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Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD; group 2 PH) is a common complication of heart failure with reduced ejection fraction and heart failure with preserved ejection fraction and is often related to disease severity and duration of these diseases. PH due to LHD is associated with negative impact on outcomes in addition to worse symptoms and exercise capacity. Risk factors for group 2 PH are older age, hypertension, atrial fibrillation, and features of metabolic syndrome. The main mechanisms for group 2 PH are believed to be vascular remodeling secondary to sustained elevated intravascular pressure.
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Affiliation(s)
- Ayedh K Alamri
- Department of Medicine, University of Utah, University of Utah School of Medicine, 30 North 1900 East, Room 4C116, Salt Lake City, UT 84132, USA
| | - Christy L Ma
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA.
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2
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Pirlamarla P, Rame E, Hoopes C, Rajapreyar I. Pulmonary vasodilator use in continuous-flow left ventricular assist device management. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:522. [PMID: 33850919 PMCID: PMC8039680 DOI: 10.21037/atm-20-4710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pulmonary hypertension (PH) due to left heart disease is the most common etiology for PH. PH in patients with heart failure with reduced fraction (HFrEF) is associated with reduced functional capacity and increased mortality. PH-HFrEF can be isolated post-capillary or combined pre- and post-capillary PH. Chronic elevation of left-sided filling pressures may lead to reverse remodeling of the pulmonary vasculature with development of precapillary component of PH. Untreated PH in patients with HFrEF results in predominant right heart failure (RHF) with irreversible end-organ dysfunction. Management of PH-HFrEF includes diuretics, vasodilators like angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers or angiotensin-receptor blocker-neprilysin inhibitors, hydralazine and nitrates. There is no role for pulmonary vasodilator use in patients with PH-HFrEF due to increased mortality in clinical trials. In patients with end-stage HFrEF and fixed PH unresponsive to vasodilator challenge, implantation of continuous-flow left ventricular assist device (cfLVAD) results in marked improvement in pulmonary artery pressures within 6 months due to left ventricular (LV) mechanical unloading. The role of pulmonary vasodilators in management of precapillary component of PH after cfLVAD is not well-defined. The purpose of this review is to discuss the pharmacologic management of PH after cfLVAD implantation.
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Affiliation(s)
- Preethi Pirlamarla
- Advanced Heart Failure and Transplant Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Eduardo Rame
- Advanced Heart Failure and Transplant Cardiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Charles Hoopes
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Indranee Rajapreyar
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama-Birmingham School of Medicine, Birmingham, AL, USA
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3
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Aleevskaya AM, Vyborov ON, Gramovich VV, Martynyuk TV. [Problematic aspects of pulmonary hypertension due to left heart disease: focus on combined postcapillary and precapillary pulmonary hypertension]. TERAPEVT ARKH 2020; 92:54-62. [PMID: 33346432 DOI: 10.26442/00403660.2020.09.000450] [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: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 11/22/2022]
Abstract
Рulmonary hypertension (PH) is a common complication of left heart diseases. In addition to a passive increase of pressure in the venous bed of the pulmonary circulation, leading to an increase of mean pulmonary pressure, signs of precapillary PH could be detected in some patients. Since 2013, a hemodynamic subtype of PH due to left heart diseases combined post/precapillary PH has been identified, with a more unfavorable prognosis and high mortality.
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Affiliation(s)
| | - O N Vyborov
- National Medical Research Center for Cardiology
| | | | - T V Martynyuk
- National Medical Research Center for Cardiology.,Pirogov Russian National Research Medical University
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Latus H, Lederle A, Khalil M, Kerst G, Schranz D, Apitz C. Evaluation of pulmonary endothelial function in Fontan patients. J Thorac Cardiovasc Surg 2019; 158:523-531.e1. [DOI: 10.1016/j.jtcvs.2018.11.144] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 11/08/2018] [Accepted: 11/22/2018] [Indexed: 11/28/2022]
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Sparrow CT, LaRue SJ, Schilling JD. Intersection of Pulmonary Hypertension and Right Ventricular Dysfunction in Patients on Left Ventricular Assist Device Support: Is There a Role for Pulmonary Vasodilators? Circ Heart Fail 2019; 11:e004255. [PMID: 29321132 DOI: 10.1161/circheartfailure.117.004255] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Left ventricular assist devices (LVADs) improve survival and quality of life in patients with advanced heart failure. Despite these benefits, combined post- and precapillary pulmonary hypertension can be particularly problematic in patients on LVAD support, often exacerbating right ventricular (RV) dysfunction. Both persistently elevated pulmonary vascular resistance and RV dysfunction are associated with adverse outcomes, including death after LVAD. These observations have led to significant interest in the use of pulmonary vasodilators to treat pulmonary hypertension and preserve RV function among LVAD-supported patients. Although pulmonary vasodilators are commonly used for the treatment of pulmonary hypertension and RV dysfunction in LVADs, the benefits of this practice remain unclear. The purpose of this review is to highlight the current challenges in managing pulmonary vascular disease and RV dysfunction in patients with heart failure on LVAD support.
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Affiliation(s)
- Christopher T Sparrow
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO
| | - Shane J LaRue
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO
| | - Joel D Schilling
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO.
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Yu W, Gu Y, Chen P, Luo J, Liu P, Chao Y, Chen SL, Zhang H. Norepinephrine stimulation downregulates the β 2 -adrenergic receptor-nitric oxide pathway in human pulmonary artery endothelial cells. J Cell Physiol 2018; 234:1842-1850. [PMID: 30132872 DOI: 10.1002/jcp.27057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/25/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Norepinephrine (NE)-mediated vasoconstriction plays an important role in pulmonary hypertension associated with left heart disease (PH-LHD). However, the role of NE-mediated endothelial cell dysfunction in the pathogenesis of PH-LHD remains to be elucidated. METHODS AND RESULTS An enzyme-linked immunosorbent assay showed that the NE concentration in the plasma of patients with PH-LHD was higher and the nitrate-nitrite concentration was lower than those in the control group. NE treatment decreased phospho-Ser633-eNOS and β2 -adrenergic receptor (β2 -AR) levels in the membrane of human pulmonary artery endothelial cells (HPAECs) analysed by western blot analysis. Consistently, fluorescence microscopy and flow cytometry showed that nitric oxide (NO) production was also decreased in HPAECs. Coimmunoprecipitation confirmed a direct interaction between β2 -AR and endothelial NO synthase (eNOS). Overexpression of β2 -AR attenuated the decline in phospho-Ser633-eNOS and NO production. Additionally, the expression of phospho-Ser633-eNOS and β2 -AR was decreased in human pulmonary artery endothelium. Finally, our results indicate that NE stimulated HPAEC proliferation, which was blocked by protein kinase A inhibitor or protein kinase B (PKB-AKT) inhibitor. CONCLUSIONS These data provide a novel mechanism for NE-decreased endothelium-derived NO and NE-induced HPAEC proliferation that leads to PH-LHD, suggesting a potential therapeutic target for PH-LHD.
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Affiliation(s)
- Wande Yu
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yue Gu
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - PeiP Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jie Luo
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Pengfei Liu
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yuelin Chao
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hang Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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van Duin RWB, Stam K, Cai Z, Uitterdijk A, Garcia-Alvarez A, Ibanez B, Danser AHJ, Reiss IKM, Duncker DJ, Merkus D. Transition from post-capillary pulmonary hypertension to combined pre- and post-capillary pulmonary hypertension in swine: a key role for endothelin. J Physiol 2018; 597:1157-1173. [PMID: 29799120 PMCID: PMC6375874 DOI: 10.1113/jp275987] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
Key points Passive, isolated post‐capillary pulmonary hypertension (PH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH This ‘activation’ of post‐capillary PH significantly increases morbidity and mortality, and is still incompletely understood. In this study, pulmonary vein banding gradually produced post‐capillary PH with structural and functional microvascular remodelling in swine. Ten weeks after banding, the pulmonary endothelin pathway was upregulated, likely contributing to pre‐capillary aspects in the initially isolated post‐capillary PH. Inhibition of the endothelin pathway could potentially stop the progression of early stage post‐capillary PH.
