151
|
Wallner M, Eaton DM, Berretta RM, Liesinger L, Schittmayer M, Gindlhuber J, Wu J, Jeong MY, Lin YH, Borghetti G, Baker ST, Zhao H, Pfleger J, Blass S, Rainer PP, von Lewinski D, Bugger H, Mohsin S, Graier WF, Zirlik A, McKinsey TA, Birner-Gruenberger R, Wolfson MR, Houser SR. HDAC inhibition improves cardiopulmonary function in a feline model of diastolic dysfunction. Sci Transl Med 2020; 12:eaay7205. [PMID: 31915304 PMCID: PMC7065257 DOI: 10.1126/scitranslmed.aay7205] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/23/2019] [Accepted: 12/03/2019] [Indexed: 12/24/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a major health problem without effective therapies. This study assessed the effects of histone deacetylase (HDAC) inhibition on cardiopulmonary structure, function, and metabolism in a large mammalian model of pressure overload recapitulating features of diastolic dysfunction common to human HFpEF. Male domestic short-hair felines (n = 31, aged 2 months) underwent a sham procedure (n = 10) or loose aortic banding (n = 21), resulting in slow-progressive pressure overload. Two months after banding, animals were treated daily with suberoylanilide hydroxamic acid (b + SAHA, 10 mg/kg, n = 8), a Food and Drug Administration-approved pan-HDAC inhibitor, or vehicle (b + veh, n = 8) for 2 months. Echocardiography at 4 months after banding revealed that b + SAHA animals had significantly reduced left ventricular hypertrophy (LVH) (P < 0.0001) and left atrium size (P < 0.0001) versus b + veh animals. Left ventricular (LV) end-diastolic pressure and mean pulmonary arterial pressure were significantly reduced in b + SAHA (P < 0.01) versus b + veh. SAHA increased myofibril relaxation ex vivo, which correlated with in vivo improvements of LV relaxation. Furthermore, SAHA treatment preserved lung structure, compliance, blood oxygenation, and reduced perivascular fluid cuffs around extra-alveolar vessels, suggesting attenuated alveolar capillary stress failure. Acetylation proteomics revealed that SAHA altered lysine acetylation of mitochondrial metabolic enzymes. These results suggest that acetylation defects in hypertrophic stress can be reversed by HDAC inhibitors, with implications for improving cardiac structure and function in patients.
Collapse
Affiliation(s)
- Markus Wallner
- Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
- Division of Cardiology, Medical University of Graz, Graz 8036, Austria
- Center for Biomarker Research in Medicine, CBmed GmbH, Graz 8010, Austria
| | - Deborah M Eaton
- Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Remus M Berretta
- Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Laura Liesinger
- Molecular Biology and Biochemistry, Gottfried Schatz Research Center, Medical University of Graz, Graz 8036, Austria
- Institute of Pathology, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz 8036, Austria
- Omics Center Graz, BioTechMed-Graz, Graz 8010, Austria
| | - Matthias Schittmayer
- Molecular Biology and Biochemistry, Gottfried Schatz Research Center, Medical University of Graz, Graz 8036, Austria
- Institute of Pathology, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz 8036, Austria
- Omics Center Graz, BioTechMed-Graz, Graz 8010, Austria
| | - Juergen Gindlhuber
- Molecular Biology and Biochemistry, Gottfried Schatz Research Center, Medical University of Graz, Graz 8036, Austria
- Institute of Pathology, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz 8036, Austria
- Omics Center Graz, BioTechMed-Graz, Graz 8010, Austria
| | - Jichuan Wu
- CENTRe: Consortium for Environmental and Neonatal Therapeutics Research, Lewis Katz School of Medicine, Department of Physiology, Department of Thoracic Medicine and Surgery, Pediatrics, Center for Inflammation, Translational and Clinical Lung Research, Temple University, Philadelphia, PA 19140, USA
| | - Mark Y Jeong
- Department of Medicine, Division of Cardiology and Consortium for Fibrosis Research and Translation, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Ying H Lin
- Department of Medicine, Division of Cardiology and Consortium for Fibrosis Research and Translation, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Giulia Borghetti
- Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Sandy T Baker
- CENTRe: Consortium for Environmental and Neonatal Therapeutics Research, Lewis Katz School of Medicine, Department of Physiology, Department of Thoracic Medicine and Surgery, Pediatrics, Center for Inflammation, Translational and Clinical Lung Research, Temple University, Philadelphia, PA 19140, USA
| | - Huaqing Zhao
- Department of Clinical Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Jessica Pfleger
- Center for Translational Medicine, Department of Pharmacology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Sandra Blass
- Molecular Biology and Biochemistry, Gottfried Schatz Research Center, Medical University of Graz, Graz 8036, Austria
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz 8036, Austria
| | - Dirk von Lewinski
- Division of Cardiology, Medical University of Graz, Graz 8036, Austria
| | - Heiko Bugger
- Division of Cardiology, Medical University of Graz, Graz 8036, Austria
| | - Sadia Mohsin
- Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Wolfgang F Graier
- Molecular Biology and Biochemistry, Gottfried Schatz Research Center, Medical University of Graz, Graz 8036, Austria
| | - Andreas Zirlik
- Division of Cardiology, Medical University of Graz, Graz 8036, Austria
| | - Timothy A McKinsey
- Department of Medicine, Division of Cardiology and Consortium for Fibrosis Research and Translation, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Ruth Birner-Gruenberger
- Molecular Biology and Biochemistry, Gottfried Schatz Research Center, Medical University of Graz, Graz 8036, Austria
- Institute of Pathology, Diagnostic and Research Center for Molecular Biomedicine, Medical University of Graz, Graz 8036, Austria
- Omics Center Graz, BioTechMed-Graz, Graz 8010, Austria
- Institute of Chemical Technology and Analytical Chemistry, Vienna University of Technology, Vienna 1060, Austria
| | - Marla R Wolfson
- CENTRe: Consortium for Environmental and Neonatal Therapeutics Research, Lewis Katz School of Medicine, Department of Physiology, Department of Thoracic Medicine and Surgery, Pediatrics, Center for Inflammation, Translational and Clinical Lung Research, Temple University, Philadelphia, PA 19140, USA
| | - Steven R Houser
- Cardiovascular Research Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA.
| |
Collapse
|
152
|
|
153
|
Moreira HT, Vasconcellos HD, Ambale-Venkatesh B, Brittain EL, Nwabuo CC, Schmidt A, Lloyd-Jones DM, Carr JJ, Lewis CE, Jacobs DR, Gidding SS, Lima JAC. Pulmonary Artery Acceleration Time in Young Adulthood and Cardiovascular Outcomes Later in Life: The Coronary Artery Risk Development in Young Adults Study. J Am Soc Echocardiogr 2020; 33:82-89.e1. [PMID: 31648849 DOI: 10.1016/j.echo.2019.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/14/2019] [Accepted: 07/16/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Lower pulmonary artery acceleration time (PAcT) is correlated with higher pulmonary artery pressure. The aim of this study was to test the hypothesis that PAcT measured in young adulthood would be associated with future cardiovascular outcomes. METHODS In the Coronary Artery Risk Development in Young Adults year 5 examination (1990-1991), PAcT was measured as the time interval from onset to peak flow velocity at the pulmonary valve annulus on Doppler echocardiography. The primary outcome was a composite of fatal or nonfatal cardiovascular disease events: myocardial infarction, non-myocardial infarction acute coronary syndrome, coronary revascularization, congestive heart failure, stroke, transient ischemic attack, carotid artery disease, and peripheral arterial disease. RESULTS PAcT was obtained in 4,171 participants (mean age, 30 ± 4 years, 55% women, 51% white). PAcT groups obtained using linear spline methodology were as follows: group I, PAcT ≥ 196 msec (n = 122); group II, PAcT < 196 and ≥115 msec (n = 3,195); and group III, PAcT < 115 msec (n = 854). During follow-up (median, 24.9 years), the primary outcome occurred in 216 participants (5.2%); 66 of 854 (7.7%) of those with PAcT < 115 msec, 149 of 3,195 (4.7%) of those with intermediate PAcT level, and one of 122 (0.8%) of those with PAcT ≥ 196 msec. In a fully adjusted model, the lowest and intermediate PAcT groups had hazard ratios of 8.3 (95% CI, 1.1-62.1; P = .04) and 6.8 (95% CI, 0.9-50.5; P = .06), respectively, in comparison with the highest PAcT group. CONCLUSIONS PAcT is useful for better identifying young adults at higher risk for cardiovascular events, who may benefit from a strict control of modifiable cardiovascular risk factors.
Collapse
Affiliation(s)
- Henrique T Moreira
- Johns Hopkins University, Baltimore, Maryland; University of São Paulo, Ribeirão Preto, Brazil
| | | | | | | | | | | | | | - John J Carr
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cora E Lewis
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | |
Collapse
|
154
|
Right ventricular involvement is an important prognostic factor and risk stratification tool in suspected cardiac sarcoidosis: analysis by cardiac magnetic resonance imaging. Clin Res Cardiol 2019; 109:988-998. [PMID: 31872264 DOI: 10.1007/s00392-019-01591-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Late gadolinium enhancement imaging (LGE) of the left ventricle (LV) by cardiac magnetic resonance (CMR) has prognostic value for patients with cardiac sarcoidosis (CS). Right ventricle (RV) dysfunction is also associated with adverse outcomes in patients with heart failure. Therefore, we sought to determine if RV LGE and dysfunction predicted adverse events in patients with suspected CS. METHODS In 103 consecutive patients with suspected CS who underwent CMR, functional and remodeling indexes of both the LV and RV were measured and the extent and localization of LGE were also analyzed. Major adverse cardiac events (MACE) were defined as cardiovascular mortality, severe ventricular tachyarrhythmia, hospitalization with heart failure, and advanced atrioventricular block. RESULTS During a median follow-up of 20.6 months, Kaplan-Meier analysis showed that decreased RV ejection fraction (EF) was associated with MACE (P < 0.001) and receiver operating characteristics curve (ROC) analysis indicated good predictive performance of RV EF for MACE (area under the ROC = 0.834). RV EF operated independently of LV EF or LGE extent for predicting MACE. In addition, the presence of LGE in RV was independently associated with MACE (P = 0.011), and a combined analysis of RV EF and RV LGE showed better risk stratification for MACE (P < 0.001). CONCLUSIONS Both RV EF and LGE were independently associated with MACE and enhanced risk stratification in patients with suspected CS. CMR may be a useful tool for detecting myocardial function and fibrosis in both the LV and RV.
