801
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Rothman RB, Ayestas MA, Dersch CM, Baumann MH. Aminorex, fenfluramine, and chlorphentermine are serotonin transporter substrates. Implications for primary pulmonary hypertension. Circulation 1999; 100:869-75. [PMID: 10458725 DOI: 10.1161/01.cir.100.8.869] [Citation(s) in RCA: 166] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coadministration of phentermine and fenfluramine (phen/fen) effectively treats obesity and possibly addictive disorders. The association of fenfluramine and certain other anorexic agents with serious side effects, such as cardiac valvulopathy and primary pulmonary hypertension (PPH), limits the clinical utility of these drugs. Development of new medications that produce neurochemical effects like phen/fen without causing unwanted side effects would be a significant therapeutic breakthrough. METHODS AND RESULTS We tested the hypothesis that fenfluramine (and other anorexic agents) might increase the risk of PPH through interactions with serotonin (5-HT) transporters. Because 5-HT transporter proteins in the lung and brain are identical, we examined, in rat brain, the effects of selected drugs on 5-HT efflux in vivo and monoamine transporters in vitro as a generalized index of transporter function. Our data show that drugs known or suspected to increase the risk of PPH (eg, aminorex, fenfluramine, and chlorphentermine) are 5-HT transporter substrates, whereas drugs that have not been shown to increase the risk of PPH are less potent in this regard. CONCLUSIONS We speculate that medications that are 5-HT transporter substrates get translocated into pulmonary cells where, depending on the degree of drug retention, their intrinsic drug toxicity, and individual susceptibility, PPH could develop as a response to high levels of these drugs or metabolites. Emerging evidence suggests that it is possible to develop transporter substrates devoid of adverse side effects. Such medications could have therapeutic application in the management of obesity, drug dependence, depression, and other disorders.
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Affiliation(s)
- R B Rothman
- Clinical Psychopharmacology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, Md, USA.
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802
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Bossone E, Duong-Wagner TH, Paciocco G, Oral H, Ricciardi M, Bach DS, Rubenfire M, Armstrong WF. Echocardiographic features of primary pulmonary hypertension. J Am Soc Echocardiogr 1999; 12:655-62. [PMID: 10441222 DOI: 10.1053/je.1999.v12.a99069] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Primary pulmonary hypertension (PPH) is essentially a diagnosis of exclusion and usually is made late because of the nonspecific nature of the early signs and symptoms. Echocardiography is a key screening test in the diagnostic algorithm of patients with suspected PPH. The purpose of this study was to define the echocardiographic Doppler features in patients with PPH at the time of diagnosis. From 1992 to 1997, 51 patients were diagnosed with PPH at our institution. All underwent a standardized transthoracic echocardiographic examination, including a contrast study and transthoracic echocardiographic examination if indicated. Pulmonary artery systolic pressure was calculated from the tricuspid regurgitation jet. The majority of patients had pulmonary artery systolic pressure greater than 60 mm Hg (96%) associated with systolic flattening of the interventricular septum (90%), enlarged right atrium (92%) and ventricle (98%), and reduced right ventricular systolic function (76%). There was an increase in the interventricular septal thickness (>1.2 cm) in 21 (43%) of 49 patients, accompanied by a septal/posterior wall ratio greater than 1.3 in 11 (22%) of 49. Although a reduction in both left ventricular systolic and diastolic volumes was noted, global left ventricular systolic function was preserved in all patients. Mitral E/A ratio was less than 0.7 in 7 (22%) patients studied. Color Doppler revealed moderate to severe tricuspid regurgitation and pulmonic insufficiency in 41 (80%) of 51 and 16 (31%) of 51 of cases, respectively. Pericardial effusion (7 small and 1 moderate) and patent foramen ovale (n = 12) were also frequently detected. At the time of initial diagnosis, PPH is associated with secondary cardiac abnormalities in the majority of patients.
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Affiliation(s)
- E Bossone
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
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803
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Hoeper MM, Maier R, Tongers J, Niedermeyer J, Hohlfeld JM, Hamm M, Fabel H. Determination of cardiac output by the Fick method, thermodilution, and acetylene rebreathing in pulmonary hypertension. Am J Respir Crit Care Med 1999; 160:535-41. [PMID: 10430725 DOI: 10.1164/ajrccm.160.2.9811062] [Citation(s) in RCA: 151] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Assessment of cardiac output is an important part of the management of patients with pulmonary hypertension. The accuracy of the thermodilution technique in patients with low cardiac output or severe tricuspid regurgitation has been questioned. To address this issue, we simultaneously compared 105 cardiac output measurements by the Fick method and thermodilution in 35 patients with pulmonary hypertension. Moreover, we evaluated the acetylene rebreathing technique, a noninvasive method of determining cardiac output. The mean difference +/- 95% limit of agreement between thermodilution and the Fick method was +0.01 +/- 1.1 L/min. The mean difference +/- 95% limit of agreement between acetylene rebreathing and the Fick method was -0.23 +/- 1.14 L/min. Neither the mean agreement nor the 95% limits of agreement of both thermodilution and acetylene rebreathing with the Fick method were affected by the presence of low cardiac output or severe tricuspid regurgitation. We conclude that thermodilution and acetylene rebreathing are useful tools for assessing cardiac output in patients with pulmonary hypertension, even in the presence of low cardiac output or severe tricuspid regurgitation.
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Affiliation(s)
- M M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
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804
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Olschewski H, Ghofrani HA, Walmrath D, Schermuly R, Temmesfeld-Wollbruck B, Grimminger F, Seeger W. Inhaled prostacyclin and iloprost in severe pulmonary hypertension secondary to lung fibrosis. Am J Respir Crit Care Med 1999; 160:600-7. [PMID: 10430735 DOI: 10.1164/ajrccm.160.2.9810008] [Citation(s) in RCA: 223] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension is a life-threatening complication of lung fibrosis. Vasodilator therapy is difficult owing to systemic side effects and pulmonary ventilation-perfusion mismatch. We compared the effects of intravenous prostacyclin and inhaled NO and aerosolized prostacyclin in randomized order and, in addition, tested for effects of oxygen and systemic calcium antagonists (CAAs) in eight patients with lung fibrosis and pulmonary hypertension. Aerosolized prostaglandin (PG)I(2) caused preferential pulmonary vasodilatation with a decrease in mean pulmonary arterial pressure from 44.1 +/- 4.2 to 31.6 +/- 3.1 mm Hg, and pulmonary vascular resistance (RL) from 810 +/- 226 to 386 +/- 69 dyn. s. cm(-)(5) (p < 0.05, respectively). Systemic arterial pressure, arterial oxygen saturation, and pulmonary right-to-left shunt flow, measured by multiple inert gas analysis, were not significantly changed. Inhaled NO similarly resulted in selective pulmonary vasodilatation, with RL decreasing from 726 +/- 217 to 458 +/- 81 dyn. s. cm(-)(5). In contrast, both intravenous PGI(2) and CAAs were not pulmonary selective, resulting in a significant drop in arterial pressure. In addition, PGI(2) infusion caused a marked increase in shunt flow. Long-term therapy with aerosolized iloprost (long-acting PGI(2) analog) resulted in unequivocal clinical improvement from a state of immobilization and severe resting dyspnea in a patient with decompensated right heart failure. We concluded that, in pulmonary hypertension secondary to lung fibrosis, aerosolization of PGI(2) or iloprost causes marked pulmonary vasodilatation with maintenance of gas exchange and systemic arterial pressure. Long-term therapy with inhaled iloprost may be life saving in decompensated right heart failure from pulmonary hypertension secondary to lung fibrosis.
