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Abstract
PURPOSE OF REVIEW Right ventricular (RV) function is an important determinant of morbidity and mortality in patients with pulmonary arterial hypertension (PAH). Although substantial progress has been made in understanding the development of RV failure in the last decennia, this has not yet resulted in the development of RV selective therapies. In this review, we will discuss the current status on the treatment of RV failure and potential novel therapeutic strategies that are currently being investigated in clinical trials. RECENT FINDINGS Increased afterload results in elevated wall tension. Consequences of increased wall tension include autonomic disbalance, metabolic shift and inflammation, negatively affecting RV contractility. Compromised RV systolic function and low cardiac output activate renin-angiotensin aldosterone system, which leads to fluid retention and further increase in RV wall tension. This vicious circle can be interrupted by directly targeting the determinants of RV wall tension; preload and afterload by PAH-medications and diuretics, but is also possibly by restoring neurohormonal and metabolic disbalance, and inhibiting maladaptive inflammation. A variety of RV selective drugs are currently being studied in clinical trials. SUMMARY Nowadays, afterload reduction is still the cornerstone in treatment of PAH. New treatments targeting important pathobiological determinants of RV failure directly are emerging.
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Affiliation(s)
- Joanne A. Groeneveldt
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
| | - Frances S. de Man
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
| | - Berend E. Westerhof
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
- Section of Systems Physiology, Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Sanz J, Sánchez-Quintana D, Bossone E, Bogaard HJ, Naeije R. Anatomy, Function, and Dysfunction of the Right Ventricle. J Am Coll Cardiol 2019; 73:1463-1482. [DOI: 10.1016/j.jacc.2018.12.076] [Citation(s) in RCA: 180] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/12/2018] [Accepted: 12/22/2018] [Indexed: 12/27/2022]
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van der Graaf M, Rojer LA, Helbing WA, Reiss IKM, Etnel JRG, Bartelds B. EXPRESS: Sildenafil for bronchopulmonary dysplasia and pulmonary hypertension: a meta-analysis. Pulm Circ 2019; 9:2045894019837875. [PMID: 30803328 PMCID: PMC6681505 DOI: 10.1177/2045894019837875] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 02/19/2019] [Indexed: 01/28/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common complication in preterm infants and often complicated by pulmonary hypertension (PH), leading to substantial morbidity and mortality. Sildenafil is often used to treat PH and improve symptoms in this condition, even though evidence of safety and effectiveness is scarce. The aim of this study was to perform a systematic review and meta-analysis about the effectiveness and safety of chronic use of sildenafil in preterm infants with BPD-associated PH. Data sources were PubMed, EMBASE, and Medline. Studies reporting the effectiveness of sildenafil therapy in BPD-associated PH in newborns and infants were included. All-cause mortality, improvement in PH, improvement in respiratory scores, and adverse events were extracted. Five studies were included, yielding a total of 101 patients with 94.2 patient-years of total follow-up. The pooled mortality rate was 29.7%/year (95% confidence interval [CI] = 6.8–52.7). Estimated pulmonary arterial pressure improved > 20% in 69.3% (95% CI = 56.8–81.8) of patients within 1–6 months. Respiratory scores improved in 15.0% (95% CI = 0.0–30.4) of patients within 2–7 days. There were no serious adverse events during sildenafil therapy. This systematic review shows that in the treatment of BPD-associated PH in preterm infants, sildenafil may be associated with improvement in PAP and respiratory scores. However, there is no clear evidence of its effect on mortality rates. Considering BPD as a complex disease with variable expression patterns, these results support the need for a prospective registry and standardized approach.