Collapse
|
155
|
Arwood MJ, Vahabi N, Lteif C, Sharma RK, Machado RF, Duarte JD. Transcriptome-wide analysis associates ID2 expression with combined pre- and post-capillary pulmonary hypertension. Sci Rep 2019; 9:19572. [PMID: 31862991 PMCID: PMC6925238 DOI: 10.1038/s41598-019-55700-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/25/2019] [Indexed: 01/11/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) patients who develop pulmonary hypertension (PH) have an increased risk of death, with combined pre- and post-capillary PH (CpcPH) having the highest risk. However, the mechanism behind PH development in HFpEF is poorly understood. We aimed to identify transcriptomic associations with PH development in HFpEF. Blood was collected from 30 HFpEF patients: 10 without PH, 10 with isolated post-capillary PH, and 10 with CpcPH. Gene expression measurements were completed using transcriptome-wide RNA sequencing. Gene expression differences were compared using a quasi-likelihood method adjusting for age, sex, race, and smoking-status. Biological pathways were compared using global gene expression differences. A replication in 34 additional heart failure patients and a validation in lung tissue from a representative mouse model were completed using quantitative PCR. Six differentially expressed genes were identified when comparing transcriptomics between subjects with CpcPH and those without PH. When tested in additional subjects, only the association with ID2 replicated. Consistent with clinical findings, Id2 expression was also upregulated in mice with HFpEF and PH. Pathway analysis identified proliferative and mitochondrial pathways associated with CpcPH. Thus, these patients may possess systemic pathophysiological differences similar to those observed in pulmonary arterial hypertension patients.
Collapse
Affiliation(s)
- Meghan J Arwood
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Nasim Vahabi
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Christelle Lteif
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Ravindra K Sharma
- Department of Physiology and Functional Genomics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Roberto F Machado
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University, Indianapolis, IN, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.
| |
Collapse
|
156
|
Hung G, Mercurio V, Hsu S, Mathai SC, Shah AA, Mukherjee M. Progress in Understanding, Diagnosing, and Managing Cardiac Complications of Systemic Sclerosis. Curr Rheumatol Rep 2019; 21:68. [PMID: 31813082 PMCID: PMC11151284 DOI: 10.1007/s11926-019-0867-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF THE REVIEW Systemic sclerosis (scleroderma) is a complex autoimmune disease that commonly involves the cardiovascular system. Even if often subclinical, cardiac involvement is considered a poor prognostic factor as it is a leading cause of death in scleroderma patients. We review the cardiac manifestations of scleroderma, the diagnostic methods useful in detection, and current advances in therapeutic management. RECENT FINDINGS Beside the routine exams for the assessment of cardiac status (including EKG, standard echocardiography, provocative tests) novel techniques such as myocardial strain imaging on echocardiography, cardiac magnetic resonance imaging, invasive hemodynamic assessment, and endomyocardial biopsy have been demonstrated to be useful in understanding the cardiac alterations that typically affect scleroderma patients. Recent application of novel cardiac detection strategies is providing increased insight into the breadth and pathogenesis of cardiac complications of scleroderma. Further studies coupling exercise provocation, invasive and imaging assessment, and mechanistic studies in scleroderma cardiac tissue are needed to develop the optimal approach to early detection of cardiac disease in scleroderma and targeted therapies.
Collapse
Affiliation(s)
- George Hung
- Division of Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ami A Shah
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 4100, Baltimore, MD, 21224, USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA.
| |
Collapse
|
157
|
Colin GC, Pouleur AC, Gerber BL, Poncelet PA, de Meester C, D’Hondt AM, Vlassenbroek A, Houard L, Gevenois PA, Ghaye B. Pulmonary hypertension detection by computed tomography pulmonary transit time in heart failure with reduced ejection fraction. Eur Heart J Cardiovasc Imaging 2019; 21:1291-1298. [DOI: 10.1093/ehjci/jez290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 07/25/2019] [Accepted: 11/11/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
To evaluate the relationships between pulmonary transit time (PTT), cardiac function, and pulmonary haemodynamics in patients with heart failure with reduced ejection fraction (HFrEF) and to explore how PTT performs in detecting pulmonary hypertension (PH).
Methods and results
In this prospective study, 57 patients with advanced HFrEF [49 men, 51 years ± 8, mean left ventricular (LV) ejection fraction 26% ± 8] underwent echocardiography, right heart catheterization, and cardiac computed tomography (CT). PTT was measured as the time interval between peaks of attenuation in right ventricle (RV) and LV and was compared between patients with or without PH and 15 controls. PTT was significantly longer in HFrEF patients with PH (21 s) than in those without PH (11 s) and controls (8 s) (P < 0.001) but not between patients without PH and controls (P = 0.109). PTT was positively correlated with pulmonary artery wedge pressure (PAWP) (r = 0.74), mean pulmonary artery pressure (r = 0.68), N-terminal pro-B-type natriuretic peptide (r = 0.60), mitral (r = 0.54), and tricuspid (r = 0.37) regurgitation grades, as well as with LV, RV, and left atrial volumes (r from 0.39 to 0.64) (P < 0.01). PTT was negatively correlated with cardiac index (r = −0.63) as well as with LV (r = −0.66) and RV (r = −0.74) ejection fractions. PAWP, cardiac index, mitral regurgitation grade, and RV end-diastolic volume were all independent predictors of PTT. PTT value ≥14 s best-detected PH with 91% sensitivity and 88% specificity (area under the receiver operating characteristic curve: 0.95).
Conclusion
In patients with HFrEF, PTT correlates with cardiac function and pulmonary haemodynamics, is determined by four independent parameters, and performs well in detecting PH.
Collapse
Affiliation(s)
- Geoffrey C Colin
- Division of Radiology, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Anne-Catherine Pouleur
- Division of Cardiology, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Bernhard L Gerber
- Division of Cardiology, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Pierre-Antoine Poncelet
- Division of Radiology, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Christophe de Meester
- Division of Cardiology, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Anne-Marie D’Hondt
- Division of Cardiology, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | | | - Laura Houard
- Division of Cardiology, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | | | - Benoit Ghaye
- Division of Radiology, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
| |
Collapse
|
158
|
Reddy YNV, Obokata M, Koepp KE, Egbe AC, Wiley B, Borlaug BA. The β-Adrenergic Agonist Albuterol Improves Pulmonary Vascular Reserve in Heart Failure With Preserved Ejection Fraction. Circ Res 2019; 124:306-314. [PMID: 30582447 DOI: 10.1161/circresaha.118.313832] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
RATIONALE Pulmonary vascular resistance fails to decrease appropriately during exercise in patients with heart failure with preserved ejection fraction (HFpEF). Interventions that enhance pulmonary vasodilation might be beneficial in this cohort but could also worsen left atrial hypertension, exacerbating lung congestion. Intravenous β-agonists reduce pulmonary vascular resistance but are not suitable for chronic use. OBJECTIVE We hypothesized that the inhaled β-adrenergic agonist albuterol would improve pulmonary vasodilation during exercise in patients with HFpEF, without increasing left heart filling pressures. METHODS AND RESULTS We performed a randomized, double-blind, placebo-controlled trial testing the effects of inhaled albuterol on resting and exercise hemodynamics in subjects with HFpEF using high-fidelity micromanometer catheters and expired gas analysis. The primary end point was pulmonary vascular resistance during exercise. Subjects with HFpEF (n=30) underwent resting and exercise hemodynamic assessment and were then randomized 1:1 to inhaled, nebulized albuterol or placebo. Rest and exercise hemodynamic testing was then repeated. Albuterol improved the primary end point of exercise pulmonary vascular resistance as compared with placebo (-0.6±0.5 versus +0.1±0.7 WU; P=0.003). Albuterol enhanced cardiac output reserve and right ventricular pulmonary artery coupling, reduced right atrial and pulmonary artery pressures, improved pulmonary artery compliance, and enhanced left ventricular transmural distending pressure (all P <0.01), with no increase in pulmonary capillary hydrostatic pressures. CONCLUSIONS Albuterol improves pulmonary vascular reserve in patients with HFpEF without worsening left heart congestion. Further study is warranted to evaluate the chronic efficacy of β-agonists in HFpEF and other forms of pulmonary hypertension. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov . Unique identifier: NCT02885636.
Collapse
Affiliation(s)
- Yogesh N V Reddy
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Masaru Obokata
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Katlyn E Koepp
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Alexander C Egbe
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Brandon Wiley
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Barry A Borlaug
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
159
|
Edmonston DL, Parikh KS, Rajagopal S, Shaw LK, Abraham D, Grabner A, Sparks MA, Wolf M. Pulmonary Hypertension Subtypes and Mortality in CKD. Am J Kidney Dis 2019; 75:713-724. [PMID: 31732231 DOI: 10.1053/j.ajkd.2019.08.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 08/30/2019] [Indexed: 12/18/2022]
Abstract
RATIONALE & OBJECTIVE Pulmonary hypertension (PH) contributes to cardiovascular disease and mortality in patients with chronic kidney disease (CKD), but the pathophysiology is mostly unknown. This study sought to estimate the prevalence and consequences of PH subtypes in the setting of CKD. STUDY DESIGN Observational retrospective cohort study. SETTING & PARTICIPANTS We examined 12,618 patients with a right heart catheterization in the Duke Databank for Cardiovascular Disease from January 1, 2000, to December 31, 2014. EXPOSURES Baseline kidney function stratified by CKD glomerular filtration rate category and PH subtype. OUTCOMES All-cause mortality. ANALYTICAL APPROACH Multivariable Cox proportional hazards analysis. RESULTS In this cohort, 73.4% of patients with CKD had PH, compared with 56.9% of patients without CKD. Isolated postcapillary PH (39.0%) and combined pre- and postcapillary PH (38.3%) were the most common PH subtypes in CKD. Conversely, precapillary PH was the most common subtype in the non-CKD cohort (35.9%). The relationships between mean pulmonary artery pressure, pulmonary capillary wedge pressure, and right atrial pressure with mortality were similar in both the CKD and non-CKD cohorts. Compared with those without PH, precapillary PH conferred the highest mortality risk among patients without CKD (HR, 2.27; 95% CI, 2.00-2.57). By contrast, in those with CKD, combined pre- and postcapillary PH was associated with the highest risk for mortality in CKD in adjusted analyses (compared with no PH, HRs of 1.89 [95% CI, 1.57-2.28], 1.87 [95% CI, 1.52-2.31], 2.13 [95% CI, 1.52-2.97], and 1.63 [95% CI, 1.12-2.36] for glomerular filtration rate categories G3a, G3b, G4, and G5/G5D). LIMITATIONS The cohort referred for right heart catheterization may not be generalizable to the general population. Serum creatinine data in the 6 months preceding catheterization may not reflect true baseline CKD. Observational design precludes assumptions of causality. CONCLUSIONS In patients with CKD referred for right heart catheterization, PH is common and associated with poor survival. Combined pre- and postcapillary PH was common and portended the worst survival for patients with CKD.