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Affiliation(s)
- H Olschewski
- Depatment of Internal Medicine II, Justus-Liebig-University, Giessen, Germany.
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805
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Jourdan KB, Evans TW, Lamb NJ, Goldstraw P, Mitchell JA. Autocrine function of inducible nitric oxide synthase and cyclooxygenase-2 in proliferation of human and rat pulmonary artery smooth-muscle cells: species variation. Am J Respir Cell Mol Biol 1999; 21:105-10. [PMID: 10385598 DOI: 10.1165/ajrcmb.21.1.3502] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Pulmonary hypertension is characterized by hypertrophy and hyperplasia of vascular smooth muscle occurring via an unknown mechanism. Cyclooxygenase (COX)-2 and inducible nitric oxide synthase (iNOS) are expressed under inflammatory conditions and produce mediators that regulate growth in some tissues. We have therefore addressed the question of COX-2 and iNOS involvement in proliferation of human and rat pulmonary artery (PA) smooth-muscle cells (SMC). Interleukin (IL)-1beta suppressed proliferation of both human and rat PA SMC. Moreover, IL-1beta induced COX-2 expression in both cell types. By contrast, IL-1beta stimulated the expression of iNOS protein in rat cells only. COX-2 induced in human cells inhibited proliferation, whereas COX-2 products in rat cells were without affect. However, iNOS activity in rat cells suppressed their proliferation. We conclude that human and rat evolution has diverged such that COX-2 and iNOS, although induced by the same mediator, have different levels of activity and functions in the two species. In humans, induction of COX-2 during pulmonary hypertension may be beneficial for long-term treatment of this disease.
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Affiliation(s)
- K B Jourdan
- Unit of Critical Care, Imperial College School of Medicine at the National Heart and Lung Institute, Royal Brompton Hospital, London, United Kingdom
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806
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Langleben D, Barst RJ, Badesch D, Groves BM, Tapson VF, Murali S, Bourge RC, Ettinger N, Shalit E, Clayton LM, Jöbsis MM, Blackburn SD, Crow JW, Stewart DJ, Long W. Continuous infusion of epoprostenol improves the net balance between pulmonary endothelin-1 clearance and release in primary pulmonary hypertension. Circulation 1999; 99:3266-71. [PMID: 10385501 DOI: 10.1161/01.cir.99.25.3266] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary pulmonary hypertension results from progressive narrowing of the precapillary pulmonary vasculature. A variety of endothelial abnormalities have been identified, including a net reduction in pulmonary clearance of the vasoconstrictor and smooth muscle mitogen endothelin-1. In many patients, net pulmonary release of endothelin-1 is observed. Chronic infusions of epoprostenol (prostacyclin) improve functional capacity, survival, and hemodynamics in patients with advanced primary pulmonary hypertension. We hypothesized that the epoprostenol infusions, as compared with conventional therapy, might alter the abnormal pulmonary endothelin-1 homeostasis. METHODS AND RESULTS Using a subset of patients from a larger randomized study comparing epoprostenol plus conventional therapy (n=11 in the present study) with conventional therapy alone (n=7 in the present study), we determined the ratio of plasma endothelin-1 levels in systemic arterial blood leaving the lung to levels in mixed venous blood entering the lung both before randomization and after 88 days of continuous therapy. There were no differences between the 2 groups before therapy, but by day 88, the epoprostenol-treated group had a greater proportion of patients (82%) with an arterial/venous ratio <1 than did the conventional therapy group, in which only 29% of patients had a ratio <1 (P<0.05). CONCLUSIONS These results suggest that continuous epoprostenol therapy may have a beneficial effect on the balance between endothelin-1 clearance and release in many patients with primary pulmonary hypertension and may provide one explanation for the salutary effect of epoprostenol in this disease.
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Affiliation(s)
- D Langleben
- Division of Cardiology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada.
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807
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Whyte RI, Robbins RC, Altinger J, Barlow CW, Doyle R, Theodore J, Reitz BA. Heart-lung transplantation for primary pulmonary hypertension. Ann Thorac Surg 1999; 67:937-41; discussion 941-2. [PMID: 10320232 DOI: 10.1016/s0003-4975(99)00176-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The operation of choice for primary pulmonary hypertension remains controversial, as heart-lung transplantation, single-lung transplantation, and double-lung transplantation have all been advocated. METHODS We reviewed our institution's experience with heart-lung transplantation for primary pulmonary hypertension. RESULTS Thirty-nine patients had heart-lung transplantation for primary pulmonary hypertension. Operative mortality rate was 18%, and actuarial survival was 72% at 1 year, 67% at 2 years, and 42% at 5 years. Freedom from obliterative bronchiolitis was 91% at 1 year, 83% at 2 years, and 70% at 5 years. Freedom from obliterative bronchiolitis-related death was 100% at 1 year, 90% at 2 years, and 87% at 5 years. Freedom from accelerated graft coronary disease was 92% at 5 years. The most frequent causes of death were infection, obliterative bronchiolitis, and accelerated graft coronary disease. CONCLUSIONS Heart-lung transplantation results in survival comparable to that reported for single or double lung transplantation. Obliterative bronchiolitis is a significant cause of late death but seems to occur less frequently with heart-lung transplantation than with lung transplantation alone. Accelerated coronary graft disease is rare in the first 5 years after transplantation.
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Affiliation(s)
- R I Whyte
- Department of Cardiothoracic Surgery, Stanford University, California 94305, USA.
