUSIONS MRI represents a promising imaging modality as an initial, single-shot study, for patients with suspected PH with the advantages of being non-invasive and having no radiation exposure.
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Affiliation(s)
- Gisela M B Meyer
- Pulmonary Hypertension Group, Santa Casa de Porto Alegre, Av. Independência, 75, Porto Alegre, Rio Grande Do Sul, 90020-160, Brazil
| | - Fernanda B Spilimbergo
- Pulmonary Hypertension Group, Santa Casa de Porto Alegre, Av. Independência, 75, Porto Alegre, Rio Grande Do Sul, 90020-160, Brazil
| | - Stephan Altmayer
- Federal University of Health Sciences of Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, Rio Grande Do Sul, 90050-170, Brazil
- Medical Imaging Research Laboratory, Federal University of Health Sciences of Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, Rio Grande Do Sul, 90050-170, Brazil
- LABIMED - Medical Imaging Research Lab, Department of Radiology, Pavilhão Pereira Filho Hospital, Irmandade Santa Casa de Misericórdia de Porto Alegre, Av. Independência, 75, Porto Alegre, 90020-160, Brazil
| | - Gabriel S Pacini
- Federal University of Health Sciences of Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, Rio Grande Do Sul, 90050-170, Brazil.
- Medical Imaging Research Laboratory, Federal University of Health Sciences of Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, Rio Grande Do Sul, 90050-170, Brazil.
- LABIMED - Medical Imaging Research Lab, Department of Radiology, Pavilhão Pereira Filho Hospital, Irmandade Santa Casa de Misericórdia de Porto Alegre, Av. Independência, 75, Porto Alegre, 90020-160, Brazil.
| | - Matheus Zanon
- Federal University of Health Sciences of Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, Rio Grande Do Sul, 90050-170, Brazil
- Medical Imaging Research Laboratory, Federal University of Health Sciences of Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, Rio Grande Do Sul, 90050-170, Brazil
- LABIMED - Medical Imaging Research Lab, Department of Radiology, Pavilhão Pereira Filho Hospital, Irmandade Santa Casa de Misericórdia de Porto Alegre, Av. Independência, 75, Porto Alegre, 90020-160, Brazil
| | - Guilherme Watte
- Department of Respiratory Medicine and Thoracic Surgery, Irmandade da Santa Casa de Misericordia de Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, 90050-170, Brazil
- LABIMED - Medical Imaging Research Lab, Department of Radiology, Pavilhão Pereira Filho Hospital, Irmandade Santa Casa de Misericórdia de Porto Alegre, Av. Independência, 75, Porto Alegre, 90020-160, Brazil
| | - Edson Marchiori
- Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Rio De Janeiro, 21941-902, Brazil
| | - Bruno Hochhegger
- Federal University of Health Sciences of Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, Rio Grande Do Sul, 90050-170, Brazil
- Medical Imaging Research Laboratory, Federal University of Health Sciences of Porto Alegre, R. Sarmento Leite, 245, Porto Alegre, Rio Grande Do Sul, 90050-170, Brazil
- LABIMED - Medical Imaging Research Lab, Department of Radiology, Pavilhão Pereira Filho Hospital, Irmandade Santa Casa de Misericórdia de Porto Alegre, Av. Independência, 75, Porto Alegre, 90020-160, Brazil
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Buggeskov KB, Grønlykke L, Risom EC, Wei ML, Wetterslev J. Pulmonary artery perfusion versus no perfusion during cardiopulmonary bypass for open heart surgery in adults. Cochrane Database Syst Rev 2018; 2:CD011098. [PMID: 29419895 PMCID: PMC6491280 DOI: 10.1002/14651858.cd011098.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Available evidence has been inconclusive on whether pulmonary artery perfusion during cardiopulmonary bypass (CPB) is associated with decreased or increased mortality, pulmonary events, and serious adverse events (SAEs) after open heart surgery. To our knowledge, no previous systematic reviews have included meta-analyses of these interventions. OBJECTIVES To assess the benefits and harms of single-shot or continuous pulmonary artery perfusion with blood (oxygenated or deoxygenated) or a preservation solution compared with no perfusion during cardiopulmonary bypass (CPB) in terms of mortality, pulmonary events, serious adverse events (SAEs), and increased inflammatory markers for adult surgical patients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, and advanced Google for relevant studies. We handsearched retrieved study reports and scanned citations of included studies and relevant reviews to ensure that no relevant trials were missed. We searched for ongoing trials and unpublished trials in the World Health Organization International Clinical Trials Registry Platform (ICTRP) and at clinicaltrials.gov (4 July 2017). We contacted medicinal firms producing preservation solutions to retrieve additional studies conducted to examine relevant interventions. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared pulmonary artery perfusion versus no perfusion during CPB in adult patients (≧ 18 years). DATA COLLECTION AND ANALYSIS Two independent review authors extracted data, conducted fixed-effect and random-effects meta-analyses, and calculated risk ratios (RRs) or odds ratios (ORs) for dichotomous outcomes. For continuous data, we have presented mean differences (MDs) and 95% confidence intervals (CIs) as estimates of the intervention effect. To minimize the risk of systematic error, we assessed risk of bias of included trials. To reduce the risk of random errors caused by sparse data and repetitive updating of cumulative meta-analyses, we applied Trial Sequential Analyses (TSAs). We used GRADE principles to assess the quality of evidence. MAIN RESULTS We included in this review four RCTs (210 participants) reporting relevant outcomes. Investigators randomly assigned participants to pulmonary artery perfusion with blood versus no perfusion during CPB. Only one trial included the pulmonary artery perfusion intervention with a preservation solution; therefore we did not perform meta-analysis. Likewise, only one trial reported patient-specific data for the outcome "pulmonary events"; therefore we have provided no results from meta-analysis. Instead, review authors added two explorative secondary outcomes for this version of the review: the ratio of partial pressure of oxygen in arterial blood (PaO2) to fraction of inspired oxygen (FiO2); and intubation time. Last, review authors found no comparable data for the secondary outcome inflammatory markers.The effect of pulmonary artery perfusion on all-cause mortality was uncertain (Peto OR 1.78, 95% CI 0.43 to 7.40; TSA adjusted CI 0.01 to 493; 4 studies, 210 participants; GRADE: very low quality). Sensitivity analysis of one trial with overall low risk of bias (except for blinding of personnel during the surgical procedure) yielded no evidence of a difference for mortality (Peto OR 1.65, 95% CI 0.27 to 10.15; 1 study, 60 participants). The TSA calculated required information size was not reached and the futility boundaries did not cross; thus this analysis cannot refute a 100% increase in mortality.The effect of pulmonary artery perfusion with blood on SAEs was likewise uncertain (RR 1.12, 95% CI 0.66 to 1.89; 3 studies, 180 participants; GRADE: very low quality). Data show an association between pulmonary artery perfusion with blood during CPB and a higher postoperative PaO2/FiO2 ratio (MD 27.80, 95% CI 5.67 to 49.93; 3 studies, 119 participants; TSA adjusted CI 5.67 to 49.93; GRADE: very low quality), although TSA could not confirm or refute a 10% increase in the PaO2/FiO2 ratio, as the required information size was not reached. AUTHORS' CONCLUSIONS The effects of pulmonary artery perfusion with blood during cardiopulmonary bypass (CPB) are uncertain owing to the small numbers of participants included in meta-analyses. Risks of death and serious adverse events may be higher with pulmonary artery perfusion with blood during CPB, and robust evidence for any beneficial effects is lacking. Future randomized controlled trials (RCTs) should provide long-term follow-up and patient stratification by preoperative lung function and other documented risk factors for mortality. One study that is awaiting classification (epub abstract with preliminary results) may change the results of this review when full study details have been published.
