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Caravita S, Faini A, Carolino D’Araujo S, Dewachter C, Chomette L, Bondue A, Naeije R, Parati G, Vachiéry JL. Clinical phenotypes and outcomes of pulmonary hypertension due to left heart disease: Role of the pre-capillary component. PLoS One 2018; 13:e0199164. [PMID: 29920539 PMCID: PMC6007912 DOI: 10.1371/journal.pone.0199164] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/01/2018] [Indexed: 12/22/2022] Open
Abstract
Background In pulmonary hypertension (PH), both wedge pressure elevation (PAWP) and a precapillary component may affect right ventricular (RV) afterload. These changes may contribute to RV failure and prognosis. We aimed at describing the different haemodynamic phenotypes of patients with PH due to left heart disease (LHD) and at characterizing the impact of pulmonary haemodynamics on RV function and outcome PH-LHD. Methods Patients with PH-LHD were compared with treatment-naïve idiopathic/heritable pulmonary arterial hypertension (PAH, n = 35). PH-LHD patients were subdivided in Isolated post-capillary PH (IpcPH: diastolic pressure gradient, DPG<7 mmHg and pulmonary vascular resistance, PVR≤3 WU, n = 37), Combined post- and pre-capillary PH (CpcPH: DPG≥7 mmHg and PVR>3 WU, n = 27), and “intermediate” PH-LHD (either DPG <7 mmHg or PVR ≤3 WU, n = 29). Results Despite similar PAWP and cardiac index, haemodynamic severity and prevalence of RV dysfunction increased from IpcPH, to “intermediate” and CpcPH. PVR and DPG (but not compliance, Ca) were linearly correlated with RV dysfunction. CpcPH had worse prognosis (p<0.05) than IpcPH and PAH, but similar to “intermediate” patients. Only NTproBNP and Ca independently predicted survival in PH-LHD. Conclusions In PH-LHD, haemodynamic characterization according to DPG and PVR provides important information on disease severity, predisposition to RV failure and prognosis. Patients presenting the CpcPH phenotype appear to have haemodynamic profile closer to PAH but with worse prognosis. In PH-LHD, Ca and NTproBNP were independent predictors of survival.
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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
| | - Sandy Carolino D’Araujo
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Laura Chomette
- 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 Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
- * E-mail:
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Charalampopoulos A, Lewis R, Hickey P, Durrington C, Elliot C, Condliffe R, Sabroe I, Kiely DG. Pathophysiology and Diagnosis of Pulmonary Hypertension Due to Left Heart Disease. Front Med (Lausanne) 2018; 5:174. [PMID: 29928642 PMCID: PMC5997828 DOI: 10.3389/fmed.2018.00174] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/18/2018] [Indexed: 11/13/2022] Open
Abstract
Pulmonary hypertension due to left heart disease (PH-LHD) is the most common type of pulmonary hypertension, although an accurate prevalence is challenging. PH-LHD includes PH due to systolic or diastolic left ventricular dysfunction, mitral or aortic valve disease and congenital left heart disease. In recent years a new and distinct phenotype of “combined post-capillary and pre-capillary PH,” based on diastolic pulmonary gradient and pulmonary vascular resistance, has been recognized. The roles of right ventricular dysfunction and pulmonary vascular compliance in PH-LHD have also been elucidated recently and they appear to have significant clinical implications. Echocardiography continues to play a seminal role in diagnosis of PH-LHD and heart failure with preserved LV ejection fraction, as it can identify valve disease and help to distinguish PH-LHD from pre-capillary PH. Right, and occasionally left heart catheterization, remains the gold-standard for diagnosis and phenotyping of PH-LHD, although Cardiac Magnetic Resonance Imaging is emerging as a useful alternative tool in non-invasive diagnostic and prognostic assessment of PH-LHD. In this review, the latest evidence for more recent advances will be discussed, including the role of fluid challenge and exercise during cardiac catheterization to unravel occult post-capillary and the role of vasoreactivity testing. The use of many or all of these diagnostic techniques will undoubtedly provide key information about sub-groups of patients with PH-LHD that might benefit from medical therapy previously considered to be only suitable for pulmonary arterial hypertension.
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Affiliation(s)
- Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Robert Lewis
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Peter Hickey
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Ian Sabroe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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53
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Guazzi M. Partitioning of pulmonary vascular resistances in group 2 pulmonary hypertension: insightful suggestions for bridging haemodynamics to underlying mechanisms. Eur Respir J 2018; 51:51/5/1800816. [PMID: 29794124 DOI: 10.1183/13993003.00816-2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 04/30/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Marco Guazzi
- Dept of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy .,Dept of Cardiology University, IRCCS Policlinico San Donato, Milan, Italy
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Tampakakis E, Shah SJ, Borlaug BA, Leary PJ, Patel HH, Miller WL, Kelemen BW, Houston BA, Kolb TM, Damico R, Mathai SC, Kasper EK, Hassoun PM, Kass DA, Tedford RJ. Pulmonary Effective Arterial Elastance as a Measure of Right Ventricular Afterload and Its Prognostic Value in Pulmonary Hypertension Due to Left Heart Disease. Circ Heart Fail 2018; 11:e004436. [PMID: 29643065 PMCID: PMC5901761 DOI: 10.1161/circheartfailure.117.004436] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 03/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with combined post- and precapillary pulmonary hypertension due to left heart disease have a worse prognosis compared with isolated postcapillary. However, it remains unclear whether increased mortality in combined post- and precapillary pulmonary hypertension is simply a result of higher total right ventricular load. Pulmonary effective arterial elastance (Ea) is a measure of total right ventricular afterload, reflecting both resistive and pulsatile components. We aimed to test whether pulmonary Ea discriminates survivors from nonsurvivors in patients with pulmonary hypertension due to left heart disease and if it does so better than other hemodynamic parameters associated with combined post- and precapillary pulmonary hypertension. METHODS AND RESULTS We combined 3 large heart failure patient cohorts (n=1036) from academic hospitals, including patients with pulmonary hypertension due to heart failure with preserved ejection fraction (n=232), reduced ejection fraction (n=335), and a mixed population (n=469). In unadjusted and 2 adjusted models, pulmonary Ea more robustly predicted mortality than pulmonary vascular resistance and the transpulmonary gradient. Along with pulmonary arterial compliance, pulmonary Ea remained predictive of survival in patients with normal pulmonary vascular resistance. The diastolic pulmonary gradient did not predict mortality. In addition, in a subset of patients with echocardiographic data, Ea and pulmonary arterial compliance were better discriminators of right ventricular dysfunction than the other parameters. CONCLUSIONS Pulmonary Ea and pulmonary arterial compliance more consistently predicted mortality than pulmonary vascular resistance or transpulmonary gradient across a spectrum of left heart disease with pulmonary hypertension, including patients with heart failure with preserved ejection fraction, heart failure with reduced ejection fraction, and pulmonary hypertension with a normal pulmonary vascular resistance.
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Affiliation(s)
- Emmanouil Tampakakis
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Sanjiv J Shah
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Barry A Borlaug
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Peter J Leary
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Harnish H Patel
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Wayne L Miller
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Benjamin W Kelemen
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Brian A Houston
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Todd M Kolb
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Rachel Damico
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Stephen C Mathai
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Edward K Kasper
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Paul M Hassoun
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - David A Kass
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.)
| | - Ryan J Tedford
- Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.).