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808
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Abstract
OBJECTIVE To review briefly the epidemiology, pathophysiology, and current treatment of primary pulmonary hypertension (PPH) and review the available clinical data on epoprostenol in PPH. DATA SOURCES A MEDLINE search (January 1966-August 1998) was used to identify case reports and clinical studies pertaining to epoprostenol in PPH. Bibliographic lists were also used. STUDY SELECTION All English-language clinical studies of epoprostenol in PPH were included. Incomplete study descriptions (abstracts) were not included. DATA EXTRACTION Study design, population, methods, clinical outcomes, and adverse effects were evaluated. DATA SYNTHESIS PPH is a relatively rare disease that results in symptoms of congestive heart failure and has a five-year survival rate of 34%. Therapy has consisted of vasodilators, anticoagulation, oxygen, and ultimately lung transplantation. Epoprostenol, which has recently become available as an integral pharmacotherapeutic option, has been shown to improve hemodynamic parameters such as cardiac output, pulmonary artery pressure, and pulmonary vascular resistance. It has been shown to improve exercise parameters, New York Heart Association (NYHA) functional class, and survival. Epoprostenol is indicated for patients with severe disease (NYHA class III or IV) who do not respond to acute vasodilator challenge or chronic calcium-channel blocker therapy. Its chronic administration is challenging as it requires continuous infusion via central venous catheter and a special infusion pump. Administration is further complicated by the 48-hour expiration of reconstituted epoprostenol and the need to refrigerate the reconstituted drug. CONCLUSIONS Epoprostenol improves hemodynamics and clinical outcome in patients with severe PPH. Epoprostenol therapy requires intensive patient education and medical monitoring, but it can improve well-being and delay the need for lung transplantation.
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Affiliation(s)
- S J Herner
- School of Pharmacy, University of Wyoming, Laramie, USA
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809
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Sanchez O, Humbert M, Sitbon O, Simonneau G. Treatment of pulmonary hypertension secondary to connective tissue diseases. Thorax 1999; 54:273-7. [PMID: 10325906 PMCID: PMC1745447 DOI: 10.1136/thx.54.3.273] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- O Sanchez
- Service de Pneumologie et Réanimation Respiratoire, UPRES Maladies Vasculaires Pulmonaires, Hôpital Antoine Béclère, Clamart, France
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810
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García-Manero G, Schuster SJ, Patrick H, Martinez J. Pulmonary hypertension in patients with myelofibrosis secondary to myeloproliferative diseases. Am J Hematol 1999; 60:130-5. [PMID: 9929105 DOI: 10.1002/(sici)1096-8652(199902)60:2<130::aid-ajh8>3.0.co;2-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We examined the clinical characteristics of six patients with myelofibrosis secondary to myeloproliferative diseases whose clinical courses were complicated by pulmonary hypertension to determine possible causal links between the two disorders. Six patients (four male, two female), with diagnoses of myeloproliferative disease, myelofibrosis (one with polycythemia vera, three with agnogenic myeloid metaplasia, one with unclassified myeloproliferative syndrome, one with essential thrombocytosis), and pulmonary hypertension are presented. Measurement of the pulmonary artery pressure was performed by Doppler echocardiography in all patients and by right sided heart catheterization in four patients. The range of resting pulmonary artery systolic pressure was 35 to 47 mmHg above the mean right atrium by echocardiography. One patient had autopsy evidence of pulmonary myeloid metaplasia and interstitial fibrosis; another had acute leukemic infiltration of the lung parenchyma. All patients had thrombocytosis; symptomatology in one patient with marked thrombocytosis improved with plateletpheresis. Two patients suffered systemic thrombosis. All patients had severe hepatomegaly. Two patients had evidence of left ventricular dysfunction. The interval between the development of dyspnea and death was less than seven months in five of the patients. A causal link between pulmonary hypertension and myelofibrosis secondary to myeloproliferative diseases is suggested for each patient. Hematopoietic infiltration of the pulmonary parenchyma, portal hypertension, thrombocytosis, hypercoagulability, and left ventricular failure may account in part for the development of pulmonary hypertension in these patients. Patients with myelofibrosis and dyspnea should have Doppler echocardiography to evaluate pulmonary artery pressures.
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Affiliation(s)
- G García-Manero
- Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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811
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Abstract
Pulmonary hypertension (mean pulmonary arterial pressure > 20mm Hg at rest or > 30mm Hg during exercise) occurs (i) as primary pulmonary hypertension (no known underlying cause), (ii) as persistent pulmonary hypertension of the newborn or (iii) secondary to a variety of lung and cardiovascular diseases. In the last 10 to 15 years there have been significant advances in the medical management of this debilitating and life-threatening disorder. The main drugs in current use are anticoagulants (warfarin, heparin) and vasodilators, especially oral calcium antagonists, intravenous prostacyclin (prostaglandin I2; epoprostenol) and inhaled nitric oxide. Calcium antagonists, (e.g. nifedipine, diltiazem) are used chiefly in primary pulmonary hypertension. They are effective in patients who give a pulmonary vasodilator response to an acute challenge with a short acting vasodilator (e.g. prostacyclin, nitric oxide or adenosine), and are used in doses greater than are usual in the treatment of other cardiovascular disorders. Prostacyclin, given by continuous intravenous infusion, is effective in patients even if they do not respond to an acute vasodilator challenge. The long term benefit in these patients is thought to reflect the antiproliferative effects of the drug and/or its ability to inhibit platelet aggregation. It is used either as long term therapy or as a bridge to transplantation. Inhaled nitric oxide, which is used mainly in persistent pulmonary hypertension of the newborn, has the particular benefit of being pulmonary selective, due to its route of administration and rapid inactivation. Anticoagulants have a specific role in the treatment of pulmonary thromboembolic pulmonary hypertension and are also used routinely in patients with primary pulmonary hypertension. Nondrug treatments for pulmonary hypertension include (i) supplemental oxygen (> or = 15 h/day), which is the primary therapy in patients with pulmonary hypertension secondary to chronic obstructive pulmonary disease and (ii) heart-lung or lung transplantation, which nowadays is regarded as a last resort. Different types of pulmonary hypertension require different treatment strategies. Future advances in the treatment of pulmonary hypertension may come from the use of drug combinations, the development of new drugs, such as endothelin antagonists, nitric oxide donors and potassium channel openers, or the application of gene therapy.
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Affiliation(s)
- J C Wanstall
- Department of Physiology and Pharmacology, University of Queensland, Brisbane, Australia.
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812
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Koniaris L. Initial steps toward consensus in the management of primary pulmonary hypertension. Chest 1998; 114:1234-5. [PMID: 9823992 DOI: 10.1378/chest.114.5.1234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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813
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Dufour B, Maître S, Humbert M, Capron F, Simonneau G, Musset D. High-resolution CT of the chest in four patients with pulmonary capillary hemangiomatosis or pulmonary venoocclusive disease. AJR Am J Roentgenol 1998; 171:1321-4. [PMID: 9798872 DOI: 10.2214/ajr.171.5.9798872] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Clinical differentiation of isolated pulmonary hypertensive arteriopathy from pulmonary capillary hemangiomatosis or pulmonary venoocclusive disease can be difficult on a clinical basis alone. Differentiation is important because misdiagnosis of pulmonary capillary hemangiomatosis or pulmonary venoocclusive disease may lead to severe vasodilator-induced pulmonary edema. The objective of our study was to determine whether high-resolution CT of the chest could distinguish pulmonary capillary hemangiomatosis or pulmonary venoocclusive disease from isolated pulmonary hypertensive arteriopathy. CONCLUSION Pulmonary hypertension in patients who also have pulmonary capillary hemangiomatosis or pulmonary venoocclusive disease shows characteristics on high-resolution CT that are not seen in patients with isolated pulmonary hypertensive arteriopathy.