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Affiliation(s)
- Katrine B Buggeskov
- Copenhagen University Hospital, RigshospitaletDepartment of Thoracic AnaesthesiologyBlegdamsvej 9CopenhagenDenmark2100
| | - Lars Grønlykke
- Copenhagen University Hospital, RigshospitaletDepartment of Thoracic AnaesthesiologyBlegdamsvej 9CopenhagenDenmark2100
| | - Emilie C Risom
- Copenhagen University Hospital, RigshospitaletDepartment of Thoracic AnaesthesiologyBlegdamsvej 9CopenhagenDenmark2100
| | - Mao Ling Wei
- West China Hospital, Sichuan UniversityChinese Evidence‐Based Medicine CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Śpiewak M, Kłopotowski M, Gawor M, Kubik A, Kowalik E, Miłosz-Wieczorek B, Dąbrowski M, Werys K, Mazurkiewicz Ł, Kożuch K, Polańska-Skrzypczyk M, Petryka-Mazurkiewicz J, Klisiewicz A, Bilińska ZT, Grzybowski J, Witkowski A, Marczak M. Quantification of mitral regurgitation in patients with hypertrophic cardiomyopathy using aortic and pulmonary flow data: impacts of left ventricular outflow tract obstruction and different left ventricular segmentation methods. J Cardiovasc Magn Reson 2017; 19:105. [PMID: 29268761 PMCID: PMC5740710 DOI: 10.1186/s12968-017-0417-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/23/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) imaging in patients with hypertrophic cardiomyopathy (HCM) enables the assessment of not only left ventricular (LV) hypertrophy and scarring but also the severity of mitral regurgitation. CMR assessment of mitral regurgitation is primarily based on the difference between LV stroke volume (LVSV) and aortic forward flow (Ao) measured using the phase-contrast (PC) technique. However, LV outflow tract (LVOT) obstruction causing turbulent, non-laminar flow in the ascending aorta may impact the accuracy of aortic flow quantification, leading to false conclusions regarding mitral regurgitation severity. Thus, we decided to quantify mitral regurgitation in patients with HCM using Ao or, alternatively, main pulmonary artery forward flow (MPA) for mitral regurgitation volume (MRvol) calculations. METHODS The analysis included 143 prospectively recruited subjects with HCM and 15 controls. MRvol was calculated as the difference between LVSV computed with either the inclusion (LVSVincl) or exclusion (LVSVexcl) of papillary muscles and trabeculations from the blood pool and either Ao (MRvolAoi or MRvolAoe) or MPA (MRvolMPAi or MRvolMPAe). The presence or absence of LVOT obstruction was determined based on Doppler echocardiography findings. RESULTS MRvolAoi was higher than MRvolMPAi in HCM patients with LVOT obstruction [47.0 ml, interquartile range (IQR) = 31.5-60.0 vs. 35.5 ml, IQR = 26.0-51.0; p < 0.0001] but not in non-obstructive HCM patients (23.0 ml, IQR = 16.0-32.0 vs. 24.0 ml, IQR = 15.3-32.0; p = 0.26) or controls (18.0 ml, IQR = 14.3-21.8 vs. 20.0 ml, IQR = 14.3-22.0; p = 0.89). In contrast to controls and HCM patients without LVOT obstruction, in HCM patients with LVOT obstruction, aortic flow-based MRvol (MRvolAoi) was higher than pulmonary-based findings (MRvolMPAi) (bias = 9.5 ml; limits of agreement: -11.7-30.7 with a difference of 47 ml in the extreme case). The differences between aortic-based and pulmonary-based MRvol values calculated using LVSVexcl mirrored those derived using LVSVincl. However, MRvol values calculated using LVSVexcl were lower in all the groups analyzed (HCM with LVOT obstruction, HCM without LVOT obstruction, and controls) and with all methods of MRvol quantification used (p ≤ 0.0001 for all comparisons). CONCLUSIONS In HCM patients, LVOT obstruction significantly affects the estimation of aortic flow, leading to its underestimation and, consequently, to higher MRvol values than those obtained with MPA-based MRvol calculations.
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Affiliation(s)
- Mateusz Śpiewak
- Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Warsaw, Poland
| | - Mariusz Kłopotowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Monika Gawor
- Department of Cardiomyopathy, Institute of Cardiology, Warsaw, Poland
| | - Agata Kubik
- Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Warsaw, Poland
| | - Ewa Kowalik
- Department of Congenital Heart Diseases, Institute of Cardiology, Warsaw, Poland
| | | | - Maciej Dąbrowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Konrad Werys
- Oxford Centre for Clinical Magnetic Resonance Research, John Radcliffe Hospital, Headington, Oxford, UK
| | | | - Katarzyna Kożuch
- Department of Congenital Heart Diseases, Institute of Cardiology, Warsaw, Poland
| | | | - Joanna Petryka-Mazurkiewicz
- Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Warsaw, Poland
- Department of Coronary and Structural Heart Diseases, Institute of Cardiology, Warsaw, Poland
| | - Anna Klisiewicz
- Department of Congenital Heart Diseases, Institute of Cardiology, Warsaw, Poland
| | - Zofia T. Bilińska
- Unit for Screening Studies in Inherited Cardiovascular Diseases, Institute of Cardiology, Warsaw, Poland
| | - Jacek Grzybowski
- Department of Cardiomyopathy, Institute of Cardiology, Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Magdalena Marczak
- Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Warsaw, Poland
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Bragazzi NL, Raffi A, Siri A, Tornali C, Martini M. [Renaissance medicine and the discovery of the lesser circulation: the role of Michael Servetus (1511-1553)]. Acta Med Hist Adriat 2017; 15:271-282. [PMID: 29402117 DOI: 10.31952/amha.15.2.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Human urine is currently the subject of biomedical investigations as a potential therapeutic resource and it continues to be used in remedies in different cultures and societies, including the Spanish culture. In this study we gather etnomedical knowledge about urotherapy and determine their associated symbolisms in Spain. A literature overview and a case study were carried out to compile urine-based remedies and as a direct analysis of symbolic systems. Urotherapy is widespread in Spanish folk medicine. Among the 204 collected remedies, those related to treatment of diseases or skin conditions predominate (63%). Remedies have been reported for the treatment of skin diseases such as eczema, chloasma, alopecia, etc. to treat or alleviate burns, chilblains, wounds or skin chapping, and as a treatment of venomous bites. Most of the collected remedies have an associated naturalist symbolism, based on local traditions and the transmission of empirical initial knowledge. The use of urine in Spain is a result of the interaction of two types of practice: a local and traditional urotherapy, rural and with a utilitarian purpose, and a technical urotherapy, limited to an urban environment and a naturopathic medicine.