Collapse
Affiliation(s)
- Daniel L Edmonston
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Kishan S Parikh
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Department of Biochemistry, Duke University Medical Center, Durham, NC
| | - Linda K Shaw
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Dennis Abraham
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Alexander Grabner
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Matthew A Sparks
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Renal Section, Durham VA Medical Center, Durham, NC
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| |
Collapse
|
160
|
Rosenkranz S, Kramer T, Gerhardt F, Opitz C, Olsson KM, Hoeper MM. Pulmonary hypertension in HFpEF and HFrEF: Pathophysiology, diagnosis, treatment approaches. Herz 2019; 44:483-490. [PMID: 31317203 DOI: 10.1007/s00059-019-4831-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pulmonary hypertension (PH) is a frequent hemodynamic condition that is highly prevalent in patients with heart failure and reduced (HFrEF) or preserved ejection fraction (HFpEF). Irrespective of left ventricular EF, the presence of PH and right ventricular (RV) dysfunction are highly relevant for morbidity and mortality in patients with heart failure. While elevated left-sided filling pressures and functional mitral regurgitation primarily lead to post-capillary PH, current guidelines and recommendations distinguish between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH), the latter being defined by a pulmonary vascular resistance (PVR) of ≥3 Wood units. Here, we describe the pathophysiology and clinical relevance of these distinct entities, and report on the diagnostic work-up including remote pulmonary artery pressure (PAP) monitoring. Furthermore, we highlight strategies to manage PH and improve RV function in heart failure, which may include optimized management of HFrEF and HFpEF (medical and interventional), sufficient volume control, catheter-based mitral valve repair, and-in selected cases-targeted PH therapy. In this context, we also highlight gaps in evidence and the need for further research.
Collapse
Affiliation(s)
- S Rosenkranz
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany.
| | - T Kramer
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - F Gerhardt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - C Opitz
- Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK-Kliniken Berlin, Berlin, Germany
| | - K M Olsson
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - M M Hoeper
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| |
Collapse
|
161
|
Tichelbäcker T, Dumitrescu D, Gerhardt F, Stern D, Wissmüller M, Adam M, Schmidt T, Frerker C, Pfister R, Halbach M, Baldus S, Rosenkranz S. Pulmonary hypertension and valvular heart disease. Herz 2019; 44:491-501. [PMID: 31312873 DOI: 10.1007/s00059-019-4823-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients with left-sided heart disease, including valvular heart disease. In this context, elevated left atrial pressure primarily leads to the development of post-capillary PH. Despite the fact that repair of left-sided valvular heart disease by surgical or interventional approaches will improve PH, recent studies have highlighted that PH (pre- or post-interventional) remains an important predictor of long-term outcome. Here, we review the current knowledge on PH in valvular heart disease taking into account new hemodynamic PH definitions, and the distinction between post- and pre-capillary components of PH. A specific focus is on the precise characterization of hemodynamics and cardiopulmonary interaction, and on potential strategies for the management of residual PH after mitral or aortic valve interventions. In addition, we highlight the clinical significance of tricuspid regurgitation, which may occur as a primary condition or as a consequence of PH and right heart dilatation (functional). In this context, proper patient selection for potential tricuspid valve interventions is crucial. Finally, the article highlights gaps in evidence, and points toward future perspectives.
Collapse
Affiliation(s)
- T Tichelbäcker
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - D Dumitrescu
- Klinik für Allgemeine und Interventionelle Kardiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
| | - F Gerhardt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - D Stern
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Wissmüller
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Adam
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - T Schmidt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - C Frerker
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - R Pfister
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Halbach
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Baldus
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Rosenkranz
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany.
| |
Collapse
|
162
|
Merino-Casallo I, Friaza V, Menao S, Domingo JM, Olivera S, Calderón EJ, Torralba MÁ. Pneumocystis jirovecii in Spanish Patients With Heart Failure. Front Public Health 2019; 7:289. [PMID: 31649914 PMCID: PMC6794361 DOI: 10.3389/fpubh.2019.00289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 09/25/2019] [Indexed: 01/03/2023] Open
Abstract
Objective:Pneumocystis colonization is frequent in patients with chronic obstructive pulmonary disease (COPD) producing local and systemic inflammation. Heart failure is also a common comorbidity among patients with COPD. Heart failure is a chronic, frequent, and disabling condition with high morbidity and mortality, but with a modifiable course where endothelial dysfunction and pulmonary arterial hypertension have great importance. Animal models have shown that Pneumocystis infection can cause relevant functionally changes in vascular responses in the lung, promoting the development of pulmonary hypertension. Pneumocystis colonization could be a hidden cause of worsening heart failure through it capacity to induce inflammatory response with subsequent endothelial dysfunction and pulmonary hypertension. The aim of the present study was to investigate the prevalence of Pneumocystis jirovecii colonization in heart failure patients and its possible association with reduced or preserved ejection fraction. Methods: A cross-sectional study was carried out including 36 heart failure patients and 36 control cases. Identification of P. jirovecii colonization was performed by means of molecular techniques in oropharyngeal washing. Results:Pneumocystis-DNA was identified in oropharyngeal washing in 1 (2.7%) of 36 heart failure patients and in 3 (8.3%) of 36 controls. Conclusions:Pneumocystis colonization does not seem to have a role in the pathophysiology of heart failure.
Collapse
Affiliation(s)
- Izarbe Merino-Casallo
- Department of Internal Medicine, "Lozano Blesa" University Hospital, Zaragoza, Spain.,Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
| | - Vicente Friaza
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Consejo Superior de Investigaciones Científicas, Seville, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Sebastián Menao
- Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain.,Department of Biochemistry, "Lozano Blesa" University Hospital, Zaragoza, Spain
| | - José María Domingo
- Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain.,Bank of Blood and Tissues of Aragón, Zaragoza, Spain
| | - Susana Olivera
- Department of Internal Medicine, "Lozano Blesa" University Hospital, Zaragoza, Spain.,Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
| | - Enrique J Calderón
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Consejo Superior de Investigaciones Científicas, Seville, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Miguel Ángel Torralba
- Department of Internal Medicine, "Lozano Blesa" University Hospital, Zaragoza, Spain.,Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain
| |
Collapse
|
163
|
Tello K, Ghofrani HA, Heinze C, Krueger K, Naeije R, Raubach C, Seeger W, Sommer N, Gall H, Richter MJ. A simple echocardiographic estimate of right ventricular-arterial coupling to assess severity and outcome in pulmonary hypertension on chronic lung disease. Eur Respir J 2019; 54:13993003.02435-2018. [PMID: 31073085 DOI: 10.1183/13993003.02435-2018] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/24/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Khodr Tello
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein A Ghofrani
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.,Dept of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - Charlotte Heinze
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Karsten Krueger
- Institute of Sports Science, Department of Exercise and Health, Leibniz University Hannover, Hannover, Germany
| | | | - Christina Raubach
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Natascha Sommer
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany.,These authors have contributed equally to this work
| | - Manuel J Richter
- Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany .,These authors have contributed equally to this work
| |
Collapse
|
164
|
Kido K, Coons JC. Efficacy and Safety of the Use of Pulmonary Arterial Hypertension Pharmacotherapy in Patients with Pulmonary Hypertension Secondary to Left Heart Disease: A Systematic Review. Pharmacotherapy 2019; 39:929-945. [PMID: 31349390 DOI: 10.1002/phar.2314] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Kazuhiko Kido
- Department of Clinical Pharmacy West Virginia University School of Pharmacy Morgantown West Virginia
| | - James C. Coons
- Department of Pharmacy and Therapeutics School of Pharmacy University of PittsburghClinical Pharmacist, CardiologyUPMC Presbyterian Hospital Pittsburgh Pennsylvania
| |
Collapse
|
165
|
[Acute right heart failure on the intensive care unit : Pathophysiology, monitoring and management]. Med Klin Intensivmed Notfmed 2019; 114:567-588. [PMID: 31456009 DOI: 10.1007/s00063-019-0603-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022]
Abstract
Right ventricular heart failure is a frequent and serious but often undetected and complex clinical challenge on the intensive care unit. The commonest causes include acute decompensation of pulmonary hypertension, pulmonary embolism, sepsis, acute respiratory distress, and cardiothoracic surgery. The gold standard of bedside diagnosis is a combination of clinical symptoms, biochemical markers (NT-proBNP) and echocardiography. For the purposes of hemodynamic monitoring and treatment management, the indication to place a pulmonary artery catheter should be made generously. The major components of management include treating the underlying disease and triggering factors, reducing pulmonary vascular resistance, increasing contractility, volume optimization, and maintenance of adequate perfusion. Mechanical circulatory support should be considered before irreversible end-organ failure develops.
Collapse
|
166
|
Santas E, Palau P, Guazzi M, de la Espriella R, Miñana G, Sanchis J, Bayes-Genís A, Lupón J, Chorro FJ, Núñez J. Usefulness of Right Ventricular to Pulmonary Circulation Coupling as an Indicator of Risk for Recurrent Admissions in Heart Failure With Preserved Ejection Fraction. Am J Cardiol 2019; 124:567-572. [PMID: 31204033 DOI: 10.1016/j.amjcard.2019.05.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/03/2019] [Accepted: 05/13/2019] [Indexed: 12/20/2022]
Abstract
In recent years, the study of right ventricular (RV) to pulmonary circulation (PC) coupling in heart failure with preserved ejection fraction (HFpEF) has been a matter of special interest. Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio has emerged as a reliable noninvasive index of RV to PC coupling. Thus, we hypothesized that TAPSE/PASP would be a predictor of readmission burden in HFpEF. One thousand one hundred and twenty seven consecutive HFpEF patients discharged for acute HF were included. In 367 patients (32.6%), PASP could not be accurately measured by echocardiography, leaving the final sample size to be 760 patients. Negative binomial regression method was used to evaluate the association between TAPSE/PASP ratio and recurrent admissions. Mean age of the cohort was 75.6 ± 9.7 years and 68.3% were women. At a median (interquartile range) follow-up of 2.0 (2.9) years, 352 (46.3%) patients died and 1,214 readmissions were registered in 482 patients (63.4%), being 506 of them HF-related. There was a stepwise increase in the rates of all-cause and HF readmissions by decreasing TAPSE/PASP ratio. After multivariable adjustment, TAPSE/PASP <0.36 was associated with a higher risk of HF-related recurrent admissions (incidence rate ratio [IRR] 1.51, 95% confidence interval [CI], 1.01 to 2.24; p = 0.040), whereas patients in the lowest quintile (TAPSE/PASP <0.28) exhibited the highest risk of both all-cause and HF-related recurrent admissions (IRR 1.40, 95% CI 1.04 to 1.87, p = 0.025; and IRR 1.85, 95% CI 1.22 to 2.80, p = 0.004, respectively). In conclusion, TAPSE/PASP ratio, as a noninvasive index of RV-PC coupling, emerges as a strong predictor of recurrent hospitalizations in HFpEF.