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Affiliation(s)
- B Dufour
- Service de Radiologie, Hôpital Antoine Béclère, Clamart, France
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814
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Robbins IM, Christman BW, Newman JH, Matlock R, Loyd JE. A survey of diagnostic practices and the use of epoprostenol in patients with primary pulmonary hypertension. Chest 1998; 114:1269-75. [PMID: 9824000 DOI: 10.1378/chest.114.5.1269] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To obtain information about the diagnosis and management of primary pulmonary hypertension (PPH), especially about the use of epoprostenol (Glaxo-Wellcome; Research Triangle Park, NC) in this patient population. BACKGROUND Long-term IV epoprostenol therapy was approved recently for use in patients with PPH who are unresponsive to conventional therapy. Although epoprostenol represents a major advance in the treatment of PPH, there is no published consensus regarding the optimal use of this therapy. METHODS A five-page survey was mailed to 23 investigators at medical centers treating five or more patients with PPH with long-term epoprostenol therapy. RESULTS Nineteen of 23 investigators responded to the survey. During the initial hemodynamic evaluation, 11 investigators used changes in pulmonary vascular resistance (PVR), pulmonary artery pressure (PAP), and cardiac output, 5 investigators considered PVR and PAP only, and 2 investigators analyzed PVR alone to define a short-term vasodilator response. During long-term therapy, two thirds of the investigators increased the dose at scheduled intervals, while all investigators increased the dose in response to worsening symptoms. Epoprostenol doses were reported to range from 0.5 to 270 ng/kg/min. Nine investigators routinely repeated right heart catheterization an average of 7.5+/-3.8 months after starting epoprostenol, and the mean decrease in pulmonary artery pressure was between 15 and 25%. CONCLUSION This survey indicates that there is wide variation in the evaluation of patients with PPH and in the use of epoprostenol therapy. The lack of consensus suggests the need for multicenter collaborative studies in order to optimize the use of epoprostenol therapy for PPH.
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Affiliation(s)
- I M Robbins
- Center for Lung Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
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815
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Yuan JX, Aldinger AM, Juhaszova M, Wang J, Conte JV, Gaine SP, Orens JB, Rubin LJ. Dysfunctional voltage-gated K+ channels in pulmonary artery smooth muscle cells of patients with primary pulmonary hypertension. Circulation 1998; 98:1400-6. [PMID: 9760294 DOI: 10.1161/01.cir.98.14.1400] [Citation(s) in RCA: 268] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary pulmonary hypertension (PPH) is a rare disease of unknown cause. Although PPH and secondary pulmonary hypertension (SPH) share many clinical and pathological characteristics, their origins may be disparate. In pulmonary artery smooth muscle cells (PASMCs), the activity of voltage-gated K+ (KV) channels governs membrane potential (Em) and regulates cytosolic free Ca2+ concentration ([Ca2+]cyt). A rise in [Ca2+]cyt is a trigger of vasoconstriction and a stimulus of smooth muscle proliferation. METHODS AND RESULTS Fluorescence microscopy and patch clamp techniques were used to measure [Ca2+]cyt, Em, and KV currents in PASMCs. Mean pulmonary arterial pressures were comparable (46+/-4 and 53+/-4 mm Hg; P=0.30) in SPH and PPH patients. However, PPH-PASMCs had a higher resting [Ca2+]cyt than cells from patients with SPH and nonpulmonary hypertension disease. Consistently, PPH-PASMCs had a more depolarized Em than SPH-PASMCs. Furthermore, KV currents were significantly diminished in PPH-PASMCs. Because of the dysfunctional KV channels, the response of [Ca2+]cyt to the KV channel blocker 4-aminopyridine was significantly attenuated in PPH-PASMCs, whereas the response to 60 mmol/L K+ was comparable to that in SPH-PASMCs. CONCLUSIONS These results indicate that KV channel function in PPH-PASMCs is inhibited compared with SPH-PASMCs. The resulting membrane depolarization and increase in [Ca2+]cyt lead to pulmonary vasoconstriction and PASMC proliferation. Our data suggest that defects in PASMC KV channels in PPH patients may be a unique mechanism involved in initiating and maintaining pulmonary vasoconstriction and appear to play a role in the pathogenesis of PPH.
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Affiliation(s)
- J X Yuan
- Departments of Medicine, Physiology and Surgery, University of Maryland School of Medicine, Baltimore, Md, USA
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816
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McCurry KR, Keenan RJ. Controlling perioperative morbidity and mortality after lung transplantation for pulmonary hypertension. Transplant Rev (Orlando) 1998. [DOI: 10.1016/s0955-470x(98)80012-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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817
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McCann UD, Eligulashvili V, Ricaurte GA. Adverse neuropsychiatric events associated with dexfenfluramine and fenfluramine. Prog Neuropsychopharmacol Biol Psychiatry 1998; 22:1087-102. [PMID: 9829290 DOI: 10.1016/s0278-5846(98)00063-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
1. There is a large body of evidence indicating that fenfluramines damage brain serotonin neurons in animals. 2. Little is known about potential adverse neuropsychiatric consequences in humans associated with use of fenfluramines that could potentially be related to serotonergic dysfunction. 3. The authors now report numerous cases of severe and, sometimes persistent, neuropsychiatric syndromes associated with fenfluramine use. 4. Thirty one representative cases are presented and summarized in table form. 5. Several of the cases presented suggest long-lasting deleterious effects of fenfluramines on brain serotonin function. 6. Clinicians should be vigilant for disorders of mood, anxiety, cognitive function and impulse control in patients previously exposed to fenfluramines.