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Affiliation(s)
- Nicola Luigi Bragazzi
- Dipartimento di Scienze della Salute, Università di Genova, Genova, Italia; Cattedra UNESCO Antropologia della Salute - Biosfera e Sistemi di Cura, Università di Genova, Genova, Italia
| | | | - Anna Siri
- Cattedra UNESCO Antropologia della Salute - Biosfera e Sistemi di Cura, Università di Genova, Genova, Italia
| | - Cristina Tornali
- Dipartimento di Scienze Biomediche e Biotecnologiche, Università di Catania, Catania, Italia
| | - Mariano Martini
- Dipartimento di Scienze della Salute, Sezione di Storia della Medicina ed Etica, Università di Genova, Genova, Italia
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Saad MM, Kamal J, Moussaly E, Karam B, Mansour W, Gobran E, Abbasi SH, Mahgoub A, Singh P, Hardy R, Das D, Brown C, Kapoor M, Demissie S, Kleiner MJ, El Charabaty E, El Sayegh SE. Relevance of B-Lines on Lung Ultrasound in Volume Overload and Pulmonary Congestion: Clinical Correlations and Outcomes in Patients on Hemodialysis. Cardiorenal Med 2017; 8:83-91. [PMID: 29617006 DOI: 10.1159/000476000] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/17/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Volume overload in patients on hemodialysis (HD) is an independent risk factor for cardiovascular mortality. B-lines detected on lung ultrasound (BLUS) assess extravascular lung water. This raises interest in its utility for assessing volume status and cardiovascular outcomes. METHODS End-stage renal disease patients on HD at the Island Rehab Center being older than 18 years were screened. Patients achieving their dry weight (DW) had a lung ultrasound in a supine position. Scores were classified as mild (0-14), moderate (15-30), and severe (>30) for pulmonary congestion. Patients with more than 60 were further classified as very severe. Patients were followed for cardiac events and death. RESULTS 81 patients were recruited. 58 were males, with a mean age of 59.7 years. 44 had New York Heart Association (NYHA) class 1, 24 had class 2, and 13 had class 3. In univariate analysis, NYHA class was associated with B-line classes (<0.001) and diastolic dysfunction (0.002). In multivariate analysis, NYHA grade strongly correlated with B-line classification (0.01) but not with heart function (0.95). 71 subjects were followed for a mean duration of 1.19 years. 9 patients died and 20 had an incident cardiac event. A Kaplan-Meier survival analysis demonstrated an interval decrease in survival times in all-cause mortality and cardiac events with increased BLUS scores (p = 0.0049). Multivariate Cox regression analysis showed the independent predictive value of BLUS class for mortality and cardiac events with a heart rate of 2.98 and 7.98 in severe and very severe classes, respectively, compared to patients in the mild class (p = 0.025 and 0.013). CONCLUSION At DW, BLUS is an independent risk factor for death and cardiovascular events in patients on HD.
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Skoro-Sajer N, Becherer A, Klepetko W, Kneussl MP, Maurer G, Lang IM. Longitudinal analysis of perfusion lung scintigrams of patients with unoperated chronic thromboembolic pulmonary hypertension. Thromb Haemost 2017; 92:201-7. [PMID: 15213862 DOI: 10.1160/th03-11-0727] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryChronic thromboembolic pulmonary hypertension (CTEPH) is the result of single or recurrent pulmonary thromboemboli that are thought to develop into organized pulmonary arterial obstructions by recurrent embolism and in situ thrombosis. Radioisotopic ventilation-perfusion scanning (V/Q scan) is a safe and highly sensitive test for pulmonary thromboembolic disease. The aim was to assess the natural history of thrombus expansion. We performed a prospective quantitative evaluation of ventilation/perfusion scintigrams (V/Q scans) in 20 patients with severe unoperated CTEPH. The baseline V/Q scan of each patient served as a reference for the second scan 21.7 ± 8.2 months later. Planar images with intravenous 99mTc-labeled human albumin macroaggregates were reconstructed in six standard projections. Perfusion scans were analyzed by a semiquantitative evaluation. In parallel, hemodynamics and clinical condition were prospectively observed. Lung perfusion scintigrams analyzed by a semi-quantitative method in patients with severe unoperated CTEPH show an apparent decrease of segmental flow abnormalities over time, paralleling right ventricular decline.
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Affiliation(s)
- Nika Skoro-Sajer
- Department of Cardiology, Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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176
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Koh VCA, Stevens MC, Salamonsen RF, Lovell NH, Lim E. Synergy of first principles modelling with predictive control for a biventricular assist device: In silico evaluation study. Annu Int Conf IEEE Eng Med Biol Soc 2017; 2017:1291-1294. [PMID: 29060112 DOI: 10.1109/embc.2017.8037068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Control for dual rotary left ventricular assist devices (LVADs) used as a biventricular assist device (BiVAD) is challenging. If the control system fails, flow imbalance between the systemic and the pulmonary circulations would result, subsequently leading to ventricular suction or pulmonary congestion. With the expectation that advanced control approaches such as model predictive control could address the challenges naturally and effectively, we developed a synergistic first principles model predictive controller (MPC) for the BiVAD. The internal model of the MPC is a simplified state-space model that has been developed and validated in a previous study. A single Frank-Starling (FS) control curve was used to define the target pump flow corresponding to the preload on each side of the heart. The MPC was evaluated in a validated numerical model using three clinical scenarios: blood loss, myocardial recovery, and exercise. Simulation results showed that the MPC was effective in adapting to changes in physiological states without causing ventricular suction or pulmonary congestion. The use of MPC for a BiVAD eliminates the need for two controllers of dual LVADs thus making the task of controller tuning easier.
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177
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Affiliation(s)
- Monish S Raut
- Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi, 110060, India.
| | - Bhushan Shah
- Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Arun Maheshwari
- Department of Cardiac Anesthesiology, Sir Ganga Ram Hospital, New Delhi, India
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178
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Carney JP, Zhang LM, Larson JJ, Lahti MT, Robinson NA, Dalmasso AP, Bianco RW. The Hancock® Valved Conduit for Right Ventricular Outflow Tract Reconstruction in Sheep for Assessing New Devices. J Heart Valve Dis 2017; 26:472-480. [PMID: 29302948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Xenograft conduits have been used successfully to repair congenital heart defects, but are prone to failure over time. Hence, in order to improve patient outcomes, better xenografts are being developed. When evaluating a conduit's performance and safety it must first be compared against a clinically available control in a large animal model. The study aim was to evaluate a clinically available xenograft conduit used in right ventricular outflow tract (RVOT) reconstruction in a sheep model. METHODS RVOT reconstruction was performed in 13 adult and juvenile sheep, using the Medtronic Hancock® Bioprosthetic Valved Conduit (Hancock conduit). The method had previously been used on patients, and a newly modified variant termed 'RVOT Extraction' was employed to facilitate the surgical procedure. Animals were monitored over predetermined terms of 70 to 140 days. Serial transthoracic echocardiography, intracardiac pressure measurements and angiography were performed. On study completion the animals were euthanized and necropsies performed. RESULTS Two animals died prior to their designated study term due to severe valvular stenosis and distal conduit narrowing, respectively. Thus, 11 animals survived the study term, with few or no complications. Generally, maximal and mean transvalvular pressure gradients across the implanted conduits were increased throughout the postoperative course. Among 11 full-term animals, seven conduits were patent with mild or no pseudointimal proliferation and with flexible leaflets maintaining the hemodynamic integrity of the valve. CONCLUSIONS RVOT reconstruction using the Hancock conduit was shown to be successful in sheep, with durable and efficient performances. With its extensive clinical use in patients, and ability for long-term use in sheep (as described in the present study) it can be concluded that the Hancock conduit is an excellent control device for the evaluation of new xenografts in future preclinical studies.