Abstract Passive, isolated post‐capillary pulmonary hypertension (IpcPH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH (CpcPH) characterized by chronic pulmonary vascular constriction and remodelling. The mechanisms underlying this ‘activation’ of passive pulmonary hypertension (PH) remain incompletely understood. Here we investigated the role of the vasoconstrictor endothelin‐1 (ET) in the progression from IpcPH to CpcPH in a swine model for post‐capillary PH. Swine underwent pulmonary vein banding (PVB; n = 7) or sham‐surgery (Sham; n = 6) and were chronically instrumented 4 weeks later. Haemodynamics were assessed for 8 weeks, at rest and during exercise, before and after administration of the ET receptor antagonist tezosentan. After sacrifice, the pulmonary vasculature was investigated by histology, RT‐qPCR and myograph experiments. Pulmonary arterial pressure and resistance increased significantly over time. mRNA expression of prepro‐endothelin‐1 and endothelin converting enzyme‐1 in the lung was increased, while ETA expression was unchanged and ETB expression was downregulated. This was associated with increased plasma ET levels from week 10 onward and a more pronounced vasodilatation to in vivo administration of tezosentan at rest and during exercise. Myograph experiments showed decreased endothelium‐dependent vasodilatation to Substance P and increased vasoconstriction to KCl in PVB swine consistent with increased muscularization observed with histology. Moreover, maximal vasoconstriction to ET was increased whereas ET sensitivity was decreased. In conclusion, PVB swine gradually developed PH with structural and functional vascular remodelling. From week 10 onward, the pulmonary ET pathway was upregulated, likely contributing to pre‐capillary activation of the initially isolated post‐capillary PH. Inhibition of the ET pathway could thus potentially provide a pharmacotherapeutic target for early stage post‐capillary PH. Passive, isolated post‐capillary pulmonary hypertension (PH) secondary to left heart disease may progress to combined pre‐ and post‐capillary or ‘active’ PH This ‘activation’ of post‐capillary PH significantly increases morbidity and mortality, and is still incompletely understood. In this study, pulmonary vein banding gradually produced post‐capillary PH with structural and functional microvascular remodelling in swine. Ten weeks after banding, the pulmonary endothelin pathway was upregulated, likely contributing to pre‐capillary aspects in the initially isolated post‐capillary PH. Inhibition of the endothelin pathway could potentially stop the progression of early stage post‐capillary PH.
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Affiliation(s)
- Richard W B van Duin
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Kelly Stam
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Zongye Cai
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - André Uitterdijk
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Ana Garcia-Alvarez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.,CIBERCV, Madrid, Spain
| | - A H Jan Danser
- Department of Pharmacology, Erasmus MC, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Pediatrics / Neonatology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
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Ramu B, Houston BA, Tedford RJ. Pulmonary Vascular Disease: Hemodynamic Assessment and Treatment Selection—Focus on Group II Pulmonary Hypertension. Curr Heart Fail Rep 2018; 15:81-93. [DOI: 10.1007/s11897-018-0377-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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9
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Guazzi M, Naeije R. Pulmonary Hypertension in Heart Failure: Pathophysiology, Pathobiology, and Emerging Clinical Perspectives. J Am Coll Cardiol 2017; 69:1718-1734. [PMID: 28359519 DOI: 10.1016/j.jacc.2017.01.051] [Citation(s) in RCA: 213] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 02/08/2023]
Abstract
Pulmonary hypertension is a common hemodynamic complication of heart failure. Interest in left-sided pulmonary hypertension has increased remarkably in recent years because its development and consequences for the right heart are now seen as mainstay abnormalities that begin in the early stages of the disease and bear unfavorable prognostic insights. However, some knowledge gaps limit our ability to influence this complex condition. Accordingly, attention is now focused on: 1) establishing a definitive consensus for a hemodynamic definition, perhaps incorporating exercise and fluid challenge; 2) implementing the limited data available on the pathobiology of lung capillaries and small arteries; 3) developing standard methods for assessing right ventricular function and, hopefully, its coupling to pulmonary circulation; and 4) searching for effective therapies that may benefit lung vessels and the remodeled right ventricle. The authors review the pathophysiology, pathobiology, and emerging clinical perspectives on pulmonary hypertension across the broad spectrum of heart failure stages.
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Affiliation(s)
- Marco Guazzi
- IRCCS Policlinico San Donato Hospital, University of Milan, Milan, Italy.
| | - Robert Naeije
- Erasme Hospital, Free University of Brussels, Brussels, Belgium
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10
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Abstract
Pulmonary hypertension associated with left heart disease is the most common form of pulmonary hypertension. Although its pathophysiology remains incompletely understood, it is now well recognized that the presence of pulmonary hypertension is associated with a worse prognosis. Right ventricular failure has independent and additive prognostic value over pulmonary hypertension for adverse outcomes in left heart disease. Recently, several new terminologies have been introduced to better define and characterize the nature and severity of pulmonary hypertension. Several new treatment options including the use of pulmonary arterial hypertension specific therapies are being considered, but there is lack of evidence. Here, we review the recent advances in this field and summarize the diagnostic and therapeutic modalities of use in the management of pulmonary hypertension associated with left heart disease.
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Affiliation(s)
- Bhavadharini Ramu
- Cardiovascular Division, Section of Advanced Heart Failure and Pulmonary Hypertension, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Thenappan Thenappan
- Cardiovascular Division, Section of Advanced Heart Failure and Pulmonary Hypertension, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN, 55455, USA.
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Lai YC, Tabima DM, Dube JJ, Hughan KS, Vanderpool RR, Goncharov DA, St Croix CM, Garcia-Ocaña A, Goncharova EA, Tofovic SP, Mora AL, Gladwin MT. SIRT3-AMP-Activated Protein Kinase Activation by Nitrite and Metformin Improves Hyperglycemia and Normalizes Pulmonary Hypertension Associated With Heart Failure With Preserved Ejection Fraction. Circulation 2016; 133:717-31. [PMID: 26813102 DOI: 10.1161/circulationaha.115.018935] [Citation(s) in RCA: 190] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 01/08/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pulmonary hypertension associated with heart failure with preserved ejection fraction (PH-HFpEF) is an increasingly recognized clinical complication of metabolic syndrome. No adequate animal model of PH-HFpEF is available, and no effective therapies have been identified to date. A recent study suggested that dietary nitrate improves insulin resistance in endothelial nitric oxide synthase null mice, and multiple studies have reported that both nitrate and its active metabolite, nitrite, have therapeutic activity in preclinical models of pulmonary hypertension. METHODS AND RESULTS To evaluate the efficacy and mechanism of nitrite in metabolic syndrome associated with PH-HFpEF, we developed a 2-hit PH-HFpEF model in rats with multiple features of metabolic syndrome attributable to double-leptin receptor defect (obese ZSF1) with the combined treatment of vascular endothelial growth factor receptor blocker SU5416. Chronic oral nitrite treatment improved hyperglycemia in obese ZSF1 rats by a process that requires skeletal muscle SIRT3-AMPK-GLUT4 signaling. The glucose-lowering effect of nitrite was abolished in SIRT3-deficient human skeletal muscle cells, and in SIRT3 knockout mice fed a high-fat diet, as well. Skeletal muscle biopsies from humans with metabolic syndrome after 12 weeks of oral sodium nitrite and nitrate treatment (IND#115926) displayed increased activation of SIRT3 and AMP-activated protein kinase. Finally, early treatments with nitrite and metformin at the time of SU5416 injection reduced pulmonary pressures and vascular remodeling in the PH-HFpEF model with robust activation of skeletal muscle SIRT3 and AMP-activated protein kinase. CONCLUSIONS These studies validate a rodent model of metabolic syndrome and PH-HFpEF, suggesting a potential role of nitrite and metformin as a preventative treatment for this disease.
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Affiliation(s)
- Yen-Chun Lai
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Diana M Tabima
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - John J Dube
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Kara S Hughan
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Rebecca R Vanderpool
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Dmitry A Goncharov
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Claudette M St Croix
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Adolfo Garcia-Ocaña
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Elena A Goncharova
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Stevan P Tofovic
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Ana L Mora
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.)
| | - Mark T Gladwin
- From Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA (Y.-C.L., D.M.T., K.S.H., R.R.V., D.A.G., E.A.G., S.P.T., A.L.M., M.T.G.); Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, PA (J.J.D.); Division of Pediatric Endocrinology, Metabolism and Diabetes Mellitus, University of Pittsburgh, Pittsburgh, PA (K.S.H.); Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, PA (C.M.St.C.); Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY (A.G.-O.); and Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA (E.A.G., S.P.T., A.L.M., M.T.G.).
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12
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Breitling S, Ravindran K, Goldenberg NM, Kuebler WM. The pathophysiology of pulmonary hypertension in left heart disease. Am J Physiol Lung Cell Mol Physiol 2015; 309:L924-41. [DOI: 10.1152/ajplung.00146.2015] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/20/2015] [Indexed: 12/17/2022] Open
Abstract
Pulmonary hypertension (PH) is characterized by elevated pulmonary arterial pressure leading to right-sided heart failure and can arise from a wide range of etiologies. The most common cause of PH, termed Group 2 PH, is left-sided heart failure and is commonly known as pulmonary hypertension with left heart disease (PH-LHD). Importantly, while sharing many clinical features with pulmonary arterial hypertension (PAH), PH-LHD differs significantly at the cellular and physiological levels. These fundamental pathophysiological differences largely account for the poor response to PAH therapies experienced by PH-LHD patients. The relatively high prevalence of this disease, coupled with its unique features compared with PAH, signal the importance of an in-depth understanding of the mechanistic details of PH-LHD. The present review will focus on the current state of knowledge regarding the pathomechanisms of PH-LHD, highlighting work carried out both in human trials and in preclinical animal models. Adaptive processes at the alveolocapillary barrier and in the pulmonary circulation, including alterations in alveolar fluid transport, endothelial junctional integrity, and vasoactive mediator secretion will be discussed in detail, highlighting the aspects that impact the response to, and development of, novel therapeutics.