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Affiliation(s)
- U D McCann
- Biological Psychiatry Branch, National Institute of Mental Health, Bethesda, MD, USA
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818
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Ricciardi MJ, Knight BP, Martinez FJ, Rubenfire M. Inhaled nitric oxide in primary pulmonary hypertension: a safe and effective agent for predicting response to nifedipine. J Am Coll Cardiol 1998; 32:1068-73. [PMID: 9768734 DOI: 10.1016/s0735-1097(98)00361-1] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the utility of inhaled nitric oxide (NO), a selective pulmonary vasodilator, for predicting the safety and acute hemodynamic response to high-dose oral nifedipine in primary pulmonary hypertension (PPH). BACKGROUND A significant decrease in pulmonary vascular resistance with an oral nifedipine challenge is predictive of an improved prognosis, and potential clinical efficacy in PPH. However, the required nifedipine trial carries significant first-dose risk of hypotension. While inhaled NO has been recommended for assessing pulmonary vasodilator reserve in PPH, it is not known whether it predicts the response to nifedipine. METHODS Seventeen patients with PPH undergoing a nifedipine trial were assessed for hemodynamic response to inhaled NO at 80 parts per million for 5 minutes. The nifedipine trial consisted of 20 mg of nifedipine hourly for 8 hours unless limited by hypotension or intolerable side effects. Patients were classified as responders and nonresponders with positive response defined as > or =20% reduction in mean pulmonary artery pressure (mPA) or pulmonary vascular resistance (PVR) with the vasodilator administration. RESULTS NO was safely administered to all participants. Seven of 17 (41.2%) responded to NO, and 8 of the 17 to nifedipine (47.1%). Nifedipine was safely administered in 14 of the 17. Three suffered either mild or severe hypotension, including one death. All NO responders also responded to nifedipine, and 9 of the 10 NO nonresponders were nifedipine nonresponders, representing a sensitivity of 87.5%, specificity of 100%, and overall predictive accuracy of 94%. All NO responders tolerated a full nifedipine trial without hypotension. There was a highly significant correlation between the effects of NO and nifedipine on PVR (r=0.67, p=0.003). CONCLUSIONS The pulmonary vascular response to inhaled NO accurately predicts the acute hemodynamic response to nifedipine in PPH, and a positive response to NO is associated with a safe nifedipine trial. In patients comparable with those evaluated, a trial of nifedipine in NO nonresponders appears unwarranted and potentially dangerous.
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Affiliation(s)
- M J Ricciardi
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA
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819
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Mueller HS, Chatterjee K, Davis KB, Fifer MA, Franklin C, Greenberg MA, Labovitz AJ, Shah PK, Tuman KJ, Weil MH, Weintraub WS. ACC expert consensus document. Present use of bedside right heart catheterization in patients with cardiac disease. American College of Cardiology. J Am Coll Cardiol 1998; 32:840-64. [PMID: 9741535 DOI: 10.1016/s0735-1097(98)00327-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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820
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Galiè N, Manes A, Uguccioni L, Serafini F, De Rosa M, Branzi A, Magnani B. Primary pulmonary hypertension: insights into pathogenesis from epidemiology. Chest 1998; 114:184S-194S. [PMID: 9741567 DOI: 10.1378/chest.114.3_supplement.184s] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Primary pulmonary hypertension (PPH) is a rare disease that affects young people predominantly of female gender. Early epidemiologic studies have shown that the diagnosis is usually made 1 to 2 years after symptoms onset, and the mean survival is reduced to 2 to 3 years thereafter. New insights into the pathogenesis of PPH by epidemiologic studies may be obtained through the utilization of informatic technologies coupled to a clear definition of the disease. Early stages of precapillary pulmonary hypertension could be identified through screening tests like echocardiography in populations with higher incidence, such as familial PPH and the conditions associated with pulmonary hypertension. These latter conditions are hemodynamically and pathologically similar to the primary form, and they can give insight into several possible aspects of the pathogenesis of PPH. Prospective registries are very useful in coordinating the collection of epidemiologic data, and new technologies, such as informatics, may improve the management and the continuous updating of the databases.
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Affiliation(s)
- N Galiè
- Institute of Cardiology, University of Bologna, Italy.
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821
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Kaneko FT, Arroliga AC, Dweik RA, Comhair SA, Laskowski D, Oppedisano R, Thomassen MJ, Erzurum SC. Biochemical reaction products of nitric oxide as quantitative markers of primary pulmonary hypertension. Am J Respir Crit Care Med 1998; 158:917-23. [PMID: 9731026 DOI: 10.1164/ajrccm.158.3.9802066] [Citation(s) in RCA: 174] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Primary pulmonary hypertension (PPH) is a rare and fatal disease of unknown etiology. Inflammatory oxidant mechanisms and deficiency in nitric oxide (NO) have been implicated in the pathogenesis of pulmonary hypertension. In order to investigate abnormalities in oxidants and antioxidants in PPH, we studied intrapulmonary NO levels, biochemical reaction products of NO, and antioxidants (glutathione [GSH], glutathione peroxidase [GPx], and superoxide dismutase [SOD]) in patients with PPH (n = 8) and healthy controls (n = 8). Intrapulmonary gases and fluids were sampled at bronchoscopy. Pulmonary hypertension was determined by right-heart catheterization. NO and biochemical reaction products of NO in the lung were decreased in PPH patients in comparison with healthy controls (NO [ppb] in airway gases: control, 8 +/- 1; PPH, 2.8 +/- 0. 9; p = 0.016; and NO products [microM] in bronchoalveolar lavage fluid [BALF]: control, 3.3 +/- 1.05; PPH, 0.69 +/- 0.21; p = 0.03). However, GSH in the lungs of PPH patients was higher than in those of controls (GSH [microM] in BALF: 0.55 +/- 0.04; PPH, 0.9 +/- 0.1; p = 0.015). SOD and GPx activities were similar in the two groups (p >/= 0.50). Biochemical reaction products of NO were inversely correlated with pulmonary artery pressures (R = -0.713; p = 0.047) and with years since diagnosis of PPH (R = -0.776; p = 0.023). NO reaction products are formed through interactions between oxidants and NO, with the end products of reaction dependent upon the relative levels of the two types of molecules. The findings of the study therefore show that NO and oxidant reactions in the lung are related to the increased pulmonary artery pressures in PPH.