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Affiliation(s)
- John P Carney
- Division of Experimental Surgery, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Lindsey M Zhang
- Division of Experimental Surgery, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Jeffrey J Larson
- Division of Experimental Surgery, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Matthew T Lahti
- Division of Experimental Surgery, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Nicholas A Robinson
- Division of Experimental Surgery, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Agustin P Dalmasso
- Division of Experimental Surgery, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Richard W Bianco
- Division of Experimental Surgery, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA. Electronic correspondence:
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179
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Benfari G, Vinco G, Sayegh K, Friedrich M, Rossi A. A New Method to Evaluate Atrial Hemodynamic and Quantify Mitral Regurgitation using Cardiovascular Magnetic Resonance: The Pulmonary Venous Flow Approach. J Heart Valve Dis 2017; 26:456-459. [PMID: 29302945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Pulmonary venous flow (PVF) provides incremental information on left ventricular (LV) diastolic function, and can support the diagnosis of severe mitral regurgitation (MR). The suggestion has been made to combine the left atrial filling volume (LA Fill) and PVF for estimating the mitral regurgitant volume, but echocardiographic PVF evaluation is known to have many limitations. The present case report includes an example of how to assess PVF using cardiovascular magnetic resonance, and a new method is proposed for quantification of the mitral regurgitant volume.
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Affiliation(s)
- Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy. Electronic correspondence:
| | - Giulia Vinco
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
- Department of Radiology, McGill University Health Centre, Montreal, Canada
| | - Karl Sayegh
- Department of Radiology, McGill University Health Centre, Montreal, Canada
| | - Matthias Friedrich
- Department of Radiology, McGill University Health Centre, Montreal, Canada
| | - Andrea Rossi
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
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180
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Knoops PGM, Biglino G, Hughes AD, Parker KH, Xu L, Schievano S, Torii R. A Mock Circulatory System Incorporating a Compliant 3D-Printed Anatomical Model to Investigate Pulmonary Hemodynamics. Artif Organs 2017; 41:637-646. [PMID: 27925228 PMCID: PMC5384635 DOI: 10.1111/aor.12809] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/22/2016] [Accepted: 06/27/2016] [Indexed: 11/29/2022]
Abstract
A realistic mock circulatory system (MCS) could be a valuable in vitro testbed to study human circulatory hemodynamics. The objective of this study was to design a MCS replicating the pulmonary arterial circulation, incorporating an anatomically representative arterial model suitable for testing clinically relevant scenarios. A second objective of the study was to ensure the system's compatibility with magnetic resonance imaging (MRI) for additional measurements. A latex pulmonary arterial model with two generations of bifurcations was manufactured starting from a 3D-printed mold reconstructed from patient data. The model was incorporated into a MCS for in vitro hydrodynamic measurements. The setup was tested under physiological pulsatile flow conditions and results were evaluated using wave intensity analysis (WIA) to investigate waves traveling in the arterial system. Increased pulmonary vascular resistance (IPVR) was simulated as an example of one pathological scenario. Flow split between right and left pulmonary artery was found to be realistic (54 and 46%, respectively). No substantial difference in pressure waveform was observed throughout the various generations of bifurcations. Based on WIA, three main waves were identified in the main pulmonary artery (MPA), that is, forward compression wave, backward compression wave, and forward expansion wave. For IPVR, a rise in mean pressure was recorded in the MPA, within the clinical range of pulmonary arterial hypertension. The feasibility of using the MCS in the MRI scanner was demonstrated with the MCS running 2 h consecutively while acquiring preliminary MRI data. This study shows the development and verification of a pulmonary MCS, including an anatomically correct, compliant latex phantom. The setup can be useful to explore a wide range of hemodynamic questions, including the development of patient- and pathology-specific models, considering the ease and low cost of producing rapid prototyping molds, and the versatility of the setup for invasive and noninvasive (i.e., MRI) measurements.
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Affiliation(s)
- Paul G M Knoops
- UCL Institute of Child Health, London, United Kingdom
- Great Ormond Street Hospital for Children, NHS Trust, London, United Kingdom
- Department of Mechanical Engineering, University College London, London, United Kingdom
| | - Giovanni Biglino
- Great Ormond Street Hospital for Children, NHS Trust, London, United Kingdom
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Alun D Hughes
- UCL Institute of Cardiovascular Science, London, United Kingdom
| | - Kim H Parker
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Linzhang Xu
- Department of Mechanical Engineering, University College London, London, United Kingdom
| | - Silvia Schievano
- UCL Institute of Child Health, London, United Kingdom
- UCL Institute of Cardiovascular Science, London, United Kingdom
| | - Ryo Torii
- Department of Mechanical Engineering, University College London, London, United Kingdom
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Abstract
Patent foramen ovale has been associated with multiple pulmonary diseases, such as pulmonary hypertension, platypnea-orthodeoxia syndrome, and chronic obstructive pulmonary disease. A connection between patent foramen ovale and chronic pulmonary disease was first described more than 2 decades ago in case reports associating patent foramen ovale with more severe hypoxemia than that expected based on the severity of the primary pulmonary disease. It has been suggested that patients with both chronic pulmonary disease and patent foramen ovale are subject to severe hypoxemia because of the right-to-left shunt. Furthermore, investigators have reported improved systemic oxygenation after patent foramen ovale closure in some patients with chronic pulmonary disease. This review focuses on the association between chronic pulmonary disease and patent foramen ovale and on the dynamics of a right-to-left shunt, and it considers the potential benefit of patent foramen ovale closure in patients who have hypoxemia that is excessive in relation to the degree of their pulmonary disease.