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Menachem JN, Birati EY, Zamani P, Owens AT, Atluri P, Bermudez CA, Drajpuch D, Fuller S, Kim YY, Mascio CE, Palanivel V, Rame JE, Wald J, Acker MA, Mazurek JA. Pulmonary hypertension: Barrier or just a bump in the road in transplanting adults with congenital heart disease. CONGENIT HEART DIS 2018; 13:492-498. [DOI: 10.1111/chd.12606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/08/2018] [Accepted: 02/28/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Jonathan N. Menachem
- Division of Cardiovascular Medicine; Vanderbilt University Medical Center; Nashville Tennessee USA
| | - Edo Y. Birati
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Payman Zamani
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Anjali T. Owens
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Pavan Atluri
- Division of Cardiothoracic Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Christian A. Bermudez
- Division of Cardiothoracic Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - David Drajpuch
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery; Children's Hospital of Philadelphia; Philadelphia Pennsylvania USA
| | - Yuli Y. Kim
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Christopher E. Mascio
- Division of Cardiothoracic Surgery; Children's Hospital of Philadelphia; Philadelphia Pennsylvania USA
| | - Vikram Palanivel
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - J. Eduardo Rame
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Joyce Wald
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Michael A. Acker
- Division of Cardiothoracic Surgery; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
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Gerges C, Gerges M, Fesler P, Pistritto AM, Konowitz NP, Jakowitsch J, Celermajer DS, Lang I. In-depth haemodynamic phenotyping of pulmonary hypertension due to left heart disease. Eur Respir J 2018; 51:13993003.00067-2018. [DOI: 10.1183/13993003.00067-2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/10/2018] [Indexed: 12/22/2022]
Abstract
The commonest cause of pulmonary hypertension (PH) is left heart disease (LHD). The current classification system for definitions of PH-LHD is under review. We therefore performed prospective in-depth invasive haemodynamic phenotyping in order to assess the site of increased pulmonary vascular resistance (PVR) in PH-LHD subsets.Based on pulmonary artery occlusion waveforms yielding an estimate of the effective capillary pressure, we partitioned PVR in larger arterial (Rup, upstream resistance) and small arterial plus venous components (Rds, downstream resistance). In the case of small vessel disease, Rup decreases and Rds increases. Inhaled nitric oxide (NO) testing was used to assess acute vasoreactivity.Right ventricular afterload (PVR, pulmonary arterial compliance and effective arterial elastance) was significantly higher in combined post- and pre-capillary PH (Cpc-PH, n=35) than in isolated post-capillary PH (Ipc-PH, n=20). Right ventricular afterload decreased during inhalation of NO in Cpc-PH and idiopathic pulmonary arterial hypertension (n=31), but remained unchanged in Ipc-PH. Rup was similar in Cpc-PH (66.8±10.8%) and idiopathic pulmonary arterial hypertension (65.0±12.2%; p=0.530) suggesting small vessel disease, but significantly higher in Ipc-PH (96.5±4.5%; p<0.001) suggesting upstream transmission of elevated left atrial pressure.Right ventricular afterload is driven by elevated left atrial pressure in Ipc-PH and is further increased by elevated small vessel resistance in Cpc-PH. Cpc-PH is responsive to inhaled NO. Our data support current definitions of PH-LHD subsets.
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Albers EL, Bradford MC, Friedland-Little JM, Hong BJ, Kemna MS, Chen JM, Law YM. Diastolic pressure indices offer a novel approach to predicting risk of graft loss after pediatric heart transplant. Pediatr Transplant 2018; 22. [PMID: 29396892 DOI: 10.1111/petr.13126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 11/28/2022]
Abstract
PH is a risk factor for GL after HTx. However, traditional parameters are not reliable predictors of risk in children. We hypothesized that DPI (dPAP and DPG) are predictive of GL in pediatric HTx recipients. The UNOS/SRTR database was reviewed to identify pediatric HTx recipients (age <18 years) between 1994 and 2013. Recipients with pretransplant hemodynamic data were grouped by diagnosis (CMP or CHD), and the groups were analyzed separately. Bivariate Cox regression analysis examined the association between hemodynamic variables and GL. DPI showed the strongest association with early GL in recipients with CMP (dPAP: HR = 1.25 [1.09-1.42]; DPG: 1.24 [1.11-1.38]). Among CHD recipients, DPI were associated with early GL in those with preexisting PH (dPAP: HR = 1.16 [1.01-1.33]; DPG: HR = 1.10 [1.00-1.21]). No cutoff values for "high-risk" DPI were identified, but a continuous relationship between higher DPI and risk of early GL was observed. DPI are associated with early GL in select pediatric HTx recipients. Our findings suggest that DPI should be considered as part of routine hemodynamic assessment for pediatric HTx candidates.
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Affiliation(s)
- Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | | | | | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Jonathan M Chen
- Division of Pediatric Cardiothoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
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Tampakakis E, Tedford RJ. Balancing the positives and negatives of the diastolic pulmonary gradient. Eur J Heart Fail 2018; 19:98-100. [PMID: 28052546 DOI: 10.1002/ejhf.704] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 11/02/2016] [Accepted: 11/02/2016] [Indexed: 11/09/2022] Open
Affiliation(s)
- Emmanouil Tampakakis
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 7125A Zayed, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 7125A Zayed, 1800 Orleans Street, Baltimore, MD, 21287, USA
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Ramu B, Houston BA, Tedford RJ. Pulmonary Vascular Disease: Hemodynamic Assessment and Treatment Selection—Focus on Group II Pulmonary Hypertension. Curr Heart Fail Rep 2018; 15:81-93. [DOI: 10.1007/s11897-018-0377-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Lakatos BK, Tokodi M, Assabiny A, Tősér Z, Kosztin A, Doronina A, Rácz K, Koritsánszky KB, Berzsenyi V, Németh E, Sax B, Kovács A, Merkely B. Dominance of free wall radial motion in global right ventricular function of heart transplant recipients. Clin Transplant 2018; 32:e13192. [PMID: 29315873 DOI: 10.1111/ctr.13192] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2018] [Indexed: 12/28/2022]
Abstract
Assessment of right ventricular (RV) function using conventional echocardiography might be inadequate as the radial motion of the RV free wall is often neglected. Our aim was to quantify the longitudinal and the radial components of RV function using three-dimensional (3D) echocardiography in heart transplant (HTX) recipients. Fifty-one HTX patients in stable cardiovascular condition without history of relevant rejection episode or chronic allograft vasculopathy and 30 healthy volunteers were enrolled. RV end-diastolic (EDV) volume and total ejection fraction (TEF) were measured by 3D echocardiography. Furthermore, we quantified longitudinal (LEF) and radial ejection fraction (REF) by decomposing the motion of the RV using the ReVISION method. RV EDV did not differ between groups (HTX vs control; 96 ± 27 vs 97 ± 2 mL). In HTX patients, TEF was lower, however, tricuspid annular plane systolic excursion (TAPSE) decreased to a greater extent (TEF: 47 ± 7 vs 54 ± 4% [-13%], TAPSE: 11 ± 5 vs 21 ± 4 mm [-48%], P < .0001). In HTX patients, REF/TEF ratio was significantly higher compared to LEF/TEF (REF/TEF vs LEF/TEF: 0.58 ± 0.10 vs 0.27 ± 0.08, P < .0001), while in controls the REF/TEF and LEF/TEF ratio was similar (0.45 ± 0.07 vs 0.47 ± 0.07). Current results confirm the superiority of radial motion in determining RV function in HTX patients. Parameters incorporating the radial motion are recommended to assess RV function in HTX recipients.
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Affiliation(s)
| | - Márton Tokodi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | | | | | | | - Kristóf Rácz
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | | | - Viktor Berzsenyi
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Endre Németh
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Balázs Sax
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Transplantation and Mechanical Circulatory Support in Adult Congenital Heart Disease-Related Advanced Heart Failure. HEART FAILURE IN ADULT CONGENITAL HEART DISEASE 2018. [DOI: 10.1007/978-3-319-77803-7_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Maron BA, Gladwin MT, Simon MA. Update in Pulmonary Vascular Disease 2015. Am J Respir Crit Care Med 2017; 193:1337-44. [PMID: 27304242 DOI: 10.1164/rccm.201601-0143up] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Bradley A Maron
- 1 Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,2 Department of Cardiology, Boston Veterans Affairs Healthcare System, Boston, Massachusetts; and
| | - Mark T Gladwin
- 3 Division of Pulmonary, Allergy, and Critical Care Medicine and
| | - Marc A Simon
- 4 Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center and Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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Guazzi M, Labate V. Pulmonary Hypertension in Heart Failure Patients: Pathophysiology and Prognostic Implications. Curr Heart Fail Rep 2017; 13:281-294. [PMID: 27858232 DOI: 10.1007/s11897-016-0306-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD), i.e., group 2 PH, is the most common reason for increased pressures in the pulmonary circuit. Although recent guidelines incorporate congenital heart disease in this classification, left-sided heart diseases of diastolic and systolic origin including valvular etiology are the vast majority. In these patients, an increased left-sided filling pressure triggers a multistage hemodynamic evolution that ends into right ventricular failure through an initial passive increase in pulmonary artery pressure complicated over time by pulmonary vasoconstriction, endothelial dysfunction, and remodeling of the small-resistance pulmonary arteries. Regardless of the underlying left heart pathology, when present, PH-LHD is associated with more severe symptoms, worse exercise tolerance, and outcome, especially when right ventricular dysfunction and failure are part of the picture. Compared with group 1 and other forms of pulmonary arterial hypertension, PH-LHD is more often seen in elderly patients with a higher prevalence of cardiovascular comorbidities and most, if not all, of the features of metabolic syndrome, especially in case of HF preserved ejection fraction. In this review, we provide an update on current knowledge and some potential challenges about the pathophysiology and established prognostic implications of group 2 PH in patients with HF of either preserved or reduced ejection fraction.