Collapse
|
167
|
|
168
|
Nasr VG, Callahan R, Wichner Z, Odegard KC, DiNardo JA. Intraluminal Pulmonary Vein Stenosis in Children. Anesth Analg 2019; 129:27-40. [DOI: 10.1213/ane.0000000000003924] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
169
|
Mene-Afejuku TO, Akinlonu A, Dumancas C, Lopez PD, Cardenas R, Sueldo C, Veranyan S, Salazar P, Visco F, Pekler G, Mushiyev S. Relationship between pulmonary hypertension and outcomes among patients with heart failure with reduced ejection fraction. Hosp Pract (1995) 2019; 47:130-135. [PMID: 31177873 DOI: 10.1080/21548331.2019.1628615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: To identify predictors of pulmonary hypertension (PHT) and the predictive value of PHT for rehospitalization among patients with heart failure with reduced ejection fraction (HFrEF). Methods: A retrospective study of 351 hospitalized patients with heart failure (HF). Patients 18 years and above with HFrEF secondary to non-ischemic cardiomyopathy were reviewed. Patients with coronary artery disease, preserved ejection fraction and other secondary causes of PHT apart from HF were excluded. PHT as a predictor of 30-day and six-month re-admission was assessed as well as important possible predictors of PHT. Cox regression analysis, multiple linear regression as well as other statistical tools were employed as deemed appropriate. Results: Thirty-seven (37) and 99 patients were re-hospitalized within 30 days and 6 months after discharge for decompensated HF, respectively. After Cox regression analysis, higher hemoglobin reduced the odds of rehospitalization for decompensated HF (p = 0.015) within 30 days after discharge while higher pulmonary artery systolic pressure (PASP) (p = 0.002) and blood urea nitrogen (BUN) (p = 0.041) increased the odds of rehospitalization within 6 months of discharge. The predictors of the PHT among patients with HFrEF after multiple linear regression were low BMI (p = 0.027), increasing age (p = 0.006) and increased left atrial diameter (LAD) on echocardiography (p = 0.0001). Conclusion: Patients with HFrEF have a high predisposition to developing PHT if at admission, they have low BMI, dilated left atrium or are older. Patients with one or more of these attributes may need more intensive therapy to reduce the risk of developing PHT and in turn reduce readmission rates.
Collapse
Affiliation(s)
- Tuoyo O Mene-Afejuku
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Adedoyin Akinlonu
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Carissa Dumancas
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Persio D Lopez
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Ramiro Cardenas
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Carla Sueldo
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Shushan Veranyan
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Peggy Salazar
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Ferdinand Visco
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA.,Division of Cardiology, `New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Gerald Pekler
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA.,Division of Cardiology, `New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| | - Savi Mushiyev
- Department of Medicine, New York Medical College, Metropolitan Hospital Center , New York , NY , USA.,Division of Cardiology, `New York Medical College, Metropolitan Hospital Center , New York , NY , USA
| |
Collapse
|
170
|
Singh I, Oliveira RKF, Naeije R, Rahaghi FN, Oldham WM, Systrom DM, Waxman AB. Pulmonary Vascular Distensibility and Early Pulmonary Vascular Remodeling in Pulmonary Hypertension. Chest 2019; 156:724-732. [PMID: 31121149 DOI: 10.1016/j.chest.2019.04.111] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/25/2019] [Accepted: 04/22/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Exercise stress testing of the pulmonary circulation may uncover decreased pulmonary vascular (PV) distensibility as a cause of impaired aerobic exercise capacity and right ventricular (RV)-pulmonary arterial (PA) uncoupling. As such, it may help in the differential diagnosis of unexplained dyspnea, including pulmonary hypertension (PH) and/or heart failure with preserved ejection fraction (HFpEF). We investigated rest and exercise invasive pulmonary hemodynamics, ventilation, and gas exchange in patients with unexplained dyspnea, including 44 patients with HFpEF (of whom 20 had a normal pulmonary vascular resistance [PVR] during exercise [ie, passive HFpEF] and 24 had a higher than normal exercise PVR), 22 patients with exercise PH, 19 patients with pulmonary arterial hypertension (PAH), and 24 age- and sex-matched normal control subjects. METHODS A PV distensibility coefficient α (%/mm Hg) was determined from multipoint PV pressure-flow plots. RV-PA coupling was quantified from the analysis of RV pressure curves to determine ratios of end-systolic to arterial elastances (Ees/Ea). Aerobic exercise capacity was estimated by peak oxygen consumption. RESULTS The α coefficient decreased from 1.35 ± 0.58%/mm Hg in control subjects and 1.1 ± 0.48%/mm Hg in patients with passive HFpEF to 0.62 ± 0.32%/mm Hg in exercise PH, 0.54 ± 0.27%/mm Hg in HFpEF with high exercise PVR, and 0.18 ± 0.16%/mm Hg in PAH. On multivariate analysis, PV distensibility was associated with decreased Ees/Ea and maximal volume of oxygen consumed. CONCLUSIONS PV distensibility is an early and sensitive hemodynamic marker of PV disease that is associated with RV-PA uncoupling and decreased aerobic exercise capacity.
Collapse
Affiliation(s)
- Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
| | - Rudolf K F Oliveira
- Division of Respiratory Medicine, Federal University of São Paulo - UNIFESP, São Paulo, Brazil
| | - Robert Naeije
- Department of Pathophysiology, Faculty of Medicine, Erasme Campus, Université Libre de Bruxelles, Brussels, Belgium
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - William M Oldham
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - David M Systrom
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| |
Collapse
|
171
|
Singh I, Rahaghi FN, Naeije R, Oliveira RKF, Systrom DM, Waxman AB. Right Ventricular-Arterial Uncoupling During Exercise in Heart Failure With Preserved Ejection Fraction: Role of Pulmonary Vascular Dysfunction. Chest 2019; 156:933-943. [PMID: 31103695 DOI: 10.1016/j.chest.2019.04.109] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/08/2019] [Accepted: 04/29/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is associated with shortened life expectancy in heart failure with preserved ejection fraction (HFpEF). The contribution of pulmonary vascular dysfunction to RV dysfunction in HFpEF is not well understood. METHODS We investigated rest and exercise invasive pulmonary hemodynamics, ventilation, and gas exchange in 67 patients with HFpEF (of whom 28 had an abnormal pulmonary vascular response during exercise referred to as HFpEF+PVR group and 39 had a normal pulmonary vascular response during exercise referred to as HFpEF group) and in 21 matched control subjects. RESULTS Both groups of patients with HFpEF had a markedly decreased peak oxygen consumption (Vo2), decreased oxygen delivery, and impaired chronotropic response. Single beat analysis of RV pressure waveforms was used to compute the end-systolic elastance (Ees) and pulmonary arterial elastance (Ea). Right ventricular-pulmonary artery (RV-PA) coupling was measured as the ratio of Ees/Ea. Exercise was associated with a preserved Ees response but a decreased Ees/Ea in patients with HFpEF with a normal PVR response, indicating partially preserved RV contractile reserve. In HFpEF+PVR, exercise-induced increase in Ees was markedly reduced, resulting in decreased Ees/Ea and RV-PA uncoupling. Patients with HFpEF+PVR with an exercise-induced decrease in Ees/Ea had lower pulmonary artery compliance, lower peak Vo2, and lower stroke volume than patients with HFpEF. CONCLUSIONS We conclude that RV-PA uncoupling is common in HFpEF and is caused by both intrinsic RV contractile impairment and afterload mismatch. Resting and dynamic RV-PA uncoupling in HFpEF is driven by an increase in RV pulsatile rather than resistive afterload. However, with the additive effects of increased RV resistive afterload, RV-PA uncoupling worsens dynamically during exercise.
Collapse
Affiliation(s)
- Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Robert Naeije
- Department of Pathophysiology, Erasmsus Campus, Brussels, Belgium
| | - Rudolf K F Oliveira
- Division of Respiratory Medicine, Federal University of São Paulo - UNIFESP, São Paulo, Brazil
| | - David M Systrom
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| |
Collapse
|
172
|
Guazzi M. Use of TAPSE/PASP ratio in pulmonary arterial hypertension: An easy shortcut in a congested road. Int J Cardiol 2019; 266:242-244. [PMID: 29887455 DOI: 10.1016/j.ijcard.2018.04.053] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/12/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Marco Guazzi
- Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, 20097 Milan, Italy; Department of Cardiology University, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy.
| |
Collapse
|
173
|
Function of Adipose-Derived Mesenchymal Stem Cells in Monocrotaline-Induced Pulmonary Arterial Hypertension through miR-191 via Regulation of BMPR2. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2858750. [PMID: 31119161 PMCID: PMC6500697 DOI: 10.1155/2019/2858750] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/25/2019] [Accepted: 03/12/2019] [Indexed: 12/18/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a serious condition. However, prevailing therapeutic strategies are not effective enough to treat PAH. Therefore, finding an effective therapy is clearly warranted. Adipose-derived mesenchymal stem cells (ASCs) and ASCs-derived exosomes (ASCs-Exos) exert protective effects in PAH, but the underlying mechanism remains unclear. Using a coculture of ASCs and monocrotaline pyrrole (MCTP)-treated human pulmonary artery endothelial cells (HPAECs), we demonstrated that ASCs increased cell proliferation in MCTP-treated HPAECs. Results showed that ASCs-Exos improved proliferation of both control HPAECs and MCTP-treated HPAECs. In addition, by transfecting ASCs with antagomir we observed that low exosomal miR-191 expression inhibited HPAECs proliferation whereas the agomir improved. Similar results were observed in vivo using a monocrotaline (MCT)-induced PAH rat model following ASCs transplantation. And ASCs transplantation attenuated MCT-induced PAH albeit less than the antagomir treated group. Finally, we found that miR-191 repressed the expression of bone morphogenetic protein receptor 2 (BMPR2) in HPAECs and PAH rats. Thus, we conjectured that miR-191, in ASCs and ASCs-Exos, plays an important role in PAH via regulation of BMPR2. These findings are expected to contribute to promising therapeutic strategies for treating PAH in the future.