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MESH Headings
- Coronary Circulation
- Disease Progression
- Echocardiography, Doppler, Color
- Echocardiography, Three-Dimensional
- Foramen Ovale, Patent/complications
- Foramen Ovale, Patent/diagnostic imaging
- Foramen Ovale, Patent/physiopathology
- Foramen Ovale, Patent/therapy
- Hemodynamics
- Humans
- Hypoxia/diagnosis
- Hypoxia/etiology
- Hypoxia/physiopathology
- Hypoxia/therapy
- Male
- Middle Aged
- Pulmonary Circulation
- Pulmonary Disease, Chronic Obstructive/complications
- Pulmonary Disease, Chronic Obstructive/diagnosis
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Pulmonary Disease, Chronic Obstructive/therapy
- Risk Factors
- Severity of Illness Index
- Treatment Outcome
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182
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Hashiguchi N, Kurita T, Miyazaki S. Catheter ablation for atrial fibrillation in a patient with unilateral left pulmonary artery agenesis: an enlarged right pulmonary vein caused arrhythmogenicity of atrial fibrillation. Europace 2017; 19:733. [PMID: 27733460 DOI: 10.1093/europace/euw188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Koch CD, Gladwin MT, Freeman BA, Lundberg JO, Weitzberg E, Morris A. Enterosalivary nitrate metabolism and the microbiome: Intersection of microbial metabolism, nitric oxide and diet in cardiac and pulmonary vascular health. Free Radic Biol Med 2017; 105:48-67. [PMID: 27989792 PMCID: PMC5401802 DOI: 10.1016/j.freeradbiomed.2016.12.015] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/18/2016] [Accepted: 12/12/2016] [Indexed: 02/07/2023]
Abstract
Recent insights into the bioactivation and signaling actions of inorganic, dietary nitrate and nitrite now suggest a critical role for the microbiome in the development of cardiac and pulmonary vascular diseases. Once thought to be the inert, end-products of endothelial-derived nitric oxide (NO) heme-oxidation, nitrate and nitrite are now considered major sources of exogenous NO that exhibit enhanced vasoactive signaling activity under conditions of hypoxia and stress. The bioavailability of nitrate and nitrite depend on the enzymatic reduction of nitrate to nitrite by a unique set of bacterial nitrate reductase enzymes possessed by specific bacterial populations in the mammalian mouth and gut. The pathogenesis of pulmonary hypertension (PH), obesity, hypertension and CVD are linked to defects in NO signaling, suggesting a role for commensal oral bacteria to shape the development of PH through the formation of nitrite, NO and other bioactive nitrogen oxides. Oral supplementation with inorganic nitrate or nitrate-containing foods exert pleiotropic, beneficial vascular effects in the setting of inflammation, endothelial dysfunction, ischemia-reperfusion injury and in pre-clinical models of PH, while traditional high-nitrate dietary patterns are associated with beneficial outcomes in hypertension, obesity and CVD. These observations highlight the potential of the microbiome in the development of novel nitrate- and nitrite-based therapeutics for PH, CVD and their risk factors.
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Affiliation(s)
- Carl D Koch
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA.
| | - Mark T Gladwin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA; Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh PA 15261, USA
| | - Bruce A Freeman
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh PA 15261, USA; Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Jon O Lundberg
- Department of Physiology and Pharmacology, Karolinska Institutet, S-17177 Stockholm, Sweden
| | - Eddie Weitzberg
- Department of Physiology and Pharmacology, Karolinska Institutet, S-17177 Stockholm, Sweden
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA; Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh PA 15261, USA; Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA 15261, USA; Department of Physiology and Pharmacology, Karolinska Institutet, S-17177 Stockholm, Sweden
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184
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Caravita S, Faini A, Deboeck G, Bondue A, Naeije R, Parati G, Vachiéry JL. Pulmonary hypertension and ventilation during exercise: Role of the pre-capillary component. J Heart Lung Transplant 2016; 36:754-762. [PMID: 28131663 DOI: 10.1016/j.healun.2016.12.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/08/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Excessive exercise-induced hyperventilation and high prevalence of exercise oscillatory breathing (EOB) are present in patients with post-capillary pulmonary hypertension (PH) complicating left heart disease (LHD). Patients with pre-capillary PH have even higher hyperventilation but no EOB. We sought to determine the impact of a pre-capillary component of PH on ventilatory response to exercise in patients with PH and left heart disease. METHODS We retrospectively compared patients with idiopathic or heritable pulmonary arterial hypertension (PAH, n = 29), isolated post-capillary PH (IpcPH, n = 29), and combined post- and pre-capillary PH (CpcPH, n = 12). Diastolic pressure gradient (DPG = diastolic pulmonary artery pressure - pulmonary wedge pressure) was used to distinguish IpcPH (DPG <7 mm Hg) from CpcPH (DPG ≥7 mm Hg). RESULTS Pulmonary vascular resistance (PVR) was higher in PAH, intermediate in CpcPH, and low in IpcPH. All patients with CpcPH but 1 had PVR >3 Wood unit. Exercise-induced hyperventilation (high minute ventilation over carbon dioxide production, low end-tidal carbon dioxide) was marked in PAH, intermediate in CpcPH, and low in IpcPH (p < 0.001) and correlated with DPG and PVR. Prevalence of EOB decreased from IpcPH to CpcPH to PAH (p < 0.001). CONCLUSIONS Patients with CpcPH may have worse hemodynamics than patients with IpcPH and distinct alterations of ventilatory control, consistent with more exercise-induced hyperventilation and less EOB. This might be explained at least in part by the presence and extent of pulmonary vascular disease.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium; Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Faini
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Gael Deboeck
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Robert Naeije
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy; Department of Health Sciences, University of Milano-Bicocca, Milan, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium.
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185
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Kuei A, Lee EW, Saab S, Busuttil RW, Durazo F, Han SH, ElKabany M, McWilliams JP, Kee ST. Inpatient Cost Assessment of Transjugular Intrahepatic Portosystemic Shunt in the USA from 2001 to 2012. Dig Dis Sci 2016; 61:2838-2846. [PMID: 27349987 DOI: 10.1007/s10620-016-4233-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 06/15/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite widespread use of transjugular intrahepatic portosystemic shunt (TIPS) for treatment of portal hypertension, a paucity of nationwide data exists on predictors of the economic impact related to TIPS. AIMS Using the National Inpatient Sample (NIS) database from 2001 to 2012, we aimed to evaluate factors contributing to hospital cost of patients admitted to US hospitals for TIPS. METHODS Using the NIS, we identified a discharge-weighted national estimate of 61,004 TIPS procedures from 2001 to 2012. Through independent sample analysis, we determined profile factors related to increases in hospital costs. RESULTS Of all TIPS cases, the mean charge adjusted for inflation to the year 2012 is $125,044 ± $160,115. The mean hospital cost adjusted for inflation is $44,901 ± $54,565. Comparing pre- and post-2005, mean charges and cost have increased considerably ($98,154 vs. $142,652, p < 0.001 and $41,656 vs. $46,453, p < 0.001, respectively). Patients transferred from a different hospital, weekend admissions, Asian/Pacific Islander patients, and hospitals in the Northeastern and Western region had higher cost. Number of diagnoses and number of procedures show positive correlations with hospital cost, with number of procedures exhibiting stronger relationships (Pearson 0.613). Comorbidity measures with highest increases in cost were pulmonary circulation disorders ($32,157 increase, p < 0.001). CONCLUSION The cost of the TIPS procedure is gradually rising for hospitals. Alongside recent healthcare reform through the Affordable Care Act, measures to reduce the economic burden of TIPS are of increasing importance. Data from this study are intended to aid physicians and hospitals in identifying improvements that could reduce hospital costs.