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Affiliation(s)
- F T Kaneko
- Departments of Pulmonary and Critical Care Medicine and Cancer Biology, Lerner Research Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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822
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Sandoval J, Gaspar J, Pulido T, Bautista E, Martínez-Guerra ML, Zeballos M, Palomar A, Gómez A. Graded balloon dilation atrial septostomy in severe primary pulmonary hypertension. A therapeutic alternative for patients nonresponsive to vasodilator treatment. J Am Coll Cardiol 1998; 32:297-304. [PMID: 9708453 DOI: 10.1016/s0735-1097(98)00238-1] [Citation(s) in RCA: 194] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES We sought to investigate the acute hemodynamic effects of graded balloon dilation atrial septostomy (BDAS) and to define the long-term impact of this procedure on New York Heart Association functional class and survival in adult patients with primary pulmonary hypertension (PPH). BACKGROUND Current treatment strategies for patients with severe and refractory PPH are limited by either technical difficulties and high mortality or cost. METHODS We studied 15 patients with severe PPH. BDAS was successfully performed in all patients by crossing the interatrial septum with a Brockenbrough needle, followed by progressive dilation of the orifice with a Mansfield balloon in a hemodynamically controlled, step-by-step manner. RESULTS BDAS caused an immediate significant fall in right ventricular end-diastolic pressure and in systemic arterial oxygen saturation and an increase in cardiac index. One patient died, and 14 survived the procedure and significantly improved their mean functional class (from 3.57 +/- 0.6 to 2.07 +/- 0.3 [mean +/- SD], p < 0.001). Exercise endurance (6-min test) also improved from 107 +/- 127 to 217 +/- 108 m (p < 0.001). Because of spontaneous closure, BDAS was repeated in four patients. The survival rate among patients who survived the procedure was 92% at 1, 2 and 3 years, which is better than that for historical control PPH patients (73%, 59% and 52%, respectively). CONCLUSIONS With careful monitoring, BDAS is a safe and useful palliative treatment for selected patients with severe PPH.
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Affiliation(s)
- J Sandoval
- Cardiopulmonary Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
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823
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Golpe R, Fernandez-Infante B, Fernandez-Rozas S. Primary pulmonary hypertension associated with human immunodeficiency virus infection. Postgrad Med J 1998; 74:400-4. [PMID: 9799910 PMCID: PMC2360988 DOI: 10.1136/pgmj.74.873.400] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Several cardiorespiratory diseases can complicate human immunodeficiency virus infection. Primary pulmonary hypertension is a rare clinical disorder which carries a bad prognosis. More than 90 cases of HIV-associated primary pulmonary hypertension have been reported to date. Although its pathogenesis remains unknown, some evidence suggests a possible role for the virus itself in its development. Genetic susceptibility may also be implicated. The clinical and histopathologic features of this entity do not differ from those of classic primary pulmonary hypertension. The diagnosis requires a high degree of clinical suspicion and a careful evaluation to rule out causes of secondary pulmonary hypertension. In addition to supportive measures, anticoagulation and vasodilators have been used to treat this disorder, although sufficient data regarding long-term results with these therapies are lacking.
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Affiliation(s)
- R Golpe
- Respiratory Section, University Hospital Marques de Valdecilla, Santander, Spain
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824
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Fartoukh M, Emilie D, Le Gall C, Monti G, Simonneau G, Humbert M. Chemokine macrophage inflammatory protein-1alpha mRNA expression in lung biopsy specimens of primary pulmonary hypertension. Chest 1998; 114:50S-51S. [PMID: 9676626 DOI: 10.1378/chest.114.1_supplement.50s] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- M Fartoukh
- Antenne d'Immunopathologie Respiratoire, Institut Paris-Sud sur les Cytokines, Hôpital Antoine Béclère, Clamart, France
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825
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Castro PF, Bourge RC, McGiffin DC, Benza RL, Fan P, Pinkard NB, McGoon MD. Intrapulmonary shunting in primary pulmonary hypertension: an observation in two patients treated with epoprostenol sodium. Chest 1998; 114:334-6. [PMID: 9674493 DOI: 10.1378/chest.114.1.334] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Continuous intravenous infusion of epoprostenol sodium in selected patients with primary pulmonary hypertension improves symptoms and survival. This report describes two patients with primary pulmonary hypertension treated with epoprostenol in whom intrapulmonary shunting and severe hypoxemia occurred. Intrapulmonary shunting was confirmed by contrast echocardiography showing delayed appearance of bubbles in the left cardiac chambers after peripheral venous injection of agitated saline solution.
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Affiliation(s)
- P F Castro
- Department of Medicine, The University of Alabama at Birmingham, 35294, USA
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826
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Rothman A, Mann DM, Behling CA, Konopka RG, Chiles PG, Pedersen CA, Moser KM. Percutaneous pulmonary endoarterial biopsy in an experimental model of pulmonary hypertension. Chest 1998; 114:241-50. [PMID: 9674476 DOI: 10.1378/chest.114.1.241] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The aims of this study were: to evaluate the performance of a novel arterial biopsy catheter in obtaining pulmonary endovascular samples in hypertensive dogs; to compare the results of pulmonary endoarterial biopsy in hypertensive vs normotensive dogs; and to assess the histologic changes in the hypertensive model. DESIGN AND INTERVENTIONS Thirty-four dogs (27 with normal pulmonary arterial pressures and seven with pulmonary hypertension) were catheterized through an external jugular vein to obtain endovascular biopsy samples from distal pulmonary arteries 2 to 3 mm in luminal diameter. To induce pulmonary hypertension, seven dogs were given repeated infusions of 0.6- to 0.9-mm ceramic microspheres into the superior vena cava. Endoarterial samples were obtained at pulmonary systolic arterial pressures ranging from 10 to 110 mm Hg. MEASUREMENTS AND RESULTS Sixty-two biopsy catheterization procedures were performed in the 34 dogs. After 12 initial procedures of technique refinement, endoarterial samples were obtained in each of the last 50 procedures (21 in normotensive dogs and 29 in hypertensive dogs). The average number of endovascular biopsy samples retrieved was 7.1 (range, 2 to 12) from a mean of 8.6 (range, 2 to 15) biopsy attempts per catheterization (success rate=83%). The average biopsy piece measured 1.13 mm in length, 0.33 mm in depth, and up to 1.0 mm in width. The biopsy success rates and endoarterial sample sizes were similar in normotensive and hypertensive dogs. Smooth muscle cells and endothelial cells were grown from the biopsy samples. There were no significant procedural complications, except for one self-limited hemorrhage. Histologically, samples obtained from dogs with pulmonary hypertension showed characteristic changes when compared with biopsies from normotensive dogs. CONCLUSION This new endoarterial biopsy catheter was safe and effective when used to obtain pulmonary endoarterial samples in dogs with normal and experimentally elevated pulmonary arterial pressures. The quality and quantity of the biopsy samples allowed identification of pathologic changes.