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Affiliation(s)
- Siegfried Breitling
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute for Chemistry and Biochemistry, Freie Universität Berlin, Germany
| | - Krishnan Ravindran
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Neil M. Goldenberg
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Wolfgang M. Kuebler
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Germany
- Departments of Surgery and Physiology, University of Toronto, Toronto, Ontario, Canada; and
- German Heart Institute Berlin, Berlin, Germany
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Rose-Jones LJ, Mclaughlin VV. Pulmonary hypertension: types and treatments. Curr Cardiol Rev 2015; 11:73-9. [PMID: 24251459 PMCID: PMC4347212 DOI: 10.2174/1573403x09666131117164122] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 07/09/2013] [Accepted: 09/27/2013] [Indexed: 11/28/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a panvasculopathy that affects the distal pulmonary arteries and leads to restricted blood flow. This increased afterload leads to adaptive mechanisms of the right ventricle, with eventual failure once it can no longer compensate. Pulmonary hypertension from associated conditions, most importantly left heart disease, i.e. heart failure, can also lead to the same sequela. Patients often experience early vague symptoms of dyspnea and exercise intolerance, and thus PH can elude clinicians until right heart failure symptoms predominate. Evidence-based treatment options with pulmo-nary vasodilators are available for those with PAH and should be employed early. It is essential that patients be accurately categorized by their etiology of PH, as treatment strategies differ, and can potentially be dangerous if employed in the wrong clinical scenario.
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Affiliation(s)
| | - Vallerie V Mclaughlin
- UNC Center for Heart & Vascular Care, 160 Dental Circle, CB 7075, Chapel Hill, NC 27599-7075, USA.
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14
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Guazzi M, Phillips SA, Arena R, Lavie CJ. Endothelial dysfunction and lung capillary injury in cardiovascular diseases. Prog Cardiovasc Dis 2014; 57:454-62. [PMID: 25446556 DOI: 10.1016/j.pcad.2014.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Cardiac dysfunction of both systolic and diastolic origins leads to increased left atrial pressure, lung capillary injury and increased resistance to gas transfer. Acutely, pressure-induced trauma disrupts the endothelial and alveolar anatomical configuration and definitively causes an impairment of cellular pathways involved in fluid-flux regulation and gas exchange efficiency, a process well identified as stress failure of the alveolar-capillary membrane. In chronic heart failure (HF), additional stimuli other than pressure may trigger the true remodeling process of capillaries and small arteries characterized by endothelial dysfunction, proliferation of myofibroblasts, fibrosis and extracellular matrix deposition. In parallel there is a loss of alveolar gas diffusion properties due to the increased path from air to blood (thickening of extracellular matrix) and loss of fine molecular mechanism involved in fluid reabsorption and clearance. Deleterious changes in gas transfer not only reflect the underlying lung tissue damage but also portend independent prognostic information and may play a role in the pathogenesis of exercise limitation and ventilatory abnormalities observed in these patients. Few currently approved treatments for chronic HF have the potential to positively affect structural remodeling of the lung capillary network; angiotensin-converting enzyme inhibitors are one of the few currently established options. Recently, more attention has been paid to novel therapies specifically targeting the nitric oxide pathway as a suitable target to improve endothelial function and permeability as well as alveolar gas exchange properties.
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, I.R.C.C.S. Policlinico San Donato, University of Milano, San Donato Milanese, Italy.
| | - Shane A Phillips
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Ross Arena
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA, USA
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15
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Abstract
The origins of the hydralazine/isosorbide dinitrate (H+ISDN) combination therapy are rooted in the first large-scale clinical trial in heart failure: V-HeFT I. Initially utilized for the balanced vasodilatory properties of each drug, we now know there is "more to the story." In fact, the maintenance of the nitroso-redox balance may be the true mechanism of benefit. Since the publication of V-HeFT I 30 years ago, H+ISDN has been the subject of much discussion and debate. Regardless of the many controversies surrounding H+ISDN, one thing is clear: therapy is underutilized and many patients who could benefit never receive the drugs. Ongoing physician and patient education are mandatory to improve the rates of H+ISDN use.
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Affiliation(s)
- Robert T Cole
- Division of Cardiology, Emory University, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Divya Gupta
- Division of Cardiology, Emory University, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA
| | - Javed Butler
- Division of Cardiology, Emory University, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA
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16
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Abstract
Pulmonary hypertension (PH), a common complication of left heart diseases (LHD), negatively impacts symptoms, exercise capacity, and outcome. Although the true prevalence of PH-LHD is unknown, a subset of patients might present significant PH that cannot be explained by a passive increase in left-sided filling pressures. The term "out-of-proportion" PH has been used to identify that population without a clear definition, which has been found less than ideal and created confusion. We propose a change in terminology and a new definition of PH due to LHD. We suggest to abandon "out-of-proportion" PH and to distinguish "isolated post-capillary PH" from "post-capillary PH with a pre-capillary component" on the basis of the pressure difference between diastolic pulmonary artery pressure and pulmonary artery wedge pressure. Although there is no validated treatment for PH-LHD, we provide insights into management and discuss completed and randomized trials in this condition. Finally, we provide recommendations for future clinical trials to establish safety and efficacy of novel compounds to target this area of unmet medical need.
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17
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Taylor BJ, Mojica CR, Olson TP, Woods PR, Frantz RP, Johnson BD. A possible role for systemic hypoxia in the reactive component of pulmonary hypertension in heart failure. J Card Fail 2013; 19:50-9. [PMID: 23273594 DOI: 10.1016/j.cardfail.2012.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 10/12/2012] [Accepted: 11/13/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND The mechanisms underlying the reactive component of pulmonary hypertension (PH) in heart failure (HF) are unclear. We examined whether resting systemic oxygen levels are related to pulmonary hemodynamics in HF. METHODS AND RESULTS Thirty-nine HF patients underwent right heart catheterization. Subsequently, patients were classified as having: 1) no PH (n = 12); 2) passive PH (n = 10); or 3) reactive PH (n = 17). Blood was drawn from the radial and pulmonary arteries for the determination of PaO(2), SaO(2), PvO(2), SvO(2), and vasoactive neurohormones. PaO(2) and PvO(2) were lower in reactive PH versus no PH and passive PH patients (65.3 ± 8.6 vs 78.3 ± 11.4 mm Hg and 74.5 ± 14.0 mm Hg; 29.2 ± 4.1 vs 36.2 ± 2.8 mm Hg and 33.4 ± 2.3 mm Hg; P < .05). SaO(2) and SvO(2) were lower in reactive PH versus no PH patients (93 ± 3% vs 96 ± 3%; 51 ± 11% vs 68 ± 4%; P < .05), but not different versus passive PH patients. The transpulmonary pressure gradient (TPG) was inversely related to PaO(2), PvO(2), SaO(2), and SvO(2) in the reactive PH patients only (r ≤ -0.557; P < .05). Similarly, plasma endothelin-1 correlated with PaO(2), PvO(2), SvO(2) (r ≤ -0.495), and TPG (r = 0.662; P < .05) in reactive PH patients only. CONCLUSIONS Systemic hypoxia may play a role in the reactive component of PH in HF, potentially via a hypoxia-induced increase in endothelial release of the vasoconstrictor endothelin-1.
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Affiliation(s)
- Bryan J Taylor
- Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, Cardiology, I.R.C.C.S., Policlinico San Donato, Department of Medical Sciences, University of Milano, Piazza Malan 1 20097, San Donato Milanese, Milano, Italy.
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Marti CN, Gheorghiade M, Kalogeropoulos AP, Georgiopoulou VV, Quyyumi AA, Butler J. Endothelial dysfunction, arterial stiffness, and heart failure. J Am Coll Cardiol 2012; 60:1455-69. [PMID: 22999723 DOI: 10.1016/j.jacc.2011.11.082] [Citation(s) in RCA: 309] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 11/26/2011] [Accepted: 11/29/2011] [Indexed: 12/11/2022]
Abstract
Outcomes for heart failure (HF) patients remain suboptimal. No known therapy improves mortality in acute HF and HF with preserved ejection fraction; the most recent HF trial results have been negative or neutral. Improvement in surrogate markers has not necessarily translated into better outcomes. To translate breakthroughs with potential therapies into clinical benefit, a better understanding of the pathophysiology establishing the foundation of benefit is necessary. Vascular function plays a central role in the development and progression of HF. Endothelial function and nitric oxide availability affect myocardial function, systemic and pulmonary hemodynamics, and coronary and renal circulation. Arterial stiffness modulates ventricular loading conditions and diastolic function, key components of HF with preserved ejection. Endothelial function and arterial stiffness may therefore serve as important physiological targets for new HF therapies and facilitate patient selection for improved application of existing agents.
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Affiliation(s)
- Catherine N Marti
- Cardiology Division, Department of Medicine, Emory University, Atlanta, Georgia, USA
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20
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Abstract
For patients with heart failure (HF), dyspnea and fatigue resulting in diminished exercise tolerance are among the main factors that contribute to decreased social and physical functioning and quality of life. There has long been evidence to suggest that measures of cardiac function, such as ejection fraction and cardiac output, only poorly correlate with a patient's exercise capacity, indicating the involvement of factors other than those impacting central circulation. The lack of a close correlation between central hemodynamics and exercise tolerance has led to investigations into alterations in the periphery, such as abnormalities in vascular endothelial function, hyperactivation of the sympathetic nervous system, and changes in structure and oxidative capacity of skeletal muscle, which are commonly seen in patients with HF. Over the past 2 decades, numerous clinical trials have demonstrated the beneficial impact of exercise training on skeletal muscle energy metabolism, vascular function, and ventilatory capacity, which correlate with improvements in exercise tolerance, hospitalization rates, and quality of life of patients with HF. In accordance with recent guidelines established by the leading cardiology societies in the United States and Europe, physicians are urged to emphasize exercise training for all clinically stable patients with HF using individualized protocols that feature early mobilization after acute exacerbations of the disease and gradual increases in intensity.