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Affiliation(s)
- Andrew Kuei
- Division of Interventional Radiology, Department of Radiology, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 2125, Los Angeles, CA, 90095-743730, USA
| | - Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 2125, Los Angeles, CA, 90095-743730, USA.
| | - Sammy Saab
- Division of Hepatology, Department of Medicine, Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, Dumont-UCLA Transplant Center, Pfleger Liver Institute, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Francisco Durazo
- Division of Hepatology, Department of Medicine, Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven-Huy Han
- Division of Hepatology, Department of Medicine, Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA
| | - Mohamed ElKabany
- Division of Hepatology, Department of Medicine, Pfleger Liver Institute, University of California at Los Angeles, Los Angeles, CA, USA
| | - Justin P McWilliams
- Division of Interventional Radiology, Department of Radiology, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 2125, Los Angeles, CA, 90095-743730, USA
| | - Stephen T Kee
- Division of Interventional Radiology, Department of Radiology, Ronald Reagan Medical Center at UCLA, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 2125, Los Angeles, CA, 90095-743730, USA
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186
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Boehme J, Sun X, Tormos KV, Gong W, Kellner M, Datar SA, Kameny RJ, Yuan JXJ, Raff GW, Fineman JR, Black SM, Maltepe E. Pulmonary artery smooth muscle cell hyperproliferation and metabolic shift triggered by pulmonary overcirculation. Am J Physiol Heart Circ Physiol 2016; 311:H944-H957. [PMID: 27591215 PMCID: PMC5114466 DOI: 10.1152/ajpheart.00040.2016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 08/08/2016] [Indexed: 11/22/2022]
Abstract
Vascular cell hyperproliferation and metabolic reprogramming contribute to the pathophysiology of pulmonary arterial hypertension (PAH). An important cause of PAH in children with congenital heart disease (CHD) is increased pulmonary blood flow (PBF). To better characterize this disease course we studied early changes in pulmonary artery smooth muscle cell (PASMC) proliferation and metabolism using a unique ovine model of pulmonary overcirculation. Consistent with PAH in adults, PASMCs derived from 4-wk-old lambs exposed to increased PBF (shunt) exhibited increased rates of proliferation. While shunt PASMCs also exhibited significant decreases in mitochondrial oxygen consumption, membrane potential, and tricarboxylic acid (TCA) cycle function, suggesting a switch to Warburg metabolism as observed in advanced PAH in adults, they unexpectedly demonstrated decreased glycolytic lactate production, likely due to enhanced flux through the pentose phosphate pathway (PPP). This may be a response to the marked increase in NADPH oxidase (Nox) activity and decreased NADPH/NADP+ ratios observed in shunt PASMCs. Consistent with these findings, pharmacological inhibition of Nox activity preferentially slowed the growth of shunt PASMCs in vitro. Our results therefore indicate that PASMC hyperproliferation is observed early in the setting of pulmonary overcirculation and is accompanied by a unique metabolic profile that is independent of HIF-1α, PDHK1, or increased glycolytic flux. Our results also suggest that Nox inhibition may help prevent pulmonary overcirculation-induced PAH in children born with CHD.
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MESH Headings
- Animals
- Blotting, Western
- Cell Proliferation
- Cells, Cultured
- Disease Models, Animal
- Electron Spin Resonance Spectroscopy
- Flow Cytometry
- Fluorescent Antibody Technique
- Glycolysis
- Hypertension, Pulmonary/metabolism
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Membrane Potential, Mitochondrial
- Metabolomics
- Mitochondria/metabolism
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/metabolism
- Myocytes, Smooth Muscle/cytology
- Myocytes, Smooth Muscle/metabolism
- NADPH Oxidases/metabolism
- Oxygen Consumption
- Pentose Phosphate Pathway
- Pulmonary Artery/cytology
- Pulmonary Artery/metabolism
- Pulmonary Circulation
- Reactive Oxygen Species/metabolism
- Sheep
- Sheep, Domestic
- Superoxides/metabolism
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Affiliation(s)
- Jason Boehme
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Xutong Sun
- Department of Medicine, University of Arizona, Tucson, Arizona; and
| | - Kathryn V Tormos
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Wenhui Gong
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Manuela Kellner
- Department of Medicine, University of Arizona, Tucson, Arizona; and
| | - Sanjeev A Datar
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Rebecca Johnson Kameny
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Jason X-J Yuan
- Department of Medicine, University of Arizona, Tucson, Arizona; and
| | - Gary W Raff
- Department of Surgery, University of California Davis, Davis, California
| | - Jeffrey R Fineman
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Stephen M Black
- Department of Medicine, University of Arizona, Tucson, Arizona; and
| | - Emin Maltepe
- Department of Pediatrics, University of California San Francisco, San Francisco, California;
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187
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Vanden Eynden F, Bol Alima M, Racape J, El Oumeiri B, Vachiéry JL, Van Nooten G. Composite indices of upstream pulmonary vascular impedance and capacitance do not help in identifying patients who should undergo pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension. Acta Cardiol 2016; 71:281-90. [PMID: 27594123 DOI: 10.2143/ac.71.3.3152088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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188
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Abstract
PURPOSE OF REVIEW The purpose is to describe the recent advances made in imaging of the right heart, including deformation imaging, tissue, and flow characterization by MRI, and molecular imaging. RECENT FINDINGS Recent developments have been made in the field of deformation imaging of the right heart, which may improve risk stratification of patients with heart failure and pulmonary hypertension. In addition, more attention has been given to load adaptability metrics of the right heart; these simplified indices, however, still face challenges from a conceptual point of view. The emergence of novel MRI sequences, such as native T1 mapping, allows better detection and quantification of myocardial fibrosis and could allow better prediction of postsurgical recovery of the right heart. Other advances in MRI include four-dimensional flow imaging, which may be particularly useful in congenital heart disease or for the detection of early stages of pulmonary vascular disease. SUMMARY The review will place the recent developments in right heart imaging in the context of clinical care and research.
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Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Kate Hanneman
- Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Andre Denault
- Department of Anesthesiology and Critical Care Division, CHUM and Montreal Heart Institute, Montreal, QC, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
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190
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FRAYSER R. In Vivo Observations On the Pulmonary Circulation and Blood Oxygen Saturation in Cats Following Intravenous Infusion of 15 Per Cent Cottonseed Oil Emulsion. Angiology 2016; 15:192-5. [PMID: 14158905 DOI: 10.1177/000331976401500406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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192
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Datar SA, Gong W, He Y, Johengen M, Kameny RJ, Raff GW, Maltepe E, Oishi PE, Fineman JR. Disrupted NOS signaling in lymphatic endothelial cells exposed to chronically increased pulmonary lymph flow. Am J Physiol Heart Circ Physiol 2016; 311:H137-45. [PMID: 27199125 PMCID: PMC4967199 DOI: 10.1152/ajpheart.00649.2015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 04/08/2016] [Indexed: 01/06/2023]
Abstract
Associated abnormalities of the lymphatic circulation are well described in congenital heart disease. However, their mechanisms remain poorly elucidated. Using a clinically relevant ovine model of a congenital cardiac defect with chronically increased pulmonary blood flow (shunt), we previously demonstrated that exposure to chronically elevated pulmonary lymph flow is associated with: 1) decreased bioavailable nitric oxide (NO) in pulmonary lymph; and 2) attenuated endothelium-dependent relaxation of thoracic duct rings, suggesting disrupted lymphatic endothelial NO signaling in shunt lambs. To further elucidate the mechanisms responsible for this altered NO signaling, primary lymphatic endothelial cells (LECs) were isolated from the efferent lymphatic of the caudal mediastinal node in 4-wk-old control and shunt lambs. We found that shunt LECs (n = 3) had decreased bioavailable NO and decreased endothelial nitric oxide synthase (eNOS) mRNA and protein expression compared with control LECs (n = 3). eNOS activity was also low in shunt LECs, but, interestingly, inducible nitric oxide synthase (iNOS) expression and activity were increased in shunt LECs, as were total cellular nitration, including eNOS-specific nitration, and accumulation of reactive oxygen species (ROS). Pharmacological inhibition of iNOS reduced ROS in shunt LECs to levels measured in control LECs. These data support the conclusion that NOS signaling is disrupted in the lymphatic endothelium of lambs exposed to chronically increased pulmonary blood and lymph flow and may contribute to decreased pulmonary lymphatic bioavailable NO.