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Affiliation(s)
- A Rothman
- Department of Pediatrics, University of California San Diego, USA
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827
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Humbert M, Sanchez O, Fartoukh M, Jagot JL, Sitbon O, Simonneau G. Treatment of severe pulmonary hypertension secondary to connective tissue diseases with continuous IV epoprostenol (prostacyclin). Chest 1998; 114:80S-82S. [PMID: 9676646 DOI: 10.1378/chest.114.1_supplement.80s] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- M Humbert
- Service de Pneumologie et Réanimation Respiratoire, Hôpital Antoine Béclère, Clamart, France
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828
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829
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Elstein D, Klutstein MW, Lahad A, Abrahamov A, Hadas-Halpern I, Zimran A. Echocardiographic assessment of pulmonary hypertension in Gaucher's disease. Lancet 1998; 351:1544-6. [PMID: 10326537 DOI: 10.1016/s0140-6736(98)10194-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Enzyme therapy has been shown to decrease the signs and symptoms of Gaucher's disease. A few patients, however, develop pulmonary hypertension on such treatment. We investigated the frequency of pulmonary hypertension in Gaucher's disease. METHODS We studied 134 adults with type 1 Gaucher's disease, including 73 patients on enzyme replacement, with echocardiography. We measured tricuspid incompetence (TI) with continuous-wave doppler. Pulmonary hypertension was indicated by a TI gradient of more than 30 mm Hg. FINDINGS Nine (7%) patients had pulmonary hypertension: all were treated and six had undergone splenectomy. Chest radiographs confirmed the presence of pulmonary hypertension in these patients as well as in most patients with TI gradients of 25-29 mm Hg. INTERPRETATION The confounding effects of disease severity and splenectomy in many treated patients precluded definitive conclusion of cause and effect. Nonetheless, we found an unexpectedly high rate of pulmonary hypertension and recommended routine echocardiographic monitoring of all treated and untreated patients with type 1 Gaucher's disease. We also suggest consideration of treatment withdrawal if the TI gradient progresses to more than 30 mm Hg.
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830
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Humbert M, Maître S, Capron F, Rain B, Musset D, Simonneau G. Pulmonary edema complicating continuous intravenous prostacyclin in pulmonary capillary hemangiomatosis. Am J Respir Crit Care Med 1998; 157:1681-5. [PMID: 9603154 DOI: 10.1164/ajrccm.157.5.9708065] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Continuous intravenous epoprostenol (prostacyclin) produces hemodynamic and symptomatic responses and improves survival in patients with severe primary pulmonary hypertension refractory to conventional medical therapy. However, it has been recently shown that short-term infusion of epoprostenol can produce pulmonary edema in pulmonary veno-occlusive disease, presumably because of increased pulmonary perfusion in the presence of downstream vascular obstruction. We describe two additional cases of pulmonary edema complicating continuous intravenous epoprostenol in patients displaying severe pulmonary hypertension and pulmonary capillary hemangiomatosis, a rare condition characterized by the proliferation of thin-walled microvessels in the alveolar walls. This report indicates that epoprostenol therapy should not be used in patients with severe pulmonary hypertension secondary to pulmonary capillary hemangiomatosis.
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Affiliation(s)
- M Humbert
- Service de Pneumologie et Réanimation Respiratoire, d'Anatomie Pathologique et de Radiologie, Hôpital Antoine Béclère, Clamart, France
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831
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Affiliation(s)
- J T Reeves
- Department of Pediatrics, University of Colorado Health Services Center, Denver, USA
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832
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McCurry KR, Keenan RJ. Controlling perioperative morbidity and mortality after lung transplantation for pulmonary hypertension. Semin Thorac Cardiovasc Surg 1998; 10:139-43. [PMID: 9620462 DOI: 10.1016/s1043-0679(98)70008-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Lung transplantation for pulmonary hypertension now accounts for more than 18% of all transplantations performed with 1-year survival rates for primary pulmonary hypertension approximating 65%. Patients have NYHA class III or IV symptoms and typically have marked right ventricular dysfunction. Accelerated or acute decompensation can occur. A decline in status leads to a patient with severe right heart failure, hepatic dysfunction and severe malnutrition, conditions that increase perioperative morbidity and mortality. Immediate right ventricular dysfunction may be related to allograft injury with persistent elevation of pulmonary artery pressures or to intrinsic right ventricular disease; this can be supported with inotropic medications. Single-lung transplantation results in postoperative physiology that can require aggressive therapy to limit mortality. When allograft dysfunction occurs, significant hypoxemia results to a greater degree than that observed with single-lung transplantations for other diseases or following double-lung transplantation. As a result, careful donor selection for a single lung transplantation is crucial. The most common reason for prolonged ventilation is allograft reperfusion injury with ventilation-perfusion mismatching. Neuromuscular blockade can decrease oxygen utilization and improve chest wall compliance, whereas lateral positioning with the native lung down can be crucial to improving V/Q matching. Differential lung ventilation allows the application of larger quantities of positive end-expiratory pressure to the injured allograft. The use of exogenous nitrates has been advocated to reduce pulmonary vascular resistance. Nitric oxide has attractive potential benefits because it can be delivered directly to the lungs and functions to dilate the pulmonary vascular bed. All else having failed, we and others have successfully used extracorporeal membrane oxygenation to support cardiopulmonary function.
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Affiliation(s)
- K R McCurry
- Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, PA 15213, USA
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833
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Lesprit P, Godeau B, Authier FJ, Soubrier M, Zuber M, Larroche C, Viard JP, Wechsler B, Gherardi R. Pulmonary hypertension in POEMS syndrome: a new feature mediated by cytokines. Am J Respir Crit Care Med 1998; 157:907-11. [PMID: 9517610 DOI: 10.1164/ajrccm.157.3.9707095] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome is a rare variant of plasma cell dyscrasia with multiple systemic manifestations. We followed the progress of 20 patients with POEMS syndrome in our institution over a 10-yr period. Pulmonary hypertension (PH) was observed in five patients. All patients suffered dyspnea on exertion, which always appeared during an exacerbation of POEMS syndrome. The typical echocardiographic signs of PH were observed in all of these patients, and the median pulmonary-artery systolic pressure was 57 mm Hg (range, 50 to 65 mm Hg). Mean pulmonary-artery pressure during right side heart catheterization in two patients was 32 mm Hg. No other explanation for the PH could be found. Overproduction of cytokines was found in all cases, with high serum concentrations of interleukin-1beta, interleukin-6, tumor necrosis factor-alpha, and vascular endothelial growth factor. We suggest that PH should be added to the list of symptoms of POEMS syndrome. Cytokines may mediate POEMS syndrome-associated PH, as proposed for the other systemic manifestations of this disorder.
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Affiliation(s)
- P Lesprit
- Département de Pathologie, Hôpital Henri Mondor, Créteil, France
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834
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Abstract
Significant advances in the treatment of pulmonary hypertension have been achieved in the past decade. Approximately one quarter of patients with primary pulmonary hypertension (PPH) can be effectively managed with chronic calcium channel blocker therapy; for the remainder, transplantation or continuous intravenous epoprostenol are complex but effective approaches. Epoprostenol therapy was initially envisioned as a bridge to transplantation, but recent experience has established this approach as an alternative to transplantation in some patients, with comparable survival rates. Not all patients derive benefit from epoprostenol, however, and adverse effects are common. Accordingly, patients who fall into New York Heart Association Functional Classes III and IV and who are refractory to oral vasodilator therapy should be evaluated both for the initiation of epoprostenol therapy and concurrent listing for transplantation. By delaying or avoiding transplantation through the use of epoprostenol, these patients may also benefit from ongoing research that targets novel therapeutic approaches and less cumbersome delivery mechanisms. Thus, epoprostenol may serve as a bridge to transplantation for some patients and to newer therapeutic options for others.
