Adult congenital heart disease with pulmonary arterial hypertension: mechanisms and management

Long-term survival of shunt closure in atrial septal defects with pulmonary arterial hypertension

OBJECTIVE

This study aims to refine closure indications and assess long-term outcomes in pulmonary arterial hypertension associated with atrial septal defect (PAH-ASD).

METHODS

We enrolled 197 PAH-ASD patients classified as unrepairable (n = 101) or repairable (n = 96), with the latter subdivided into direct repair (DR, n = 74) and treat-and-repair (TR, n = 22) groups. Closure criteria included pulmonary vascular resistance (PVR) 3-6 Wood units and Qp/Qs ≥1.5. The TR group received targeted therapy before closure.

RESULTS

Targeted therapy significantly improved TR group hemodynamics: PVR decreased from 8.0 ± 2.0 to 3.0 ± 1.0 WU (p < 0.001); Qp/Qs increased from 1.7 ± 0.4 to 2.3 ± 0.3 (p < 0.001). Post-closure, pulmonary artery systolic pressure significantly decreased in both TR (67 ± 15 to 38 ± 9 mmHg) and DR groups (66 ± 17 to 40 ± 10 mmHg) (both p < 0.001). Right ventricular remodeling improved significantly. During median follow-up (3.7-4.5 years), mortality was lower in repairable versus unrepairable groups (1 vs. 10 deaths). Univariate COX analysis identified ASD closure as a protective factor (HR 0.093, 95 %CI [0.01,0.98].

CONCLUSION

ASD closure improves long-term survival in select PAH-ASD patients. Targeted therapy enables closure in previously ineligible patients.

Variation and significance of serum microRNA-21 level in pediatric pulmonary artery hypertension associated with congenital heart disease

Objective

This study strives to the variation and significance of microRNA-21 (miR-21) in children with congenital heart disease (CHD)-related pulmonary artery hypertension (PAH).

Methods

Children with CHD (n = 179) were selected as subjects, including 101 children without PAH and 78 children with PAH. All children underwent general data collection, laboratory examination, echocardiography and cardiac catheterization. After detection of serum miR-21 expression, the predictive value and the impacts of serum miR-21 for PAH and postoperative critical illness were analyzed.

Results

Serum creatine kinase isoenzyme (CK-MB), B-type natriuretic peptide (BNP) and miR-21 were elevated, but ejection fraction (EF) and cardiac index (CI) were decreased in the CHD-PAH group. Serum miR-21 assisted in predicting PAH in CHD children, with the area under curve (AUC) of 0.801 (95% CI of 0.735∼0.857), a cut-off value of 2.56, sensitivity of 73.08, and specificity of 72.28%. Serum miR-21 in children with CHD-PAH was correlated with clinicopathological indicators such as systolic pulmonary artery pressure, mean pulmonary arterial pressure, BNP and CI. Serum miR-21 helped predict the development of postoperative critical illness in children with CHD-PAH, with an AUC of 0.859 (95% CI: 0.762-0.927, cut-off value: 4.55, sensitivity: 69.57%, specificity: 92.73%). Increased serum miR-21 was an independent risk factor of postoperative critical illness in children with CHD-PAH.

Conclusion

Serum miR-21 was upregulated in children with CHD-PAH, which may serve as a predictive biomarker for the onset of PAH and postoperative critical illness in CHD children.

Pulmonary Hypertension in Adult Congenital Heart Disease-Related Heart Failure

Already a challenging condition to define, adult congenital heart disease (ACHD) -associated heart failure (HF) often incorporates specific anatomies, including intracardiac and extracardiac shunts, which require rigorous diagnostic characterization and heighten the importance of clinicians proactively considering overall hemodynamic impacts of using specific therapies. The presence of elevated pulmonary vascular resistance dramatically increases the complexity of managing patients with ACHD-HF. Total circulatory management in patients with ACHD-HF requires input from multidisciplinary care teams and thoughtful and careful utilization of medical, interventional, and surgical approaches.

Applications of the ultrasound-guided nerve block technique for nonanalgesic effects

The nerve block technique guided by ultrasound has been able to accurately block tiny nerves throughout the body in recent years. It has been increasingly used to treat multisystem diseases or analgesia in surgical patients, but the latter accounted for the vast majority of cases. The nonanalgesic effect of nerve blocks is also in wide demand. After searching ultrasound-guided nerve block works on the PubMed database, we systematically summarized the current clinical application of the nerve block technique and the unique role and related mechanism of nerve block in the prevention and treatment of multi-system diseases or symptoms, including disorders of the circulatory and respiratory systems, postoperative cognitive dysfunction, immune function, posttraumatic stress disorder, and postoperative digestive system, to put forward the potential prospective application in future and serve as a reference for future research of nerve block therapy in these diseases mentioned.

The use of pulmonary arterial hypertension therapies in Eisenmenger syndrome

INTRODUCTION

For many years, treatment options for patients with Eisenmenger physiology had been restricted to conservative measures to alleviate multi-system complications. The use of pulmonary arterial hypertension (PAH)-targeted therapies in patients with Eisenmenger syndrome (ES) changed the course of the disease, since they substantially improved clinical outcomes and increased survival.

AREAS COVERED

In this review, we primarily focus on the use of PAH pharmacotherapies in ES. A literature search was carried out in PubMed, Scopus and Cochrane Database up to May 2021. We thoroughly discuss current evidence about mechanisms of action, safety, and efficacy of these agents and present challenges and gaps in literature regarding the recommended treatment approach.

EXPERT OPINION

Unlike other forms of PAH, we usually treat patients with ES more conservatively as we lack evidence that aggressive management is safe and effective in this complex population. Several issues on the time of initiation of PAH-targeted therapies, choice between monotherapy vs. upfront combination therapy, and time of escalation still remain challenging and require further investigation. Therapeutic management should be guided by patients' individual evaluation based on available prognostic markers. More well-designed trials are warranted to assess the benefits of new PAH-targeted agents and combination therapies.