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Haddad F, Kudelko K, Mercier O, Vrtovec B, Zamanian RT, de Jesus Perez V. Pulmonary hypertension associated with left heart disease: characteristics, emerging concepts, and treatment strategies. Prog Cardiovasc Dis 2011; 54:154-67. [PMID: 21875514 DOI: 10.1016/j.pcad.2011.06.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Left heart disease (LHD) represents the most common causes of pulmonary hypertension (PH). Whether caused by systolic or diastolic dysfunction or valvular heart disease, a hallmark of PH associated with LHD is elevated left atrial pressure. In all cases, the increase in left atrial pressure causes a passive increase in pulmonary pressure. In some patients, a superimposed active component caused by pulmonary arterial vasoconstriction and vascular remodeling may lead to a further increase in pulmonary arterial pressure. When present, PH is associated with a worse prognosis in patients with LHD. In addition to local abnormalities in nitric oxide and endothelin production, gene modifiers such as serotonin polymorphisms may be associated with the pathogenesis of PH in LHD. Optimizing heart failure regimens and corrective valve surgery represent the cornerstone of the treatment of PH in LHD. Recent studies suggest that sildenafil, a phosphodiesterase-5 inhibitor, is a promising agent in the treatment of PH in LHD. Unloading the left ventricle with circulatory support may also reverse severe PH in patients with end-stage heart failure allowing candidacy to heart transplantation.
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Affiliation(s)
- Francois Haddad
- Division of Cardiovascular Medicine, Stanford School of Medicine, CA 94305, USA.
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22
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Cole RT, Kalogeropoulos AP, Georgiopoulou VV, Gheorghiade M, Quyyumi A, Yancy C, Butler J. Hydralazine and isosorbide dinitrate in heart failure: historical perspective, mechanisms, and future directions. Circulation 2011; 123:2414-22. [PMID: 21632515 DOI: 10.1161/circulationaha.110.012781] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
Pulmonary hypertension (PH) with left-sided heart disease is defined, according to the latest Venice classification, as a Group 2 PH, which includes left-sided ventricular or atrial disease, and left-sided valvular diseases. These conditions are all associated with increased left ventricular filling pressure. Although PH with left-sided heart disease is a common entity, and long-term follow-up trials have provided firm recognition that development of left-sided PH carries a poor outcome, available data on incidence, pathophysiology, and therapy are sparse. Mitral stenosis was reported as the most frequent cause of PH several decades ago, but PH with left-sided heart disease is now usually caused by systemic hypertension and ischemic heart disease. In patients with these conditions, PH develops as a consequence of impaired left ventricular relaxation and distensibility. Chronic sustained elevation of cardiogenic blood pressure in pulmonary capillaries leads to a cascade of untoward retrograde anatomical and functional effects that represent specific targets for therapeutic intervention. The pathophysiological and clinical importance of the hemodynamic consequences of left-sided heart disease, starting with lung capillary injury and leading to right ventricular overload and failure, are discussed in this Review, focusing on PH as an evolving contributor to heart failure that may be amenable to novel interventions.
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Affiliation(s)
- Marco Guazzi
- Cardiopulmonary Unit, University of Milan, San Paolo Hospital, Via A. di Rudinì 8, 20142 Milan, Italy.
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24
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Guglin M, Khan H. Pulmonary hypertension in heart failure. J Card Fail 2010; 16:461-74. [PMID: 20610227 DOI: 10.1016/j.cardfail.2010.01.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 01/14/2010] [Accepted: 01/19/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pulmonary hypertension occurs in 60% to 80% of patients with heart failure and is associated with high morbidity and mortality. METHODS AND RESULTS Pulmonary artery pressure correlates with increased left ventricular end-diastolic pressure. Therefore, pulmonary hypertension is a common feature of heart failure with preserved as well as reduced systolic function. Pulmonary hypertension is partially reversible with normalization of cardiac filling pressures. Pulmonary vasculature remodeling and vasoconstriction create a second component, which does not reverse immediately, but has been shown to improve with vasoactive drugs and especially with left ventricular assist devices. CONCLUSION Many drugs used for idiopathic pulmonary arterial hypertension are being considered as treatment options for heart failure-related pulmonary hypertension. This is of particular significance in the heart transplant population. Randomized clinical trials with interventions targeting heart failure patients with elevated pulmonary artery pressure would be justified.
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Affiliation(s)
- Maya Guglin
- Department of Cardiology, University of South Florida, Tampa, Florida 33618, USA.
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25
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Nellessen U, Inselmann G, Ludwig J, Jahns R, Capell AJ, Eigel P. Rest and exercise hemodynamics before and after valve replacement--a combined Doppler/catheter study. Clin Cardiol 2009; 23:32-8. [PMID: 10680027 PMCID: PMC6655087 DOI: 10.1002/clc.4960230107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemodynamic improvement is a common finding following valve replacement. However, despite a normally functioning prosthesis and normal left ventricular ejection fraction, some patients may show an abnormal hemodynamic response to exercise. METHODS In a combined catheter/Doppler study, rest and exercise hemodynamics were evaluated in 23 patients following aortic (n = 12) (Group 1) or mitral valve (n = 11) (Group 2) replacement and compared with preoperative findings. Patient selection was based on absence of coronary artery disease and left ventricular failure as shown by preoperative angiography. Cardiac output, pulmonary artery pressure, pulmonary capillary pressure, and pulmonary resistance were measured by right heart catheterization, whereas the gradient across the valve prosthesis was determined by Doppler echocardiography. Postoperative evaluation was done at rest and during exercise. The mean follow-up was 8.2 +/- 2.2 years in Group 1 and 4.2 +/- 1 years in Group 2. RESULTS With exercise, there was a significant rise in cardiac output in both groups. In Group 1, mean pulmonary pressure/capillary pressure decreased from 24 +/- 9/18 +/- 9 mmHg preoperatively to 18 +/- 2/12 +/- 4 mmHg postoperatively (p < 0.05), and increased to 43 +/- 12/30 +/- 8 mmHg with exercise (p < 0.05). The corresponding values for Group 2 were 36 +/- 12/24 +/- 6 mmHg preoperatively, 24 +/- 7/17 +/- 6 mmHg postoperatively (p < 0.05), and 51 +/- 2/38 +/- 4 mmHg with exercise (p < 0.05). Pulmonary vascular resistance was 109 +/- 56 dyne.s.cm-5 preoperatively, 70 +/- 39 dyne.s.cm-5 postoperatively (p < 0.05), and 70 +/- 36 dyne.s.cm-5 with exercise in Group 1. The corresponding values for Group 2 were 241 +/- 155 dyne.s.cm-5, 116 +/- 39 dyne.s.cm-5 (p < 0.05), and 104 +/- 47 dyne.s.cm-5. There was a significant increase in the gradients across the valve prosthesis in both groups, showing a significant correlation between the gradient at rest and exercise. No correlation was found between valve prosthesis gradient and pulmonary pressures. CONCLUSION Exercise-induced pulmonary hypertension and abnormal left ventricular filling pressures seem to be a frequent finding following aortic or mitral valve replacement. Both hemodynamic abnormalities seem not to be determined by obstruction to flow across the valve prosthesis and may be concealed, showing nearly normal values at rest but a pathologic response to physical stress.
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Affiliation(s)
- U Nellessen
- Johanniter-Krankenhaus der Altmark, Stendal gGmbH, Medizinische Klinik II, Germany
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Bozzetti G, Ranucci M, Grillone G. Concomitant Pulmonary Hypertension and Vasoplegia Syndrome After Heart Transplant: A Challenging Picture. J Cardiothorac Vasc Anesth 2008; 22:868-71. [DOI: 10.1053/j.jvca.2007.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Indexed: 11/11/2022]
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Abstract
Patients with heart failure (HF) due to left ventricular (LV) systolic dysfunction have abnormal endothelium-dependent, nitric oxide-cyclic guanosine monophosphate-mediated vasodilation in the pulmonary and skeletal muscle vasculature. Therefore, inhibition of type 5 phosphodiesterase (PDE5), the principle enzyme responsible for cyclic guanosine monophosphate catabolism in the lungs and skeletal muscle, has been targeted in an effort to counteract vasoconstriction that contributes to increased right and LV afterload in HF. The efficacy of PDE5 inhibition in the treatment of pulmonary arterial hypertension has led to the investigation of its potential utility in the treatment of HF patients with secondary pulmonary hypertension. Moreover, recent preclinical studies suggest direct myocardial effects of PDE5 inhibition that may counteract beta-adrenergic, hypertrophic, and pro-apoptotic signaling, three critical pathways in the development of LV dysfunction. This review outlines both the underlying rationale and the results of initial studies of the therapeutic effects of PDE5 inhibition in HF.