Collapse
|
174
|
Yue W, Tong L, Liu X, Weng X, Chen X, Wang D, Dudley SC, Weir EK, Ding W, Lu Z, Xu Y, Chen Y. Short term Pm2.5 exposure caused a robust lung inflammation, vascular remodeling, and exacerbated transition from left ventricular failure to right ventricular hypertrophy. Redox Biol 2019; 22:101161. [PMID: 30861460 PMCID: PMC6411784 DOI: 10.1016/j.redox.2019.101161] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/17/2022] Open
Abstract
Heart failure (HF) is the single largest cause for increased hospitalization after fine particulate matter (PM2.5) exposure. Patients with left HF often progress to right ventricular (RV) failure even with optimal medical care. An increase of PM2.5 of 10 μg per cubic meter was associated with a 76% increase in the risk of death from cardiovascular disease in 4 years' period. However, the role and mechanism of PM2.5 in HF progression are not known. Here we investigated the role of PM2.5 exposure in mice with existing HF mice produced by transverse aortic constriction (TAC). TAC-induced HF caused lung inflammation, vascular remodeling and RV hypertrophy. We found increased PM2.5 profoundly exacerbated lung oxidative stress in mice with existing left HF. To our surprise, PM2.5 exposure had no effect on LV hypertrophy and function, but profoundly exacerbated lung inflammation, vascular remodeling, and RV hypertrophy in mice with existing left HF. These striking findings demonstrate that PM2.5 and/or air pollution is a critical factor for overall HF progression by regulating lung oxidative stress, inflammation and remodeling as well as RV hypertrophy. Improving air quality may save HF patients from a dismal fate.
Collapse
Affiliation(s)
- Wenhui Yue
- Department of Cardiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lei Tong
- College of Life Science, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Xiaohong Liu
- Shanxi Provincial People's Hospital, Taiyuan, China
| | - Xinyu Weng
- Department of Cardiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaoyu Chen
- College of Life Science, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Dongzhi Wang
- Department of Cardiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Samuel C Dudley
- Cardiovascular Division and Lillehei Heart Institute, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - E Kenneth Weir
- Cardiovascular Division and Lillehei Heart Institute, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Wenjun Ding
- College of Life Science, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhongbing Lu
- College of Life Science, University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.
| | - Yingjie Chen
- Cardiovascular Division and Lillehei Heart Institute, University of Minnesota Medical School, Minneapolis, MN 55455, USA.
| |
Collapse
|
175
|
Vezzosi T, Schober KE. Doppler-derived echocardiographic evidence of pulmonary hypertension in cats with left-sided congestive heart failure. J Vet Cardiol 2019; 23:58-68. [PMID: 31174730 DOI: 10.1016/j.jvc.2019.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 01/21/2019] [Accepted: 01/28/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pulmonary hypertension (PH) caused by left-sided congestive heart failure (L-CHF) is common in dogs and contributes to clinical signs and outcome. The aim of this study was to evaluate the prevalence of Doppler echocardiography-derived PH in a population of cats with L-CHF. ANIMALS The study involved 131 cats with L-CHF and 56 control cats. METHODS The study design is retrospective, observational study. Tricuspid regurgitation velocity, right atrial dimension, right ventricular (RV) dimension and function, RV wall thickness, pulmonary artery (PA) dimension, Doppler-derived systolic time intervals of PA flow, and presence of septal flattening were evaluated. Pulmonary hypertension was considered if tricuspid regurgitation velocity was >2.7 m/s. RESULTS Tricuspid regurgitation was present in 57/131 (44%) of cats with L-CHF and 24/56 (43%) in control cats based on color flow Doppler. Doppler-derived of PH was identified in 22/131 cats with L-CHF (17%). In 15/22 cats, PH was associated with cardiomyopathy, in 5/22 cases with congenital heart disease, and in 2/22 cases with other causes. Cats with Doppler-derived PH more often had chronic L-CHF, as opposed to acute L-CHF (p<0.05). All cats with Doppler-derived PH had subjectively-assessed right-sided heart enlargement, with larger right atrial and RV diameters (p<0.001), increased RV wall thickness (p<0.05), and higher prevalence of septal flattening (<0.001) and PA enlargement (p<0.05). CONCLUSIONS Pulmonary hypertension identified by Doppler echocardiography is not a common finding in cats with L-CHF. Right-sided heart enlargement, more frequently observed, may raise the suspicion of PH in cats with L-CHF.
Collapse
Affiliation(s)
- T Vezzosi
- Department of Veterinary Sciences, University of Pisa, via Livornese, 56122, San Piero a Grado, Pisa, Italy.
| | - K E Schober
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, 601 Vernon L Tharp Street, Columbus, OH, 43210, USA
| |
Collapse
|
176
|
Zhang H, Zhang J, Chen M, Xie DJ, Kan J, Yu W, Li XB, Xu T, Gu Y, Dong J, Gu H, Han Y, Chen SL. Pulmonary Artery Denervation Significantly Increases 6-Min Walk Distance for Patients With Combined Pre- and Post-Capillary Pulmonary Hypertension Associated With Left Heart Failure. JACC Cardiovasc Interv 2019; 12:274-284. [DOI: 10.1016/j.jcin.2018.09.021] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/05/2018] [Accepted: 09/13/2018] [Indexed: 12/23/2022]
|
177
|
Feng W, Wang J, Yan X, Zhai C, Shi W, Wang Q, Zhang Q, Li M. Paclitaxel alleviates monocrotaline-induced pulmonary arterial hypertension via inhibition of FoxO1-mediated autophagy. Naunyn Schmiedebergs Arch Pharmacol 2019; 392:605-613. [PMID: 30683943 DOI: 10.1007/s00210-019-01615-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 01/15/2019] [Indexed: 12/11/2022]
Abstract
It has been demonstrated that activation of autophagy is involved in the development of pulmonary arterial hypertension (PAH). Recent studies have shown that cytosolic forkhead box protein O1 (FoxO1) activates autophagy in cancer cells. Paclitaxel has been found to potentially reverse PAH progression. However, the role of FoxO1 and the effects of paclitaxel on autophagy in the pathogenesis of PAH remain unknown. PAH was generated by intraperitoneal injection of monocrotaline (MCT) to rats. The right ventricular systolic pressure (RVSP), the right ventricle hypertrophy index (RV/LV+S), and the percentage of medial wall thickness (%MT) were used to detect the development of PAH. Hematoxylin and eosin staining was performed to measure pulmonary vascular remodeling. The protein level, phosphorylation, and nucleus translocation of FoxO1 and the levels of LC3A, LC3B, and Beclin-1 were examined by immunoblotting. The results showed that in spite of reduced expression of FoxO1, elevated phosphorylation of FoxO1 caused most of FoxO1 accumulating in cytosolic fraction in MCT-PAH rats. Autophagy was also activated in the MCT-PAH group. In cultured rat pulmonary arterial smooth muscle cells (PASMCs), knockdown of FoxO1 markedly blocked autophagy activation, indicating that elevation of cytosolic FoxO1 stimulates autophagy activation. Treatment of PAH rats with paclitaxel reduced FoxO1 phosphorylation and increased FoxO1 nuclear accumulation, despite increased FoxO1 expression, therefore suppressed autophagy, finally reduced elevated RVSP, RV/LV+S, and %MT in MCT-induced PAH. Taken together, paclitaxel inhibits pulmonary vascular remodeling by FoxO1-mediated autophagy suppression, suggesting that paclitaxel might be a novel therapeutic agent for the prevention and treatment of PAH.
Collapse
Affiliation(s)
- Wei Feng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- National Local Joint Engineering Research Center for Precision Surgery &Regenerative Medicine, Xi'an, Shaanxi, China
- Shaanxi Provincial Center Medicifor Regenerativene and Surgery Engineering Research, Xi'an, Shaanxi, China
| | - Jian Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- National Local Joint Engineering Research Center for Precision Surgery &Regenerative Medicine, Xi'an, Shaanxi, China
- Shaanxi Provincial Center Medicifor Regenerativene and Surgery Engineering Research, Xi'an, Shaanxi, China
| | - Xin Yan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Cui Zhai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Wenhua Shi
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- National Local Joint Engineering Research Center for Precision Surgery &Regenerative Medicine, Xi'an, Shaanxi, China
- Shaanxi Provincial Center Medicifor Regenerativene and Surgery Engineering Research, Xi'an, Shaanxi, China
| | - Qingting Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- National Local Joint Engineering Research Center for Precision Surgery &Regenerative Medicine, Xi'an, Shaanxi, China
- Shaanxi Provincial Center Medicifor Regenerativene and Surgery Engineering Research, Xi'an, Shaanxi, China
| | - Qianqian Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Manxiang Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| |
Collapse
|
178
|
Raina A, Meeran T. Right Ventricular Dysfunction and Its Contribution to Morbidity and Mortality in Left Ventricular Heart Failure. Curr Heart Fail Rep 2019; 15:94-105. [PMID: 29468529 DOI: 10.1007/s11897-018-0378-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE In patients with left-sided HF, there has been less emphasis on the pathophysiology of the RV in terms of diagnostic evaluation and treatment, versus focus on structural abnormalities of the LV. This review seeks to delineate the importance of RV dysfunction in terms of its contribution to symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. RECENT FINDINGS Recent studies have demonstrated that RV dysfunction is common in both HFpEF and HFrEF, but more pronounced in HFrEF. LV dysfunction and atrial fibrillation are most commonly associated with RV dysfunction in left-sided HF. RV dysfunction may develop due to afterload-dependent and afterload-independent pathways. Regardless, RV dysfunction is strongly associated with functional limitations and worsened survival in patients with left-sided HF. In patients with HFpEF, a recent study showed that RV failure was the most common cause of overall mortality. Among LVAD patients and patients post-cardiac transplantation, RV dysfunction is also strongly associated with survival. Despite a number of previous and ongoing clinical trials that target the RV directly or decrease RV afterload in left-sided HF, there are no definitive therapies specifically targeting RV dysfunction in left-sided HF patients CONCLUSIONS: RV dysfunction is an important determinant of symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. Further research is needed to developed pharmacotherapy that may target the RV specifically in left-sided HF patients.