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Affiliation(s)
- Marisa van der Graaf
- Department of Pediatrics, Division of
Cardiology, Erasmus University Medical Centre - Sophia Children’s Hospital,
Rotterdam, The Netherlands
| | - Leonne Arindah Rojer
- Department of Pediatrics, Division of
Cardiology, Erasmus University Medical Centre - Sophia Children’s Hospital,
Rotterdam, The Netherlands
| | - Willem Arnold Helbing
- Department of Pediatrics, Division of
Cardiology, Erasmus University Medical Centre - Sophia Children’s Hospital,
Rotterdam, The Netherlands
- Department of Pediatrics, Division of
Cardiology, Radboud University Medical Centre - Amalia Children’s Hospital,
Nijmegen, The Netherlands
| | - Irwin Karl Marcel Reiss
- Department of Pediatrics, Division of
Cardiology, Erasmus University Medical Centre - Sophia Children’s Hospital,
Rotterdam, The Netherlands
| | | | - Beatrijs Bartelds
- Department of Pediatrics, Division of
Cardiology, Erasmus University Medical Centre - Sophia Children’s Hospital,
Rotterdam, The Netherlands
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54
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Sulica R, Sangli S, Chakravarti A, Steiger D. Clinical and hemodynamic benefit of macitentan and riociguat upfront combination in patients with pulmonary arterial hypertension. Pulm Circ 2019; 9:2045894019826944. [PMID: 30638432 PMCID: PMC6378454 DOI: 10.1177/2045894019826944] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
In this open-label study, we evaluated the effect of upfront macitentan and riociguat combination in newly diagnosed pulmonary arterial hypertension (PAH) patients. In 15 consecutive PAH patients, we collected clinical and hemodynamic data at baseline, visit 1 (median 4 months) and visit 2 (median 12 months). Survival and transplantation status were analyzed over 36 months. Statistical analysis included student t-test and 95% confidence interval (CI) ( t-statistic or Clopper-Pearson). Kaplan-Meier was used to estimate survival rate. There were 11/15 women (mean age 56 years), in World Health Organization (WHO) functional class (FC) III ( n = 14) or IV ( n = 1). The 6 min walk distance increased from 281.6 m (baseline) to 315.7 m (visit 1) and visit 2 (313.9 m), representing a 34- and 32-m change ( P < 0.05), respectively, associated with Borg score improvements. Brain natriuretic peptide decreased: 318.2 pg/mL (baseline) to 122.0 pg/mL (visit 1) and 98.6 pg/mL (visit 2) ( P < 0.05). WHO FC improved in eight patients (53%, 95% CI 27%-79%). Pulmonary vascular resistance (9.2 to 5.7 Wood Units) and mean pulmonary artery pressure (47.3 to 38.9 mmHg) decreased; cardiac index increased (2.3 to 3.0 L/min/m2) (baseline to visit 2, all P < 0.05). All patients had intermediate and high risk score (baseline); at 1-year follow-up, dual therapy led to reduction to low risk score in 7/15 (47%) patients. There were no unexpected or serious side effects. Three patients died due to unrelated causes; one patient received a lung transplant. Transplant-free survival rate (36 months) was 85%. Preliminary evidence is provided for effectiveness of initial macitentan and riociguat combination therapy in PAH.
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Affiliation(s)
- Roxana Sulica
- 1 NYU Langone Pulmonary Hypertension Program, New York University School of Medicine, USA
| | - Swathi Sangli
- 2 Pulmonary and Critical Care Department, Mayo Clinic, Rochester, USA
| | - Aloke Chakravarti
- 3 Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Beth Israel Hospital, New York, USA
| | - David Steiger
- 3 Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Beth Israel Hospital, New York, USA.,4 Icahn School of Medicine at Mount Sinai, New York, USA
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55
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Li JH, Zhang HD, Wang ZZ, Lu QQ, Li D, Lian TY, Lv ZC, Jiang X, Wu Y, Ye J, Zhao S, Yang Z. Acute Iloprost Inhalation Improves Right Ventricle Function in Pulmonary Artery Hypertension: A Cardiac Magnetic Resonance Study. Front Pharmacol 2019; 9:1550. [PMID: 30719004 PMCID: PMC6348276 DOI: 10.3389/fphar.2018.01550] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/19/2018] [Indexed: 12/17/2022] Open
Abstract
Background: Right ventricle (RV) function is among the most important prognostic factors for pulmonary arterial hypertension (PAH) patients. Inhaled iloprost, an inhaled member of the prostacyclin family, is effective for the treatment of severe PAH and acute RV failure. However, the acute effects of iloprost on RV physiology have not been thoroughly explored in the past. Materials and Methods: This prospective study involved 69 incident PAH patients, including 23 idiopathic PAH (IPAH) patients, 26 patients with PAH associated with connective tissue disease (CTD-PAH) and 20 with PAH associated with congenital heart disease (CHD-PAH). All patients underwent both right heart catheterization and cardiac magnetic resonance imaging at baseline and 20 min after 5 μg iloprost inhalation. Results: Acute iloprost inhalation reduced PVR from 13 ± 7 to 10 ± 6 Wood U (P < 0.001), increased RV ejection fraction (RVEF) from 31 ± 11 to 35 ± 12 % (P < 0.001), increased RV stroke volume from 53 ± 21 to 57 ± 22 ml (P < 0.001) and decreased RV end-diastolic volume from 179 ± 67 to 172 ± 69 ml (P < 0.001). Acute iloprost inhalation-induced RVEF improvement was correlated with the degree of PVR reduction (P < 0.001) in IPAH patients, but not in CTD-PAH or CHD-PAH patients. Conclusion: Acute iloprost inhalation improved RVEF, RV stroke volume and decreased RV volume in IPAH and CTD-PAH patients. Iloprost-induced RVEF increase was proportional to PVR reduction in IPAH patients, but not in CTD-PAH or CHD-PAH patients.