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Affiliation(s)
- Gregory D Lewis
- Cardiology Division, Bigelow 800, MassachusettsGeneral Hospital, 55 Fruit St., Boston, MA 02114, USA
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28
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Abstract
Lung capillary pressure in healthy humans at rest ranges between 6 and 10 mmHg. At maximal effort or in pathophysiological conditions such as left sided heart disease or massive pulmonary vasoconstriction, for example in high-altitude pulmonary disease, capillary pressure may be markedly elevated. Increased capillary pressure directly affects transendothelial fluid dynamics and thus results in the formation of hydrostatic lung edema. Excessive pressure increases may cause capillary stress failure. Recent studies, however, suggest that the microvascular response to lung capillary hypertension is more complex. Pressure, strain and shear stress cause dysfunction of the capillary endothelium characterized by an imbalanced release of vasoactive mediators. Endothelial dysfunction evokes a multicellular response with features of vasoconstriction, inflammation, and vascular leakage, thrombosis, and remodeling. These active cellular reactions contribute to the pathophysiological process and may be specifically targeted by new therapeutic strategies.
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Affiliation(s)
- Wolfgang M Kuebler
- Department of Anesthesiology, Deutsches Herzzentrum, Free University of Berlin, Berlin, Germany.
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29
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Abstract
Erectile dysfunction (ED) is highly prevalent in patients with chronic heart failure (CHF) and is among the most distressing symptoms in this patient population. Although the safety and efficacy of phosphodiesterase 5 (PDE5) inhibitors in the management of ED have been evaluated in many cardiovascular disease populations, scant data are available in patients with CHF. In published studies, the short-term safety and efficacy of sildenafil in patients with stable mild-to-moderate CHF with ED appears to be comparable to that observed in other populations with cardiovascular disease. Evidence is not available on the effects of vardenafil or tadalafil in CHF. In addition to their benefits in the treatment of ED, preliminary studies suggest that PDE5 inhibitors enhance endothelial function in patients with CHF and have beneficial effects on pulmonary hemodynamics and exercise capacity in patients with pulmonary hypertension. Additional studies are needed to determine the therapeutic potential of this class of agents in these disease states.
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Affiliation(s)
- Milan D Patel
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut 06510, USA
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30
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Kubánek M, Málek I, Kautzner J, Hegarová M, Wiendl M, Lupínek P, Karasová L, Lánská V. The value of B-type natriuretic peptide and big endothelin-1 for detection of severe pulmonary hypertension in heart transplant candidates. Eur J Heart Fail 2005; 7:1149-55. [PMID: 15916922 DOI: 10.1016/j.ejheart.2004.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2004] [Revised: 10/12/2004] [Accepted: 12/20/2004] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Severe pulmonary hypertension (PH) and increased pulmonary vascular resistance (PVR) are important risk factors that predict early postoperative mortality after orthotopic heart transplantation. The aim of our study was to determine the value of B-type natriuretic peptide (BNP) and big endothelin-1 (big ET1) for prediction of severe PH in heart transplant candidates. METHODS The study population included 43 potential heart transplant candidates (38 males, mean age 52 +/- 7 years). All underwent repeated right-heart catheterizations (2-5 studies) at an interval of 3-4 months, giving a total of 124 examinations, associated with blood sampling for BNP and big ET1 analysis. Severe PH was defined as the mean pulmonary artery pressure (MPAP) > 40 mmHg. RESULTS Significantly high PVR (PVR > 3.0 Wood units and TPG > 15 mmHg) was noted on 12 occasions in 10 patients; always in the presence of severe PH. Low BNP levels (<67 pg/ml) ruled out the presence of severe PH with a 100% sensitivity, however, with a low specificity (34%). An increase in plasma BNP > 30 pg/ml (>40% of initial value) in subjects with a previous MPAP< or =40 mmHg detected development of severe PH with a 100% sensitivity and an 80-88% specificity. As a total of 58% of patients presented repeatedly with MPAP< or =40 mmHg, serial BNP testing could reduce the need for hemodynamic studies in this subgroup down to 12-20%. CONCLUSIONS Serial BNP testing in hemodynamically stable heart transplant candidates with MPAP< or =40 mmHg allows reliable detection of development of severe PH, and may significantly reduce the need for repeated right-heart catheterizations in these patients.
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Affiliation(s)
- Milos Kubánek
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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Katz SD, Hryniewicz K, Hriljac I, Balidemaj K, Dimayuga C, Hudaihed A, Yasskiy A. Vascular endothelial dysfunction and mortality risk in patients with chronic heart failure. Circulation 2005; 111:310-4. [PMID: 15655134 DOI: 10.1161/01.cir.0000153349.77489.cf] [Citation(s) in RCA: 307] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endothelial function is known to be impaired in subjects with chronic heart failure (CHF), but the association between endothelial function and subsequent mortality risk in CHF has not been previously reported. METHODS AND RESULTS Biomarkers of endothelial function in the systemic arterial circulation (flow-mediated dilation [FMD] in the brachial artery) and the pulmonary circulation (exhaled nitric oxide [NO] production during submaximal exercise) were prospectively assessed in 259 subjects with New York Heart Association class II-III CHF. In subjects with FMD measurements (n=149), there were 12 deaths and 5 urgent transplantations over a median follow-up period of 841 days. In subjects with exhaled NO production measurements (n=110), there were 18 deaths and 1 urgent transplantation over a median follow-up period of 396 days. Both decreased FMD and decreased exhaled NO production were associated with increased risk of death or urgent transplantation after adjustment for other known CHF prognostic factors (age, etiology of CHF, functional class, left ventricular ejection fraction) in Cox multivariate proportional-hazards models (adjusted hazard ratio [HR] estimate for a 1% decrease in FMD=1.20; 95% confidence interval [CI], 1.03 to 1.45; P=0.027; adjusted HR estimate for a 1-ppb/min decrease in exhaled NO production=1.31, 95% CI, 1.01 to 1.69, P=0.04). CONCLUSIONS Endothelial dysfunction in CHF, as assessed by FMD in the brachial artery and exhaled NO production during submaximal exercise, is associated with an increased mortality risk in subjects with both ischemic and nonischemic CHF.
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Affiliation(s)
- Stuart D Katz
- Department of Internal Medicine, Yale University School of Medicine, 135 College St, Ste 301, New Haven, CT 06510, USA.
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Tsutsui JM, Xie F, Cano M, Chomas J, Phillips P, Radio SJ, Lof J, Porter TR. Detection of retained microbubbles in carotid arteries with real-time low mechanical index imaging in the setting of endothelial dysfunction. J Am Coll Cardiol 2004; 44:1036-46. [PMID: 15337216 DOI: 10.1016/j.jacc.2004.05.056] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Revised: 05/13/2004] [Accepted: 05/18/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We sought to determine if intravenously injected microbubbles would be retained by the carotid arteries (CAs) in the setting of endothelial dysfunction (ED) using a linear transducer equipped with a low mechanical index pulse sequence scheme (PSS). BACKGROUND Microbubbles normally pass freely through large and small vessels but are retained in regions with ED. New high-frequency low mechanical index PSS can potentially be utilized to image these retained microbubbles. METHODS Intravenous albumin- and lipid-encapsulated microbubbles were administered in seven pigs while imaging the CAs before and after a 20% intralipid infusion to induce hypertriglyceridemia. The degree of microbubble retention was quantified by measuring endothelial acoustic intensity (AI) after clearance of free-flowing microbubbles. Microbubble adherence was also evaluated after selective balloon injury of the CAs. The CA diameter responses to acetylcholine were quantified. RESULTS After induction of hypertriglyceridemia, adherence of albumin-encapsulated microbubbles was visually evident in all CAs, and endothelial AI increased significantly (p < 0.001 compared with baseline). The CA responses to acetylcholine went from vasodilation at baseline to vasoconstriction during hypertriglyceridemia. Endothelial AI also increased in the balloon-stretched vessels (p < 0.01 compared with uninjured vessels) after albumin-encapsulated microbubble injection, with a ring of microbubbles selectively adhering to the injured segment. This retention was not observed with lipid-encapsulated microbubbles. Scanning electron microscopy confirmed that albumin-coated microbubbles adhered to endothelial cells. CONCLUSIONS Retention of intravenously injected albumin microbubbles occurs in the setting of both global and regional ED in large vessels and can be noninvasively imaged with high-frequency low mechanical index PSS.
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Affiliation(s)
- Jeane M Tsutsui
- Section of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska 68198-1165, USA
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Abstract
Assessment of the pulmonary circulation and right ventricular function is a cornerstone in the evaluation of the patient as a potential heart transplant recipient. The importance of pulmonary hypertension is linked to outcomes in the posttransplant period. Preoperative pulmonary vascular resistance is an independent risk factor for early death after heart transplantation. Pulmonary hypertension can be classified as reversible, or irreversible if not rapidly responsive to pharmacologic maneuvers. However, in most patients, the major component is likely to reverse with vasodilators, because of the central role played by the endothelium in the control of pulmonary vascular tone. To discriminate between patients with reversible and irreversible pulmonary hypertension, provocative therapies are used, and baseline and the postprovocation hemodynamic parameters are measured. To date, there is no reliable hemodynamic threshold beyond which right ventricular failure is certain to occur, nor are there values below which right ventricular failure is always avoidable. Because of this uncertainty, it becomes clear that only through careful preoperative assessment can this life-threatening condition be recognized preoperatively and, hence, managed in the posttransplant recovery period.