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Affiliation(s)
- Marco Guazzi
- University Cardiology Department, IRCCS Policlinico San Donato, University of Milano, Piazza Malan, 2, 20097, Milan, Italy.
| | - Valentina Labate
- University Cardiology Department, IRCCS Policlinico San Donato, University of Milano, Piazza Malan, 2, 20097, Milan, Italy
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Adusumalli S, Mazurek JA. Pulmonary Hypertension Due to Left Ventricular Cardiomyopathy: Is it the Result or Cause of Disease Progression? Curr Heart Fail Rep 2017; 14:507-513. [PMID: 29063280 PMCID: PMC5846484 DOI: 10.1007/s11897-017-0368-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to define pulmonary hypertension in the setting of left heart disease (PH-LHD), discuss its epidemiology and pathophysiology, and highlight the cause and effect relationship it has with disease progression in the setting of cardiomyopathy. RECENT FINDINGS Both pulmonary hypertension (PH) and heart failure are becoming increasingly common. As such, PH-LHD is now the most common form of PH. The pathophysiology of the condition relates to backward transmission of elevated left ventricular filling pressures into the pulmonary circulation and, ultimately, right ventricular (RV) strain/dysfunction. It is evident that these pathophysiologic processes are both the effect and cause of left heart disease progression. In this review, we describe the complex relationship between disease progression in left ventricular cardiomyopathy and PH-LHD. Clinicians and researchers should take note of the importance of PH-LHD and RV dysfunction to appropriately risk stratify patients and develop therapies for the condition.
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Affiliation(s)
- Srinath Adusumalli
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Advanced Heart Failure/Transplantation and Pulmonary Hypertension Programs, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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65
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Ghio S, Crimi G, Pica S, Temporelli PL, Boffini M, Rinaldi M, Raineri C, Scelsi L, Pistono M, Totaro R, Guida S, Oltrona Visconti L. Persistent abnormalities in pulmonary arterial compliance after heart transplantation in patients with combined post-capillary and pre-capillary pulmonary hypertension. PLoS One 2017; 12:e0188383. [PMID: 29176890 PMCID: PMC5703525 DOI: 10.1371/journal.pone.0188383] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/22/2017] [Indexed: 11/28/2022] Open
Abstract
Background The hemodynamic definitions of pulmonary hypertension (PH) in left heart disease have recently been refined to better match the characteristics required to reflect the presence of pulmonary vascular disease. Accordingly, we tested the hypothesis that abnormalities in the stiffness of pulmonary circulation would persist after heart transplantation in patients with combined post-capillary and pre-capillary PH (Cpc-PH) in contrast to those with isolated post-capillary PH (Ipc-PH). Methods We retrospectively analyzed right heart hemodynamics in a cohort of 295 consecutive patients with heart failure and advanced left ventricular systolic dysfunction (LVSD) before and 1 year after heart transplantation. Results According to their baseline hemodynamic profile, patients were classified as: 75 Cpc-PH, 111 Ipc-PH, and 98 without PH (no-PH), and 11 pre-capillary PH. One year after heart transplantation, pulmonary artery pressures, pulmonary vascular resistance and cardiac index normalized in all patients regardless of the baseline hemodynamic profile. However, pulmonary arterial compliance remained lower in Cpc-PH patients (from 1.6±1.2 at baseline to 3.7±1.4 ml/mmHg at 1 year) than in Ipc-PH (from 1.2±2.0 to 4.4±2.3 ml/mmHg) and no-PH patients (from 3.7±2.0 to 4.5±1.8 ml/mmHg); (adjusted p = 0.03 Ipc-PH vs. Cpc-PH INT<0.001). Conclusions In heart failure patients with advanced LVSD, a hemodynamic profile characterized by Cpc-PH predicts the persistence of a stiffer pulmonary circulation at 1 year after heart transplantation.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
- * E-mail:
| | - Gabriele Crimi
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Silvia Pica
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | | | - Massimo Boffini
- Division of Cardiac Surgery, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Division of Cardiac Surgery, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Claudia Raineri
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Massimo Pistono
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, Veruno, Italy
| | - Rossana Totaro
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Stefania Guida
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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Ghio S, Crimi G, Temporelli PL, Traversi E, La Rovere MT, Cannito A, Vizza D, Scelsi L, Raineri C, Guazzi M, Oltrona Visconti L. Haemodynamic effects of an acute vasodilator challenge in heart failure patients with reduced ejection fraction and different forms of post-capillary pulmonary hypertension. Eur J Heart Fail 2017; 20:725-734. [PMID: 29148140 DOI: 10.1002/ejhf.1067] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/01/2017] [Accepted: 10/02/2017] [Indexed: 12/28/2022] Open
Abstract
AIMS The most recent European guidelines have proposed new definitions of pulmonary hypertension (PH) in left heart disease, to better approach the characteristics required to reflect the presence of pulmonary vascular disease. The purpose of this study was to assess whether different haemodynamic definitions of post-capillary PH imply a different reversibility of PH in response to acute vasodilator administration in heart failure patients with reduced ejection fraction and PH (HFrEF-PH). METHODS AND RESULTS Right heart catheterization and reversibility testing was performed in 156 HFrEF-PH patients. Patients were classified as combined post-capillary and pre-capillary pulmonary hypertension (Cpc-PH) vs. isolated post-capillary pulmonary hypertension (Ipc-PH) and on the basis of diastolic pulmonary gradient (DPG) ≥ 7 vs. < 7 mmHg or of transpulmonary gradient (TPG) >12 vs. ≤12 mmHg. After vasodilator administration, Cpc-PH patients showed a greater per cent improvement in pulmonary vascular resistance (PVR), DPG and TPG as compared with Ipc-PH patients (all Pint < 0.001); only pulmonary compliance (PCa) improved less in Cpc-PH than in Ipc-PH patients (Pint = 0.007). However, despite vasodilatation, Cpc-PH patients remained in an unfavourable portion of the inverse hyperbolic relationship between PVR and PCa. The number of patients in whom PVR was reduced below 2.5 wood units was similar in Cpc-PH, DPG ≥7 mmHg and TPG >12 mmHg groups (28.3, 26.7 and 18.9%, respectively). CONCLUSION Although substantial improvements in PVR, DPG and TPG were observed in Cpc-PH patients after acute vasodilator administration, this response was associated with persistent abnormalities in the PVR vs. PCa relationship. The link between baseline right heart haemodynamics and pulmonary vascular disease remains elusive.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gabriele Crimi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Egidio Traversi
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Montescano, Italy
| | | | - Antonia Cannito
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Dario Vizza
- Pulmonary Hypertension Unit, Department of Cardiovascular and Respiratory Science, Sapienza University of Rome, Italy
| | | | | | - Marco Guazzi
- Heart Failure Unit and Cardiopulmonary Laboratory, Cardiology, IRCCS Policlinico San Donato University Hospital, Milano, Italy
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Handoko ML, De Man FS, Oosterveer FPT, Bogaard HJ, Vonk-Noordegraaf A, Westerhof N. A critical appraisal of transpulmonary and diastolic pressure gradients. Physiol Rep 2017; 4:4/17/e12910. [PMID: 27587711 PMCID: PMC5027345 DOI: 10.14814/phy2.12910] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/01/2016] [Indexed: 11/24/2022] Open
Abstract
Pulmonary hypertension (PH) resulting from left heart failure is an increasingly recognized clinical entity. To distinguish isolated postcapillary PH from combined post‐ and precapillary PH, the use of a diastolic pressure gradient (DPG = diastolic Pulmonary Artery Pressure − Pulmonary Arterial Wedge Pressure, dPAP − PAWP) has been advocated over the transpulmonary pressure gradient (TPG = mean Pulmonary Artery Pressure − PAWP, mPAP − PAWP) since DPG was suggested to be independent of cardiac output (CO) and only slightly related to PAWP, while TPG depends on both. We quantitatively derived and compared the DPG and TPG. Using right heart catheterization data (n = 1054), we determined systolic pulmonary artery pressure (sPAP), dPAP and mPAP, PAWP, and CO. From this data, we derived TPG and DPG and tested their dependence on PAWP and CO. We found that dPAP and sPAP are proportional with mPAP over a wide range of PAWP (1–31 mmHg), with dPAP = 0.62mPAP and sPAP = 1.61mPAP. As a consequence, TPG and DPG are equally dependent on PAWP: TPG = mPAP − PAWP, and DPG = 0.62mPAP − PAWP. Furthermore, we showed that both TPG and DPG depend on CO. The absolute increase in DPG with CO is 62% of the TPG increase with CO, but the relative dependence is the same. Both TPG and DPG depend on PAWP and CO. Thus, in principle, there are no major advantages for using DPG to distinguish postcapillary pulmonary hypertension from combined post‐ and precapillary pulmonary hypertension.