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Affiliation(s)
- S P Gaine
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore 21201-1192, USA
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835
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Ferlinz J. Right ventricular diastolic performance: compliance characteristics with focus on pulmonary hypertension, right ventricular hypertrophy, and calcium channel blockade. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 43:206-43. [PMID: 9488559 DOI: 10.1002/(sici)1097-0304(199802)43:2<206::aid-ccd22>3.0.co;2-k] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
MESH Headings
- Animals
- Calcium Channel Blockers/therapeutic use
- Coronary Disease/complications
- Coronary Disease/physiopathology
- Diastole
- Humans
- Hypertension/complications
- Hypertension/physiopathology
- Hypertension, Pulmonary/complications
- Hypertension, Pulmonary/physiopathology
- Hypertrophy, Right Ventricular/complications
- Hypertrophy, Right Ventricular/physiopathology
- Lung Diseases, Obstructive/complications
- Lung Diseases, Obstructive/physiopathology
- Ventricular Dysfunction, Right/complications
- Ventricular Dysfunction, Right/drug therapy
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Right/drug effects
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Affiliation(s)
- J Ferlinz
- Department of Medicine, Aleda E. Lutz V.A. Medical Center, Saginaw, Michigan 48602, USA
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836
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Palmer SM, Robinson LJ, Wang A, Gossage JR, Bashore T, Tapson VF. Massive pulmonary edema and death after prostacyclin infusion in a patient with pulmonary veno-occlusive disease. Chest 1998; 113:237-40. [PMID: 9440597 DOI: 10.1378/chest.113.1.237] [Citation(s) in RCA: 180] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Pulmonary veno-occlusive disease (PVOD) is a rare form of pulmonary hypertension associated with fibrotic occlusion of the smaller pulmonary veins. Although vasodilator therapy is effective in many patients with primary pulmonary hypertension, the role of vasodilators in PVOD is unclear because of concerns about precipitating pulmonary edema. Recently, however, there have been reports of successful therapy with oral vasodilators or intravenous administration of prostacyclin in patients with PVOD. In contrast, a patient with PVOD is described who developed acute pulmonary edema and respiratory failure during low-dose prostacyclin infusion, leading to death. This report suggests that vasodilators, especially prostacyclin, must be used with extreme caution in patients with known PVOD.
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Affiliation(s)
- S M Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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837
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Friedman R, Mears JG, Barst RJ. Continuous infusion of prostacyclin normalizes plasma markers of endothelial cell injury and platelet aggregation in primary pulmonary hypertension. Circulation 1997; 96:2782-4. [PMID: 9386137 DOI: 10.1161/01.cir.96.9.2782] [Citation(s) in RCA: 106] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary pulmonary hypertension (PPH) is characterized by vascular injury of pulmonary arterioles, in which endothelial dysfunction may play a major role. Although continuous infusion of prostacyclin (prostaglandin I2, a potent vasodilator released by vascular endothelial cells) improves the clinical status and survival in PPH, its mechanism or mechanisms of action remain unclear. METHODS AND RESULTS We measured endothelium-derived clotting factors and assayed platelet aggregation in 64 patients (26 adults and 38 children) with PPH before long-term PGI2 therapy. Repeat studies were performed in 42 patients (18 adults, 24 children) after one year of PGI2 therapy. At baseline, 87% of adults and 79% of children had abnormal platelet aggregation. In addition, factor VIII, von Willebrand (vW) antigen, and ristocetin cofactor levels were abnormally high in 92%, 72%, and 52%, respectively, of the adults versus 29%, 16%, and 16%, respectively, of the children (P<.005 adults versus children). With long-term PGI2, platelet aggregation normalized in 83% of the adults and 80% of the children who had platelet aggregation abnormalities at baseline (P<.01). Factor VIII, vW antigen, and ristocetin cofactor also decreased with long-term PGI2 in both groups (P<.02). The ratio of ristocetin cofactor to vW antigen, which may reflect biological activity of vW factor, increased with long-term PGI2 in adults from an abnormally low level (0.6+/-0.2) to normal level (1.10+/-0.4), and in children the ratio increased from 0.8+/-0.3 to 1.3+/-0.4 (normal, 0.8 to 1.4). CONCLUSIONS Alterations in the coagulation system may contribute to the pathogenesis of PPH; the normalization of these endothelial markers concomitant with improvement in hemodynamic parameters with long-term PGI2 suggests that long-term PGI2 remodels the pulmonary vascular bed with subsequent decreases in endothelial cell injury and hypercoagulability.
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Affiliation(s)
- R Friedman
- Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, NY 10032, USA
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838
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An Efficient Catalytic Stereoselective Route to a Key Intermediate for the Synthesis of the Long-Lived PGI2 Analog ZK 96480 (CicaprostTM). Tetrahedron Lett 1997. [DOI: 10.1016/s0040-4039(97)01803-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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839
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Abstract
Pulmonary hypertension occurs as a consequence of numerous and varied conditions, all of which result in an elevation of pulmonary vascular resistance. Over the past decade, significant progress has been made in understanding the factors which contribute to the progressive nature of pulmonary vascular disease, and in identifying new treatments for pulmonary hypertension. The majority of these therapeutic options are pharmacologic, but for specific circumstances, surgical therapy may be a consideration. This article discusses nonspecific therapies for all patients with pulmonary hypertension, vasodilator therapy (including screening for vasodilator responsiveness, standard oral agents, and newer intravenous or inhalational therapies) and surgical options applicable to specific situations.
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Affiliation(s)
- H I Palevsky
- Pulmonary and Critical Care Division, Hospital of the University of Pennsylvania Medical Center, Philadelphia, USA
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Farnie DE, Storrow A, Whitley H. Syncope in a 2-year-old: ED presentation of primary pulmonary hypertension. Ann Emerg Med 1997; 30:337-42. [PMID: 9287898 DOI: 10.1016/s0196-0644(97)70172-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We describe the case of a previously well 2-year-old girl who was found to have primary pulmonary hypertension (PPH) after presenting to the ED with syncope. Although physical examination findings were normal, an ECG and chest radiograph showed signs of PPH. The patient's hospital course was significant for syncopal episodes and sudden death while she awaited a heart transplant. This case illustrates that suspected cardiac syncope in the young warrants a focused ED evaluation with attention to causes of a life-threatening nature.
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Affiliation(s)
- D E Farnie
- Department of Emergency Medicine, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, TX, USA
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