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Affiliation(s)
- Maria Eugenia Natale
- Heart Failure and Transplant Center University Hospitals of Cleveland, OH 44106, USA.
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Berger RMF, Cromme-Dijkhuis AH, Hop WCJ, Kruit MN, Hess J. Pulmonary arterial wall distensibility assessed by intravascular ultrasound in children with congenital heart disease: an indicator for pulmonary vascular disease? Chest 2002; 122:549-57. [PMID: 12171830 DOI: 10.1378/chest.122.2.549] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Both pulmonary hypertension and pulmonary overflow are associated with functional and structural changes of the pulmonary arterial wall. Current techniques to evaluate the pulmonary vasculature neglect the pulsatile nature of pulmonary flow. STUDY OBJECTIVES To determine whether the dynamic properties of the pulmonary arterial wall are altered in patients with abnormal pulmonary hemodynamics due to congenital heart defects, and whether these changes are associated with the progression of pulmonary vascular disease (PVD). PATIENTS AND METHODS In 43 children with PVD due to congenital heart defects and 12 control subjects, pulmonary arterial pulsatility (the relative increase in vessel area during the cardiac cycle) and distensibility (the inverse of the stress/strain elastic modulus) were determined with intravascular ultrasound. Results were correlated with clinical and hemodynamic parameters. RESULTS Pulsatility correlated with pulmonary pulse pressure (p < 0.001), pulmonary-to-systemic vascular resistance ratio (PVR/SVR) [p = 0.001], and hemoglobin concentration (p = 0.01). However, when corrected for these variables, pulsatility did not differ between patients and control subjects. In contrast, arterial wall distensibility decreased with the severity of PVD and correlated independently with pulmonary-to-systemic arterial pressure ratio (p < 0.001) and PVR/SVR (p = 0.03), and with hemoglobin concentration (p < 0.01). Adjusted for hemodynamic variables, distensibility was still decreased in patients with PVD compared to control subjects. CONCLUSIONS These results demonstrate that pulmonary arterial wall distensibility is progressively decreased in PVD; moreover, this decreased distensibility is, in part, related to increased distending pressure as a result of pulmonary hypertension but also, in part, to stiffening of the arterial wall during the disease process. Arterial wall distensibility may be of additional value in the evaluation of pulmonary vasculature and ventricular workload.
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Affiliation(s)
- Rolf M F Berger
- Department of Pediatrics, Division of Pediatric Cardiology, Sophia Children's Hospital/University Hospital Rotterdam, Rotterdam, The Netherlands.
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35
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Deuchar GA, Docherty A, MacLean MR, Hicks MN. Pulmonary hypertension secondary to left ventricular dysfunction: the role of nitric oxide and endothelin-1 in the control of pulmonary vascular tone. Br J Pharmacol 2002; 135:1060-8. [PMID: 11861335 PMCID: PMC1573195 DOI: 10.1038/sj.bjp.0704529] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
1. Using an in vivo model of pulmonary hypertension (PHT) secondary to left ventricular dysfunction (LVD), the pulmonary arterial response to the nitric oxide synthase (NOS) blocker L-NAME (30 micromol.min(-1) i.v.) and the subsequent responses to cumulatively administered endothelin-1 (ET-1) (0.001 -- 4 nmol.kg(-1) i.v.) or big ET-1 (0.1 -- 2.0 nmol.kg(-1) i.v.) were studied. Additionally, the effect of the non-selective ET-1 receptor antagonist, SB209670, was investigated. 2. Eight weeks after coronary artery ligation or sham operation, rabbits demonstrated increased mean pulmonary arterial pressure (PAP) accompanied by right ventricular hypertrophy. 3. Blockade of NOS caused a greater increase in basal PAP (increased by 7.7 +/- 1.1 mmHg c.f. 3.8 +/- 1.0 mmHg in controls, P<0.05) and uncovered a greater pulmonary pressor response to exogenous ET-1 in rabbits with PHT (increased by 10.2 +/- 2.3 mmHg c.f. 4.9 +/- 1.0 mmHg in controls, P<0.05). 4. Big ET-1 evoked a pulmonary pressor effect, in both groups of rabbits, that was increased following blockade of NOS and was more potent in rabbits with PHT. 5. The non-selective ET-1 receptor antagonist, SB209670, reduced basal PAP (from 16.9 mmHg to 15.9 mmHg, P < 0.05) in rabbits with PHT and blocked the response to ET-1 in the presence of L-NAME. 6. In conclusion, the results demonstrate that basal NO activity masks a pulmonary pressor response to exogenously administered ET-1. An increased responsiveness to ET-1 was shown in the pulmonary arterial bed of rabbits with PHT secondary to LVD, implicating a pathophysiological role for ET-1 in this model.
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Affiliation(s)
- Graeme A Deuchar
- Department of Medical Cardiology, University of Glasgow, Royal Infirmary, Glasgow G31 2ER
| | - Andrew Docherty
- Department of Medical Cardiology, University of Glasgow, Royal Infirmary, Glasgow G31 2ER
| | - Margaret R MacLean
- Division of Neuroscience and Biomedical Systems, IBLS, West Medical Building, University of Glasgow, Glasgow G12 8QQ
| | - Martin N Hicks
- Department of Medical Cardiology, University of Glasgow, Royal Infirmary, Glasgow G31 2ER
- Author for correspondence:
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Bressollette E, Dupuis J, Bonan R, Doucet S, Cernacek P, Tardif JC. Intravascular ultrasound assessment of pulmonary vascular disease in patients with pulmonary hypertension. Chest 2001; 120:809-15. [PMID: 11555514 DOI: 10.1378/chest.120.3.809] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Measurements of pulmonary pressure and resistance are still considered to be the "gold standard" in the evaluation of pulmonary hypertension (PH), despite their limitations in predicting irreversible disease. Hemodynamic assessment also only provides a global evaluation of the pulmonary vascular bed, whereas PH is an inhomogeneous disease of the vessel wall. METHODS AND RESULTS We assessed the value of intravascular ultrasound (IVUS) in 30 patients with suspected PH and correlated the structural changes in distal pulmonary arteries found on IVUS with conventional hemodynamic data. Plasma endothelin (ET)-1 levels and pulmonary ET-1 extraction also were measured as markers of the severity of PH. The anatomic abnormalities revealed by IVUS were more severe in the lower lobes than in the upper lobes, as evidenced by the greater percentage of wall thickness (WT), the smaller lumen diameter/WT and lumen area/total vessel area (p < 0.05 for each). IVUS anatomic indexes correlated directly with hemodynamic data (eg, with pulmonary arterial systolic pressure; r = 0.56; p < 0.001) and ET-1 levels but inversely with pulmonary ET-1 extraction. CONCLUSION Patients with PH have greater pulmonary arterial WT that is more severe in the lower lobes than in the upper lobes. The severity of structural abnormalities found on IVUS is directly correlated with hemodynamic findings and ET-1 levels. IVUS may provide useful additional information in the assessment of patients with PH.
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Affiliation(s)
- E Bressollette
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
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Moraes DL, Colucci WS, Givertz MM. Secondary pulmonary hypertension in chronic heart failure: the role of the endothelium in pathophysiology and management. Circulation 2000; 102:1718-23. [PMID: 11015353 DOI: 10.1161/01.cir.102.14.1718] [Citation(s) in RCA: 290] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pulmonary vascular resistance is frequently elevated in patients with chronic left ventricular failure as a result of dysregulation of vascular smooth muscle tone and structural remodeling. The former is reversible over a period of minutes to days by pharmacological vasodilators, whereas the latter is relatively fixed and may resolve only slowly, over months to years. These abnormalities are due, at least in part, to pulmonary vascular endothelial dysfunction that results in impaired nitric oxide availability and increased endothelin expression. In patients with chronic heart failure, the resulting pulmonary hypertension directly affects right ventricular function and may affect exercise capacity, morbidity, and mortality. New treatment strategies, which include the use of agents that increase nitric oxide availability or oppose the actions of endothelin, may improve the structure and function of the pulmonary vasculature in patients with chronic heart failure.