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Affiliation(s)
- M Louis Handoko
- Department of Cardiology, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Frances S De Man
- Department of Pulmonary Diseases, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands Department of Physiology, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Frank P T Oosterveer
- Department of Pulmonary Diseases, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Harm-Jan Bogaard
- Department of Pulmonary Diseases, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pulmonary Diseases, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Nico Westerhof
- Department of Pulmonary Diseases, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands Department of Physiology, VU University Medical Center/Institute for Cardiovascular Research, Amsterdam, The Netherlands
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68
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Rosenkranz S, Hoeper MM. Pulmonary vascular indices and survival in left heart disease: illusion of conclusion? Eur J Heart Fail 2017; 20:256-259. [PMID: 29052305 DOI: 10.1002/ejhf.1022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 08/28/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Stephan Rosenkranz
- Internal Medicine Clinic III, University of Cologne Heart Centre (Herzzentrum der Universität zu Köln), Cologne, Germany.,Cologne Cardiovascular Research Centre, University of Cologne Heart Centre, Cologne, Germany
| | - Marius M Hoeper
- Pneumology Clinic, Hannover Medical School, Hannover, Germany.,German Centre for Lung Research (Deutsches Zentrum für Lungenforschung), Giessen, Germany
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69
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Adir Y, Guazzi M, Offer A, Temporelli PL, Cannito A, Ghio S. Pulmonary hemodynamics in heart failure patients with reduced or preserved ejection fraction and pulmonary hypertension: Similarities and disparities. Am Heart J 2017; 192:120-127. [PMID: 28938958 DOI: 10.1016/j.ahj.2017.06.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 06/16/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The current understanding of pulmonary hypertension (PH) due to left ventricular diseases does not distinguish heart failure (HF) with reduced ejection fraction (HFrEF) from HF and preserved ejection fraction (HFpEF), in terms of pulmonary hemodynamics. The value of pulmonary vascular compliance (PCa) and diastolic pulmonary gradient (DPG) as predictors of survival in either HF syndrome is controversial. The aims of our study were to compare the pulmonary hemodynamics in the two HF phenotypes, given similar values of pulmonary artery wedge pressure (PAWP), and to evaluate the impact of PCa and DPG on survival. METHODS We retrospectively reviewed the charts of 168 PH-HFrEF and 86 PH-HFpEF patients. The independent association of PCa and DPG with prognosis was assessed by means of a Cox proportional hazard model. All cause survival was analyzed over an average follow-up period of 50 months. RESULTS PH-HFpEF patients had a significantly higher DPG than PH-HFrEF patients (6.1±7.1 vs 1.8±4.5 mmHg, adjusted P=.025). PCa was similar in PH-HFpEF and PH-HFrEF. PCa was a significant predictor of survival, according to previously described preset cutoffs (2.15 mL/mmHg in HFrEF and 1.1 mL/mmHg in HFpEF) and based on a continuous scale; whereas DPG had no impact on survival in both patients groups. CONCLUSION Our findings suggest that for similar levels of PAWP, pulmonary circulation may be stiffer in patients with HFpEF-PH than patients with HFrEF-PH, leading to higher DPGs. Nonetheless, PCa rather than DPG emerged as the stronger predictor of survival in both left-sided PH phenotypes.
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70
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Zhuo DX, Bilchick KC, Mazimba S. Preoperative Invasive Hemodynamic Determinants of Survival Among Patients Undergoing Aortic or Mitral Valve Surgery. J Cardiothorac Vasc Anesth 2017; 32:1273-1280. [PMID: 29317120 DOI: 10.1053/j.jvca.2017.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate the association of preoperative invasive hemodynamic parameters with mortality in valvular heart surgery. DESIGN Retrospective cohort study. SETTING Single tertiary academic medical center. PARTICIPANTS A total of 382 patients who underwent preoperative right and/or left heart catheterization before open aortic valve replacement (AVR), open mitral valve repair/replacement (MVR), or combined AVR and MVR, from July 2009 to December 2014. INTERVENTIONS Retrospective chart review. MEASUREMENTS AND MAIN RESULTS Common hemodynamic indices derived from direct catheterization measurements were assessed, including pulmonary artery systolic pressure (PASP), pulmonary artery pulse pressure (PPP), mean pulmonary capillary wedge pressure (mPCWP), pulmonary artery pulsatility index, diastolic pressure gradient, left ventricular work index, and right ventricular work index. Bivariable and multivariable associations of these measures with survival were determined using Cox proportional hazards regression. Kaplan-Meier survival curves were generated using the log-rank test. The median age of the cohort was 69 years (interquartile range 60-79 years), and 162 (42.4%) of the patients were female. Elevated PASP (hazard ratio [HR] 1.32 per 10 mmHg, p < 0.0001), elevated PPP (HR 1.48 per 10 mmHg, p < 0.0001), and elevated mPCWP (HR 1.95 per 10 mmHg, p < 0.0001) were all associated with decreased survival, as was decreased diastolic blood pressure (DBP) (p = 0.005). The combination of elevated PPP and decreased DBP was associated with the worst outcomes. CONCLUSIONS PASP, PPP, mPCWP, and DBP were significantly associated with mortality in valvular heart surgery patients. These hemodynamic parameters may be useful in risk stratification of this population subset.
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Affiliation(s)
- David X Zhuo
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA.
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Advanced Heart Failure and Transplant Center, Charlottesville, VA
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Naeije R, Gerges M, Vachiery JL, Caravita S, Gerges C, Lang IM. Hemodynamic Phenotyping of Pulmonary Hypertension in Left Heart Failure. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.004082. [PMID: 28912263 DOI: 10.1161/circheartfailure.117.004082] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Increased pulmonary venous pressure secondary to left heart disease is the most common cause of pulmonary hypertension (PH). The diagnosis of PH due to left heart disease relies on a clinical probability assessment followed by the invasive measurements of a mean pulmonary artery pressure (PAP) ≥25 mm Hg and mean wedged PAP (PAWP) >15 mm Hg. A combination of mean PAP and mean PAWP defines postcapillary PH. Postcapillary PH is generally associated with a diastolic pulmonary pressure gradient (diastolic PAP minus mean PAWP) <7 mm Hg, a transpulmonary pressure gradient (mean PAP minus mean PAWP) <12 mm Hg, and pulmonary vascular resistance ≤3 Wood units (WU). This combination of criteria defines isolated postcapillary PH. Postcapillary PH with elevated vascular gradients and pulmonary vascular resistance defines combined post- and precapillary PH (Cpc-PH). Postcapillary PH is associated with a decreased survival in proportion to increased pulmonary vascular gradients, decreased pulmonary arterial compliance, and reduced right ventricular function. The Cpc-PH subcategory occurs in 12% to 13% of patients with PH due to left heart disease. Patients with Cpc-PH have severe PH, with higher diastolic pulmonary pressure gradient, transpulmonary pressure gradient, and pulmonary vascular resistance and more pronounced ventilatory responses to exercise, lower pulmonary arterial compliance, depressed right ventricular ejection fraction, and shorter life expectancy than isolated postcapillary PH. Cpc-PH bears similarities to pulmonary arterial hypertension. Whether Cpc-PH is amenable to therapies targeting the pulmonary circulation remains to be tested by properly designed randomized controlled trials.
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Affiliation(s)
- Robert Naeije
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Mario Gerges
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Jean-Luc Vachiery
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Sergio Caravita
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Christian Gerges
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.)
| | - Irene M Lang
- From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.).
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Wright SP, Moayedi Y, Foroutan F, Agarwal S, Paradero G, Alba AC, Baumwol J, Mak S. Diastolic Pressure Difference to Classify Pulmonary Hypertension in the Assessment of Heart Transplant Candidates. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.004077. [PMID: 28912262 DOI: 10.1161/circheartfailure.117.004077] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/15/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The diastolic pressure difference (DPD) is recommended to differentiate between isolated postcapillary and combined pre-/postcapillary pulmonary hypertension (Cpc-PH) in left heart disease (PH-LHD). However, in usual practice, negative DPD values are commonly calculated, potentially related to the use of mean pulmonary artery wedge pressure (PAWP). We used the ECG to gate late-diastolic PAWP measurements. We examined the method's impact on calculated DPD, PH-LHD subclassification, hemodynamic profiles, and mortality. METHODS AND RESULTS We studied patients with advanced heart failure undergoing right heart catheterization to assess cardiac transplantation candidacy (N=141). Pressure tracings were analyzed offline over 8 to 10 beat intervals. Diastolic pulmonary artery pressure and mean PAWP were measured to calculate the DPD as per usual practice (diastolic pulmonary artery pressure-mean PAWP). Within the same intervals, PAWP was measured gated to the ECG QRS complex to calculate the QRS-gated DPD (diastolic pulmonary artery pressure-QRS-gated PAWP). Outcomes occurring within 1 year were collected retrospectively from chart review. Overall, 72 of 141 cases demonstrated PH-LHD. Within PH-LHD, the QRS-gated DPD yielded higher calculated DPD values (3 [-1 to 6] versus 0 [-4 to 3] mm Hg; P<0.01) and a greater proportion of Cpc-PH (24% versus 8%; P<0.01) versus the usual practice DPD. Cases reclassified as Cpc-PH based on QRS-gated DPD demonstrated higher pulmonary arterial pressures versus isolated postcapillary pulmonary hypertension (P<0.05). One-year mortality was similar between PH-LHD groups. CONCLUSIONS The DPD calculated in usual practice is underestimated in PH-LHD, which may classify Cpc-PH patients as isolated postcapillary pulmonary hypertension. The QRS-gated DPD reclassifies a subset of PH-LHD patients from isolated postcapillary pulmonary hypertension to Cpc-PH, which is characterized by an adverse hemodynamic profile.