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Affiliation(s)
- Sanjeev A Datar
- Department of Pediatrics, University of California, San Francisco, San Francisco, California;
| | - Wenhui Gong
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Youping He
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Michael Johengen
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Rebecca J Kameny
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Gary W Raff
- Department of Surgery, University of California, Davis, Davis, California
| | - Emin Maltepe
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Peter E Oishi
- Department of Pediatrics, University of California, San Francisco, San Francisco, California; Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California; and
| | - Jeffrey R Fineman
- Department of Pediatrics, University of California, San Francisco, San Francisco, California; Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California; and
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193
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Alpard SK, Wang D, Deyo DJ, Smolarz CM, Chambers S, Zwischenberger JB. Optional active compliance chamber performance in a pulmonary artery-pulmonary artery configured paracorporeal artificial lung. Perfusion 2016; 22:81-6. [PMID: 17708156 DOI: 10.1177/0267659107078483] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Our group has developed a paracorporeal artificial lung (PAL) attached in a pulmonary artery (PA) to PA in series configuration to address profound respiratory failure and serve as a bridge to transplant and/or recovery. We recently designed, developed and converted our passive pre-PAL compliance chamber to an active, synchronized, counterpulsating assist device to relieve right heart strain and offset increased work placed on the right ventricle when the PAL is attached. In this study, we evaluated the safety and performance of both a valved and non-valved optional active compliance chamber (OACC) in a PA-PA PAL for right heart assistance in normal adult sheep. Methods : Eleven sheep (30—50 kg) were divided into non-valved OACC (n = 6) and valved (n = 5) OACC groups. To mimic pulmonary hypertension, a C-clamp was placed distal to the OACC-PAL and occluded until a 20% decrease in cardiac output (CO) was achieved. The OACC was activated, and right ventricular pressure (RVP), pulmonary artery pressure (PAP), mean arterial pressure (MAP) and CO were recorded. Results: All eleven animals tolerated the implantation of the OACC PAL. Activation of the OACC resulted in a significant increase in CO. Systolic and diastolic right ventricular pressure decreased in both groups. Lastly, counterpulsation increased the mean PAP in all animals and peak PAP reached 89 mmHg. Despite providing right heart assistance, synchronizing the counterpulsation was technically difficult, and the high peak PA pressures resulted in anastomotic bleeding in all animals and anastomotic breakdown in 4/11 animals. Conclusions: An OACC PAL perfused by the right ventricle applied in series with the pulmonary circulation reduces ventricular load and improves cardiac efficiency. These preliminary data suggest the potential of an artificial lung in unloading the strained right ventricle and acting as a bridge to transplantation. The augmented peak PA pressures, resulting in bleeding and anastomotic breakdown, and complexity in synchronizing the cardiac cycle with the pulsations of the augmented OACC, compromise this configuration. Perfusion (2007) 22, 81—86.
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Affiliation(s)
- Scott K Alpard
- Department of Surgery University of Texas Medical Branch, Galveston, TX 77555-0528, USA
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194
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Abstract
Pulsatile pulmonary blood flow plays an important role in regulating shear-stress-mediated release of endothelium-derived nitric oxide and endothelin-1, and it reduces pulmonary vascular resistance by passive capillary recruitment. The aim of this study was to demonstrate changes in pulmonary capillary structure and endothelial function induced by the chronic nonpulsatile flow of the Fontan circulation. A canine model with nonpulsatile flow in the right lung was established, and sacrificed 3 months later. Compared to the left lung, wall thickness of the pulmonary arterioles was thinner, endothelin-1 expression was weaker, endothelial nitric oxide synthase activity was stronger, and there was a good correlation between the histomorphometric and immunohistochemical findings. These data indicate that long-term nonpulsatile flow can lead to endothelial dysfunction, which may be involved in distention and vascular structure remodeling due to the increase in pulmonary vascular resistance; but it also can lead to increased patency of the arteriovenous shunt, which might be at least partly involved in pulmonary arteriovenous fistula development and exercise limitation after the Fontan operation.
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Affiliation(s)
- Zongtao Yin
- Department of Cardiovascular Surgery, Shenyang Northern Hospital, 83 Wenhua Road, Shenhe District, Shenyang 110016, China.
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195
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Najm HK, Jha NK, Godman M, Al Mutairi M, Rezk AI, Momenah T. Pulmonary Atresia, VSD in Association with Coronary-Pulmonary Artery Fistula. Asian Cardiovasc Thorac Ann 2016; 15:335-8. [PMID: 17664210 DOI: 10.1177/021849230701500415] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Congenital coronary-pulmonary artery fistula is rare in patients with pulmonary atresia and ventricular septal defect. The nomenclature, physiological, clinical, and surgical implications of these fistulas are yet to be defined. We report a one-year-old child with pulmonary atresia, ventricular septal defect, and a right coronary-pulmonary artery fistula who also had a diminutive, disconnected left pulmonary artery in addition to aortopulmonary collaterals. The patient underwent corrective surgery. However, the fate of diminutive pulmonary arteries is unknown. The literature was reviewed to explore the clinical or surgical implications of such fistulas for improved understanding and management in the future.
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Affiliation(s)
- Hani K Najm
- Department of Cardiac Surgery, King Fahad Hospital, Riyadh, Saudi Arabia
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196
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Abstract
Improvement in the ratio of PaO2 to the fraction of inspired oxygen and treatment of pulmonary infections in donors have been cited as important goals for improving lungs before implantation and restoring marginal lungs to the donor pool. Likewise, improving donor PaO2 is often critical for other organs during donor care. The common physiological mechanisms responsible for hypoxemia are ventilation/perfusion mismatching, abnormal oxygen diffusion, and hypoventilation. These mechanisms are discussed and treatment options are considered.