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MESH Headings
- Antihypertensive Agents/therapeutic use
- Cardiac Output, Low/complications
- Chronic Disease
- Endothelin Receptor Antagonists
- Endothelins/metabolism
- Endothelium, Vascular/pathology
- Endothelium, Vascular/physiology
- Exercise/physiology
- Humans
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/metabolism
- Hypertension, Pulmonary/mortality
- Nitric Oxide/metabolism
- Nitric Oxide/therapeutic use
- Vascular Resistance
- Vasodilation
- Ventricular Dysfunction, Left/complications
- Ventricular Function, Left
- Ventricular Function, Right
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Affiliation(s)
- D L Moraes
- Cardiovascular Section, Boston University Medical Center, Boston, MA 02118, USA
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Capomolla S, Febo O, Guazzotti G, Gnemmi M, Mortara A, Riccardi G, Caporotondi A, Franchini M, Pinna GD, Maestri R, Cobelli F. Invasive and non-invasive determinants of pulmonary hypertension in patients with chronic heart failure. J Heart Lung Transplant 2000; 19:426-38. [PMID: 10808149 DOI: 10.1016/s1053-2498(00)00084-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In patients with chronic heart failure, pulmonary hypertension is an important predictive marker of adverse outcome. Its invasive and non-invasive determinants have not been evaluated. OBJECTIVE This study was performed to evaluate hemodynamic determinants of pulmonary hypertension in chronic heart failure and to compare the predictive value of Doppler indices with that of invasively measured hemodynamic indices. METHODS Right heart catheterization and transthoracic echo-Doppler were simultaneously performed in 259 consecutive patients with chronic heart failure (ejection fraction 24% +/- 7%) who were in sinus rhythm and receiving optimized medical therapy. Systolic pulmonary artery pressure (sPAP), cardiac index, transpulmonary gradient pressure, and pulmonary wedge pressure (PWP) were measured invasively. Left atrial and ventricular systolic and diastolic volumes, the ratio of maximal early to late diastolic filling velocities (E/A ratio), deceleration time (DT) and atrial filling fraction (AFF) of transmitral flow, systolic fraction of forward pulmonary venous flow (SFpvf), and mitral regurgitation were quantified by echo-Doppler. RESULTS Patients with pulmonary hypertension had greater left atrial systolic and diastolic dysfunction, more left ventricular diastolic abnormalities, and greater hemodynamic impairment. The correlations between systolic left ventricular indices, mitral regurgitation, and sPAP were generally poor. Among invasive and non-invasive measurements, PWP (r = 0.89, p < 0.0001) and SFpvf (r = -0.68, p < 0.0001) showed the strongest correlation with sPAP. When we compared all patients with those without mitral regurgitation, the correlations between E/A ratio (r = 0.56 vs r = 0. 74, p < 0.002), SFpvf (r = -0.68 vs r = -0.84, p < 0.03), and systolic pulmonary artery pressure were significantly stronger. Multivariate analysis revealed that PWP was the strongest invasive independent predictor of systolic pulmonary artery pressure in patients with (R(2) = 0.87, p < 0.0001) and without (R(2) = 0.90, p < 0.0001) mitral regurgitation. A PWP > or= 18 mm Hg (odds ratio [95% CL], 142 (41-570) was strongly associated with systolic pulmonary hypertension. Among non-invasive variables DT, SFpvf, and AFF were identified as independent predictors of sPAP in patients with (R(2) = 0.56, p < 0.0001) and without (R(2) = 0.78, p < 0.0001) mitral regurgitation. A DT < 130 (odds ratio [95% CL], 3.5 (1.3-8.5), SFfvp < 40% (odds ratio [95% CL], 333 (41-1,007), and AFF < 30% (odds ratio [95% CL], 2 (1.3-7) most strongly predicted systolic pulmonary hypertension. CONCLUSIONS The results of this study indicate that in patients with chronic heart failure, venous pulmonary congestion is an important determinant of systolic pulmonary artery hypertension. Hemodynamic and Doppler determinants showed similar predictive power in identifying systolic pulmonary artery hypertension.
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Affiliation(s)
- S Capomolla
- Salvatore Maugeri Foundation-Institute of Medical Care and Research, Montescano (Pavia), Italy
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Wensel R, Opitz CF, Kleber FX. Acetylcholine but not sodium nitroprusside exerts vasodilation in pulmonary hypertension secondary to chronic congestive heart failure. J Heart Lung Transplant 1999; 18:877-83. [PMID: 10528750 DOI: 10.1016/s1053-2498(99)00041-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Reduced endothelium-dependent vasodilation contributes to the development of pulmonary hypertension in chronic congestive heart failure (CHF). We investigated pulmonary endothelium-dependent and independent vasodilation in patients with CHF. METHODS We studied 42 patients with CHF (age 55 +/- 10, NYHA Classes II-III, left ventricular ejection fraction 27 +/- 10%, mean PAP 29 +/- 12 mmHg). The endothelial vasodilator capacity of pulmonary resistance vessels was assessed by the infusion of acetylcholine into a pulmonary artery branch while measuring the blood flow velocity with a Doppler flow wire. For comparison endothelium-independent vasodilation was measured with the response to sodium nitroprusside. The conductance vessel diameter (4.4 +/- 0.2 mm) was determined by intravascular ultrasound. Acetylcholine was administered at concentrations of 10(-6) to 10(-4) mol/l, sodium nitroprusside was administered at concentrations of 0.125 and 0.25 microg/kg per min. The effects on conductance vessel diameter were investigated in 12 patients by the measurement of diameter and flow velocity following the administration of acetylcholine and sodium nitroprusside. RESULTS Acetylcholine markedly increased blood flow velocity (+39 +/- 7% at 10(-4) mol/l; p < .05). This correlated with the baseline PAP (r = 0.58; p < .05) and pulmonary vascular resistance (r = 0.58; p < .05). Sodium nitroprusside caused a small increase in the flow velocity (5 +/- 2% at 0.125, 12 +/- 4% at 0.25 microg/kg per minute; p < .05) that was accompanied by systemic vasodilation. The conductance vessel diameter was unchanged after acetylcholine was administered and was only marginally decreased after the administration of sodium nitroprusside. CONCLUSIONS In CHF acetylcholine reveals preserved receptor-mediated endothelial vasodilation, that is positively correlated to pulmonary hypertension, and cannot be reproduced by sodium nitroprusside.
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Affiliation(s)
- R Wensel
- Humboldt University Berlin, Germany
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40
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Reindl I, Wernecke KD, Opitz C, Wensel R, König D, Dengler T, Schimke I, Kleber FX. Impaired ventilatory efficiency in chronic heart failure: possible role of pulmonary vasoconstriction. Am Heart J 1998; 136:778-85. [PMID: 9812071 DOI: 10.1016/s0002-8703(98)70121-8] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with chronic heart failure show impairment of ventilatory efficiency, defined as the relation between ventilation and carbon dioxide output. It is caused by ventilation of excess physiologic dead space. We hypothesized a role of active vasoconstriction in the increase of physiologic dead space, presumed to lead to alveolar hypoperfusion. METHODS AND RESULTS In 57 patients with chronic heart failure (New York Heart Association classification II through IV, ejection fraction 25.6%+/-10.4%) and 7 control subjects, gas exchange at rest and on exercise was compared with hemodynamic measurements and, in a subgroup of 15 patients, with endothelin-1, epinephrine, and norepinephrine levels in the pulmonary and systemic circulation. Ventilatory efficiency at rest (VE/VCO2 ratio) correlated with ventilatory efficiency on exercise (VE vs VCO2 slope). Impairment of ventilatory efficiency correlated strongly negative with exercise tolerance (maximal oxygen uptake: r = -0.67) and cardiac output (r = -0.66) and positive with pulmonary hypertension (mean pulmonary artery pressure: r = 0.69, pulmonary vascular resistance: r = 0.60). None of the vasoconstrictors correlated with reduction of ventilatory efficiency in the subgroup studied. CONCLUSIONS Impairment of ventilatory efficiency in chronic heart failure is correlated with resting pulmonary artery pressures and associated with the impairment of exercise capacity. An imbalance of pulmonary vascular tone probably leads to both pulmonary hypertension and alveolar hypoperfusion.
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Affiliation(s)
- I Reindl
- Department of Internal Medicine and Working Group for Biometrics, Charité, Humboldt University Berlin, Germany
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Cooper CJ, Jevnikar FW, Walsh T, Dickinson J, Mouhaffel A, Selwyn AP. The influence of basal nitric oxide activity on pulmonary vascular resistance in patients with congestive heart failure. Am J Cardiol 1998; 82:609-14. [PMID: 9732889 DOI: 10.1016/s0002-9149(98)00400-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Increased pulmonary resistance may reduce survival and treatment options in patients with congestive heart failure. Nitric oxide (NO) is a determinant of normal pulmonary resistance vessel tone. We tested the hypothesis that loss of NO function contributes to increased pulmonary vascular resistance index (PVRI) in congestive heart failure. Pulmonary arterial resistance vessel function was studied in 25 conscious adults. Three groups were studied: 8 controls, 9 patients with congestive heart failure and normal PVRI, and 8 patients with congestive heart failure and raised PVRI. Segmental arterial flow was determined with a Doppler wire and quantitative angiography. NG-monomethyl-L-arginine (L-NMMA) was used to inhibit NO, whereas phenylephrine was used as an endothelium-independent control. The response to inhibition of NO with L-NMMA was less in patients with congestive heart failure and elevated PVRI than in patients with congestive heart failure and normal PVRI (p <0.05). The difference in response between the congestive heart failure groups was specific to NO-dependent regulation because the response to the endothelium-independent constrictor phenylephrine was not different (p = 0.92). There was no difference in response to L-NMMA between controls and patients with congestive heart failure and normal PVRI. The response to L-NMMA correlated to PVRI. In adults with congestive heart failure, NO appears to play an important role in maintaining normal pulmonary resistance.