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Affiliation(s)
- Stephen P Wright
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Yasbanoo Moayedi
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Farid Foroutan
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Suhail Agarwal
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Geraldine Paradero
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Ana C Alba
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Jay Baumwol
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.)
| | - Susanna Mak
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto, Ontario, Canada (S.P.W., S.M.); Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada (S.P.W., Y.M., F.F., S.A., G.P., A.C.A., S.M.); and Advanced Heart Failure and Cardiac Transplant Service, Division of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia (J.B.).
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73
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Houston BA, Tedford RJ. Is pulmonary artery wedge pressure a Fib in A-Fib? Eur J Heart Fail 2017; 19:1491-1494. [PMID: 28948710 DOI: 10.1002/ejhf.992] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/09/2017] [Indexed: 11/06/2022] Open
Affiliation(s)
- Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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74
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Imamura T, Chung B, Nguyen A, Rodgers D, Sayer G, Adatya S, Sarswat N, Kim G, Raikhelkar J, Ota T, Song T, Juricek C, Kagan V, Jeevanandam V, Mehra M, Burkhoff D, Uriel N. Decoupling Between Diastolic Pulmonary Artery Pressure and Pulmonary Capillary Wedge Pressure as a Prognostic Factor After Continuous Flow Ventricular Assist Device Implantation. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.003882. [PMID: 28912260 DOI: 10.1161/circheartfailure.117.003882] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 08/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND A cohort of heart failure (HF) patients receiving left ventricular assist devices (LVADs) has decoupling of their diastolic pulmonary artery pressure and pulmonary capillary wedge pressure. However, the clinical implications of this decoupling remain unclear. METHODS AND RESULTS In this prospective study, patients with LVADs underwent routine invasive hemodynamic ramp testing with right heart catheterization, during which LVAD speeds were adjusted. Inappropriate decoupling was defined as a >5 mm Hg difference between diastolic pulmonary artery pressure and pulmonary capillary wedge pressure. The primary outcomes of survival and heart failure readmission rates after ramp testing were assessed. Among 63 LVAD patients (60±12 years old and 25 female [40%]), 27 patients (43%) had inappropriate decoupling at their baseline speed. After adjustment of their rotation speed during ramp testing, 30 patients (48%) had inappropriate decoupling. Uni/multivariable Cox analyses demonstrated that decoupling was the only significant predictor for the composite end point of death and heart failure readmission during the 1 year following the ramp study (total of 18 events; hazards ratio, 1.09; 95% confidence interval, 1.04-1.24; P<0.05). Furthermore, normalization of decoupling (n=8) during ramp testing was significantly associated with higher 1-year heart failure readmission-free survival rate compared with the non-normalized group (n=19, 100% versus 53%; P=0.035). CONCLUSIONS The presence of inappropriate decoupling was associated with worse outcomes in patients with LVADs. Prospective, large-scale multicenter studies to validate the result are warranted.
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Affiliation(s)
- Teruhiko Imamura
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Ben Chung
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Ann Nguyen
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Daniel Rodgers
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Gabriel Sayer
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Sirtaz Adatya
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Nitasha Sarswat
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Gene Kim
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Jayant Raikhelkar
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Takeyohi Ota
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Tae Song
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Colleen Juricek
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Viktoriya Kagan
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Valluvan Jeevanandam
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Mandeep Mehra
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Daniel Burkhoff
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.)
| | - Nir Uriel
- From the Department of Medicine (T.I., B.C., A.N., D.R., G.S., S.A., N.S., G.K., J.R., N.U.) and Department of Surgery (T.O., T.S., C.J., V.K., V.J.), University of Chicago Medical Center, IL; Department of Medicine, Brigham and Women's Hospital, Boston, MA (M.M.); and Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (D.B.).
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75
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Gómez-López EA. Hipertensión pulmonar asociada a enfermedad cardiaca izquierda. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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76
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Assad TR, Hemnes AR, Larkin EK, Glazer AM, Xu M, Wells QS, Farber-Eger EH, Sheng Q, Shyr Y, Harrell FE, Newman JH, Brittain EL. Clinical and Biological Insights Into Combined Post- and Pre-Capillary Pulmonary Hypertension. J Am Coll Cardiol 2017; 68:2525-2536. [PMID: 27931609 DOI: 10.1016/j.jacc.2016.09.942] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/09/2016] [Accepted: 09/19/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common and morbid complication of left heart disease with 2 subtypes: isolated post-capillary pulmonary hypertension (Ipc-PH) and combined post-capillary and pre-capillary pulmonary hypertension (Cpc-PH). Little is known about the clinical or physiological characteristics that distinguish these 2 subphenotypes or if Cpc-PH shares molecular similarities to pulmonary arterial hypertension (PAH). OBJECTIVES The goal of this study was to test the hypothesis that the hemodynamic and genetic profile of Cpc-PH would more closely resemble PAH than Ipc-PH. METHODS Vanderbilt University's electronic medical record linked to a DNA biorepository was used to extract demographic characteristics, clinical data, invasive hemodynamic data, echocardiography, and vital status for all patients referred for right heart catheterization between 1998 and 2014. Shared genetic variants between PAH and Cpc-PH compared with Ipc-PH were identified by using pre-existing single-nucleotide polymorphism data. RESULTS A total of 2,817 patients with PH (13% Cpc-PH, 52% Ipc-PH, and 20% PAH) were identified. Patients with Cpc-PH were on average 6 years younger, with more severe pulmonary vascular disease than patients with Ipc-PH, despite similar comorbidities and prevalence, severity, and chronicity of left heart disease. After adjusting for relevant covariates, the risk of death was similar between the Cpc-PH and Ipc-PH groups (hazard ratio: 1.14; 95% confidence interval: 0.96 to 1.35; p = 0.15) when defined according to diastolic pressure gradient. We identified 75 shared exonic single-nucleotide polymorphisms between Cpc-PH and PAH enriched in pathways involving cell structure, extracellular matrix, and immune function. These genes are expressed, on average, 32% higher in lungs relative to other tissues. CONCLUSIONS Patients with Cpc-PH develop pulmonary vascular disease similar to patients with PAH, despite younger age and similar prevalence of obesity, diabetes mellitus, and left heart disease compared with patients with Ipc-PH. An exploratory genetic analysis in Cpc-PH identified genes and biological pathways in the lung known to contribute to PAH pathophysiology, suggesting that Cpc-PH may be a distinct and highly morbid PH subphenotype.
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Affiliation(s)
- Tufik R Assad
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Emma K Larkin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Andrew M Glazer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Quinn S Wells
- Vanderbilt Center for Translational and Clinical Cardiovascular Research, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric H Farber-Eger
- Vanderbilt Center for Translational and Clinical Cardiovascular Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Quanhu Sheng
- Center for Quantitative Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yu Shyr
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee; Center for Quantitative Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - John H Newman
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Evan L Brittain
- Vanderbilt Center for Translational and Clinical Cardiovascular Research, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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77
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Jose A, King CS, Shlobin OA, Kiernan JM, Cossa NA, Brown AW, Nathan SD. Ventricular Diastolic Pressure Ratio as a Marker of Treatment Response in Pulmonary Hypertension. Chest 2017; 152:980-989. [PMID: 28527879 DOI: 10.1016/j.chest.2017.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 03/30/2017] [Accepted: 05/01/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is diagnosed and classified through right-sided heart catheterization, with a number of hemodynamic markers used to help guide treatment decisions. These markers may not reflect the complex remodeling of the right ventricle or the interplay between ventricles and struggle to predict treatment response. This study investigates the use of a novel marker: the ratio of left ventricular end-diastolic pressure to right ventricular end-diastolic pressure (LVEDP/RVEDP) in predicting treatment outcomes in a cohort of patients with PH. METHODS We performed a retrospective analysis of patients with PH at INOVA Fairfax Hospital's advanced lung disease program with simultaneous left-sided and right-sided heart catheterization. The primary end point was the time to clinical improvement, defined by an improvement in distance walked on the 6-min walk test (6MWT) of > 35 m in a year without interceding hospitalization for worsening PH or the need for additional PH therapy. RESULTS A total of 51 patients were included in the final analysis, 21 of whom (41.2%) had a salutary treatment effect with a mean improvement in the 6MWT of 75 m. Treatment responders were more likely to have a lower LVEDP/RVEDP ratio (1.08 vs 1.62; P = .051). This association persisted in the final multivariate regression model after adjustment for age and sex and controlling for severity of PH (OR, 0.17; 95% CI, 0.03-0.65; P = .024). CONCLUSIONS The LVEDP/RVEDP ratio is a novel marker for therapeutic response in patients with PH treated with pulmonary vasodilator medications and may offer robust predictive value independent of existing markers of disease severity.