Collapse
Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA. .,Pulmonary Hypertension Program, Section of Heart Failure/Transplant/MCS & Pulmonary Hypertension, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212-4772, USA.
| | - Talha Meeran
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| |
Collapse
|
179
|
Lombard FW, Liang Y. Risk Factors for Mitral Valve Surgery: Atrial Fibrillation and Pulmonary Hypertension. Semin Cardiothorac Vasc Anesth 2019; 23:57-69. [PMID: 30608218 DOI: 10.1177/1089253218821694] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Yafen Liang
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
180
|
Therapeutic potential of phosphodiesterase type 5 inhibitors in heart failure with preserved ejection fraction and combined post- and pre-capillary pulmonary hypertension. Int J Cardiol 2019; 283:152-158. [PMID: 30777406 DOI: 10.1016/j.ijcard.2018.12.078] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/04/2018] [Accepted: 12/28/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Heart failure with preserved ejection fraction (HFpEF) is frequently associated with pulmonary hypertension (PH), which substantially impacts survival. Based on pulmonary vascular resistance (PVR) and the diastolic pressure gradient (DPG), current guidelines distinguish between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH). However, the therapeutic consequences of this sub-classification remain entirely unclear. We specifically investigated the efficacy and safety of PDE5i in patients with HFpEF and CpcPH. METHODS In 40 hemodynamically precisely characterized patients with HFpEF and Cpc-PH who were treated with a PDE5i for at least 12 months, the therapeutic effect on 6-minute walk distance (6MWD), WHO functional class (FC), NTproBNP levels, right ventricular function, and hospitalization rates was evaluated. RESULTS Patients' mean age was 73 ± 9 years, and comorbidities were frequent (78% hypertension, 58% atrial fibrillation, 35% diabetes). Initially, 38 patients (95%) were in WHO-FC III and 2 patients (5%) in WHO-FC II. Prior to PDE5i initiation, mean PAPm was 46.2 ± 10.3 mmHg, PAWP 21.2 ± 4.7 mmHg, DPG 5.5 ± 7.2 mmHg, and PVR 6.2 ± 3.0 WU. After 12 months of PDE5i therapy, the 6MWD increased from initially 277 ± 17 to 340 ± 18 m (p < 0.001), and the proportion of patients in WHO-FC I/II increased from 5% to 37.5%. NTproBNP levels decreased by 33% (p = 0.004), and TAPSE improved from 16.8 ± 0.7 mm at baseline to 18.2 ± 0.6 mm (p = 0.01). The rate of HF-associated hospitalizations was substantially lower in the 12 months post PDE5i initiation compared to the prior 12 months. The DPG had no impact on the response to therapy. No deaths occurred, and typical side effects of PDE5i were observed. CONCLUSION These data indicate that at least a subset of precisely characterized patients with HFpEF and CpcPH who tolerate PDE5i may benefit from targeted therapy. A randomized study in this particular sub-population is warranted.
Collapse
|
181
|
Lai YC, Wang L, Gladwin MT. Insights into the pulmonary vascular complications of heart failure with preserved ejection fraction. J Physiol 2018; 597:1143-1156. [PMID: 30549058 DOI: 10.1113/jp275858] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022] Open
Abstract
Pulmonary hypertension in the setting of heart failure with preserved ejection fraction (PH-HFpEF) is a growing public health problem that is increasing in prevalence. While PH-HFpEF is defined by a high mean pulmonary artery pressure, high left ventricular end-diastolic pressure and a normal ejection fraction, some HFpEF patients develop PH in the presence of pulmonary vascular remodelling with a high transpulmonary pressure gradient or pulmonary vascular resistance. Ageing, increased left atrial pressure and stiffness, mitral regurgitation, as well as features of metabolic syndrome, which include obesity, diabetes and hypertension, are recognized as risk factors for PH-HFpEF. Qualitative studies have documented that patients with PH-HFpEF develop more severe symptoms than those with HFpEF and are associated with more significant exercise intolerance, frequent hospitalizations, right heart failure and reduced survival. Currently, there are no effective therapies for PH-HFpEF, although a number of candidate drugs are being evaluated, including soluble guanylate cyclase stimulators, phosphodiesterase type 5 inhibitors, sodium nitrite and endothelin receptor antagonists. In this review we attempt to provide an updated overview of recent findings pertaining to the pulmonary vascular complications in HFpEF in terms of clinical definitions, epidemiology and pathophysiology. Mechanisms leading to pulmonary vascular remodelling in HFpEF, a summary of pre-clinical models of HFpEF and PH-HFpEF, and new candidate therapeutic strategies for the treatment of PH-HFpEF are summarized.
Collapse
Affiliation(s)
- Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
182
|
Moghaddam N, Swiston JR, Levy RD, Lee L, Huckell VF, Brunner NW. Clinical and hemodynamic factors in predicting response to fluid challenge during right heart catheterization. Pulm Circ 2018; 9:2045894018819803. [PMID: 30507348 PMCID: PMC6300866 DOI: 10.1177/2045894018819803] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Fluid challenge during right heart catheterization has been used for unmasking pulmonary hypertension (PH) related to left-sided heart disease. We evaluated the clinical and hemodynamic factors affecting the response to fluid challenge and investigated the role of fluid challenge in the classification and management of PH patients. We reviewed the charts of 67 patients who underwent fluid challenge with a baseline pulmonary arterial wedge pressure (PAWP) of ≤ 18 mmHg. A positive fluid challenge (PFC) was defined as an increase in PAWP to > 18 mmHg after 500 mL saline infusion. Clinical characteristics and echocardiographic and hemodynamic parameters were compared between PFC and negative fluid challenge (NFC). PFC was associated with female sex, increased BMI, and hypertension. A greater rise in PAWP was observed in PFC (6.8 ± 2.3 vs. 3.8 ± 2.7 mmHg, P = 0.001). A larger increase in PAWP correlated with a lower transpulmonary gradient (r = –0.42, P < 0.001), diastolic pulmonary gradient (r = –0.42, P < 0.001), and pulmonary vascular resistance (r = –0.38, P < 0.001). We found 100% of the patients with PFC were classified as WHO group 2 PH compared to 49% of the NFC patients (P < 0.001). Fewer patients with PFC were started on advanced PH therapies and more were discharged from PH clinic. A PFC and the magnitude of PAWP increase after saline loading are associated with parameters related to left heart disease. In our population, fluid challenge appeared to influence the classification of PH and whether patients are started on therapy or discharged from clinic.
Collapse
Affiliation(s)
- Nima Moghaddam
- 1 Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John R Swiston
- 2 Division of Respirolgy, University of British Columbia, Vancouver, BC, Canada
| | - Robert D Levy
- 2 Division of Respirolgy, University of British Columbia, Vancouver, BC, Canada
| | - Lisa Lee
- 2 Division of Respirolgy, University of British Columbia, Vancouver, BC, Canada
| | - Victor F Huckell
- 3 Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Nathan W Brunner
- 3 Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
183
|
Domingo E, Grignola JC, Trujillo P, Aguilar R, Roman A. Proximal pulmonary arterial wall disease in patients with persistent pulmonary hypertension after successful left-sided valve replacement according to the hemodynamic phenotype. Pulm Circ 2018; 9:2045894018816972. [PMID: 30430894 PMCID: PMC6295709 DOI: 10.1177/2045894018816972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Regression of pulmonary hypertension (PH) is often incomplete after successful left-sided valve replacement (LSVR). Proximal pulmonary arterial (PPA) wall disease can be involved in patients with persistent-PH after LSVR, affecting the right ventricular to pulmonary arterial (RV-PA) coupling. Fifteen patients underwent successful LSVR at least one year ago presenting PH by echo (> 50 mmHg). Prosthesis-patient mismatch and left ventricular dysfunction were discarded. All patients underwent hemodynamic and intravascular ultrasound (IVUS) study. We estimated PPA stiffness (elastic modulus [EM]) and the relative area wall thickness (AWT). Acute vasoreactivity was assessed by inhaled nitric oxide (iNO) testing. RV-PA coupling was estimated by the tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure ratio. Patients were classified as isolated post-capillary PH (Ipc-PH; pulmonary vascular resistance [PVR] ≤ 3 WU and/or diastolic pulmonary gradient [DPG] < 7 mmHg) and combined post- and pre-capillary PH (Cpc-PH; PVR > 3 WU and DPG ≥ 7 mmHg). Both Ipc-PH and Cpc-PH showed a significant increase of EM and AWT. Despite normal PVR and DPG, Ipc-PH had a significant decrease in pulmonary arterial capacitance and RV-PA coupling impairment. Cpc-PH had worse PA stiffness and RV-PA coupling to Ipc-PH ( P < 0.05). iNO decreased RV afterload, improving the cardiac index and stroke volume only in Cpc-PH ( P < 0.05). Patients with persistent PH after successful LSVR have PPA wall disease and RV-PA coupling impairment beyond the hemodynamic phenotype. Cpc-PH is responsive to iNO, having the worse PA stiffness and RV-PA coupling. The PPA remodeling could be an early event in the natural history of PH associated with left heart disease.
Collapse
Affiliation(s)
- Enric Domingo
- 1 Area del Cor, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,2 Physiology Department, School of Medicine, Universitat Autonoma, Barcelona, Spain
| | - Juan C Grignola
- 3 Pathophysiology Department, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Pedro Trujillo
- 4 Cardiology Department, Centro Cardiovascular Universitario, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Rio Aguilar
- 5 Cardiology Department, Hospital de la Princesa, Madrid, Spain
| | - Antonio Roman
- 6 Department of Neumology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,7 Ciberes, IS Carlos III, Madrid, Spain
| |
Collapse
|
184
|
Abstract
Pulmonary hypertension (PH) is a common hemodynamic evolution of heart failure (HF) with preserved or reduced ejection fraction, responsible for congestion, symptoms worsening, exercise limitation, and negative outcome. In HF of any origin, PH develops in response to a passive backward pressure transmission as result of increased left atrial pressure. Sustained pressure injury and chronic venous congestion can trigger pulmonary vasoconstriction and vascular remodeling, leading to irreversible pulmonary vascular disease, right ventricular hypertrophy, and failure. In this article, the key determinants of this "dangerous liaison" are analyzed with some digressions on related "leitmotiv" at the horizon.
Collapse
Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, IRCCS Policlinico San Donato, Piazza E. Malan 2, San Donato Milanese, Milano 20097, Italy.
| |
Collapse
|
185
|
McGregor G, Powell R, Finnegan S, Nichols S, Underwood M. Exercise rehabilitation programmes for pulmonary hypertension: a systematic review of intervention components and reporting quality. BMJ Open Sport Exerc Med 2018; 4:e000400. [PMID: 30364456 PMCID: PMC6196941 DOI: 10.1136/bmjsem-2018-000400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 02/02/2023] Open
Abstract
Objectives To identify the components, and assess the reporting quality, of exercise training interventions for people living with pulmonary hypertension. Design Systematic review with analysis of intervention reporting quality using the Consensus on Exercise Reporting Template (CERT). Data sources Eligible studies in the Cochrane Systematic Review of exercise-based rehabilitation for pulmonary hypertension, updated with a new search of relevant databases from 1 August 2016 to 15 January 2018. Eligibility criteria Peer-reviewed journal articles of randomised and non-randomised controlled trials, and non-controlled prospective observational studies, investigating dynamic exercise training interventions in adult humans with diagnosed pulmonary hypertension, reporting on at least one physiological and/or psychosocial outcome. Results Interventions typically involved cycle ergometry and walking. They were delivered as 3-week inpatient, or outpatient and/or home-based programmes, lasting for 4–15 weeks. Components relating specifically to exercise prescription were described satisfactorily and in more detail than motivational/behavioural change strategies, adherence and fidelity. Mean CERT score was 13.1 (range 8–17) out of a possible maximum score of 19. No studies fully reported every aspect of an exercise intervention to the standard recommended by CERT. Summary/conclusion Considerable variability was evident in the components and reporting quality of interventions for exercise rehabilitation studies in pulmonary hypertension. Interventional studies using exercise training should pay greater attention to describing motivational/behavioural change strategies, adherence and fidelity. Detailed description of these parameters is essential for the safe and effective replication of exercise rehabilitation interventions for pulmonary hypertension in clinical practice. Trial registration number CRD42018085558.