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Affiliation(s)
- Jing-Hui Li
- The Key Lab of Pulmonary Vascular Medicine and FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong-Da Zhang
- The Key Lab of Pulmonary Vascular Medicine and FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhen-Zhen Wang
- Tianjin Medical University General Hospital, Tianjin, China
| | - Qing-Qing Lu
- Tianjin Medical University General Hospital, Tianjin, China
| | - Dong Li
- Tianjin Medical University General Hospital, Tianjin, China
| | - Tian-Yu Lian
- The Key Lab of Pulmonary Vascular Medicine and FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Chao Lv
- The Key Lab of Pulmonary Vascular Medicine and FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- The Key Lab of Pulmonary Vascular Medicine and FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Wu
- The Key Lab of Pulmonary Vascular Medicine and FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jue Ye
- The Key Lab of Pulmonary Vascular Medicine and FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shihua Zhao
- The Key Lab of Pulmonary Vascular Medicine and FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenwen Yang
- Tianjin Medical University General Hospital, Tianjin, China
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56
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Viswanathan G, Mamazhakypov A, Schermuly RT, Rajagopal S. The Role of G Protein-Coupled Receptors in the Right Ventricle in Pulmonary Hypertension. Front Cardiovasc Med 2018; 5:179. [PMID: 30619886 PMCID: PMC6305072 DOI: 10.3389/fcvm.2018.00179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/30/2018] [Indexed: 12/14/2022] Open
Abstract
Pressure overload of the right ventricle (RV) in pulmonary arterial hypertension (PAH) leads to RV remodeling and failure, an important determinant of outcome in patients with PAH. Several G protein-coupled receptors (GPCRs) are differentially regulated in the RV myocardium, contributing to the pathogenesis of RV adverse remodeling and dysfunction. Many pharmacological agents that target GPCRs have been demonstrated to result in beneficial effects on left ventricular (LV) failure, such as beta-adrenergic receptor and angiotensin receptor antagonists. However, the role of such drugs on RV remodeling and performance is not known at this time. Moreover, many of these same receptors are also expressed in the pulmonary vasculature, which could result in complex effects in PAH. This manuscript reviews the role of GPCRs in the RV remodeling and dysfunction and discusses activating and blocking GPCR signaling to potentially attenuate remodeling while promoting improvements of RV function in PAH.