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Affiliation(s)
- Arun Jose
- Pulmonary, Critical Care, and Sleep Medicine Division, The George Washington University Medical Faculty Associates, Washington, DC.
| | - Christopher S King
- Advanced Lung Disease and Transplant Program, INOVA Fairfax Hospital, Falls Church, VA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, INOVA Fairfax Hospital, Falls Church, VA
| | - Joseph M Kiernan
- Cardiovascular Disease and Interventional Cardiology Program, INOVA Fairfax Hospital, Falls Church, VA
| | - Nicolas A Cossa
- Cardiovascular Disease and Interventional Cardiology Program, INOVA Fairfax Hospital, Falls Church, VA
| | - A Whitney Brown
- Advanced Lung Disease and Transplant Program, INOVA Fairfax Hospital, Falls Church, VA
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, INOVA Fairfax Hospital, Falls Church, VA
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78
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Brunner NW, Yue SF, Stub D, Ye J, Cheung A, Leipsic J, Lauck S, Dvir D, Perlman G, Htun N, Fahmy P, Prakash R, Eng L, Ong K, Tsang M, Cairns JA, Webb JG, Wood DA. The prognostic importance of the diastolic pulmonary gradient, transpulmonary gradient, and pulmonary vascular resistance in patients undergoing transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2017; 90:1185-1191. [PMID: 28471090 DOI: 10.1002/ccd.27107] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/23/2017] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To evaluate the association between markers of precapillary pulmonary hypertension (PH) and survival in transcatheter aortic valve replacement (TAVR). BACKGROUND The importance of precapillary PH has been sparsely investigated in patients undergoing TAVR. It may prove an important risk factor for poor outcomes. METHODS We identified patients at our institution undergoing TAVR with a baseline right heart catheterization (RHC) demonstrating PH. We evaluated the association between markers of precapillary PH and survival including the diastolic pulmonary gradient (DPG), transpulmonary gradient (TPG), and pulmonary vascular resistance (PVR). A multivariable analysis was performed using Cox Proportional Hazards Models, adjusting for age, gender, body mass index, and pulmonary artery systolic pressure (PASP) on echocardiography. RESULTS We identified 133 patients with PH on RHC. Of these 111 had low DPG and 22 had high DPG. All 3 markers of precapillary PH were associated with worse survival post TAVR, with OR of 2.1 (95% CI 1.1-3.9, P = 0.02), 3.4 (95% CI 1.8-6.4, P < 0.001) and 2.5 (95% CI 1.4-4.5, P = 0.003) for high DPG, TPG, and PVR, respectively. On multivariable analysis, both TPG and PVR remained predictors of worse survival, with OR of 3.4 (95% CI 1.7-6.9, P = 0.001) and 2.5 (95% CI 1.4-4.5, P = 0.003). Echocardiographic PASP and DPG were not predictive of survival. CONCLUSIONS In patients undergoing TAVR, parameters of precapillary PH are associated with lower survival, and provide incremental prognostication over echocardiographic PASP. RHC should continue to play an important role in risk stratification prior to TAVR. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Nathan W Brunner
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Su Fei Yue
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dion Stub
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jian Ye
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anson Cheung
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sandra Lauck
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Danny Dvir
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gidon Perlman
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nay Htun
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Fahmy
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Roshan Prakash
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lim Eng
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin Ong
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Tsang
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Cairns
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - John G Webb
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A Wood
- Centre for Heart Valve Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
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79
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Palazzini M, Dardi F, Manes A, Bacchi Reggiani ML, Gotti E, Rinaldi A, Albini A, Monti E, Galiè N. Pulmonary hypertension due to left heart disease: analysis of survival according to the haemodynamic classification of the 2015 ESC/ERS guidelines and insights for future changes. Eur J Heart Fail 2017; 20:248-255. [DOI: 10.1002/ejhf.860] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 11/11/2022] Open
Affiliation(s)
- Massimiliano Palazzini
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
| | - Fabio Dardi
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
| | - Alessandra Manes
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
| | - Maria L. Bacchi Reggiani
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
| | - Enrico Gotti
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
| | - Andrea Rinaldi
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
| | - Alessandra Albini
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
| | - Enrico Monti
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
| | - Nazzareno Galiè
- Department of Investigational, Diagnostic and Specialty Medicine; University of Bologna; Bologna Italy
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80
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Berthelot E, Bailly MT, Hatimi SE, Robard I, Rezgui H, Bouchachi A, Montani D, Sitbon O, Chemla D, Assayag P. Pulmonary hypertension due to left heart disease. Arch Cardiovasc Dis 2017; 110:420-431. [PMID: 28411107 DOI: 10.1016/j.acvd.2017.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/24/2017] [Indexed: 01/03/2023]
Abstract
Pulmonary hypertension due to left heart disease, also known as group 2 pulmonary hypertension according to the European Society of Cardiology/European Respiratory Society classification, is the most common cause of pulmonary hypertension. In patients with left heart disease, the development of pulmonary hypertension favours right heart dysfunction, which has a major impact on disease severity and outcome. Over the past few years, this condition has been considered more frequently. However, epidemiological studies of group 2 pulmonary hypertension are less exhaustive than studies of other causes of pulmonary hypertension. In group 2 patients, pulmonary hypertension may be caused by an isolated increase in left-sided filling pressures or by a combination of this condition with increased pulmonary vascular resistance, with an abnormally high pressure gradient between arteries and pulmonary veins. A better understanding of the conditions underlying pulmonary hypertension is of key importance to establish a comprehensive diagnosis, leading to an adapted treatment to reduce heart failure morbidity and mortality. In this review, epidemiology, mechanisms and diagnostic approaches are reviewed; then, treatment options and future approaches are considered.
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Affiliation(s)
| | - Minh Tam Bailly
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Safwane El Hatimi
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ingrid Robard
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Hatem Rezgui
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Amir Bouchachi
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, Hôpital Bicêtre, Le Kremlin Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olivier Sitbon
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, Hôpital Bicêtre, Le Kremlin Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Denis Chemla
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France; AP-HP, Service de Physiologie, Unité INSERM U_999, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Patrick Assayag
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
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81
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Bourji KI, Kelemen BW, Mathai SC, Damico RL, Kolb TM, Mercurio V, Cozzi F, Tedford RJ, Hassoun PM. Poor survival in patients with scleroderma and pulmonary hypertension due to heart failure with preserved ejection fraction. Pulm Circ 2017; 7:409-420. [PMID: 28597765 PMCID: PMC5467929 DOI: 10.1177/2045893217700438] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pulmonary hypertension due to heart failure with preserved ejection fraction (PH-HFpEF) has been poorly studied in patients with systemic sclerosis (SSc). We sought to compare clinical characteristics and survival of SSc patients with PH-HFpEF (SSc-PH-HFpEF) versus pulmonary arterial hypertension (SSc-PAH). We hypothesized that patients with SSc-PH-HFpEF have a similar poor overall prognosis compared with patients with SSc-PAH when matched for total right ventricular load. The analysis included 117 patients with SSc-PH (93 with SSc-PAH versus 24 with SSc-PH-HFpEF) enrolled prospectively in the Johns Hopkins PH Registry. We examined baseline demographics and hemodynamics at diagnostic right heart catheterization (RHC), two-dimensional echocardiographic characteristics, six-minute walking distance (6MWD), treatment modalities, and laboratory values (serum NT-proBNP, creatinine, uric acid, and sodium), and assessed survival. Demographics and clinical features were similar between the two groups. Baseline RHC showed significantly higher pulmonary and right heart pressures in the SSc-PH-HFpEF compared with the SSc-PAH group. Trans-pulmonary gradient (TPG), however, was equally elevated without significant difference between the groups. SSc-PH-HFpEF patients had left atrial enlargement on echocardiography compared with SSc-PAH patients. No significant differences were found between groups for 6MWD, NT-proBNP, and other laboratory values. Although overall median survival time was 4.6 years with no difference in mortality rate between the two groups (SSc-PH-HFpEF versus SSc-PAH: 75% versus 59%; P = 0.26), patients with SSc-PH-HFpEF had a twofold increased risk of death compared with SSc-PAH patients after adjusting for hemodynamics. Concomitant intrinsic pulmonary vascular disease and HFpEF likely contribute to very poor survival in patients with SSc-PH-HFpEF.