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Affiliation(s)
- David J Powner
- Vivian L. Smith Center for Neurologic Research, University of Texas Health Science Center at Houston, TX, USA
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197
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Kato A, Drolet C, Yoo SJ, Redington AN, Grosse-Wortmann L. Vicious circle between progressive right ventricular dilatation and pulmonary regurgitation in patients after tetralogy of Fallot repair? Right heart enlargement promotes flow reversal in the left pulmonary artery. J Cardiovasc Magn Reson 2016; 18:34. [PMID: 27268132 PMCID: PMC4897954 DOI: 10.1186/s12968-016-0254-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 05/25/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The left pulmonary artery (LPA) contributes more than the right (RPA) to total pulmonary regurgitation (PR) in patients after tetralogy of Fallot (TOF) repair, but the mechanism of this difference is not well understood. This study aimed to analyze the interplay between heart and lung size, mediastinal geometry, and differential PR. METHODS Forty-eight Cardiovascular Magnetic Resonance (CMR) studies in patients after TOF repair were analyzed. In addition to the routine blood flow and ventricular volume quantification cardiac angle between the thoracic anterior-posterior line and the interventricular septum, right and left lung areas as well as right and left hemithorax areas were measured on an axial image. Statistical analysis was performed to compare flow parameters between RPA and LPA and to assess correlation among right ventricular volume, pulmonary blood flow parameters and lung area. RESULTS There was no difference between LPA and RPA diameters. The LPA showed significantly less total forward flow (2.49 ± 0.87 L/min/m(2) vs 2.86 ± 0.89 L/min/m(2); p = 0.02), smaller net forward flow (1.40 ± 0.51 vs 1.89 ± 0.60 mL/min/m(2); p = <0.001), and greater regurgitant fraction (RF) (34 ± 10 % vs 43 ± 12 %; p = 0.001) than the RPA. There was no difference in regurgitant flow volume between RPA and LPA (p = 0.29). Indexed right ventricular end-diastolic volume (RVEDVi) correlated with LPA RF (R = 0.48, p < 0.001), but not with RPA RF (p = 0.09). Larger RVEDVi correlated with a more leftward cardiac axis (R = 0.46, p < 0.001) and with smaller left lung area (R = -0.58, p < 0.001). LPA RF, but not RPA RF, correlated inversely with left lung area (R = -0.34, p = 0.02). The follow-up CMRs in 20 patients showed a correlation of the rate of RV enlargement with the rates of LPA RF worsening (R = 0.50, p = 0.03), and of increasing left lung compression (R = -0.55, p = 0.012). CONCLUSION An enlarged and levorotated heart is associated with left lung compression and impaired flow into the left lung.
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Affiliation(s)
- Atsuko Kato
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, M5G 1X8, ON, Canada
| | - Christian Drolet
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, M5G 1X8, ON, Canada
- now: Université Laval, Quebec City, QC, Canada
| | - Shi-Joon Yoo
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, M5G 1X8, ON, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Andrew N Redington
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, M5G 1X8, ON, Canada
- now: Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Lars Grosse-Wortmann
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, M5G 1X8, ON, Canada.
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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198
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Wehrum T, Hagenlocher P, Lodemann T, Vach W, Dragonu I, Hennemuth A, von Zur Mühlen C, Stuplich J, Ngo BTT, Harloff A. Age dependence of pulmonary artery blood flow measured by 4D flow cardiovascular magnetic resonance: results of a population-based study. J Cardiovasc Magn Reson 2016; 18:31. [PMID: 27245203 PMCID: PMC4888740 DOI: 10.1186/s12968-016-0252-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/19/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND It was our aim to systematically analyze pulmonary artery blood flow within different age-groups in the general population using 4D flow cardiovascular magnetic resonance (CMR) in order to provide a context for interpreting results of future studies (e.g., in pulmonary hypertension) using this technique. METHODS An age-stratified sample (n = 126) of the population of the city of Freiburg, Germany, underwent ECG-triggered and navigator-gated 4D flow CMR at 3 T of the pulmonary arteries and the thoracic aorta. Analysis planes were placed in the main, left, and right pulmonary artery using dedicated software. Study participants were divided into three groups (1:20-39; 2:40-59; and 3:60-80 years of age). Subsequently, pulmonary blood flow was visualized, quantified and compared between groups. RESULTS Time-to-peak of systolic antegrade flow was shorter, peak and average velocities and flow volumes were lower in older subjects. At the end of systole, retrograde flow in the main pulmonary artery was observed in all but one subject. Subsequently, a second antegrade flow peak occurred in diastole which was lower in older subjects. Age was an independent predictor of hemodynamic change after adjustment for cardiovascular risk factors and body-mass-index. During systole, abnormal vortices occurred in the main pulmonary artery in four male subjects. CONCLUSIONS Comprehensive analysis of pulmonary blood flow was feasible in all subjects. We were able to detect an independent effect of ageing on pulmonary hemodynamics reflecting increased vessel stiffness and reduced pulmonary circulation. Findings of this study may be helpful for discriminating physiological from pathological flow in patients with pulmonary diseases in the future.
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Affiliation(s)
- Thomas Wehrum
- Department of Neurology, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.
| | - Paul Hagenlocher
- Department of Neurology, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
| | - Thomas Lodemann
- Department of Neurology, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
| | - Werner Vach
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - Iulius Dragonu
- Department of Diagnostic Radiology - Medical Physics, University Medical Center Freiburg, Freiburg, Germany
| | | | | | - Judith Stuplich
- Department of Cardiology, University Heart Center Freiburg, Freiburg, Germany
| | - Ba Thanh Truc Ngo
- Department of Cardiology, University Heart Center Freiburg, Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany
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199
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Cosarderelioglu C, Cosar AM, Gurakar M, Pustavoitau A, Russell SD, Dagher NN, Gurakar A. Portopulmonary Hypertension and Liver Transplant: Recent Review of the Literature. EXP CLIN TRANSPLANT 2016; 14:113-120. [PMID: 27015528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Portopulmonary hypertension is one of the main pulmonary conditions affecting patients with liver disease and/or portal hypertension. Other conditions include hepatopulmonary syndrome and hepatic hydrothorax. Portopulmonary hypertension is caused by pulmonary vasoconstriction and increased pulmonary vascular resistance. It develops as a result of portal hypertension with or without liver disease and is associated with a higher morbidity and mortality. However, portopulmonary hypertension is usually asymptomatic; the most common symptoms are dyspnea, fatigue, and peripheral edema. All liver transplant candidates should be screened for potential portopulmonary hypertension because its coexistence can affect survival rates after transplant. All patients with cirrhosis who present with dyspnea should also be screened. Transthoracic echocardiography is a noninvasive, useful method for screening, but right heart-sided catheterization remains the criterion standard for diagnosis. Portopulmonary hypertension carries a poor prognosis without liver transplant, and its severe form is considered to be a contraindication for liver transplant. Treating patients with pulmonary arterial hypertension-specific therapies before liver transplant for moderate and severe portopulmonary hypertension appears to be beneficial.
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200
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Evlakhov VI, Poyasov IZ, Ovsyannikov VI, Shaidakov EV. [MECHANISMS OF THE PULMONARY CIRCULATORY CHANGES FOLLOWING EXPERIMENTAL INFERIOR VENA CAVA STENOSIS]. Ross Fiziol Zh Im I M Sechenova 2016; 102:307-316. [PMID: 30188665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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