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Affiliation(s)
- Gayathri Viswanathan
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Argen Mamazhakypov
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus Liebig University of Giessen, Giessen, Germany
| | - Ralph T Schermuly
- Department of Internal Medicine, Member of the German Center for Lung Research (DZL), Justus Liebig University of Giessen, Giessen, Germany
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, United States
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57
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Fischer L, Benjamin N, Blank N, Egenlauf B, Fischer C, Harutyunova S, Koegler M, Lorenz HM, Marra AM, Nagel C, Xanthouli P, Bossone E, Grünig E. Right heart size and function significantly correlate in patients with pulmonary arterial hypertension - a cross-sectional study. Respir Res 2018; 19:216. [PMID: 30409145 PMCID: PMC6225631 DOI: 10.1186/s12931-018-0913-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/16/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The objective of this study was to assess, whether right atrial (RA) and ventricular (RV) size is related to RV pump function at rest and during exercise in patients with pulmonary arterial hypertension (PAH). METHODS We included 54 patients with invasively diagnosed PAH that had been stable on targeted medication. All patients underwent clinical assessments including right heart catheterization and echocardiography at rest and during exercise. RV output reserve was defined as increase of cardiac index (CI) from rest to peak exercise (∆CIexercise). Patients were classified according to the median of RA and RV-area. RV pump function and further clinical parameters were compared between groups by student's t-test. Uni- and multivariate Pearson correlation analyses were performed. RESULTS Patients with larger RA and/or RV-areas (above a median of 16 and 20cm2, respectively) showed significantly lower ∆CIexercise, higher mean pulmonary arterial pressure, pulmonary vascular resistance at rest and NT-proBNP levels. Furthermore, patients with higher RV-areas presented with a significantly lower RV stroke volume and pulmonary arterial compliance at peak exercise than patients with smaller RV-size. RV area was identified as the only independent predictor of RV output reserve. CONCLUSION RV and RA areas represent valuable and easily accessible indicators of RV pump function at rest and during exercise. Cardiac output reserve should be considered as an important clinical parameter. Prospective studies are needed for further evaluation.
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Affiliation(s)
- Lukas Fischer
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Norbert Blank
- Department of Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Christine Fischer
- Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Maria Koegler
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,IRCCS SDN Research Institute, Naples, Italy
| | - Christian Nagel
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.,Lung Centre, Klinikum Mittelbaden, Baden-Baden Balg, Baden-Baden, Germany
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Eduardo Bossone
- Heart Department, Cardiology Division, "Cava de' Tirreni and Amalfi Coast" Hospital, University of Salerno, Salerno, Italy
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Röntgenstrasse 1, D-69126, Heidelberg, Germany. .,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.
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58
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Abstract
The most common cause of right heart failure is increased afterload caused by pulmonary hypertension. Right ventricular function adaptation to increased afterload is basically systolic, with secondary increase in dimensions and systemic congestion. Increased right ventricular dimensions and decreased ejection fraction are associated with a decreased survival in severe pulmonary hypertension. Targeted therapies titrated to reverse the right ventricular remodeling dimensions improve survival in severe pulmonary hypertension.
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59
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Westerhof BE, Saouti N, van der Laarse WJ, Westerhof N, Vonk Noordegraaf A. Treatment strategies for the right heart in pulmonary hypertension. Cardiovasc Res 2018; 113:1465-1473. [PMID: 28957540 PMCID: PMC5852547 DOI: 10.1093/cvr/cvx148] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 09/01/2017] [Indexed: 02/06/2023] Open
Abstract
The function of the right ventricle (RV) determines the prognosis of patients with pulmonary hypertension. While much progress has been made in the treatment of pulmonary hypertension, therapies for the RV are less well established. In this review of treatment strategies for the RV, first we focus on ways to reduce wall stress since this is the main determinant of changes to the ventricle. Secondly, we discuss treatment strategies targeting the detrimental consequences of increased RV wall stress. To reduce wall stress, afterload reduction is the essential. Additionally, preload to the ventricle can be reduced by diuretics, by atrial septostomy, and potentially by mechanical ventricular support. Secondary to ventricular wall stress, left-to-right asynchrony, altered myocardial energy metabolism, and neurohumoral activation will occur. These may be targeted by optimising RV contraction with pacing, by iron supplement, by angiogenesis and improving mitochondrial function, and by neurohumoral modulation, respectively. We conclude that several treatment strategies for the right heart are available; however, evidence is still limited and further research is needed before clinical application can be recommended.
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Affiliation(s)
- Berend E Westerhof
- Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.,Department of Medical Biology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nabil Saouti
- Department of Cardio-Thoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Willem J van der Laarse
- Department of Physiology, Institute for Cardiovascular Research, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Nico Westerhof
- Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Diseases, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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60
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Peacock AJ. Measuring the effects of treatment in patients with PAH: should we image the right ventricle? Eur Respir J 2017; 49:49/6/1700805. [PMID: 28663319 DOI: 10.1183/13993003.00805-2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 04/24/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, UK
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