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Affiliation(s)
- Khalil I Bourji
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.,2 Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Benjamin W Kelemen
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Stephen C Mathai
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Rachel L Damico
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Todd M Kolb
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Valentina Mercurio
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Franco Cozzi
- 2 Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Ryan J Tedford
- 3 Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul M Hassoun
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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82
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Lundgren J, Söderlund C, Rådegran G. Impact of postoperative pulmonary hypertension on outcome after heart transplantation. SCAND CARDIOVASC J 2017; 51:172-181. [PMID: 28326855 DOI: 10.1080/14017431.2017.1304569] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We wanted to investigate the effects of postoperative pulmonary hypertension (PHpostop: mean pulmonary artery pressure [MPAP] ≥ 25 mmHg), diastolic pressure gradient (DPG), pulmonary vascular resistance (PVR), and repeated hemodynamic measurements on long-term survival after heart transplantation (HT). DESIGN Eighty-nine patients who underwent HT at Skåne University Hospital in Lund in the period 1988-2010 and who were evaluated with right-heart-catheterization at rest, prior to HT and repeatedly during the first postoperative year, were grouped based on their MPAP, DPG, and PVR. RESULTS One year after HT, survival was lower in patients with PHpostop than in those without, in patients with DPG ≥7 mmHg than in those with DPG <7 mmHg, and in patients with PVR >3 WU than in those with PVR ≤3 WU. Moreover, compared to patients with no PHpostop or with PHpostop at one evaluation during the first year after HT, PHpostop at repeated evaluations was associated with higher mortality (hazard ratio 3.4, 95% CI 1.4-8.0). There was no significant difference in acute cellular rejection between patients with and without PHpostop, but postoperative kidney function was worse in patients with repeated PHpostop. CONCLUSIONS When defined according to present guidelines, PH one year after HT may emerge as a prognostic marker for long-term outcome after HT. Moreover, PHpostop at repeated evaluations during the first year after HT had stronger prognostic value than PHpostop at a single examination, illustrating a means of identifying a high-risk population. However, confirmation in larger multi-center studies is warranted.
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Affiliation(s)
- Jakob Lundgren
- a Department of Clinical Sciences Lund, Cardiology , Lund University , Lund , Sweden.,b The Hemodynamics Laboratory, Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine , Skåne University Hospital , Lund , Sweden
| | - Carl Söderlund
- a Department of Clinical Sciences Lund, Cardiology , Lund University , Lund , Sweden.,b The Hemodynamics Laboratory, Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine , Skåne University Hospital , Lund , Sweden
| | - Göran Rådegran
- a Department of Clinical Sciences Lund, Cardiology , Lund University , Lund , Sweden.,b The Hemodynamics Laboratory, Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine , Skåne University Hospital , Lund , Sweden
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83
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Maeder MT, Schoch OD, Kleiner R, Joerg L, Weilenmann D, Swiss Medical Weekly. Pulmonary hypertension associated with left-sided heart disease. Swiss Med Wkly 2017; 147:w14395. [DOI: 10.57187/smw.2017.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Pulmonary hypertension associated with left-sided heart disease (PH-LHD) is the most common type of pulmonary hypertension. In patients with left-sided heart disease, the presence of pulmonary hypertension is typically a marker of more advanced disease, more severe symptoms, and worse prognosis. In contrast to pulmonary arterial hypertension, PH-LHD is characterised by an elevated pulmonary artery wedge pressure (postcapillary pulmonary hypertension) without or with an additional precapillary component (isolated postcapillary vs combined postcapillary and precapillary pulmonary hypertension). Transthoracic echocardiography is the primary noninvasive imaging tool to estimate the probability of pulmonary hypertension and to establish a working diagnosis on the mechanism of pulmonary hypertension. However, right heart catheterisation is always required if significant pulmonary hypertension is suspected and exact knowledge of the haemodynamic constellation is necessary. The haemodynamic constellation (mean pulmonary artery pressure, mean pulmonary artery wedge pressure, left ventricular end-diastolic pressure) in combination with clinical information and imaging findings (mainly echocardiography, coronary angiography and cardiac magnetic resonance imaging) will usually allow the exact mechanism underlying PH-LHD to be defined, which is a prerequisite for appropriate treatment. The general principle for the management of PH-LHD is to treat the underlying left-sided heart disease in an optimal manner using drugs and/or interventional or surgical therapy. There is currently no established indication for pulmonary arterial hypertension-specific therapies in PH-LHD, and specific therapies may even cause harm in patients with PH-LHD.
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84
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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: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [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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85
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Abstract
Pulmonary hypertension associated with left heart disease is the most common form of pulmonary hypertension. Although its pathophysiology remains incompletely understood, it is now well recognized that the presence of pulmonary hypertension is associated with a worse prognosis. Right ventricular failure has independent and additive prognostic value over pulmonary hypertension for adverse outcomes in left heart disease. Recently, several new terminologies have been introduced to better define and characterize the nature and severity of pulmonary hypertension. Several new treatment options including the use of pulmonary arterial hypertension specific therapies are being considered, but there is lack of evidence. Here, we review the recent advances in this field and summarize the diagnostic and therapeutic modalities of use in the management of pulmonary hypertension associated with left heart disease.
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Affiliation(s)
- Bhavadharini Ramu
- Cardiovascular Division, Section of Advanced Heart Failure and Pulmonary Hypertension, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Thenappan Thenappan
- Cardiovascular Division, Section of Advanced Heart Failure and Pulmonary Hypertension, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN, 55455, USA.
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86
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Nagy AI, Venkateshvaran A, Merkely B, Lund LH, Manouras A. Determinants and prognostic implications of the negative diastolic pulmonary pressure gradient in patients with pulmonary hypertension due to left heart disease. Eur J Heart Fail 2016; 19:88-97. [PMID: 27748008 DOI: 10.1002/ejhf.675] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/14/2016] [Accepted: 09/08/2016] [Indexed: 11/11/2022] Open
Abstract
AIMS The diastolic pulmonary pressure gradient (DPG) has recently been introduced as a specific marker of combined pre-capillary pulmonary hypertension (Cpc-PH) in left heart disease (LHD). However, its diagnostic and prognostic superiority compared with traditional haemodynamic indices has been challenged lately. Current recommendations explicitly denote that in the normal heart, DPG values are greater than zero, with DPG ≥7 mmHg indicating Cpc-PH. However, clinicians are perplexed by the frequent observation of DPG <0 mmHg (DPGNEG ), as its physiological explanation and clinical impact are unclear to date. We hypothesized that large V-waves in the pulmonary artery wedge pressure (PAWP) curve yielding asymmetric pressure transmission might account for DPGNEG and undertook this study to clarify the physiological and prognostic implications of DPGNEG . METHODS AND RESULTS Right heart catheterization and echocardiography were performed in 316 patients with LHD due to primary myocardial dysfunction or valvular disease. A total of 256 patients had PH-LHD, of whom 48% demonstrated DPGNEG . The V-wave amplitude inversely correlated with DPG (r = -0.45, P < 0.001) in patients with low pulmonary vascular resistance (PVR), but not in those with elevated PVR (P > 0.05). Patients with large V-waves had negative and lower DPG than those without augmented V-waves (P < 0.001) despite similar PVR (P >0.05). Positive, but normal DPG (0-6 mmHg) carried a worse 2-year prognosis for death and/or heart transplantation than DPGNEG (hazard ratio 2.97; P < 0.05). CONCLUSION Our results advocate against DPGNEG constituting a measurement error. We propose that DPGNEG can partially be ascribed to large V-waves and carries a better prognosis than DPG within the normal positive range.