Collapse
Affiliation(s)
- Gordon McGregor
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital, Coventry, UK.,School of Health & Life Sciences, Coventry University, Coventry, UK
| | - Richard Powell
- Department of Cardiopulmonary Rehabilitation, Centre for Exercise & Health, University Hospital, Coventry, UK
| | - Susanne Finnegan
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Martin Underwood
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
186
|
Guay CA, Morin-Thibault LV, Bonnet S, Lacasse Y, Lambert C, Lega JC, Provencher S. Pulmonary hypertension-targeted therapies in heart failure: A systematic review and meta-analysis. PLoS One 2018; 13:e0204610. [PMID: 30307953 PMCID: PMC6181322 DOI: 10.1371/journal.pone.0204610] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/11/2018] [Indexed: 12/29/2022] Open
Abstract
Background Pulmonary hypertension (PH) due to left heart failure (HF) is the most common form of PH. However, treatment is unclear because there are conflicting results about safety and efficacy of PH-targeted therapies. Objectives To assess the effects of PH-targeted therapy on exercise capacity in HF patients. Methods MEDLINE, EMBASE and the Cochrane Library were searched from January 1990 to July 2017 for randomized controlled trials comparing PH-targeted therapies to conventional therapy in HF. The primary outcome was to assess the effects on exercise capacity. Secondary outcomes included mortality, hospitalisation, NT-proBNP levels, echocardiographic and hemodynamics parameters and discontinuation rate. Results 22 studies were included (n = 5448), including 3, 8 and 11 studies with low, high and unknown risk of bias, respectively. PH-targeted therapies were associated with an improvement of exercise capacity (standardized mean difference 0.29;95%CI:0.08–0.50, p = 0.006). Pre-specified subgroup analyses found that this improvement was predominantly observed in studies evaluating phosphodiesterase-5 inhibitors and prostanoids and in patients with reduced ejection fraction. Moreover, systolic pulmonary artery pressure measured by echocardiography was improved (mean difference: -7.5mmHg; [95%CI]: -14.9,-0.1, p = 0.05), which was also entirely driven by studies evaluating phosphodiesterase-5 inhibitors. However, PH-targeted therapies were associated with an increased treatment discontinuation rates and a potential increase in mortality compared to standard treatment. Conclusions In conclusion, PH-targeted therapies and especially phosphodiesterase-5 inhibitors may improve exercise capacity in patients with HF. However, an increase in adverse outcomes was likely. Moreover, most studies were at high or unknown risk of bias, precluding confident conclusions about the effects of PH-targeted therapies.
Collapse
Affiliation(s)
- Charles-Antoine Guay
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Louis-Vincent Morin-Thibault
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Sebastien Bonnet
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
| | - Yves Lacasse
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
| | - Caroline Lambert
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Jean-Christophe Lega
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service de Médecine Interne-Pathologie Vasculaire, Lyon, France
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
- * E-mail:
| |
Collapse
|
187
|
Johns CS, Wild JM, Rajaram S, Tubman E, Capener D, Elliot C, Condliffe R, Charalampopoulos A, Kiely DG, Swift AJ. Identifying At-Risk Patients with Combined Pre- and Postcapillary Pulmonary Hypertension Using Interventricular Septal Angle at Cardiac MRI. Radiology 2018; 289:61-68. [PMID: 29969067 PMCID: PMC6190488 DOI: 10.1148/radiol.2018180120] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/06/2018] [Accepted: 04/16/2018] [Indexed: 12/21/2022]
Abstract
Purpose To assess interventricular septal (IVS) angle in the identification of combined pre- and postcapillary pulmonary hypertension (Cpc-PH) in patients with pulmonary hypertension (PH) due to left-sided heart disease. Materials and Methods In this retrospective study, consecutive, incident patients suspected of having PH underwent same-day right-sided heart catheterization (RHC) and MRI at a PH referral center between April 2012 and April 2017. The diagnostic accuracy of the IVS angle to identify Cpc-PH in patients with pulmonary arterial wedge pressure (PAWP) greater than 15 mmHg was assessed by using receiver operator characteristic curves, sensitivity, specificity, and negative and positive predictive values. IVS angle also was assessed as a predictor of all-cause mortality by using Cox uni- and multivariable proportional hazards regression. Results A total of 708 patients underwent same-day MRI and RHC, and 171 patients had PAWP greater than 15 mmHg. Mean age was 70 years (range, 21-90 years) (women: mean age, 69 years; range, 21-88 years) (men: mean age, 71 years; range, 43-90 years). Systolic IVS angle correlated with diastolic pulmonary gradient (DPG) (r = 0.739, P < .001). Receiver operating characteristic curve analysis showed septal angle enabled identification of Cpc-PH (DPG ≥ 7), with an area under the receiver operating characteristic curve of 0.911 (P < .001). A 160° threshold, derived from the first half of patients with raised PAWP, enabled identification of a DPG of at least 7 mmHg with 67% sensitivity and 93% specificity (P < .001) in the second cohort of patients with raised PAWP. IVS angle was predictive of all-cause mortality (standardized univariable hazard ratio, 1.615; P < .01). Conclusion The systolic interventricular septal angle is elevated in patients with combined pre- and postcapillary pulmonary hypertension and enables one to predict those patients who have PH due to left-sided heart disease who have an increased risk of death. Published under a CC BY 4.0 license. Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Christopher S. Johns
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - James M. Wild
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Smitha Rajaram
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Euan Tubman
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - David Capener
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Charlie Elliot
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Robin Condliffe
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Athanasios Charalampopoulos
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - David G. Kiely
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Andrew J. Swift
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| |
Collapse
|
188
|
Targoński R, Sadowski J, Starek-Stelmaszczyk M, Targoński R, Rynkiewicz A. Prognostic significance of red cell distribution width and its relation to increased pulmonary pressure and inflammation in acute heart failure. Cardiol J 2018; 27:394-403. [PMID: 30234900 DOI: 10.5603/cj.a2018.0103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/11/2018] [Accepted: 06/10/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Red cell distribution width (RDW) in acute heart failure (AHF) is accepted as a prognostic indicator with unclear pathophysiological ties. The aim of this study was to evaluate the prognostic value of RDW in AHF patients in relation to clinical and echocardiographic data. METHODS 170 patients with AHF were retrospectively studied. All patients had laboratory testing and an echocardiogram performed within 24 h of admission to the Cardiology Department. RESULTS During the mean 193 ± 111 days of follow-up, 33 patients died. More advanced age, high RDW and low peak early diastolic velocity of the lateral mitral annulus (MVe') were independent predictors of all-cause mortality with hazard ratios of: 1.05 (95% CI 1.02-1.09), p < 0.005, 1.40 (95% CI 1.22-1.60), p < 0.001, and 0.77 (95% CI 0.63-0.93), p < 0.007, respectively. In a stepwise multiple linear regression model, RDW was correlated with hemoglobin concentration (standardized b = -0.233, p < 0.001), mean corpuscular volum (standardized b = -0.230, p < 0.001), mean corpuscular hemoglobin concentration (standardized b = -0.207, p < 0.007), the natural logarithm of C-reactive protein (CRP) (standardized b = 0.184, p < 0.004) and tricuspid regurgitation peak gradient (TRPG) values (standardized b = 0.179, p < 0.006), whereas MVe' was correlated with atrial fibrillation (standardized b = 0.269, p < 0.001). CONCLUSIONS The present data demonstrates a novel relation between higher levels of RDW and elevated TRPG and high sensitivity CRP values in patients with AHF. These findings suggest that RDW, the most important mortality predictor, is independently associated with elevated pulmonary pressure and systemic inflammation in patients with AHF. Moreover, in AHF patients, more advanced age and decreased MVe' are also independently associated with total mortality risk.
Collapse
Affiliation(s)
- Ryszard Targoński
- Department of Cardiology, University of Warmia and Mazury in Olsztyn, Oczapowskiego 2, 10-900 Olsztyn, Poland.
| | - Janusz Sadowski
- Department of Cardiology, University of Warmia and Mazury in Olsztyn, Oczapowskiego 2, 10-900 Olsztyn, Poland
| | | | | | - Andrzej Rynkiewicz
- Department of Cardiology, University of Warmia and Mazury in Olsztyn, Oczapowskiego 2, 10-900 Olsztyn, Poland
| |
Collapse
|
189
|
Martens P, Verbrugge FH, Bertrand PB, Verhaert D, Vandervoort P, Dupont M, Tang WW, Janssens S, Mullens W. Effect of Cardiac Resynchronization Therapy on Exercise-Induced Pulmonary Hypertension and Right Ventricular-Arterial Coupling. Circ Cardiovasc Imaging 2018; 11:e007813. [DOI: 10.1161/circimaging.118.007813] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.M., F.H.V., P.B.B., D.V., P.V., M.D., W.M.)
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium. (P.M.)
| | | | - Philippe B. Bertrand
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.M., F.H.V., P.B.B., D.V., P.V., M.D., W.M.)
| | - David Verhaert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.M., F.H.V., P.B.B., D.V., P.V., M.D., W.M.)
| | - Pieter Vandervoort
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.M., F.H.V., P.B.B., D.V., P.V., M.D., W.M.)
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.M., F.H.V., P.B.B., D.V., P.V., M.D., W.M.)
| | - W.H. Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.)
| | - Stefan Janssens
- Department of Cardiology, University Hospital Leuven (UZ Leuven), Belgium (S.J.)
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (P.M., F.H.V., P.B.B., D.V., P.V., M.D., W.M.)
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium. (W.M.)
| |
Collapse
|
190
|
Pulmonary hypertension associated with left heart disease: Updated Recommendations of the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:53-62. [PMID: 30527996 DOI: 10.1016/j.ijcard.2018.08.080] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 12/25/2022]
Abstract
In the summer of 2016, delegates from the German Society of Cardiology (DGK), the German Respiratory Society (DGP), and the German Society of Pediatric Cardiology (DGPK) met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary hypertension (PH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines, aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH associated with left heart disease. In this context, the European Guidelines point out that the drugs currently approved to treat patients with PAH (prostanoids, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, sGC stimulators) have not sufficiently been investigated in other forms of PH. However, despite the lack of respective efficacy data, an uncritical use of targeted PAH drugs in patients with PH associated with left heart disease is currently observed at an increasing rate. This development is a matter of concern. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease. In that sense, the distinction between isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH) and their proper definition may be of particular relevance. The detailed results and recommendations of the working group on PH associated with left heart disease, which were last updated in the spring of 2018, are summarized in this article.