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Affiliation(s)
- C J Cooper
- Department of Medicine, Medical College of Ohio, Toledo 43699-0008, USA
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42
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Day RW, Tani LY. Pulmonary intravascular ultrasound in infants and children with congenital heart disease. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 41:395-8. [PMID: 9258481 DOI: 10.1002/(sici)1097-0304(199708)41:4<395::aid-ccd9>3.0.co;2-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A three-layered appearance of the pulmonary arterial wall has only been described by intravascular ultrasound in adults or autopsy studies of patients with pulmonary hypertension. Thus, pulmonary intravascular ultrasound was performed in 11 patients during heart catheterization to test the hypothesis that distinct layers of peripheral pulmonary arteries can be imaged in infants and children with congenital heart disease. A 3.5 Fr 30 MHz ultrasound catheter was used to image proximal pulmonary arteries with an internal diameter of 3 to 6 mm and distal pulmonary arteries with an internal diameter of 1.5 to 2 mm. Three layers were identified in the proximal arteries of 10 patients but could not be identified in the distal arteries of any patient. There was a significant linear correlation between the indexed dimension of the medial echolucent vascular wall layer and pulmonary vascular resistance. We conclude that intravascular ultrasound can identify vascular changes consistent with medial hypertrophy in the branch pulmonary arteries of young patients with corresponding degrees of pulmonary hypertension.
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Affiliation(s)
- R W Day
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, USA.
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Enriquez-Sarano M, Rossi A, Seward JB, Bailey KR, Tajik AJ. Determinants of pulmonary hypertension in left ventricular dysfunction. J Am Coll Cardiol 1997; 29:153-9. [PMID: 8996308 DOI: 10.1016/s0735-1097(96)00436-6] [Citation(s) in RCA: 228] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This study sought to analyze the determinants of pulmonary hypertension in patients with left ventricular dysfunction. BACKGROUND Pulmonary hypertension in patients with left ventricular dysfunction is a predictor of poor outcome. The independent role of cardiac functional abnormalities in the genesis of pulmonary hypertension is unclear. METHODS In 102 consecutive patients with primary left ventricular dysfunction (ejection fraction < 50%), systolic pulmonary artery pressure was prospectively measured by Doppler echocardiography (using tricuspid regurgitant velocity), and left ventricular systolic and diastolic function, functional mitral regurgitation, cardiac output and left atrial volume were quantified. RESULTS Systolic pulmonary artery pressure was elevated in patients with left ventricular dysfunction (51 +/- 14 mm Hg [mean +/- SD]), but the range was wide (23 to 87 mm Hg). Of the numerous variables correlating significantly with systolic pulmonary artery pressure, the strongest were mitral deceleration time (r = -0.61, p = 0.0001; odds ratio of pulmonary pressure > or = 50 mm Hg [95% confidence interval] if < 150 ms, 48.8 [14.8 to 161]) and mitral effective regurgitant orifice (r = 0.50, p = 0.0001; odds ratio [95% confidence interval] if > or = 20 mm2, 5.9 [2.3 to 15.5]). In multivariate analysis, these two variables were the strongest predictors of systolic pulmonary artery pressure in association with age (p = 0.005). Ejection fraction or end-systolic volume was not an independent predictor of pulmonary artery pressure. CONCLUSIONS Pulmonary hypertension is frequent and highly variable in patients with left ventricular dysfunction. It is not independently related to the degree of left ventricular systolic dysfunction but is strongly associated with diastolic dysfunction (shorter mitral deceleration time) and the degree of functional mitral regurgitation (larger effective regurgitant orifice). These results emphasize the importance of assessing diastolic function and quantifying mitral regurgitation in patients with left ventricular dysfunction.
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Affiliation(s)
- M Enriquez-Sarano
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Cooper CJ, Landzberg MJ, Anderson TJ, Charbonneau F, Creager MA, Ganz P, Selwyn AP. Role of nitric oxide in the local regulation of pulmonary vascular resistance in humans. Circulation 1996; 93:266-71. [PMID: 8548898 DOI: 10.1161/01.cir.93.2.266] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endothelium-derived nitric oxide (NO) may be an important mediator of vascular resistance in the pulmonary circulation. We tested the hypotheses that in conscious adults the endothelium, through NO production, is important in maintaining basal pulmonary vascular resistance and that it can increase NO production further in response to receptor-mediated stimulation, leading to further vasodilation. METHODS AND RESULTS Pulmonary arterial resistance vessel function was studied within the distribution of a segmental lower lobe pulmonary artery in eight conscious adults 37 to 76 years old who were undergoing cardiac catheterization. Segmental blood flow was determined with use of a Doppler-tip guide wire and quantitative angiography. Drugs were administered locally within the segmental artery through an infusion catheter. NG-Monomethyl-L-arginine (L-NMMA) was used as a specific inhibitor of NO production, whereas acetylcholine (ACh) was used to test receptor-mediated vasodilation. To demonstrate that vasodilation to ACh was NO dependent, ACh response was tested alone, in the presence of L-NMMA, and in the presence of a control constrictor phenylephrine. Basal pulmonary vascular resistance was NO dependent because L-NMMA infusion resulted in a dose-dependent decrease in local flow velocity (P < .005), with flow decreasing 33% at the highest dose of L-NMMA. ACh infusion resulted in a dose-dependent increase in flow velocity (P = .001). The ACh response was at least in part NO dependent because it was diminished by the presence of L-NMMA (P < .05). The effect of L-NMMA on the ACh response was not due to nonspecific preconstriction because L-NMMA diminished the ACh response significantly more than did the endothelium-independent constrictor phenylephrine (P < .05) despite comparable preconstriction. CONCLUSIONS In healthy conscious adults, (1) normal basal pulmonary resistance is maintained in part by continuous local production of NO and (2) the local NO production is responsive to receptor-mediated stimulation, leading to further vasodilation, and can be tested with ACh.
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Affiliation(s)
- C J Cooper
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Adatia I, Perry S, Landzberg M, Moore P, Thompson JE, Wessel DL. Inhaled nitric oxide and hemodynamic evaluation of patients with pulmonary hypertension before transplantation. J Am Coll Cardiol 1995; 25:1656-64. [PMID: 7759720 DOI: 10.1016/0735-1097(95)00048-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES We investigated the effect of inhaled nitric oxide and infused acetylcholine in patients with pulmonary hypertension undergoing cardiac catheterization before cardiopulmonary transplantation. BACKGROUND The fate of patients under consideration for transplantation of the heart or lungs, or both, is influenced by the evaluation of their pulmonary vascular reactivity. METHODS We evaluated 11 patients who were classified into two groups on the basis of mean left atrial pressure > 15 mm Hg (group I, n = 6) or < or = 15 mm Hg (group II, n = 5). All patients inhaled nitric oxide at 80 ppm. This was preceded by an infusion of 10(-6) mol/liter of acetylcholine in seven consecutive patients (n = 3 in group I, n = 4 in group II). RESULTS In group I, inhaled nitric oxide decreased pulmonary artery pressure from (mean +/- SE) 71 +/- 13 to 59 +/- 10 mm Hg (p < 0.05), pulmonary vascular resistance from 14.9 +/- 3.8 to 7.6 +/- 1.7 Um2 (p < 0.05) and intrapulmonary shunt fraction from 17.8 +/- 3.6% to 12.7 +/- 2.1% (p < 0.05). Left atrial pressure tended to increase from 27 +/- 4 to 32 +/- 5 mm Hg (p = 0.07). In group II pulmonary vascular resistance decreased in response to nitric oxide from 36.4 +/- 9.0 to 31.1 +/- 7.9 Um2 (p < 0.05). Cardiac index, systemic pressure and resistance did not change in either group. Seven patients who received acetylcholine had no significant alteration in pulmonary hemodynamic variables. CONCLUSIONS These preliminary observations suggest that nitric oxide is a potent pulmonary vasodilator with minimal systemic effects. It may be useful in discriminating patients needing combined heart and lung transplantation from those requiring exchange of the heart alone.
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Affiliation(s)
- I Adatia
- Department of Cardiology, Children's Hospital, Boston, Massachusetts 02115, USA
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Schwartz SL, Pandian NG, Crowley R, Kumar R. Intracardiac echocardiography without fluoroscopy: potential of a balloon-tipped, flow-directed ultrasound catheter. Am Heart J 1995; 129:598-603. [PMID: 7872192 DOI: 10.1016/0002-8703(95)90290-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Intracardiac echocardiography is a technique that uses catheter-based ultrasound transducers placed within the heart to image cardiac structures. One disadvantage to this technique is that it requires fluoroscopy for catheter placement. This study was performed to evaluate a prototype balloon-tipped, flow-directed catheter for use during intracardiac echocardiography in seven dogs. With the balloon deflated, the catheter could not be successfully advanced without fluoroscopy. Even with fluoroscopic imaging, catheter advancement was often difficult. With the balloon inflated, it could easily be passed into the pulmonary artery without fluoroscopy in 12 of 14 attempts. Images of the cardiac chambers, valves, and pulmonary artery could be obtained. In conclusion, use of a balloon-tipped, flow-directed catheter for intracardiac echocardiography and pulmonary artery imaging can be performed without the use of fluoroscopy. With continued refinements, such as enhancement of the visual field, intracardiac echocardiography could possibly be performed at the bedside to assess cardiac function or assist with interventional procedures.
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Affiliation(s)
- S L Schwartz
- Department of Medicine, New England Medical Center Hospitals, Tufts University School of Medicine, Boston, MA
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Porter TR, Mohanty PK, Pandian NG. Intravascular ultrasound imaging of pulmonary arteries. Methodology, clinical applications, and future potential. Chest 1994; 106:1551-7. [PMID: 7956417 DOI: 10.1378/chest.106.5.1551] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- T R Porter
- Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston
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