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Affiliation(s)
- Anikó Ilona Nagy
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ashwin Venkateshvaran
- School for Technology and Health, Royal Institute of Technology, Stockholm, Sweden.,Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Lars H Lund
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Aristomenis Manouras
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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87
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Diastolic pulmonary gradient predicts outcomes in group 1 pulmonary hypertension (analysis of the NIH primary pulmonary hypertension registry). Respir Med 2016; 119:81-86. [DOI: 10.1016/j.rmed.2016.08.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/22/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
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88
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Naeije R, Hemnes AR. The difficult diagnosis of pulmonary vascular disease in heart failure. Eur Respir J 2016; 48:308-10. [DOI: 10.1183/13993003.00789-2016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/25/2016] [Indexed: 11/05/2022]
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89
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Galiè N, Manes A, Palazzini M. The difficult diagnosis of pulmonary vascular disease in heart failure. Eur Respir J 2016; 48:311-4. [DOI: 10.1183/13993003.00854-2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/05/2016] [Indexed: 01/05/2023]
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90
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Agarwal M, Waxman AB. Physiological Techniques and Pulmonary Hypertension - Left Heart Disease. Prog Cardiovasc Dis 2016; 59:30-41. [PMID: 27211586 DOI: 10.1016/j.pcad.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 05/11/2016] [Indexed: 01/06/2023]
Abstract
Group 2 Pulmonary hypertension (PH) is associated with left heart disease (LHD;Group 2 PH) and is the most common form of PH. Group 2 PH represents an important subgroup of patients with LHD where the development of PH leads to a significant increase in morbidity and mortality. Early diagnosis may provide an opportunity to intervene and significantly delay progression. In addition to clinical suspicion, several approaches including hemodynamic assessment, exercise testing, and imaging techniques play an important role in better disease characterization and management. Here, we review the role of physiologic based hemodynamic and exercise assessments of Group 2 PH patients.
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Affiliation(s)
- Manyoo Agarwal
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA; Pulmonary and Critical Care Medicine, Center for Pulmonary Heart Disease, Brigham and Women's Hospital Heart and Vascular Center
| | - Aaron B Waxman
- Pulmonary and Critical Care Medicine, Center for Pulmonary Heart Disease, Brigham and Women's Hospital Heart and Vascular Center; Pulmonary and Critical Care Medicine, Cardiovascular Medicine, Pulmonary Vascular Disease Program, Center for Pulmonary-Heart Diseases, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School.
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91
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Gerges M, Gerges C, Lang IM. How to define pulmonary hypertension due to left heart disease. Eur Respir J 2016; 48:553-5. [DOI: 10.1183/13993003.00432-2016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/20/2016] [Indexed: 11/05/2022]
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92
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Hussain N, Charalampopoulos A, Ramjug S, Condliffe R, Elliot CA, O'Toole L, Swift A, Kiely DG. Pulmonary hypertension in patients with heart failure and preserved ejection fraction: differential diagnosis and management. Pulm Circ 2016; 6:3-14. [PMID: 27162611 PMCID: PMC4860544 DOI: 10.1086/685021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The most common cause of pulmonary hypertension (PH) due to left heart disease (LHD) was previously rheumatic mitral valve disease. However, with the disappearance of rheumatic fever and an aging population, nonvalvular LHD is now the most common cause of group 2 PH in the developed world. In this review, we examine the challenge of investigating patients who have PH and heart failure with preserved ejection fraction (HF-pEF), where differentiating between pulmonary arterial hypertension (PAH) and PH-LHD can be difficult, and also discuss the entity of combined precapillary and postcapillary PH. Given the proven efficacy of targeted therapy for the treatment of PAH, there is increasing interest in whether these treatments may benefit selected patients with PH associated with HF-pEF, and we review current trial data.
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Affiliation(s)
- Nehal Hussain
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Sheila Ramjug
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Laurence O'Toole
- Department of Cardiology, Northern General Hospital, Sheffield NHS Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Andrew Swift
- Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Sheffield NHS Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield National Health Service (NHS) Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
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93
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Gerges C, Gerges M, Skoro-Sajer N, Zhou Y, Zhang L, Sadushi-Kolici R, Jakowitsch J, Lang MB, Lang IM. Hemodynamic Thresholds for Precapillary Pulmonary Hypertension. Chest 2016; 149:1061-73. [DOI: 10.1378/chest.15-0928] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 09/19/2015] [Accepted: 10/01/2015] [Indexed: 01/10/2023] Open
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94
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Rosenkranz S, Gibbs JSR, Wachter R, De Marco T, Vonk-Noordegraaf A, Vachiéry JL. Left ventricular heart failure and pulmonary hypertension. Eur Heart J 2016; 37:942-54. [PMID: 26508169 PMCID: PMC4800173 DOI: 10.1093/eurheartj/ehv512] [Citation(s) in RCA: 437] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/20/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022] Open
Abstract
In patients with left ventricular heart failure (HF), the development of pulmonary hypertension (PH) and right ventricular (RV) dysfunction are frequent and have important impact on disease progression, morbidity, and mortality, and therefore warrant clinical attention. Pulmonary hypertension related to left heart disease (LHD) by far represents the most common form of PH, accounting for 65-80% of cases. The proper distinction between pulmonary arterial hypertension and PH-LHD may be challenging, yet it has direct therapeutic consequences. Despite recent advances in the pathophysiological understanding and clinical assessment, and adjustments in the haemodynamic definitions and classification of PH-LHD, the haemodynamic interrelations in combined post- and pre-capillary PH are complex, definitions and prognostic significance of haemodynamic variables characterizing the degree of pre-capillary PH in LHD remain suboptimal, and there are currently no evidence-based recommendations for the management of PH-LHD. Here, we highlight the prevalence and significance of PH and RV dysfunction in patients with both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), and provide insights into the complex pathophysiology of cardiopulmonary interaction in LHD, which may lead to the evolution from a 'left ventricular phenotype' to a 'right ventricular phenotype' across the natural history of HF. Furthermore, we propose to better define the individual phenotype of PH by integrating the clinical context, non-invasive assessment, and invasive haemodynamic variables in a structured diagnostic work-up. Finally, we challenge current definitions and diagnostic short falls, and discuss gaps in evidence, therapeutic options and the necessity for future developments in this context.
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Affiliation(s)
- Stephan Rosenkranz
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937 Köln, Germany Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Köln, Germany
| | - J Simon R Gibbs
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital London, London, UK
| | - Rolf Wachter
- Klinik für Kardiologie und Pneumologie, Herzzentrum, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Germany German Cardiovascular Research Center (DZHK), Göttingen, Germany
| | - Teresa De Marco
- Division of Cardiology, University of California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Jean-Luc Vachiéry
- Department of Cardiology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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95
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Yamabe S, Dohi Y, Fujisaki S, Higashi A, Kinoshita H, Sada Y, Hidaka T, Kurisu S, Yamamoto H, Kihara Y. Prognostic Factors for Survival in Pulmonary Hypertension Due to Left Heart Disease. Circ J 2016; 80:243-9. [DOI: 10.1253/circj.cj-15-0708] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sayuri Yamabe
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yoshihiro Dohi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | | | - Akifumi Higashi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Hiroki Kinoshita
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yoshiharu Sada
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Takayuki Hidaka
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Hideya Yamamoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
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96
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Houston BA, Kalathiya RJ, Stevens GR, Russell SD, Tedford RJ. One-and-done: Do left ventricular assist device patients on the transplant list really need frequent right heart catheterization assessments for pulmonary hypertension? J Heart Lung Transplant 2015; 34:1637-9. [DOI: 10.1016/j.healun.2015.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 06/17/2015] [Accepted: 07/13/2015] [Indexed: 11/15/2022] Open
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Abstract
Pulmonary hypertension (PH) associated with left heart disease (PH-LHD) is the most common type of PH, but its natural history is not well understood. PH-LHD is diagnosed by right heart catheterisation with a mean pulmonary arterial pressure ≥25 mmHg and a pulmonary capillary wedge pressure >15 mmHg. The primary causes of PH-LHD are left ventricular dysfunction of systolic and diastolic origin, and valvular disease. Prognosis is poor and survival rates are low. Limited progress has been made towards specific therapies for PH-LHD, and management focuses on addressing the underlying cause of the disease with supportive therapies, surgery and pharmacological treatments. Clinical trials of therapies for pulmonary arterial hypertension in patients with PH-LHD have thus far been limited and have provided disappointing or conflicting results. Robust, long-term clinical studies in appropriate target populations have the potential to improve the outlook for patients with PH-LHD. Herein, we discuss the knowledge gaps in our understanding of PH-LHD, and describe the current unmet needs and challenges that are faced by clinicians when identifying and managing patients with this disease. Pulmonary hypertension due to left heart disease is associated with multiple unmet medical needshttp://ow.ly/TFET8
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98
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Gerges M, Gerges C, Pistritto AM, Lang MB, Trip P, Jakowitsch J, Binder T, Lang IM. Pulmonary Hypertension in Heart Failure. Epidemiology, Right Ventricular Function, and Survival. Am J Respir Crit Care Med 2015; 192:1234-46. [DOI: 10.1164/rccm.201503-0529oc] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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99
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Selby VN, De Marco T. Current Treatment Strategies in Pulmonary Hypertension Associated with Left Heart Disease. CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-015-0075-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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100
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