Collapse
|
191
|
Abstract
Pulmonary hypertension (PH) due to left heart disease, or WHO group 2 PH, is the most frequent cause of PH. It affects approximately 50% to 60% of patients with heart failure with preserved ejection fraction as well as 60% of those with heart failure with reduced ejection fraction and contributes significantly to disease progression and unfavorable outcomes. The diagnosis of PH is associated with poor prognosis and significant morbidity and mortality.
Collapse
|
192
|
Santiago-Vacas E, Farrero M, Ivey-Miranda JB, Castel MÁ, García-Álvarez A, Rios J, Perez-Villa F. Initial experience with bosentan for the management of pulmonary hypertension after heart transplantation. Clin Transplant 2018; 32:e13364. [PMID: 30058129 DOI: 10.1111/ctr.13364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/25/2018] [Accepted: 07/25/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) after heart transplantation (HT) is associated to right ventricular (RV) dysfunction and increased morbidity and mortality. We present our experience with bosentan for the treatment of PH after HT. METHODS A retrospective evaluation of patients with PH receiving bosentan post-transplant was performed. Pulmonary hemodynamics before and after bosentan (BG) and clinical outcomes were assessed and compared to a historical control group (CG) not receiving bosentan. RESULTS Between 2013 and 2016, 21 patients were treated post-transplant with bosentan. Twenty-four hours after bosentan initiation, there were significant decreases in systolic (42.5 ± 8 to 38.1 ± 8 mm Hg, P = 0.015), diastolic (21.4 ± 4 to 17.8 ± 6 mm Hg, P = 0.008) and mean (29.6 ± 5 to 25 ± 6 mm Hg, P = 0.001) pulmonary artery pressures (PAP), transpulmonary gradient (13.1 ± 3 to 9.7 ± 4 mm Hg, P < 0.001), diastolic gradient (5.2 ± 4 to 2.3 ± 3 mm Hg, P = 0.001) and pulmonary vascular resistance (PVR) (2.2 ± 1 to 1.6 ± 1WU, P = 0.015). This effect was maintained at day 3. Compared with CG, BG showed significantly more decrease in PVR (0.7 ± 0.9 vs 0.3 ± 1.7WU, P = 0.025) and mean PAP (4.6 ± 5.2 vs 1.5 ± 4.4 mm Hg, P = 0.040). RV function 7 days post-transplant was significantly better in BG compared to CG, P = 0.004. There were not clinically significant interactions between bosentan and immunosuppressive treatment. CONCLUSIONS Bosentan, initiated early post-transplant, was associated with a significant decrease in PVR. Bosentan was well tolerated and did not interact with immunosuppressive treatment.
Collapse
Affiliation(s)
- Evelyn Santiago-Vacas
- Heart Failure and Heart Transplantation Unit, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain
| | - Marta Farrero
- Heart Failure and Heart Transplantation Unit, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain
| | - Juan B Ivey-Miranda
- Heart Failure and Heart Transplantation Unit, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain
| | - Maria Ángeles Castel
- Heart Failure and Heart Transplantation Unit, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain
| | - Ana García-Álvarez
- Heart Failure and Heart Transplantation Unit, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain
| | - José Rios
- Medical Statistics Core Facility, August Pi and Sunyer Biomedical Research Institute (IDIBAPS), Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Felix Perez-Villa
- Heart Failure and Heart Transplantation Unit, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain
| |
Collapse
|
193
|
Adenovirus Coding for Interleukin-2 and Tumor Necrosis Factor Alpha Replaces Lymphodepleting Chemotherapy in Adoptive T Cell Therapy. Mol Ther 2018; 26:2243-2254. [PMID: 30017877 DOI: 10.1016/j.ymthe.2018.06.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/01/2018] [Accepted: 06/01/2018] [Indexed: 02/08/2023] Open
Abstract
Lymphodepleting preconditioning with high-dose chemotherapy is commonly used to increase the clinical efficacy of adoptive T cell therapy (ACT) strategies, however, with severe toxicity for patients. Conversely, oncolytic adenoviruses are safe and, when engineered to express interleukin-2 (IL-2) and tumor necrosis factor alpha (TNF-α), they can achieve antitumor immunomodulatory effects similar to lymphodepletion. Therefore, we compare the safety and efficacy of such adenoviruses with a cyclophosphamide- and fludarabine-containing lymphodepleting regimen in the setting of ACT. Human adenovirus (Ad5/3-E2F-D24-hTNF-α-IRES-hIL-2; TILT-123) replication was studied using a Syrian hamster pancreatic tumor model (HapT1) infused with tumor-infiltrating lymphocytes (TILs). Using the oncolytic virus instead of lymphodepletion resulted in superior efficacy and survival. Immune cells responsive to TNF-α IL-2 were studied using an immunocompetent mouse melanoma model (B16.OVA) infused with ovalbumin-specific T (OT-I) cells. Here, the adenovirus approach improved tumor control together with increased intratumoral Th1 cytokine levels and infiltration of CD8+ T cells and CD86+ dendritic cells. Similar to humans, lymphodepleting preconditioning caused severe cytopenias, systemic inflammation, and damage to vital organs. Toxicity was minimal in adenovirus- and OT-I-treated mice. These findings demonstrate that ACT can be effectively facilitated by cytokine-coding adenovirus without requiring lymphodepletion, a rationale being clinically investigated.
Collapse
|
194
|
Abstract
Pulmonary hypertension (PH) is a progressive disease with high associated morbidity and mortality despite the development of novel therapies. Palliative care is a multidisciplinary field focused on optimization of quality of life and overall supportive care for patients and their families in the setting of life-limiting illness. Although the benefits of palliative care in oncology are well described, there are few studies regarding the timing and involvement of palliative care in PH patients. In this paper, we describe the importance of longitudinal advance care planning, including suggestions for addressing difficult topics such as end-of-life care, and the role of palliative care providers in helping guide these discussions throughout the course of the illness.
Collapse
Affiliation(s)
- Charles L. Rhee
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, IL
| | - Michael Cuttica
- Division of Pulmonary and Critical Care Medicine, Northwestern University; Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
195
|
|
196
|
Rudski L, Gargani L, Naeije R, Bossone E. Authors' Reply: Pulmonary Flow Wave Morphology Characteristics of Pulmonary Hypertension. J Am Soc Echocardiogr 2018; 31:964-965. [PMID: 29937411 DOI: 10.1016/j.echo.2018.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Lawrence Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | | | | |
Collapse
|
197
|
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
| |
Collapse
|
198
|
Konstam MA, Kiernan MS, Bernstein D, Bozkurt B, Jacob M, Kapur NK, Kociol RD, Lewis EF, Mehra MR, Pagani FD, Raval AN, Ward C. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e578-e622. [DOI: 10.1161/cir.0000000000000560] [Citation(s) in RCA: 335] [Impact Index Per Article: 55.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose:
The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.
Methods:
The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations.
Results:
Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking.
Conclusions:
RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.
Collapse
|
199
|
Raina A, Patarroyo-Aponte M. Prevention and Treatment of Right Ventricular Failure During Left Ventricular Assist Device Therapy. Crit Care Clin 2018; 34:439-452. [PMID: 29907275 DOI: 10.1016/j.ccc.2018.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Left ventricular assist devices (LVAD) are increasingly used for the treatment of end-stage heart failure. Right ventricular (RV) failure after LVAD implantation is an increasingly common clinical problem, occurring in patients early after continuous flow LVAD implant. RV failure is associated with a substantial increase in post-LVAD morbidity and mortality. RV failure can be predicted using preoperative hemodynamic, clinical, and echocardiographic variables and a variety of risk prediction algorithms. However, RV failure may also develop due to unanticipated intraoperative or perioperative factors. Early recognition and treatment are critical in terms of mitigating the impact of RV failure on post-LVAD outcomes.
Collapse
Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772, USA.
| | - Maria Patarroyo-Aponte
- Cardiovascular Institute, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772, USA
| |
Collapse
|
200
|
Duarte JD, Kansal M, Desai AA, Riden K, Arwood MJ, Yacob AA, Stamos TD, Cavallari LH, Zamanian RT, Shah SJ, Machado RF. Endothelial nitric oxide synthase genotype is associated with pulmonary hypertension severity in left heart failure patients. Pulm Circ 2018; 8:2045894018773049. [PMID: 29718770 PMCID: PMC5946646 DOI: 10.1177/2045894018773049] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The biological mechanisms behind the development of pulmonary hypertension in the setting of left heart failure (HF-PH), including combined pre- and post-capillary pulmonary hypertension (Cpc-PH), remains unclear. This study aimed to use candidate polymorphisms in nitric oxide synthase (NOS) genes to explore the role of NOS in HF-PH. DNA samples from 118 patients with HF-PH were genotyped for the NOS3 rs1799983 and NOS2 rs3730017 polymorphisms. A multiple regression model was used to compare hemodynamic measurements between genotype groups. Patients with the T/T genotype at rs1799983 possessed a nearly 10 mmHg increased transpulmonary gradient (TPG) compared to those with other genotypes (P = 0.006). This finding was replicated in an independent cohort of 94 HF-PH patients (P = 0.005). However, when tested in a cohort of 162 pre-capillary pulmonary arterial hypertension patients, no association was observed. In a combined analysis of both HF-PH cohorts, mean pulmonary artery pressure (mPAP), diastolic pulmonary gradient (DPG), and CpcPH status were also associated with rs1799983 genotype (P = 0.005, P = 0.03, and P = 0.02, respectively). In patients with HF-PH, the NOS3 rs1799983 polymorphism is associated with TPG, and potentially mPAP and DPG as well. These findings suggest that endothelial NOS (encoded by NOS3) may be involved in the pulmonary vascular remodeling observed in Cpc-PH and warrants further study.
Collapse
Affiliation(s)
- Julio D Duarte
- 1 Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Mayank Kansal
- 2 12247 Division of Cardiology, University of Illinois College of Medicine, Chicago, IL, USA
| | - Ankit A Desai
- 3 Department of Medicine and Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Katherine Riden
- 1 Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Meghan J Arwood
- 1 Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Alex A Yacob
- 4 Division of Pulmonary & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas D Stamos
- 2 12247 Division of Cardiology, University of Illinois College of Medicine, Chicago, IL, USA
| | - Larisa H Cavallari
- 1 Center for Pharmacogenomics, Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Roham T Zamanian
- 4 Division of Pulmonary & Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Sanjiv J Shah
- 5 Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Roberto F Machado
- 6 Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|